Managing the tension between caring and charting: Labor and delivery nurses' experiences of the electronic health record.

Over a decade following the nationwide push to implement electronic health records (EHRs), the focus has shifted to addressing the cognitive burden associated with their use. Most research and discourse about the EHR's impact on clinicians' cognitive work has focused on physicians rather than on nursing-specific issues. Labor and delivery nurses may encounter unique challenges when using EHRs because they also interact with an electronic fetal monitoring system, continuously managing and synthesizing both maternal and fetal data. This grounded theory study explored labor and delivery nurses' perceptions of the EHR's impact on their cognitive work. Data were individual interviews and participant observations with twenty-one nurses from two labor and delivery units in the western U.S. and were analyzed using dimensional analysis. Nurses managed the tension between caring and charting using various strategies to integrate the EHR into their dynamic, high-acuity, specialty practice environment while using EHRs that were not designed for perinatal patients. Use of the EHR and associated technologies disrupted nurses' ability to locate and synthesize information, maintain an overview of the patient's status, and connect with patients and families. Individual-, group-, and environmental-level factors facilitated or constrained nurses' integration of the EHR. These findings represent critical safety failures requiring comprehensive changes to EHR designs and better processes for responding to end-user experiences. More research is needed to develop EHRs that support the dynamic and relationship-based nature of nurses' work and to align with specialty practice environments.

Biculturalism in couple support for diabetes care in U.S.-born Chinese Americans.

Support in couples living with type 2 diabetes is associated with better health outcomes but support provision in collectivistic cultures has received limited research attention. To address this gap, we focused on couple dynamics and support in type 2 diabetes in U.S.-born Chinese Americans. Acculturation processes, particularly biculturalism, that is, the capacity to enact habits and practices from both the heritage and U.S. mainstream culture, were explored. Employing interpretive phenomenological methods, we conducted multiple narrative interviews with each of 15 couples regarding illness challenges and couple responses. Interviews were conducted in varied contexts, including with the couple, and in group interviews with people with diabetes or spouses. The unit of analysis was the couple, and narrative themes within the text were explored within the context of holistic couple summaries. We identified three key aspects of couple support: (i) Assisting with the diabetes treatment regimen; (ii) Moderating social and contextual factors that impede diabetes care; and (iii) Providing relational care and empathy for living with this challenging chronic condition. Support reflecting cultural maintenance of Chinese beliefs and practices include other directedness, family centeredness, and concerns for harmony and balance. Bicultural support patterns were also apparent in spousal communication that was both indirect and direct, and relationships marked by both interdependence and respect for independence or autonomy, reflecting both Chinese and U.S. cultural orientations, respectively. Working clinically with second and third generation Chinese immigrants requires clinical assessment of and responsiveness to couples' acculturation levels and bicultural skills.

Women's experiences when unsure about whether or not to have an abortion in the first trimester.

Abortion during the first trimester is legal in most Western countries. However, deciding to terminate a pregnancy is a challenging process, and some women arrive at the abortion clinic still not absolutely certain. We explored the experiences of 13 pregnant Norwegian women struggling to finalize their decision, interviewing them before and after their decision. Verification of the pregnancy meant a new reality for the women. They started to consider their readiness, describing the experience as a lonely journey during which their values were challenged. A feeling of existential loneliness dominated the decision-making process and the implementation.

System-Level Barriers and Facilitators for Foregoing or Withdrawing Dialysis: A Qualitative Study of Nephrologists in the United States and England.

