Evaluating Social Determinants of Health Related to Cancer Survivorship and Quality of Care.

BACKGROUND: Social determinants of health posit that negative outcomes are influenced by individuals living in underserved and underresourced neighborhoods. OBJECTIVE: This study examines a cancer diagnosis, race/ethnicity, age, geographic location (residence), education, and social economic status factors at disease onset and treatment. METHODS: A multivariable PO regression analysis was run for quality of care at testing or diagnosis, and quality of care at treatment and the quality of received care compared with another person. RESULTS: Participants are representative of the Southern Community Cohort Study (SCCS) of adults diagnosed with breast (n = 263), prostate (n = 195), lung (n = 46), colorectal (n = 105), or other cancers (n = 526). This study includes cancer survivors who completed the SCCS Baseline and Cancer Navigation Surveys in urban (73.13%) and rural (26.87%) areas. White participants reported a higher quality of received care for testing or diagnosis and care for treatment compared with Black participants. Participants with high school or equivalent education (odds ratio, 1.662; 95% confidence interval, 1.172-2.356; P = .0044) or some college or junior college education (odds ratio, 1.970; 95% confidence interval, 1.348-2.879; P = .0005) were more likely to report a better level of quality of received care for treatment. CONCLUSIONS: The SCCS represents individuals who are historically underrepresented in cancer research. The results of this study will have broad implications across diverse communities to reduce disparities and inform models of care. IMPLICATIONS FOR PRACTICE: Nurses are positioned to evaluate the quality of population health and design and lead interventions that will benefit underserved and underresourced communities.

Promoting sleep in hospitals: An integrative review of nurses' attitudes, knowledge and practices.

AIMS: To explore nurses' knowledge, attitudes and practices related to improving hospitalized patients' sleep. DESIGN: Integrative review. DATA SOURCES: We searched CINAHL, PubMed and PsycInfo electronically including a manual search of references listed within the relevant studies. Original, peer-reviewed studies published in English between 2000 and 2022 evaluating nurses' sleep knowledge, attitudes, or practices to improve inpatients' sleep were reviewed. REVIEW METHODS: This review was guided by Whittemore and Knafl method and followed PRISMA guidelines to search the literature. Fifteen articles reporting nurses' sleep knowledge, attitudes or practices to improve inpatients' sleep were included. The quality appraisal was done using the Mixed Methods Appraisal Tool version 2018. RESULTS: Inadequate training of nurses regarding sleep hygiene and insufficiency in sleep-promoting practices were apparent. Most studies reported that nurses hold positive attitudes about sleep. The acuity of patients' health conditions affected their perception of sleep priorities. Lack of organizational sleep policies/protocols and coworkers' attitudes negatively impacted nurses' motivation to implement sleep hygiene interventions. Interventions reported in the studies were reducing noise and nursing interventions at night, using a clock for time orientation, earplugs, reducing light, keeping patients awake during the daytime, maintaining comfortable room temperature and managing patients' stress. These practices were hindered by poor knowledge, negative attitudes, patients' acuity and lack of sleep assessment tools. CONCLUSION: It is essential to support nursing practice to improve patients' sleep in hospitals through interventions that target nurses' knowledge, attitudes and confidence towards implementing sleep hygiene interventions to improve patients' sleep and, consequently, their health outcomes during hospitalization. IMPACT: This integrative review explored nurses' knowledge, attitudes and practices to improve patients' sleep during hospitalization. It revealed that expanding nurses' sleep knowledge and empowering them to implement sleep promotion practices are needed. Nursing educators and leaders need to be involved. NO PATIENT OR PUBLIC CONTRIBUTION: This paper is an integrative review and does not include patient or public contribution.

Exposing othering in nursing education praxis.

This paper defines and analyzes the processes of "othering" as they manifest in the practice and praxis of nursing education. Othering is bound up in the establishment and reinforcement of norms, and shores up power inequities that negatively impact faculty, students, and patients. While previous analyses have addressed othering in nursing more broadly, this paper adds a consideration of the multiple processes of othering that operate within the context of nursing education spaces. Cases from recent nursing education literature are interpreted through the frameworks of exclusionary, inclusionary, and structural othering, and provide specific illustrations of the concepts described. The paper concludes by arguing for an application of norm-critical pedagogical practice to counteract, disrupt and dismantle othering processes within nursing education.

