Study Protocol to Evaluate Influences of Stress and Inflammation on Mucositis in Adolescents and Young Adults With Cancer.

BACKGROUND: Adolescent and young adult (AYA) cancer diagnoses are rising, and gains in survivorship are falling behind for this age group. Dose-limiting toxicities of therapy, including mucositis, are more frequent in this age group and may be contributing to poorer survivorship. Animal models and observational studies suggest that stress and inflammation may be contributing to the high prevalence of dose-limiting mucositis in this age demographic. The AYA oncology population has been an overlooked and underresearched oncology demographic, leading to poor understanding of why this age group has high side-effect burdens and poorer cancer survival. OBJECTIVES: This article describes a novel, prospective clinical study in AYAs receiving chemotherapy designed to evaluate if stress at the time of chemotherapy administration predicts the development of dose-limiting mucositis and determines if stress-induced inflammatory profiles mediate this relationship. This is the first study to translate these stress and inflammation findings from animal models to a nurse-centered research design in humans. METHODS: Persons aged 15-39 years who are receiving chemotherapy with a significant (>20%) risk of developing mucositis will be recruited for a prospective study. Baseline stress is measured through participant questionnaires, and blood is collected to analyze for inflammatory markers. Participants receive chemotherapy as clinically planned and complete a daily survey of mucositis symptoms for 14 days after chemotherapy. Regression and mediation analysis will determine if stress and inflammatory profiles predict the development of dose-limiting mucositis. RESULTS: This model of inquiry through a nursing framework uses a biobehavioral model that considers physiological and psychological risk factors for chemotherapy toxicities. This study is also an important translational science study essential in bringing data from laboratory studies to the clinical arena. The study may also be important to implementation science because assessing the ability of critically ill individuals to participate in low-burden clinical studies may yield essential findings to improve care delivery. DISCUSSION: Findings from this work will identify potentially modifiable factors that may be manipulated to minimize chemotherapy toxicities and lead to improved survival. Data from this study will inform larger research endeavors to better understand symptom development in this high-risk oncological population.

International consensus-based policy recommendations to advance universal palliative care access from the American Academy of Nursing Expert Panels.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. On behalf of the Academy, these evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. Through improved palliative nursing education, nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative care nurses worldwide, nurses can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations. Part II herein provides a summary of international responses and policy options that have sought to enhance universal palliative care and palliative nursing access to date. Additionally, we provide ten policy, education, research, and clinical practice recommendations based on the rationale and background information found in Part I. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter.

Recommendations for Emergency Departments Caring for Persons with Opioid Use and Opioid Use Disorders: An Integrative Review.

INTRODUCTION: The emergency department is a primary portal to care for persons after an opioid overdose and those with an opioid use disorder. The aim of this integrative review was to provide best practice recommendations for nurses caring for this highly stigmatized and often undertreated population. METHODS: An integrative review was conducted using studies focusing on adults treated with opioid agonist-antagonist medications in the emergency department. The integrative review method by Whittemore and Knafl was used to guide this review and enhance its rigor. RESULTS: Twelve studies were included in the review. Opioid care begins with identifying opioid use risk, followed by implementing tailored strategies including opioid agonist-antagonist treatment if indicated, referral to treatment when warranted, and follow-up opioid use monitoring when feasible. Eleven recommendations provide guidance on integrating best practices into routine emergency care. DISCUSSION: The emergency department is an ideal setting for addressing the opioid crisis. Nurses can use the recommendations from this review to lead system change and more effectively manage the care of persons with opioid use and opioid withdrawal, and those at risk for opioid overdose.

American Academy of Nursing Expert Panel consensus statement on nursing's roles in ensuring universal palliative care access.

The purpose of this consensus paper was to convene leaders and scholars from eight Expert Panels of the American Academy of Nursing and provide recommendations to advance nursing's roles and responsibility to ensure universal access to palliative care. Part I of this consensus paper herein provides the rationale and background to support the policy, education, research, and clinical practice recommendations put forward in Part II. On behalf of the Academy, the evidence-based recommendations will guide nurses, policy makers, government representatives, professional associations, and interdisciplinary and community partners to integrate palliative nursing services across health and social care settings. The consensus paper's 43 authors represent eight countries (Australia, Canada, England, Kenya, Lebanon, Liberia, South Africa, United States of America) and extensive international health experience, thus providing a global context for the subject matter. The authors recommend greater investments in palliative nursing education and nurse-led research, nurse engagement in policy making, enhanced intersectoral partnerships with nursing, and an increased profile and visibility of palliative nurses worldwide. By enacting these recommendations, nurses working in all settings can assume leading roles in delivering high-quality palliative care globally, particularly for minoritized, marginalized, and other at-risk populations.

How Patient Education Influences Utilization of Nonpharmacological Modalities for Persistent Pain Management: An Integrative Review.

