The Effects of Organizational Characteristics, Individual Nurse Characteristics, and Occupational Fatigue on Missed Care at Night.

BACKGROUND: Missed care is defined as the omission or delay of necessary patient care and is internationally reported by nurses as a significant safety risk. Nurses working at night also report high levels of occupational fatigue that, coupled with inadequate staffing and practice environment support, may impede a nurse's ability to carry out the nursing process and lead to more missed care. OBJECTIVE: The study's objective was to examine the interrelationships among organizational and nurse characteristics, occupational fatigue, and missed care among nurses working at night. METHODS: A cross-sectional design was used. Participants included registered nurses (RNs) who worked at night in New Jersey acute care hospitals. Multiple linear regression and simple moderation analyses were performed to examine the associations. RESULTS: Nurses reported missing necessary care at night. Unsupportive practice environments, high RN workloads, high patient-RN ratios, high chronic fatigue levels, and low intershift recovery were individually associated with missed care at night. High patient-to-RN ratios and chronic fatigue were independently associated with missed care. However, patient-to-registered-staffing levels had the most considerable effect on missed care at night. Nurses' years of experience and the number of hours of sleep between shifts were significant moderators of the relationship between occupational fatigue states and missed care. DISCUSSION: This study is the first to examine the interrelationship between occupational fatigue levels, organizational and nurse characteristics, and missed care at night. There is an urgent need to implement strategies in hospital organizations that foster work schedules and adequate staffing patterns that lessen nurses' occupational fatigue levels to ensure our workforce's and patients' safety.

Racial Disparities and Pressure Injuries Among Hospitalized Patients.

OBJECTIVE: To describe the demographic factors, hospitalization-related factors, comorbid states, and social determinants of health among racial groups in a sample of patients with a primary or secondary diagnosis of pressure injury (PI) admitted to New Jersey hospitals during the year 2018. METHODS: Researchers conducted a retrospective analysis of the Health Care Utilization Project's 2018 New Jersey State Inpatient Database. Patients with a primary or secondary diagnosis of PI (sacrum, buttocks, or heels; N = 17,781) were included in the analytic sample. Analysis compared patients who identified as Black (n = 3,515) with all other racial groups combined (n = 14,266). RESULTS: A higher proportion of Black patients were admitted for a PI (P < .001) and had higher proportions of stage 4 PIs (P < .001) but a lower proportion of stage 1 PIs (P < .001). Higher proportions of Black patients were younger, resided in lower income communities, and identified Medicaid as their primary payor source. CONCLUSIONS: Results highlight the racial disparities that exist among patients with PIs in this diverse state and may represent a much larger problem. Clinical research examining the impact of skin tone rather than by racial group is needed. The impact of racial disparities on social determinants of health with regard to PIs remains largely unknown, but its importance cannot be underestimated.

Differences in elective epilepsy monitoring unit admission rates by race/ethnicity and primary payer in New Jersey.

Elective admission to the epilepsy monitoring unit (EMU) is an essential service provided by epilepsy centers, particularly for those with drug-resistant epilepsy. Given previously characterized racial and socioeconomic healthcare disparities in the management of epilepsy, we sought to understand access and utilization of this service in New Jersey (NJ). We examined epilepsy hospitalizations in NJ between 2014 and 2016 using state inpatient and emergency department (ED) databases. We stratified admissions by race/ethnicity and primary payer and used these to estimate and compare (1) admission rates per capita in NJ, as well as (2) admission rates per number of ED visits for each group. Patients without insurance underwent elective EMU admission at the lowest rates across all racial/ethnic groups and payer types studied. Black patients with Medicaid and private insurance were admitted at disproportionately low rates relative to their number of ED visits. Hispanic/Latino and Asian/Pacific Islanders with private insurance, Hispanic/Latinos with Medicaid, and Asian/Pacific Islanders with Medicare were also admitted at low rates per capita within each respective payer category. Future studies should focus on addressing causal factors driving healthcare disparities in epilepsy, particularly for patients without adequate health insurance coverage and those who have been historically underserved by the healthcare system.