Developing a Theory of Norm-Criticism in Nursing Education.

In this article, we explore the core concepts of norm-critical pedagogy developed in Sweden and only recently applied to nursing education praxis. These concepts, norms, power , and othering , are defined and demonstrated with exemplars from recent nursing education research. The theoretical model illustrates the ways in which these elements articulate in relationship to each other in nursing education praxis in ways that are dynamic, interlocking-like the gears of a clock-and resistant to interruption. We discuss the potential of a structurally oriented critical reflexivity-an equal and opposite force to the motion of the gears-to interrupt their motion.

A Multilevel Approach to Investigate Relationships Between Healthcare Resources and Lung Cancer.

BACKGROUND: Screening for lung cancer is an evidence-based but underutilized measure to reduce the burden of lung cancer mortality. Lack of adequate data on geographic availability of lung cancer screening inhibits the ability of healthcare providers to help patients with decision-making and impedes equity-focused implementation of screening-supportive services. OBJECTIVES: This analysis used data from the 2012-2016 Surveillance, Epidemiology, and End Results (SEER) Program, the Behavioral Risk Factor Surveillance System, and the county health ranking to examine (a) which cancer resources and county-level factors are associated with late-stage lung cancer at diagnosis and (b) associations between county rurality and lung cancer incidence/mortality rates. METHODS: Using the New York state SEER data, we identified 68,990 lung cancer patients aged 20-112 years; 48.3% had late-stage lung cancers, and the average lung cancer incidence and mortality rates were 70.7 and 46.2 per 100,000, respectively. There were 144 American College of Radiology-designated lung cancer screening centers and 376 Federally Qualified Health Centers identified in New York state. County rurality was associated with a higher proportion of late-stage lung cancers and higher lung cancer mortality rates. DISCUSSION: Visual geomapping showed the scarcity of rural counties' healthcare resources. County rurality is a significant factor in differences in lung cancer screening resources and patient outcomes. Use of publicly available data with geospatial methods provides ways to identify areas for improvement, populations at risk, and additional infrastructure needs.

Precision Medicine Testing and Disparities in Health Care for Individuals With Non-Small Cell Lung Cancer: A Narrative Review.

PROBLEM IDENTIFICATION: Precision medicine initiatives provide opportunities for optimal targeted therapy in individuals with non-small cell lung cancer. However, there are barriers to these initiatives that reflect social determinants of health. LITERATURE SEARCH: MEDLINE®, CINAHL®, PsycINFO®, Embase®, and Google ScholarTM databases were searched for articles published in English in the United States from 2016 to 2020. DATA EVALUATION: Data that were collected included individual demographic information, specific diagnosis, status of targeted genomic testing, and receipt of targeted therapy. All studies were retrospective and involved database review of insurance claims or medical records. SYNTHESIS: Individuals with non-small cell lung cancer received less genetic testing and targeted therapy if they were of a lower socioeconomic status, had public health insurance or no health insurance, were Black, or lived in rural communities. IMPLICATIONS FOR NURSING: Social determinants of health affect health equity, including in precision medicine initiatives for individuals with lung cancer. Gaining an understanding of this impact is the first step in mitigating inequities.

Patients' Perceptions at Diagnosis: Lung Cancer Discovery and Provider Relationships.

BACKGROUND: In the United States, most lung cancer cases are diagnosed at advanced stages, limiting treatment options and impacting survival. This study presents patients' perspectives on the complexity of factors influencing a lung cancer diagnosis. Lung cancer awareness regarding risks, symptoms, smoking behaviors, family history, and environmental factors can lead to preventative and early detection measures. OBJECTIVE: The aim of this study was to explore lung cancer patient perspectives on lung cancer awareness within the context of an earlier study to understand sleep-wake disturbances in adults with non-small cell lung cancer. METHODS: A content analysis was used to analyze the original deidentified longitudinal interview data collected from 26 patients diagnosed with lung cancer. RESULTS: Of the original 26 participants, 16 were included in this secondary data analysis. The participants were primarily females (n = 10) and Whites (n = 13), with ages ranging between 49 and 83 years. Half of the sample was diagnosed with stage IV lung cancer and most of the sample was on chemotherapy (n = 10). Two key themes were identified: the lung cancer discovery and the patient-physician relationship. CONCLUSIONS: Unspecific initial symptoms, lack of knowledge and screening, as well as fear of the diagnosis delayed seeking medical care. Patient-physician relationships were hindered by smoking-associated stigma, inadequate sharing of information, and lack of coordinated, holistic care. Positive communication strategies are critical between patients and providers to meet patients' specific needs. IMPLICATIONS FOR PRACTICE: Educational interventions that enhance lung cancer awareness may improve prevention and screening actions, improve timely healthcare intervention, and reduce incidence and mortality.