OBJECTIVES: Opioid analgesic misuse and abuse has given rise to an epidemic that has added to an increase in opioid-related overdoses and deaths. Adults with persistent noncancer pain (PNCP) are primarily treated with opioid analgesics. Many remain on these medications long term. Most of these patients are unaware of other effective measures for managing PNCP, such as nonpharmacologic modalities (NPMs). This lack of familiarity with NPMs presents a key contributor to the problem of NPM underuse among adult PNCP patients. This integrative review sought to identify key factors that contribute to NPMs underuse and the effect of education on patients' adoption or use for PNCP management. DESIGN: Integrative review. DATA SOURCES: A literature search was conducted using PubMed, CINAHL, Embase, Cochrane, and hand-searching of the literature published between 2002 and November 2017. REVIEW/ANALYSIS METHODS: Systematic screening using the Johns Hopkins Nursing evidence appraisal tools yielded articles that were analyzed and synthesized to identify themes, and patterns. RESULTS: Nineteen research articles were identified with these main themes: NPMs are effective in PNCP management, lack of familiarity with NPMs influences patients' willingness to try them, and access to local NPMs must be addressed to facilitate use. CONCLUSIONS: Findings suggest that patient education about NPMs has the potential to motivate patients to try these modalities, which may increase overall use of NPMs for PCNP. Nurses could play a vital role in ensuring evidence-based NPMs are introduced to PNCP patients, which could increase patients' use of these measures and improve outcomes.

Educating Ambulatory Care Nurses to Address Substance Use.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) for substance use has an impact on morbidity and mortality and health care cost. LOCAL PROBLEM: Nurses in ambulatory care settings may lack knowledge about evidence-based substance use SBIRT. METHODS: A comparison of pre- and postintervention data was performed to determine whether knowledge improved and to identify facilitators and barriers to SBIRT implementation. INTERVENTIONS: Nurses completed an online self-paced program focusing on alcohol and drug use screening, motivational interviewing used in a brief intervention, and referral to specialty treatment. RESULTS: Postintervention knowledge scores increased (P < .001). Facilitator and barrier themes included time, education, resources, receptivity, and interprofessional collaboration. CONCLUSIONS: The implementation of the SBIRT online program was feasible for nurses to complete during work hours and resulted in increased SBIRT-related knowledge.

Evaluating the Outcomes of a Web-Based Stress Management Program for Nurses and Nursing Assistants.

OBJECTIVE: The purpose of this quality improvement project was to determine the utilization, satisfaction, and effect of a web-based stress management program for nurses and nursing assistants (NAs). METHODS: This quality improvement project provided BREATHE, a web-based stress management program that consisted of six modules that describe, identify, and help nurses manage stress for 31 nurses and NAs working on a subacute rehabilitation unit at a mid-Atlantic community hospital. MEASUREMENTS: The number of login attempts and time spent on the program were included, as were the nurse stress scale (NSS), a 34-item validated instrument that captures seven dimensions of stress, and a seven-item satisfaction survey given at the end of the modules. RESULTS: Nurses utilized and were satisfied with the evidence-based program BREATHE and reported significant improvement in NSS scores. LINKING EVIDENCE TO ACTION: Findings suggest that BREATHE was effective at reducing the NSS score among nurses and NAs. The web-based nature of the program allowed nurses to engage in it at times most convenient for them, which added to the program's acceptability and overall satisfaction.

Nurse-Led Delivery of Brief Interventions for At-Risk Alcohol Use: An Integrative Review.

BACKGROUND: Nurses are in key positions to reduce the global burden associated with alcohol, yet many are ill-prepared to screen for alcohol use and intervene accordingly. The purpose of this integrative review was to identify best practices for educating nurses to work with patients who are at risk for alcohol-related adverse consequences, implement alcohol screening, and deliver alcohol brief interventions (ABIs). AIMS: To identify and synthesize findings from randomized control trials of ABIs delivered by nurses to patients identified through screening to be at risk because of alcohol use. METHOD: The results of 11 published randomized control trials identified from a multi-database search were synthesized. RESULTS: The Alcohol Use Disorder Identification Test was used for alcohol screening in more than half of the studies. Most of the ABIs were based on motivational interviewing and delivered in 30 minutes or less. While there was limited information on the characteristics of nurses who delivered the interventions and how nurses were prepared to deliver the ABIs, the exemplar was a full day workshop teaching nurses on an evidence-based framework for the ABI. All studies measured alcohol consumption as an outcome, yet few used rigorous methods for obtaining this self-reported data. CONCLUSIONS: A 1-day workshop is recommended as an educational modality to prepare nurses to implement the Alcohol Use Disorder Identification Test for identification of persons who are at risk because of alcohol use, deliver a structured brief intervention in less than 30 minutes, and utilize a standard measure of alcohol consumption for evaluation.

