Student Reflections on Learning in a Doctoral-Level Writing Course.

BACKGROUND: Programs to improve student writing have been deployed widely in nursing graduate education, but few operational indicators exist for measuring their value. PROBLEM: The challenge of measuring outcomes reflects the complexity of what transpires when graduate students write. Better understanding is needed of what it means to students to "learn" from writing support. APPROACH: A full-semester writing course was implemented in a nursing science PhD program. In formative course assessment activities, students identified problems in early drafts of their work, which they subsequently learned to detect and resolve. In this article, students report what was learned. CONCLUSION: Writing skills, like clinical skills, are intertwined with intellectual maturation and sense of professional identity. Writing, like clinical learning, requires an investment of time and labor far beyond what is typical in didactic approaches to classroom-based graduate education. Our experience suggests a need to reconceptualize writing pedagogy in nursing.

Design and Implementation of a New Orientation Program Based on Core Competencies and a Clinical Mentor Model.

A large pediatric hospital redesigned the traditional task-based orientation program to one based on the Synergy Model for Patient Care nurse competencies, enhanced identification of learning needs, critical thinking exercises, and use of experienced staff in the role of clinical mentor. Development of a role to coordinate the learning experiences of the new hire was essential to creation of a model built upon the framework of the core competencies needed to care for a unit's population of patients.

What is "determinant" in the social determinants of health? A case seen through multiple lenses.

Social determinants of health are a subject of growing interest, yet criticisms have emerged about the way determinants are conceptualized in nursing. A tendency to focus on readily observable living conditions and measurable demographic characteristics can divert attention, it has been said, from the less visible underlying processes which shape social life and health. To illustrate how the analytic perspective determines what becomes visible or invisible as a "determinant" in health, this paper presents a case exemplar. Drawing from news reports and research in real estate economics and urban policy analysis, it explores a single local infectious illness outbreak through a series of progressively more abstract units of inquiry, considering mechanisms of lending and debt financing, housing supply, property valuation, tax policy, change in the structure of the financial industry, and international patterns of migration and capital flow, among other factors, which contributed in various ways to creating unsafe living conditions. An analytic exercise calling attention to dynamism and complexity in social processes, the paper offers a political-economy-based approach that serves as a cautionary note against oversimplification in discussions of health causality.

Children's falls inside the inpatient setting: A qualitative study of parent perceptions and the implications for falls prevention messaging.

PURPOSE: To explore how parents understand their children's falls during hospitalization and how they perceive hospital interventions and messaging related to fall risk and prevention. DESIGN AND METHODS: Semi-structured interviews were conducted to explore parent-caregiver descriptions of their children's falls during hospitalization. Prospective purposive sampling was used to identify eligible participants. Interviews were conducted with the parent-caregiver who was present at the time of the fall event. Themes were coded both inductively and deductively using a constant comparative method. RESULTS: Twelve parent-child groupings participated. Three themes emerged: parental knowledge of risk, parent sense of threat to the identity of the child, and age differences in perception of level of controllability of risk. CONCLUSIONS: Falls prevention education is usually delivered as a straightforward presentation of generic factual information about risk factors, with the assumption that families need more information. Findings from this study challenge this approach. This study indicates that parent-caregivers have fairly high levels of knowledge about children's fall risks; parent-caregiver beliefs about the controllability of falls may differ based on age of the child; finally, as has been found in previous studies of adult falls, parent-caregivers may perceive hospital falls prevention measures as a source of potential threat to their child''s already vulnerable social identity. PRACTICE IMPLICATIONS: Involving the parent-caregiver in the fall risk assessment and collaborative development of falls prevention interventions may increase family alliance with health advice and reduce the incidence of falls in hospitalized children.

Experiences of U.S. Nurses Compared With Nonnurses in the First Year of COVID-19: Findings From a National Registry.