BACKGROUND: Despite a growing body of literature suggesting that dialysis does not confer morbidity or mortality benefits for all patients with chronic kidney failure, the initiation and continuation of dialysis therapy in patients with poor prognosis is commonplace. Our goal was to elicit nephrologists' perspectives on factors that affect decision making regarding end-stage renal disease. STUDY DESIGN: Semistructured, individual, qualitative interviews. METHODOLOGY: Participants were purposively sampled based on age, race, sex, geographic location, and practice type. Each was asked about his or her perspectives and experiences related to foregoing and withdrawing dialysis therapy. ANALYTICAL APPROACH: Interviews were audiotaped, transcribed, and analyzed using narrative and thematic analysis. RESULTS: We conducted 59 semistructured interviews with nephrologists from the United States (n=41) and England (n=18). Most participants were 45 years or younger, men, and white. Average time since completing nephrology training was 14.2±11.6 (SD) years. Identified system-level facilitators and barriers for foregoing and withdrawing dialysis therapy stemmed from national and institutional policies and structural factors, how providers practice medicine (the culture of medicine), and beliefs and behaviors of the public (societal culture). In both countries, the predominant barriers described included lack of training in end-of-life conversations and expectations for aggressive care among non-nephrologists and the general public. Primary differences included financial incentives to dialyze in the United States and widespread outpatient conservative management programs in England. LIMITATIONS: Participants' views may not fully capture those of all American or English nephrologists. CONCLUSIONS: Nephrologists in the United States and England identified several system-level factors that both facilitated and interfered with decision making around foregoing and withdrawing dialysis therapy. Efforts to expand facilitators while reducing barriers could lead to care practices more in keeping with patient prognosis.

Understanding barriers to medication, dietary, and lifestyle treatments prescribed in polycystic kidney disease.

BACKGROUND: Autosomal dominant polycystic kidney disease (PKD) is the most common genetic renal disease and the fourth leading cause of end-stage renal disease in the United States. Although there is no cure for PKD, several treatments are considered to be beneficial, including blood pressure control, exercise, low-salt diet, and high volume water intake. However, levels of understanding of the importance of these treatments and adherence to these recommendations vary among patients. This study explores illness perception models of patients with PKD to reveal barriers in adherence to prescribed therapies; satisfaction with medical care; and sources of medical information. METHODS: We designed a phenomenological interview study to evaluate illness perception models of individuals with PKD. Patients were identified from the national PKD Foundation e-mail distribution list (N = 190) and responded voluntarily to an introductory survey (N = 50). Seventeen PKD patients in the Bay Area were scheduled for one-on-one in-depth interviews with one trained interviewer (W-CT). Open-ended questions administered with an interview guide were used to evaluate patients' beliefs. RESULTS: Mean age was 56.6 +/- 12 years (range 29-78); 65% were female. Many of the PKD patients in this study were highly motivated and willing to incorporate blood pressure, exercise, low-salt diet, and high volume water intake into their daily routines. Barriers to adherence to these therapies include personal beliefs and confusion due to unclear recommendations. CONCLUSIONS: These findings suggest there is variability between what patients understand about their disease and treatments and what they believe their doctors have told them. Not all physicians focus on lifestyle-based treatments, but the majority of PKD patients in our study are motivated and willing to incorporate blood pressure control, exercise, low-salt diet, and high volume water intake into their daily routines and would like specific recommendations on how to implement these. These findings support a role for further exploring patient beliefs about the disease and its necessary treatments in order to design strategies to improve communication and meet the needs of these patients.

"I don't have to explain, people understand": Acceptability and Cultural Relevance of a Mobile Health Lifestyle Intervention for Filipinos with Type 2 Diabetes.