Effects of End-of-Life Communication Knowledge, Attitudes, and Perceived Behavioral Control on End-of-Life Communication Behaviors Among Nephrology Nurse Practitioners.

The scope of end-of-life communication is not well known among nephrology advanced practice nurses (APNs). Guided by the Theory of Planned Behavior, the study aimed to examine the independent effects of knowledge, attitude, and perceived behavioral control on the engagement of APNs in end-of-life communication and the mediating and moderating effects of attitude and perceived behavioral control on the relationships between knowledge and end-of-life communication. A theoretically derived 17-item survey measuring the concepts was administered to a convenience sample of 127 APNs. Descriptive statistics, Pearson's correlation, and multiple linear regression were employed. Attitudes and perceived behavioral control on end-of-life communication mediated and moderated the relationship between knowledge of end-of-life communication and engagement in end-of-life communication among nephrology APNs.

The effects of race and workplace racism on nurses' intent to leave the job: The mediating roles of job dissatisfaction and emotional distress.

BACKGROUND: There is scant evidence of quantifiable effects of workplace racism on nurses' job-related outcomes. PURPOSE: The study aimed to examine associations among race, workplace racism, emotional distress, job dissatisfaction, and intent to leave among hospital-based nurses. METHODS: This study used a correlational design with six measures in a statewide sample of 788 hospital-based nurses. FINDINGS: Non-White nurses intended to leave the job at a higher rate than White nurses. Non-White nurses reported negative racial climates, multiple racial microaggression experiences, and high job dissatisfaction and emotional distress. Non-white race and workplace racism had significant individual effects on intent to leave. Job dissatisfaction and emotional distress significantly mediated indirect effects of non-White race, negative racial climates, and racial microaggressions on nurses' intent to leave. DISCUSSION: In efforts to retain nurses of color in hospitals, there is an urgent need to mitigate workplace racism in these settings.

Functional Status and Engagement in Physical Activity Among Maintenance Dialysis Patients: A Mixed Methods Study.

Rationale & Objective: People receiving maintenance hemodialysis (HD) experience significant activity barriers but desire the ability to do more and remain independent. To learn about how to help people who require dialysis stay active, a mixed methods study was designed to assess functional status and explore participants' lived activity experiences. Study Design: A concurrent mixed methods design was chosen to increase understanding of the real-life activity experiences of people who require dialysis through in-depth interviews paired with functional status measures. The qualitative findings were fully integrated with the quantitative results to link characteristics associated with different physical activity levels. Setting & Participants: A purposive sample of 15 adult patients receiving maintenance HD for at least 3 months was recruited from 7 dialysis centers in Newark, New Jersey. Analytical Approach: Thematic analysis using principles of interpretive phenomenology. Fully integrated quantitative and qualitative data with joint displays and conversion mixed methods. Results: Participants had a median age of 58 years and were predominantly African American (83%) and men (67%). Three descriptive categories were generated about the participants. They described physical activity as a routine daily activity rather than structured exercise. All participants experienced substantial hardship in addition to chronic kidney disease and expressed that family, friends, and faith were essential to their ability to be active. An overarching theme was generated for participants' mindsets about physical activity. Within the mindset theme, we discerned 3 subthemes comprising characteristics of participants' mindsets by levels of engagement in physical activity. Limitations: While code saturation and trends in functional status measures were achieved with 15 participants, a larger sample size would allow for deeper meaning saturation and statistical inference. Conclusions: Patients receiving maintenance HD with an engaged mindset exhibited more adaptive coping skills, moved more, wanted to help others, and had a normal body weight habitus. These participants employed adaptive coping skills to carry out daily life activities of importance, highlighting the value of adaptive coping to help overcome the challenges of being physically active.

The Growing Demand for Home Dialysis Therapies: Challenges and Potential Solutions.