Update to 2019-2022 ONS Research Agenda: Rapid Review to Address Structural Racism and Health Inequities.

PURPOSE: The Oncology Nursing Society (ONS) formed a team to develop a necessary expansion of the 2019-2022 ONS Research Agenda, with a focus on racism and cancer care disparities. METHODS: A multimethod consensus-building approach was used to develop and refine the research priorities. A panel of oncology nurse scientists and equity scholars with expertise in health disparities conducted a rapid review of the literature, consulted with experts and oncology nurses, and reviewed priorities from funding agencies. RESULTS: Critical gaps in the literature were identified and used to develop priority areas for oncology nursing research, practice, and workforce development. SYNTHESIS: This is the first article in a two-part series that discusses structural racism and health inequities within oncology nursing. In this article, three priority areas for oncology nursing research are presented; in the second article, strategies to improve cancer disparities and equity and diversity in the oncology workforce are described. IMPLICATIONS FOR RESEARCH: Research priorities are presented to inform future research that will provide methods and tools to increase health equity and reduce structural racism in oncology nursing practice, research, education, policy, and advocacy.

Update to 2019-2022 ONS Research Agenda: Rapid Review to Promote Equity in Oncology Healthcare Access and Workforce Development.

PURPOSE: The Oncology Nursing Society (ONS) tasked a rapid response research team (RRRT) to develop priorities to increase diversity, equity, and inclusivity in oncology clinical care and workforce development. METHODS: An RRRT of experts in health disparities conducted a rapid review of the literature, consulted with oncology nurse leaders and disparities researchers, and reviewed priorities from funding agencies. RESULTS: Significant gaps in the current oncology disparities literature were identified and used to inform priority areas for future research practice and workforce development in oncology nursing. SYNTHESIS: This is the second article in a two-part series that presents findings on structural racism and health inequities in oncology nursing. In the first article, three priority areas for oncology nursing research were presented. In this article, strategies to improve diversity, equity, and inclusivity in clinical practice and the oncology workforce are described. IMPLICATIONS FOR RESEARCH: Recommendations are presented to inform research, clinical, administrative, and academic oncology nursing settings on increasing diversity, equity, and inclusivity and deconstructing structural racism.

Access to Cancer Care Resources in a Federally Qualified Health Center: a Mixed Methods Study to Increase the Understanding of Met and Unmet Needs of Cancer Survivors.

Assessing the met and unmet needs of cancer survivors is critical in optimizing access to cancer services especially in underserved populations. The purpose of this study is to expand our understanding of the priority needs for cancer survivorship within racial/ethnic and underserved populations that speak either English or Spanish and seek health care in a federally qualified health center (FQHC). A convergent mixed methods design integrating survey and focus group data was utilized for this study. A total of 17 participants were enrolled in the study. The meta-inferences were drawn by looking across the top ten matched survey and focus group met and unmet needs including psychological, informational, and health system as well as patient care and support. The preferred languages of participants were Spanish 53% (n = 9) and English 47% (n = 8), and the survival breakdown was 65% (n = 11) within 0-5 years with 17.5% (n = 3), 6-10 years and 17.5% (n = 3), and 17.5% (n = 3) > 11 years. The most frequently met needs included health care providers and hospital staff being attentive to their physical and emotional needs and feeling they were treated with respect. Unmet needs were often related to physical and daily living needs such as pain, fatigue, sadness, depression, and not being able to work. Providing a needs-based approach of cancer health services in a FQHC or similar community-based health center is critical to meet the needs of cancer survivors to improve health outcomes and quality of life.