BACKGROUND: Filipino Americans have the highest risk for obesity-related type 2 diabetes and related complications compared with all major Asian American subgroups. Identifying effective interventions to improve Filipino health outcomes are needed to reduce this health disparity. OBJECTIVE: To assess the acceptability and cultural relevance of the PilAm Go4Health program - a culturally adapted mobile health weight-loss lifestyle intervention including virtual social networking for Filipino Americans with type 2 diabetes. DESIGN SETTING PARTICIPANTS: Qualitative semi-structured post-program interviews explored perceptions of 45 Filipino Americans with type 2 diabetes in Northern California regarding their perceptions of the acceptability and cultural relevance of PilAm Go4Health. Participants' mean age was 57.6 years. Sixty-seven interviews were recorded, transcribed, and thematically analyzed by four independent coders. RESULTS: Over half (n=26, 57.8%) of the respondents found that a culturally tailored intervention program enhanced their engagement. All (n=45) of the respondents felt that mobile health technology promoted their self-efficacy. A majority of the respondents (n=29, 64.4%) expressed that they progressed from despair to self-efficacy as a result of their participation in the intervention. More than one-fourth of the participants (n=13, 28.8%) discussed that the intervention needed further cultural tailoring. CONCLUSIONS: Overall, PilAm Go4Health - a mobile health weight-loss lifestyle intervention - was acceptable and culturally relevant for Filipino Americans with type 2 diabetes. Findings may help inform clinician and researchers on effective intervention strategies for diabetes self-management when designing interventions for diverse populations.

Acculturation and bicultural efficacy effects on Chinese American immigrants' diabetes and health management.

The primary goal of this study was to examine effects of bicultural efficacy, or perceived confidence in dealing with bicultural acculturation stressors, on type 2 diabetes management and health for first-generation, Cantonese-speaking, Chinese American immigrants (N = 162) recruited for a larger community-based diabetes intervention study (Chesla et al. in Res Nurs Health 36(4):359-372, 2013. doi: 10.1002/nur.21543 ). The current study also tested whether a new Bicultural Efficacy in Health Management (BEFF-HM) scale is a more robust predictor of diabetes and health outcomes than proxy (years in the U.S.) and general acculturation measures. Hierarchical regression analyses of cross-sectional data revealed that high BEFF-HM was significantly related to positive outcomes on five of six diabetes and health measures as hypothesized after accounting for participant characteristics, proxy and general acculturation measures, and social support. Proxy and general acculturation measures failed to predict any study outcome supporting our secondary hypothesis that BEFF-HM is a better predictor of Chinese American immigrants' diabetes and health management. An immigrant-focused research approach advances understanding of acculturation and bicultural efficacy effects on health by identifying key acculturation domains for study.

Assessing the cultural in culturally sensitive printed patient-education materials for Chinese Americans with type 2 diabetes.

Type 2 diabetes affects Chinese Americans at an alarming rate. To address this health disparity, research in the area of cultural sensitivity and health literacy provides useful guidelines for creating culturally appropriate health education. In this article, we use discourse analysis to examine a group of locally available, Chinese- and English-language diabetes print documents from a surface level and deep structure level of culture. First, we compared these documents to research findings about printed health information to determine whether and how these documents apply current best practices for health literacy and culturally appropriate health communication. Second, we examined how diabetes as a disease and diabetes management is being constructed. The printed materials addressed surface level culture through the use of Chinese language, pictures, foods, and exercises. From a deeper cultural level, the materials constructed diabetes management as a matter of measurement and control that contrasted with previous research suggesting an alternative construction of balance. A nuanced assessment of both surface and deeper levels of culture is essential for creating health education materials that are more culturally appropriate and can lead to increased health literacy and improved health outcomes.

Weaving dreamcatchers: mothering among American Indian women who were teen mothers.

AIMS: The aim of this study was to explore the mothering experience and practice among reservation-based adult American Indian women who had been adolescent mothers. BACKGROUND: Adolescent American Indian women are at an elevated risk for teen pregnancy and poor maternal/child outcomes. Identifying mothering practices among this population may help guide intervention development that will improve health outcomes. DESIGN: A collaborative orientation to community-based participatory research approach. METHODS: Employing interpretive phenomenology, 30 adult American Indian women who resided on a Northwestern reservation were recruited. In-depth, face-to-face and telephone interviews were conducted between 2007-2008. FINDINGS: Women shared their mothering experience and practice, which encompassed a lifespan perspective grounded in their American Indian cultural tradition. Four themes were identified as follows: mother hen, interrupted mothering and second chances, breaking cycles and mothering a community. Mothering originated in childhood, extended across their lifespan and moved beyond mothering their biological offspring. CONCLUSION: These findings challenge the Western construct of mothering and charge nurses to seek culturally sensitive interventions that reinforce positive mothering practices and identify when additional mothering support is needed across a woman's lifespan.