The End-Stage Renal Disease Treatment (ETC) Model, an aspect of the Advancing American Kidney Health Initiative implemented by the Centers for Medicare and Medicaid Services (CMS) in 2019, is designed to shift the predominant in-center hemodialysis dialysis model in the United States to a home dialysis model. This shift represents a monumental change in the treatment of end stage kidney failure and is occurring amid a strained nursing workforce. The CMS Conditions for Coverage for dialysis facilities mandate registered nurse responsibility for the conduct of patients' home dialysis training, and the current nursing shortage presents challenges because the need for nephrology nurses will increase to meet the growing demand for home dialysis during the ETC implementation period. As the ETC Model is implemented in randomly selected dialysis facilities across the United States, nephrology nurses must have leading roles as full partners with CMS and other stakeholders for the mutual determination of short- and long-term solutions for meeting the growing home dialysis training demands.

Effects of Race, Workplace Racism, and COVID Worry on the Emotional Well-Being of Hospital-Based Nurses: A Dual Pandemic.

Persons of color in the US experience the worst COVID-related outcomes and account for the majority of COVID-19 cases and hospitalizations among healthcare workers. In a pandemic where minority populations and healthcare workers are among the hardest hit, nurses of color are undoubtedly taxed. Moreover, their workplace racism experiences represent a dual pandemic in that the effects of COVID-19 worries and workplace racism may synergize to the detriment of their emotional well-being. The purpose of this study was to examine the direct, indirect, and interactive effects of individual (race, COVID worry), interpersonal (workplace racial microaggressions), and institutional (racial climate) factors on hospital-based nurses' emotional well-being. A sample of 788 registered nurses who worked in New Jersey hospitals completed an electronic survey. Compared to White nurses, nonwhite nurses reported higher emotional distress, more negative racial climates, more racial microaggressions, and higher levels of COVID worry. Nurses' worry about getting sick from COVID and multiple racial microaggression experiences had the largest effects on the likelihood of high emotional distress. Racism variables and worry about COVID mediated indirect effects of nonwhite race on emotional distress. Racial microaggressions mediated an indirect effect of racial climate on this outcome. Nurses who were worried about getting sick from COVID and experienced multiple microaggressions and/or the most negative racial climates had severe emotional distress. There is a need for sustained investment in a racially diverse nursing workforce. Mitigating workplace racism in hospitals is crucial, particularly during public health crises that disproportionately threaten minority populations and healthcare workers.

Mental Health and Health-Related Quality of Life Among Nephrology Nurses: A Survey-Based Cross-Sectional Study.

Nephrology nurses face health and wellness challenges due to significant work-related stressors. This survey, conducted online between July 24 and August 17, 2020, assessed the psychological well-being of nephrology nurses in the United States during the COVID-19 pandemic (n = 393). Respondents reported feeling burned out from work (62%), symptoms of anxiety (47% with Generalized Anxiety Disorder-7 [GAD-7] scores ≥ 5), and major depressive episodes (16% with Patient Health Questionnaire-2 [PHQ-2] scores ≥ 3). Fifty-six percent (56%) of survey respondents reported caring for COVID-19 patients, and 62% were somewhat or very worried about COVID-19. Factors, including high workload, age, race, and the COVID-19 pandemic, may partially explain the high proportion of nephrology nurses who reported symptoms of burnout, anxiety, and depression.

Timing of Home Health Care Initiation and 30-Day Rehospitalizations among Medicare Beneficiaries with Diabetes by Race and Ethnicity.