BACKGROUND: Nursing professional organizations and media sources indicated early in the pandemic that the physical and psychological effects of COVID-19 might be distinct and possibly greater in nurses than in other types of healthcare workers (HCWs). OBJECTIVES: Based on survey data collected in Healthcare Worker Exposure Response and Outcomes (HERO), a national registry of U.S. HCWs, this study compared the self-reported experiences of nurses with other HCWs during the first 13 months of the pandemic. METHODS: Nurse responses were compared to responses of nonnurse HCWs in terms of viral exposure, testing and infection, access to personal protective equipment (PPE), burnout, and well-being. Logistic regression models were used to examine associations between nurse and nonnurse roles for the binary end points of viral testing and test positivity for COVID-19. We also examined differences by race/ethnicity and high-risk versus low-risk practice settings. RESULTS: Of 24,343 HCWs in the registry, one third self-identified as nurses. Nurses were more likely than other HCWs to report exposure to SARS-CoV-2, problems accessing PPE, and decreased personal well-being, including burnout, feeling tired, stress, trouble sleeping, and worry. In adjusted models, nurses were more likely than nonnurse HCWs to report viral testing and test positivity for COVID-19 infection. Nurses in high-risk settings were more likely to report viral exposure and symptoms related to well-being; nurses in low-risk settings were more likely to report viral testing and test positivity. Black or Hispanic nurses were most likely to report test positivity. DISCUSSION: Differences were identified between nurses and nonnurse HCWs in access to PPE, physical and mental well-being measures, and likelihood of reporting exposure and infection. Among nurses, testing and infection differed based on race and ethnicity, and type of work setting. Our findings suggest further research and policy are needed to elucidate and address social and occupational disparities.

A Quality Improvement Initiative to Provide Timely Central Vascular Access in a Neonatal Intensive Care Unit.

BACKGROUND: Timely central venous access is essential in the care of critically ill neonates. Peripherally inserted central catheters (PICCs) are the preferred form of central venous access when umbilical venous catheters cannot be placed or are discontinued. However, time delays increase risk for injury from peripheral intravenous lines and may contribute to inconsistent delivery of necessary fluids and medications. PURPOSE: The aim of this quality improvement project was to decrease wait times for PICC placement in the neonatal intensive care unit (NICU). METHODS: A unit-based PICC team was developed consisting of NICU nurses and attending neonatologists and implemented in 2 phases. Data were collected from chart reviews before, during, and after implementation of the team. We tracked time between PICC order and placement and number of attempts. Hospital metrics on peripheral intravenous line infiltrations and central line-associated blood stream infection were also monitored. At the end of the project, we continued tracking outcomes to determine whether gains would be sustained past the project period. RESULTS: Implementation of a unit-based interdisciplinary specialty team led to a 50% reduction in mean PICC wait times from 1.2 days to 0.58 days. Benefits of the initiative were sustained past the initial project period. IMPLICATIONS FOR PRACTICE: The development of a dedicated, local team played a key role in improving vascular access in the NICU. IMPLICATIONS FOR RESEARCH: Proximity of specialized teams provides a solution to address gaps in care in the NICU.

Examining clinical training through a bicultural lens: Experiences of genetic counseling students who identify with a racial or ethnic minority group.

Biculturals are individuals who have had significant exposure to more than one culture and who possess more than one cultural frame of reference. In the United States, this term has been used to describe both immigrants and members of racial or ethnic minority groups who live within the majority white culture. Biculturals develop a distinct repertoire of social and cognitive skills and have been shown to engage in a process of cultural frame switching in response to salient cultural cues. Through a conceptual lens offered by current research on biculturalism, this article examines transcripts of focus groups we collected for a study on the clinical training experiences of genetic counseling students who identify with a racial or ethnic minority group. We conducted a constructivist grounded theory study, collecting data via 13 videoconference focus groups with 32 recent graduates of genetic counseling training programs who identify with a racial or ethnic minority group. We focus here on two of the thematic categories identified in that study related to participants' experiences interacting with patients during supervised clinical rotations. We find three ways in which being bicultural influenced these genetic counselors' patient interactions. First, participants described interactions with both culturally concordant and culturally discordant patients that highlighted the salience of their racial, ethnic, or cultural identity in these encounters. Second, they reported sensitivity to social nuances between and within cultures, reflecting the findings of prior research about heightened cultural awareness in biculturals. Third, they described switching cultural frames in response to their patients' identities which, at times, created conflict between their professional and culturally concordant frameworks. The results of this study suggest that the influence of a student's racial, ethnic, or cultural identity on interactions with patients should be discussed within the supervisory relationship, and that being bicultural confers advantages in learning to provide culturally responsive care.

Supporting a sense of inclusion and belonging for genetic counseling students who identify as racial or ethnic minorities.