Predictors of Psychological Distress Among Rural Family/Friend Caregivers of People Living With Dementia in the United States: Consequences of the COVID-19 Pandemic.

OBJECTIVES: Caregivers of persons living with dementia in rural United States are a vulnerable population. During the coronavirus disease 2019 (COVID-19) pandemic, rural communities experienced heightened disparities in social services, healthcare, suicides, and mortality. Guided by the Caregiving Stress Process Model, this study examines the relationship between the stressors and resources of rural caregivers of persons living with dementia and their experience of depression, stress, and COVID-19. METHODS: One hundred and fifty-two rural caregivers of persons living with dementia completed an online survey, March 1, 2021-April 30, 2022. Analyses used baseline responses to validated scales and an open-ended question, "How has COVID impacted your life as a caregiver?" Dependent variables were depressive symptoms and stress. Bivariate and hierarchical linear regression analyses examined associations of stressors and resources with depressive symptoms and stress. Thematic analysis examined open-ended question responses. RESULTS: Among examined stressors, high care burden (b = 1.94, p < .05) and loneliness (b = 0.76, p < .0001) were positively associated with depressive symptoms. Loneliness (b = 0.24, p < .05) and ≥41 hr spent caregiving per week (reference 10-20 hr; b = 0.99, p < .05) were associated with stress. Among examined resources, self-efficacy for caregiving (b = -0.21, p < .05) was inversely associated with stress. Qualitative results confirmed quantitative results and identified additional pandemic-related themes in stressors and resources. DISCUSSION: We found that caregiver burden, loneliness, and caregiving hours were associated with greater psychological distress among rural caregivers of persons living with dementia during the pandemic, whereas self-efficacy for caregiving was protective. Rural caregivers need increased support to address care burdens and enhance psychological resources for caregiving. CLINICAL TRIAL REGISTRATION NUMBER: NCT04428112.

Testing the efficacy of culturally adapted coping skills training for Chinese American immigrants with type 2 diabetes using community-based participatory research.

Chinese Americans demonstrate greater prevalence of diabetes than non-Hispanic whites and find standard diabetes care disregards their cultural health beliefs. Academic researchers and Chinatown agencies collaborated to culturally adapt and test an efficacious cognitive-behavioral intervention using community-based participatory research. Using a delayed-treatment repeated-measures design, 145 adult Chinese immigrants with Type 2 diabetes completed treatment. Immediate benefits of treatment were evident in the improvement (p < .05) in diabetes self-efficacy, diabetes knowledge, bicultural efficacy, family emotional and instrumental support, diabetes quality of life, and diabetes distress. Prolonged benefits were evident in all changed variables 2 months post-intervention. The CBPR approach enabled the development of a culturally acceptable, efficacious behavioral intervention, and provides a model for working with communities that demonstrate health disparities.

Parental advocacy styles for special education students during the transition to adulthood.

In an ethnographic study of planning for the transition to adulthood, we explored parental advocacy styles in special education settings for youth and young adults with chronic health conditions and developmental disabilities. Of 61 parents, 43 were satisfied with outcomes in negotiations for school services for their children. We identified three parental advocacy styles for these parents: (a) high-profile parents, who insisted on specific, wide-ranging services for their children that often resulted in conflict with educators; (b) strategic parents, who negotiated for selected goals and were willing to compromise, and (c) grateful-gratifier parents, who formed close relationships with educators and trusted them to make appropriate decisions. Eighteen parents were overwhelmed, burned out, or unfocused, and generally dissatisfied with outcomes of educational planning meetings. Professional efforts to enhance parental advocacy can target development of skills and strategies that have worked for successful negotiators.