Older adults with diabetes are at elevated risk of complications following hospitalization. Home health care services mitigate the risk of adverse events and facilitate a safe transition home. In the United States, when home health care services are prescribed, federal guidelines require they begin within two days of hospital discharge. This study examined the association between timing of home health care initiation and 30-day rehospitalization outcomes in a cohort of 786,734 Medicare beneficiaries following a diabetes-related index hospitalization admission during 2015. Of these patients, 26.6% were discharged to home health care. To evaluate the association between timing of home health care initiation and 30-day rehospitalizations, multivariate logistic regression models including patient demographics, clinical and geographic variables, and neighborhood socioeconomic variables were used. Inverse probability-weighted propensity scores were incorporated into the analysis to account for potential confounding between the timing of home health care initiation and the outcome in the cohort. Compared to the patients who received home health care within the recommended first two days, the patients who received delayed services (3-7 days after discharge) had higher odds of rehospitalization (OR, 1.28; 95% CI, 1.25-1.32). Among the patients who received late services (8-14 days after discharge), the odds of rehospitalization were four times greater than among the patients receiving services within two days (OR, 4.12; 95% CI, 3.97-4.28). Timely initiation of home health care following diabetes-related hospitalizations is one strategy to improve outcomes.

Racial Disparities in Post-Acute Home Health Care Referral and Utilization among Older Adults with Diabetes.

Racial and ethnic disparities exist in diabetes prevalence, health services utilization, and outcomes including disabling and life-threatening complications among patients with diabetes. Home health care may especially benefit older adults with diabetes through individualized education, advocacy, care coordination, and psychosocial support for patients and their caregivers. The purpose of this study was to examine the association between race/ethnicity and hospital discharge to home health care and subsequent utilization of home health care among a cohort of adults (age 50 and older) who experienced a diabetes-related hospitalization. The study was limited to patients who were continuously enrolled in Medicare for at least 12 months and in the United States. The cohort (n = 786,758) was followed for 14 days after their diabetes-related index hospitalization, using linked Medicare administrative, claims, and assessment data (2014-2016). Multivariate logistic regression models included patient demographics, comorbidities, hospital length of stay, geographic region, neighborhood deprivation, and rural/urban setting. In fully adjusted models, hospital discharge to home health care was significantly less likely among Hispanic (OR 0.8, 95% CI 0.8-0.8) and American Indian (OR 0.8, CI 0.8-0.8) patients compared to White patients. Among those discharged to home health care, all non-white racial/ethnic minority patients were less likely to receive services within 14-days. Future efforts to reduce racial/ethnic disparities in post-acute care outcomes among patients with a diabetes-related hospitalization should include policies and practice guidelines that address structural racism and systemic barriers to accessing home health care services.

Hispanic Children Hospitalized With Acute Lymphoblastic Leukemia Are at Increased Risk of Pancreatitis.

BACKGROUND: There have been remarkable advances in overall survival following the diagnosis of acute lymphoblastic leukemia in childhood, but toxicities, including pancreatitis, remain a concern. Pancreatitis occurs early in therapy, before extensive exposure to the chemotherapy agents associated with its development, indicating there are underlying risk factors for some children. The role of race/ethnicity in treatment-related pancreatitis has not been well established. OBJECTIVE: The aim of this study was to examine the relationship between race/ethnicity and pancreatitis in children hospitalized with acute lymphoblastic leukemia in the United States in 2016. METHODS: This was an analysis of a nationally representative database of pediatric hospitalizations. The sample consisted of 21 775 records with documentation of the diagnosis of acute lymphoblastic leukemia. Statistical methods included descriptive statistics, bivariate analyses using the χ2 test, and multilevel logistic regression models. RESULTS: Pancreatitis was documented in 1.6% of hospital discharges. Compared with white children, Hispanic children were at increased risk of pancreatitis during hospitalization (P = .002). There were no differences among black (P = .469), Asian (P = .364), or other-race children (P = .937). CONCLUSIONS: Hispanic children hospitalized with acute lymphoblastic leukemia are at greater risk of pancreatitis than white children. Reasons for this disparity are likely due to both genetic and social factors. IMPLICATIONS FOR PRACTICE: Nurses must be active participants in the research process with the goal of enrolling patients with diverse backgrounds in clinical trials. Inclusive research will provide increased understanding of a holistic toxicity risk profile.

Using ICD-10 codes to identify elective epilepsy monitoring unit admissions from administrative billing data: A validation study.