Racial and ethnic minority graduate students in a variety of academic and professional disciplines have been reported to experience microaggressions and feelings of isolation during the course of their training. The purpose of this constructivist grounded theory study was to characterize the training experiences of genetic counseling students who identify as racial or ethnic minorities. The goal of enhancing racial and ethnic diversity has been discussed for decades within the genetic counseling profession, but the actual training experience of underrepresented minorities has yet to be fully explored. We conducted 13 videoconference focus groups with 32 recent graduates of genetic counseling training programs who identify as racial or ethnic minorities. This paper presents results from three of the thematic categories identified in that larger study: Participants' interactions with classmates, Sense of belonging in the GC profession, and Available or desired supports. Participants reported experiencing negative interactions within their training program, during supervised clinical rotations, and at professional events; negative interactions included comments suggesting they did not belong in the United States, being confused with another non-white classmate, and intrusive questions or assumptions about their family, culture, or religion that were not similarly directed at white classmates. Trainees who were Muslim or Black/African American reported feeling particularly isolated by these incidents. Participants reported that they sought support from a variety of sources following negative experiences. Non-minority program faculty were perceived as able to offer listening or action but not understanding or guidance, which were perceived as more likely to be available from individuals who identify as racial or ethnic minorities. Results of this exploratory study suggest the need for training programs to ensure that appropriate supports are available to minority students, including diverse faculty and staff and non-program resources.

Nature-based Group Therapy Reflections: A Grounded Theory Study.

Nature-based therapies have a long history in mental health care. Beneficial effects have been documented for nature-based therapies in a variety of other health care settings. The aims of this grounded theory study were to understand the processes of maintaining nature-based therapeutic groups and the value of the activities to patients in a psychiatric inpatient setting. Over a nine-month period, semi-structured surveys of patient responses to nature-based activities were administered to patients in a pilot therapy group assessing the feasibility of a nature-based group program. Findings indicated that the group promoted use of the senses, social interaction, and care of self/others. Perceptions of benefits led to a nuanced understanding of the effects of being in contact with nature. Based on our findings we offer a preliminary theoretical model for patient engagement with nature-based programming in inpatient mental health care.

Conscripted curriculum: The experiences of minority genetic counseling students.

While the lack of racial and ethnic diversity in the genetic counseling profession has been discussed for decades, little attention has been paid to the training experiences of under-represented minorities. Under-represented minority graduate students in other disciplines have been reported to experience microaggressions and feelings of isolation during training, and they are often informally enlisted to educate classmates about issues related to race. In 2019, sociologist Lauren Olsen coined the term conscripted curriculum to describe the utilization of minority medical students to elucidate issues of race or ethnicity for their classmates. The conscripted curriculum arises when these topics are taught in a small-group discussion format that relies on students sharing their individual experiences to educate their classmates. In classrooms with limited diversity, the expectation to contribute falls disproportionately on students from non-majority groups. In this qualitative study, we conducted videoconference focus groups with 32 recent graduates of genetic counseling training programs who identified as racial or ethnic minorities. We present the results of two thematic categories that emerged from that study: the participants' perspectives on the cultural competency curriculum in their training programs and the participants' feelings of being pressed into service as spokespeople for their cultural groups. Participants described the cultural competency training as occurring primarily in a small-group discussion format in which students were expected to share their personal experiences. During these discussions, minority students, especially those in less-diverse class cohorts, felt obliged to contribute their perspectives in order to educate non-minority classmates about issues of race and ethnicity, leading to feelings of frustration and exhaustion. The results reflect a conscripted curriculum as described by Olsen (2019). Journal of Health and Social Behavior, 60(1), 55-68, in which minority students bear the burden of educating their classmates about the social basis of race. Genetic counseling training programs should critically examine their cultural competency curriculum to create a more equitable training environment.

Confronting the Social Determinants of Health: Has the Language of Trauma Informed Care Become a Defense Mechanism?

Many writers have been calling for the incorporation of trauma-informed care (TIC) in nursing education and practice, with some recently advocating the adoption of formal TIC competencies in psychiatric nursing. In light of this heightened interest, it is worth engaging seriously with criticisms of TIC. This paper reviews some of the published criticisms of TIC, starting with those emerging from within the TIC scholarly community. These focus mostly on matters of methodological rigor and conceptual clarity. It then presents critiques that emerge through the lenses of feminism, cultural sociology, and psychoanalysis. These focus on the shift away from political and historical consciousness in some TIC language and call attention to discursive mechanisms that split off our concern for patients from concern about ongoing social determinants of trauma in the world. The paper then addresses the implications for TIC in nursing, advocating a social justice orientation to the teaching of trauma.