Health and psychosocial outcomes in U.S. adult patients with diabetes from diverse ethnicities.

Within the United States, diabetes is a serious public health concern and patients with diabetes are more likely to experience clinical depression, psychological distress, and depressive symptoms than those without. Negative psychosocial factors are associated with poorer diabetes management and glycemic control. Overall, both the rates of diabetes and related psychological distress are greater for persons of diverse ethnicities than for non-Latino whites, and have reached epidemic proportions in certain groups. The following article will provide an overview across ethnicities of the rates of diabetes, health outcomes, psychosocial outcomes, and unique cultural and linguistic challenges that contribute to disparities within US diabetes patients of diverse ethnicities. Using this information, our hope is that health care practitioners and researchers alike can better respond to the psychosocial needs of ethnically diverse patients.

Working with culture: culturally appropriate mental health care for Asian Americans.

AIM: The aim of this study is to describe how mental healthcare providers adapted their practice to meet the unique needs of Asian Americans. BACKGROUND: As the number of ethnic minorities and multicultural patients and families rapidly increases, cultural competency becomes an essential skill for all healthcare providers. The lack of knowledge about how healthcare providers grapple with diverse cultures and cultural competency limits the ability of others to deliver patient-centred care across cultural lines. METHODS: Interpretive phenomenology guided the design and conduct of this study. Twenty mental healthcare providers who treated Asian Americans were recruited. Narrative data were collected through face-to-face, in-depth interviews between 2006 and 2007. RESULTS/FINDINGS: Three characteristics of culturally appropriate care for Asian Americans were identified. Cultural brokering: providers addressed issues stemming from cultural differences via bicultural skills education. Asian American patients generally received broader education than current literature recommended. Supporting families in transition: providers assisted Asian American families during transition from and to professional care. Using cultural knowledge to enhance competent care: providers' knowledge of Asian culture and flexible attitudes affected the care that they provided. Culturally competent providers were able to identify cultural issues that were relevant to the specific situation, and incorporated cultural solutions into the care provided. CONCLUSION: Culturally appropriate care is nuanced and context specific. Thus, more sophisticated and broader conceptualizations are necessary to prepare nurses for such complex practice.

Challenges and struggles: lived experiences of individuals with co-occurring disorders.

Approximately 20 million people have substance abuse disorder in a given year, and approximately 7-10 million of them will have co-occurring disorders (CODs) of both mental illness and substance abuse. Individuals with COD have higher rates of other chronic health problems (i.e., diabetes) and multiple rehospitalizations and overutilize emergent services. Despite their elevated risk for physical morbidities, there is a dearth of literature that focuses on the impact for those with COD of having multiple physical health disorders. The purpose of this interpretive study was to understand, describe, and illustrate the social and structural barriers that individuals with COD of mental illness, substance abuse, and general medical conditions encounter in regard to their health care. A purposive sampling of 20 individuals with COD (11 men and 9 women; 65% African American) were recruited from community treatment centers and supportive housing sites. Social and structural barriers to managing medical health conditions while living with COD were identified in three realms: (a) in having interpersonal relationships with health care providers, (b) in negotiating an arduous health care "system," and (c) in trying to manage health conditions while living in unstable shelter.

Do family interventions improve health?

The central aim of this article is to examine the evidence that family interventions improve health in persons with chronic illness and their family members, across the life span. The review focuses on recent meta-analyses of randomized controlled trials of family intervention research. In adults, evidence supports the salutary effects of family interventions versus usual medical care for patient health and mental health, and for family member health. In children, robust evidence supports family-based multimodal interventions for obesity treatment. Reasonable evidence supports family approaches to type 1 diabetes treatment in children. Nurses led the research or were members of interdisciplinary research teams in several of these literatures, representing one quarter to one third of the research cited, but were absent in other literatures, such as family treatment of childhood obesity.

Preventing Type 2 Diabetes Among Midlife Women: A Feasibility Study Comparing a Combined Sleep and Lifestyle Intervention With a Standard Lifestyle Intervention.