Video-electroencephalogram (EEG) monitoring in the epilepsy monitoring unit (EMU) is essential for managing epilepsy and seizure mimics. Evaluation of care in the EMU would benefit from a validated code set capable of identifying EMU admissions from administrative databases comprised of large, diverse cohorts. We assessed the ability of code-based queries to parse EMU admissions from administrative billing records in a large academic medical center over a four-year period, 2016-2019. We applied prespecified queries for admissions coded as follows: 1) elective, 2) receiving video-EEG monitoring, and 3) including diagnoses typically required by major US healthcare payers for EMU admission. Sensitivity (Sn), specificity (Sp), and predictive value positive/negative (PVP, PVN) were determined. Two approaches were highly effective. Incorporating epilepsy, seizure, or seizure mimic codes as the admitting diagnosis (assigned at admission; Sn 96.3%, Sp 100.0%, PVP 98.3%, and PVN 100.0%) or the principal diagnosis (assigned after discharge; Sn 94.9%, Sp 100.0%, PVP 98.8%, and PVN 100.0%) identified elective adult EMU admissions with comparable reliability (p = 0.096). The addition of surgical procedure codes further separated EMU admissions for intracranial EEG monitoring. When applied to larger, more comprehensive datasets, these code-based queries should enhance our understanding of EMU utilization and access to care on a scalable basis.

Increased Risk of Severe Sepsis in Hispanic Children Hospitalized With Acute Myeloid Leukemia.

The purpose of this study, a secondary analysis of a publicly available database, was to identify racial and ethnic disparities in the risk of severe sepsis facing children undergoing the intensive therapy necessary to treat acute myeloid leukemia (AML). The sample consisted of 1,913 hospitalizations of children, younger than 21 years, in the United States during the year 2016 with documentation of both AML and at least one infectious complication. Binary logistic regression models were used to examine the association between race/ethnicity and severe sepsis in children with AML and infection. We found that, after controlling for potential confounding variables, the odds of developing severe sepsis were significantly increased for Hispanic children compared with White children. There were no significant differences in the likelihood of the development of sepsis in Black, Asian, or other race children. The increased risk of severe sepsis for Hispanic children may contribute to the disparate rates of overall survival in this group. This inequitable rate of severe sepsis was evident despite the generally accepted practice of retaining children in the hospital throughout recovery of blood counts following AML therapy. Nurses are in a position to identify and eliminate modifiable risk factors contributing to this disparity.

Registered Nurse Staffing, Workload, and Nursing Care Left Undone, and Their Relationships to Patient Safety in Hemodialysis Units.

Patient safety is an important foundation of high-quality care. Yet little is known regarding the effects of nursing indicators on patient safety in dialysis units. The purpose of this study was to examine interrelationships among registered nurse (RN) staffing, workload, nursing care left undone, and patient safety outcomes in hemodialysis settings. The sample consisted of 104 staff nurses who worked in hemodialysis facilities and completed a mailed survey. Low RN staffing, high RN workloads, and RN nursing care left undone were significantly associated with unsafe patient shift change periods and low safety ratings. Care left undone was an indirect pathway through which low RN staffing and high workloads impacted safety. Patient safety in hemodialysis units can be enhanced by ensuring adequate RN staffing and reasonable RN workloads, as well as redesigning responsibilities so RNs can complete necessary care activities.

The Perfect Storm: Stakeholder Perspectives on Factors Contributing to Hospital Admissions for Patients Undergoing Maintenance Hemodialysis.

Patients living with end stage renal disease (ESRD) who are undergoing hemodialysis experience frequent hospitalizations associated with complications of care and exacerbations of illness. Efforts to reduce hospitalizations have had limited success. The purpose of this study was to explore why hospitalizations occur from the perspectives of patients undergoing hemodialysis treatment, their caregivers, and health care providers. Semi-structured interviews and focus groups were conducted with 21 patients living with ESRD, 10 caregivers, and three focus groups with health care professionals. Findings are discussed under four main themes: Graft site/Catheter/Access issues, "My resistance is low," "I could not breathe,"" and "The perfect storm." Results highlight the complexity of care and vulnerability of patients with ESRD. Further interprofessional research is needed to improve transitional care and care delivery for patient populations receiving hemodialysis.