Moving Beyond the Behavior-Change Framework for Smoking Cessation: Lessons for a Critical Ontology From the Case of Inpatient Psychiatric Units.

BACKGROUND: Leading scholars have called on nursing schools to pay more attention to smoking cessation in the education of nursing students. AIM: This article argues that attention to this subject should include a rethinking of the behavior-change framework that forms the methodological basis of this field. METHOD: Drawing on classic and contemporary work in sociology, anthropology, and critical public health, this article explores the specific example of smoking in long-term inpatient units to illustrate the limitations of a behavior-based ontology and suggest an alternative conceptual vocabulary. RESULTS: An alternative approach posits smoking as a social practice. It sheds light on situational factors that incentivize smoking and might be contributing to patient resistance to cessation. CONCLUSIONS: A different conceptual framing of smoking can point to interventions beyond the level of individuals, focusing instead on the broader interface between people and situations, where decisions and desires meet institutional and organizational dynamics and structures of opportunity and access.

Facilitating a Major Staffing Transition in a State Psychiatric Hospital With Changes to Nursing Orientation.

BACKGROUND: A large state psychiatric hospital experienced a state-mandated Reduction in Force that resulted in the abrupt loss and rapid turnover of more than 40% of its nursing and paraprofessional staff. The change exemplified current national trends toward downsizing and facility closure. OBJECTIVE: This article describes revisions to the nursing orientation program that supported cost containment and fidelity to mission and clinical practices during the transition. DESIGN: An existing nursing orientation program was reconfigured in alignment with principles of rational instructional design and a core-competencies model of curriculum development, evidence-based practices that provided tactical clarity and commonality of purpose during a complex and emotionally charged transition period. RESULTS: Program redesign enabled efficiencies that facilitated the transition, with no evidence of associated negative effects. CONCLUSION: The process described here offers an example for hospitals facing similar workforce reorganization in an era of public sector downsizing.

Therapeutic doll play in the treatment of a severely impaired psychiatric inpatient: dramatic clinical improvements with a nontraditional nursing intervention.

Interest has grown in the use of doll therapy, particularly in geropsychiatric and dementia care settings. In a long-term state psychiatric hospital, a dollhouse-play activity was implemented in an effort to engage an acutely disturbed, middle-aged woman undergoing medication trials and whose symptoms had been refractory to conventional treatments. A schedule of nondirective dollhouse-play activities was implemented over an 8-week period. Measures of behavioral change were tracked. Dramatic clinical improvements were seen, including significant reductions in verbal and physical aggression, use of as-needed medications, and need for close one-to-one monitoring. Improvements were seen prior to achievement of therapeutic drug levels. The patient was successfully discharged from the hospital. Doll play has recently been associated with clinical benefits in the care of patients with dementia and has long been deployed in childhood mental health treatment. The current findings suggest doll play may have applications as a time-limited intervention in the treatment of major psychiatric disorders in adults and warrants consideration when achieving therapeutic alliance has proven particularly challenging.

Using structured clinical feedback to encourage alternatives to use of "P.R.N." medication in a state psychiatric hospital.

OBJECTIVE: The study examined whether reductions in the use of pro re nata (p.r.n.) psychotropic medications could be achieved in a large public-sector psychiatric hospital, without adverse behavioral consequences, by disseminating a database that tracks p.r.n. use to clinical teams. METHODS: A performance improvement project was implemented over 28 months, involving all 166 patients in one section of a state psychiatric hospital. A spread- sheet tracking p.r.n. administration for each patient was provided weekly to unit treatment teams. Clinical outcome monitoring focused on the number of p.r.n. administrations and on p.r.n. "events," defined as ≥ 3 multiple administrations per week and ≥ 10 per month. Episodes of patient seclusion, restraint, and violent incidents were also monitored. RESULTS: From September 2008 to December 2010, with a stable patient population census, total monthly administrations of psychotropic p.r.n. medications decreased from 642 to 240; administrations of non-psychotropic "medical" p.r.n. agents also decreased, from 279 to 72. In year-by-year comparisons, significant decreases (P < 0.05) were observed in the total number of psychotropic and medical p.r.n. administrations, in weekly as well as monthly p.r.n. events, and in the number of patients receiving any p.r.n. administrations. There was no change from 2008 to 2010 in the number of violent incidents; the use of both seclusion and restraint decreased (P < 0.05). CONCLUSION: The findings suggest that p.r.n. use can be reduced safely through timely feedback of relevant clinical data.