PURPOSE: The purpose of this pilot study was to evaluate the feasibility, acceptability, and initial efficacy of adding a sleep extension intervention to a well-established diabetes prevention intervention among midlife women with short sleep duration at risk for type 2 diabetes. METHODS: For this 2-group comparative design, 26 women with prediabetes or metabolic syndrome and sleep duration <7 hours were recruited from the community to participate in an 8-session diet and physical activity lifestyle intervention alone (L-alone) or L-alone plus a behavioral sleep intervention (L+Sleep). Body mass index (BMI), waist circumference, and other outcomes were compared at baseline and 3 and 6 months using analysis of covariance. RESULTS: Incorporating a sleep intervention into lifestyle changes proved feasible and acceptable to midlife women at risk for type 2 diabetes. Significant decreases in BMI and waist circumference over time were observed in both groups, but comparative efficacy of L+Sleep versus L-alone yielded few group differences. Exploratory analysis indicated that women who increased their sleep to ≥7 h/night, regardless of group assignment, lost more weight than women who continued to report sleeping <7 h/night. CONCLUSION: Adding sleep extension to a lifestyle change intervention proved feasible and satisfactory to participants, but initial efficacy did not differentiate the 2 intervention groups.

Conducting a qualitative culture study of pediatric palliative care.

While conducting a grounded theory study of Chinese American and Mexican American families' experiences in pediatric palliative care, we encountered a number of unanticipated challenges regarding project development, Institutional Review Boards, recruitment, data collection, and data analysis. In this article, we describe our experiences, strategies, and insights for the benefit of other researchers and clinicians in the field.

The electronic health record's impact on nurses' cognitive work: An integrative review.

BACKGROUND: Technology use can impact human performance and cognitive function, but few studies have sought to understand the electronic health record's impact on these dimensions of nurses' work. OBJECTIVE: The purpose of this review was to synthesize the literature on the electronic health record's impact on nurses' cognitive work. DESIGN: Integrative review. DATA SOURCES: MEDLINE/PubMed, CINAHL, Embase, Web of Science, and PsycINFO. REVIEW METHODS: The literature search focused on 3 concepts: the electronic health record, cognition, and nursing practice, and yielded 4910 articles. Following a stepwise process of duplicate removal, title and abstract review, full text review, and reference list searches, a total of 18 studies were included: 12 qualitative, 4 mixed-methods, and 2 quantitative studies from the United States (13), Scandinavia (2), Australia (1), Austria (1), and Canada (1). The Mixed Methods Appraisal Tool was used to assess the quality of eligible studies. RESULTS: Five themes identified how nurses and other clinicians used the electronic health record and perceived its impact: 1) forming and maintaining an overview of the patient, 2) cognitive work of navigating the electronic health record, 3) use of cognitive tools, 4) forming and maintaining a shared understanding of the patient, and 5) loss of information and professional domain knowledge. Most studies indicated that forming and maintaining an overview of the patient at both the individual and team level were difficult when using the electronic health record. Navigating the volumes of information was challenging and increased clinicians' cognitive work. Information was perceived to be scattered and fragmented, making it difficult to see the chronology of events and to situate and understand the clinical implications of various data. The template-driven nature of documentation and limitations on narrative notes restricted clinicians' ability to express their clinical reasoning and decipher the reasoning of colleagues. Summary reports and handoff tools in the electronic health record proved insufficient as stand-alone tools to support nurses' work throughout the shift and during handoff, causing them to rely on self-made paper forms. Nurses needed tools that facilitated their ability to individualize and contextualize information in order to make it clinically meaningful. CONCLUSION: The electronic health record was perceived by nurses as an impediment to contextualizing and synthesizing information, communicating with other professionals, and structuring patient care. Synthesizing and communicating information at the individual and team levels are known drivers of patient safety. The findings from this review have implications for electronic health record design.