Effects of a transtheoretical model-based WeChat health education programme on self-management among haemodialysis patients: A longitudinal experimental intervention study.

AIM: To examine the effects of a transtheoretical model-based WeChat health education programme on self-management in haemodialysis patients in China. DESIGN: A longitudinal experimental intervention study. METHODS: Patients (N = 120) who underwent haemodialysis from December 2015-November 2017 were recruited and randomly allocated to either group 1 (who received a 3-month WeChat health education immediately after randomization) or group 2 (who was combined with group 1 and received the same intervention at the 5th month after enrolment in the study). Self-management, knowledge and self-efficacy were assessed at baseline (T0 ), 3 months after enrolment in the study (T1 ), 21 months after enrolment in the study (T2 ). RESULTS: There were significant group effects on self-efficacy; time effects on partnership, self-care, emotion management with total self-management; interaction effects on problem-solving and emotion management within total self-management according to the two-way repeated measures ANCOVA. Further between-group comparisons indicated that patients in group 1 had better self-management than those in group 2 at T1 . Within-group comparisons demonstrated that, compared with the baseline values, group 1 had significantly improved self-management at T1 ; however, group 2 had improved self-management at T2 . CONCLUSION: The transtheoretical model-based WeChat health education programme had a potentially positive effect on improving the self-management of haemodialysis patients. IMPACT: Self-management is often difficult yet crucial for haemodialysis patients. This study indicated that the transtheoretical model-based WeChat health education resulted in improved self-management in haemodialysis patients and can be implemented in continuing care during the interdialysis period to improve self-management in patients. TRIAL REGISTRATION: ChiCTR1800018172.

Associations among race, residential segregation, community income, and emergency department use by adults with end-stage renal disease.

OBJECTIVE: The purpose of this study was to examine independent and interactive effects of race, community income, and racial residential segregation on the likelihood of ED revisits by persons with end-stage renal disease (ESRD). DESIGN: A retrospective analysis of de-identified data abstracted from Health Care Utilization and Cost Project's (HCUP) 2014 New Jersey State Emergency Department (ED) Database and American Community Survey (ACS) was conducted. SAMPLE: The analytic sample was comprised of 2,859 ED encounters in 2014 by non-Hispanic Black and White persons over 18 years of age with ESRD who were treated and released from the ED. MEASUREMENTS: The HCUP database was the data source for ED revisit, race, median community income, and covariate (age, gender, marital status, number of chronic conditions) variables in the study. The 2014 ACS was the source for racial segregation Dissimilarity Index scores across NJ counties. RESULTS: Living in communities with lower median income and high racial segregation was associated with a higher likelihood of ED revisits. Black race interacted with community income and racial segregation in its effect on ED revisits. CONCLUSION: Efforts are needed to direct geo-targeted interventions and resources to socially disadvantaged communities to lessen disparities in ED visits among dialysis patients.

Emphasizing the Value of Nephrology Nursing Through Nursing-Sensitive Indicators: A Call for Action.

Nursing is the largest healthcare profession in the United States (U.S.). As principal frontline caregivers in the U.S. healthcare system, nurses have tremendous influence over a patient's healthcare experience. A growing body of evidence states that the nursing workforce has a direct impact on healthcare quality. A standardized approach to measuring nursing's contribution to patient care and safety using nursing-sensitive quality indicators assists in examining the extent to which nurses and nursing affect the quality and safety of health care. This article focuses on nursing-sensitive quality indicators and discusses healthcare quality indicators and nursing-sensitive indicators used in the U.S. A summary of the work of the American Nephrology Nurses' Association Task Force on Nephrology Nursing-Sensitive Quality Indicators (NNSQI) and an NNSQI exemplar are provided.