Enhancing behavioral change among lung cancer survivors participating in a lifestyle risk reduction intervention: a qualitative study.

PURPOSE: Early detection and improved treatment have increased lung cancer survival. Lung cancer survivors have more symptom distress and lower function compared with other cancer survivors; however, few interventions are available to improve health-related quality of life (HR-QOL). Lifestyle risk reduction interventions have improved HR-QOL in other cancer survivors. The purpose of this study was to explore lung cancer survivor perspectives on making behavioral changes in the context of a lifestyle risk reduction intervention. METHODS: Twenty-two lung cancer survivors participated in interviews after completing the Healthy Directions (HD) intervention. Interviews were audiotaped, transcribed, and analyzed using inductive content analysis. Demographic and clinical characteristics were gathered through a survey and analyzed using descriptive statistics. RESULTS: Five main themes were identified: (1) the diagnosis was a motivator for behavior change, (2) participants had to deal with disease consequences, (3) the coach provided guidance, (4) strategies for change were initiated, and (5) social support sustained behavioral changes. Other important subthemes were the coach helped interpret symptoms, which supported self-efficacy and goal setting, and survivors employed self-monitoring behaviors. Several participants found the recommended goals for physical activity were difficult and were discouraged if unable to attain the goal. Findings underscore the need for individualized prescriptions of physical activity, especially for sedentary survivors. CONCLUSIONS: Lung cancer survivors described the benefits of coaching to enhance their engagement in behavioral change. Additional research is needed to validate the benefit of the HD intervention to improve HR-QOL among this vulnerable and understudied group of cancer survivors.

Exploring Medicaid claims data to understand predictors of healthcare utilization and mortality for Medicaid individuals with or without a diagnosis of lung cancer: a feasibility study.

Health disparities in low-income populations complicate care for at-risk individuals or those diagnosed with lung cancer and may influence their patterns of healthcare utilization. The purpose of this study is to examine whether age, sex, provider's affiliation, Medicare dual eligibility, and number of comorbidities can predict healthcare utilization, as well as to examine factors influencing mortality in lung biopsy patients. A retrospective review of de-identified Medicaid claims of adults having a lung biopsy in 2013 resulted in classification into lung cancer and non-lung cancer cases based on a lung cancer diagnostic code within 30 days after biopsy. Biopsy cases were further divided by whether or not the provider's institution was accredited by the Commission on Cancer (CoC). Inpatient (IP), outpatient (OP), and emergency department (ED) utilization was followed from initial date of biopsy through 2015, or to the earliest date of death, disenrollment, or study end for both groups. The result of Cox proportional hazards regression model indicated that age and the number of comorbidities significantly predicted OP use and the number of comorbidities significantly predicted ED use in patients with lung cancer. However, for non-lung cancer patients, only the number of comorbidities significantly predicted IP and ED uses. Furthermore, for patients with lung cancer, the significant factors of mortality included IP use per month and the number of comorbidities. Patients with lung cancer who received a lung biopsy by a CoC-accredited organization had a longer time of survival from the biopsy event. Our findings suggest that understanding predictors of healthcare utilization and mortality may create opportunities to improve health and quality of life through better healthcare coordination.

Feasibility and acceptability of "healthy directions" a lifestyle intervention for adults with lung cancer.

OBJECTIVE: The aims of this feasibility study of an adapted lifestyle intervention for adults with lung cancer were to (1) determine rates of enrollment, attrition, and completion of 5 nurse-patient contacts; (2) examine demographic characteristics of those more likely to enroll into the program; (3) determine acceptability of the intervention; and (4) identify patient preferences for the format of supplemental educational intervention materials. METHODS: This study used a single-arm, pretest and posttest design. Feasibility was defined as ≥20% enrollment and a completion rate of 70% for 5 nurse-patient contact sessions. Acceptability was defined as 80% of patients recommending the program to others. Data was collected through electronic data bases and phone interviews. Descriptive statistics, Fisher's exact test and Wilcoxon rank sum test were used for analyses. RESULTS: Of 147 eligible patients, 42 (28.6%) enrolled and of these, 32 (76.2%) started the intervention and 27 (N = 27/32; 84.4%; 95% CI, 67.2%-94.7%) completed the intervention. Patients who were younger were more likely to enroll in the study (P = .04) whereas there were no significant differences by gender (P = .35). Twenty-three of the 24 (95.8%) participants' contacted posttest recommended the intervention for others. Nearly equal numbers of participants chose the website (n = 16, 50%) vs print (n = 14, 44%). CONCLUSION: The intervention was feasible and acceptable in patients with lung cancer. Recruitment rates were higher and completion rates were similar as compared to previous home-based lifestyle interventions for patients with other types of cancer. Strategies to enhance recruitment of older adults are important for future research.

Perceptions about participation in cancer clinical trials in New York state.

BACKGROUND: Clinical trials are valuable in advancing cancer care through the investigation of ways in which to better prevent, detect and diagnose, and/or treat cancer. Recruitment of adults into clinical trials has historically been low. OBJECTIVE: To survey adult cancer patients who reside in New York state to better understand their participation in and attitudes about clinical trials. METHODS: From January 2012-April 2013, we conducted a one-time survey about clinical trials in 8 cancer-treatment or cancer-patient support organizations in the state. Surveys were offered in person and online to adults with a past or current cancer diagnosis. Analysis was limited to adults who resided in the state and provided a self-reported status of previous participation in clinical trials. RESULTS: Of the 1,832 participants who completed the survey, 1,475 were included in the analysis. Our sample represented all regions of the state. Most of the respondents (68.1%) had never participated in a clinical trial. Almost 32% said they had never received information about research studies. Most (84%) felt that patients should be asked to participate in clinical trials, but fewer (70%) were willing to be approached about participation. LIMITATIONS: The sample is predominantly white and female and overrepresents breast and hematologic cancers. CONCLUSIONS: Increased outreach coupled with a team approach to educate and enroll patients in clinical trials may be the necessary first steps to increase participation in trials and ensure a diverse sample of participants.

Stress among new oncology nurses.

New oncology nurses face multiple stressors related to the predicted nursing shortage,demanding work responsibilities, and growing complexity of cancer care. The confluence of these stressors often causes new nurses to leave their profession. The loss of new nurses leads to staffing, economic, and safety concerns, which have a significant impact on the quality of oncology nursing care.

Cancer fear and fatalism: how African American participants construct the role of research subject in relation to clinical cancer research.

BACKGROUND: Lack of African American participation in cancer clinical trials has been identified as a critical problem. Historical interactions related to race, identity, and power may contribute to continued inequity in healthcare and research participation. OBJECTIVE: The aim of this study was to explore the perceptions of African Americans regarding cancer and research and how these perceptions shape their beliefs about participating as cancer research subjects. METHODS: Three African American focus groups were conducted including people who had never participated in cancer research, those who had, and those who were asked but refused (n = 16). Discussion focused on their perceptions of cancer research and actual or potential participation as research subjects. Data were coded using both structured and inductive coding methods. RESULTS: Fear and fatalism emerged in relation to research, race, power, and identity and were related to larger historical and social issues rather than only individual thoughts or feelings. Participants described fears of the unknown, death, mistrust, conspiracy, and discrimination together with positive/negative tensions between self, family, and community responsibilities. CONCLUSION: Complex identities linked perceptions of cancer and cancer research with broader historical and cultural issues. Fear, fatalism, and current and historical relationships influence how people perceive themselves as research subjects and may influence their decisions to participate in cancer research. IMPLICATION FOR PRACTICE: Acknowledging how complex factors including race and racism contribute to health disparities may give nurses and other healthcare providers a better appreciation of how historical, social, and cultural dynamics at individual, community, and organizational levels influence access to and participation in cancer research.

Uniting postcolonial, discourse, and linguistic theory to explore participation of African Americans in cancer research as an effect of social and historical race relationships.

This article uses a historical framework of postcolonialism; discourse analytic concepts (significance, identity, and relationships); and 5 social and cultural linguistic principles of emergence, positionality, indexicality, relationality, and partialness as a theoretical and methodological triangulation approach to data analysis of focus group discussion. Exemplars of focus group data from a study exploring African American participation in research demonstrate the application of this combined framework as a useful tool for analysis. This approach allows for examination of identity and interaction and generates a more rigorous and complete understanding of how individuals use language to construct identity as participants or nonparticipants in research.