Review of Treatment for Central Spinal Neuropathic Pain and Its Effect on Quality of Life: Implications for Neuromyelitis Optica Spectrum Disorder.

OBJECTIVES: Neuromyelitis optica spectrum disorder (NMOSD) causes disabling and persistent central neuropathic pain (NP). Because the pain syndrome in NMOSD is severe and often intractable to analgesic treatment, it interferes with quality of life in patients. No interventional trials have been published looking at response to interventions for pain in NMOSD. This is a synthesis of the literature surveying the impact on quality of life of interventions in all mechanisms of central spinal NP. This review has important implications for management of pain in NMOSD. METHODS AND DATA SOURCES: A systematic database search was conducted using PubMed, Embase, and CINAHL Plus with keywords including "spinal cord," "quality of life," and "neuropathic pain" in an attempt to identify original research that targeted spinal NP treatment and used quality of life as an outcome measure. Both pharmacologic and nonpharmacologic treatments were sought out. RESULTS: Twenty-one studies meeting our eligibility criteria were identified and evaluated, 13 using pharmacologic treatments and 8 using nonpharmacologic interventions. Overall, sample sizes were modest, and effects on decreasing pain and/or improving quality of life were suboptimal. CONCLUSIONS: This review provides researchers with a foundation from which to start a more thorough and thoughtful investigation into the management of NP in NMOSD and underscores the importance of including quality of life as a clinically meaningful outcome measure.

Increasing Competence in Pressure Injury Prevention Using Competency-Based Education in Adult Intensive Care Unit.

BACKGROUND: There is a significant focus on pressure injury prevention to promote better patient outcomes and control health care cost. LOCAL PROBLEM: In 2016, the institution's pressure injury quarterly prevalence survey showed that two-thirds of the patients surveyed who developed unit-acquired pressure injury stage 2 and greater were in the adult intensive care units. METHODS: The quality improvement project used a pre- and postintervention design. INTERVENTIONS: The adult medical intensive care unit (MICU) executed a competency-based education project to increase staff implementation of pressure injury prevention. RESULTS: Following initiation of competency-based education, staff documentation of pressure injury prevention implementation increased, and unit-acquired pressure injury stage 2 and greater rates were reduced. CONCLUSIONS: The use of a competency-based education program may be effective in increasing pressure injury prevention in the intensive care unit.

Descriptions of the Pain Experience in Adults and Adolescents with Cystic Fibrosis.

BACKGROUND: People living with cystic fibrosis experience pain that is associated with decreased quality of life, poorer health outcomes, and increased mortality. Though pain is highly prevalent as a symptom, it is currently unknown how persons with CF describe their pain experiences or the ways those experiences impact their lives. AIMS: To explore and describe ways adolescents and adults with CF experience pain. Design/Setting/Subjects/Methods: An exploratory descriptive design was implemented to perform interviews with 10 individuals with CF and self-reported moderate to severe pain. The interviews explored their pain experiences within five domains: Pain Characteristics, Activities, Relationships, Work/School Life, and Health Care Team. Transcribed interviews underwent a content analysis with team-based constant comparisons. RESULTS: Individuals with CF identify the disease as being painful; express how pain negatively affects all aspects of their lives, including loss of functionality and productivity; and are able to disclose their pain to those with whom they have relationships. Adolescents feel an emotional toll from the loss of socialization as a result of pain and feel their health care team adequately supports their pain. Adults express a unique emotional pain component to CF and feel stigmatized and unsupported by their health care team when asking for pain management solutions. CONCLUSION: There are differences in how pain is perceived by adolescents and adults with CF that have otherwise not been reported in the current literature. Further explorations of pain across the lifespan and health care provider attitudes toward pain management are needed to guide the development of effective pain management interventions for those with CF.

Acute Pain and Depressive Symptoms: Independent Predictors of Insomnia Symptoms among Adults with Sickle Cell Disease.

No studies to date have systematically investigated insomnia symptoms among adults with sickle cell disease (SCD). The purpose of this study was to (1) describe the prevalence of insomnia symptoms and (2) identify biopsychosocial predictors in community-dwelling adults with SCD. Cross-sectional analysis of baseline data from 263 African American adults with SCD (aged 18 years or older). Measures included the Insomnia Severity Index (ISI), Center for Epidemiologic Studies in Depression scale, Urban Life Stress Scale, Brief Pain Inventory, and a chronic pain item. SCD genotype was extracted from the medical record. A slight majority (55%) of the sample reported clinically significant insomnia symptomatology (ISI ≥ 10), which suggests that insomnia symptoms are prevalent among community-dwelling African American adults with SCD. While insomnia symptoms were associated with a number of biopsychosocial characteristics, depressive symptoms and acute pain were the only independent predictors. Given the high number of participants reporting clinically significant insomnia symptoms, nurses should screen for insomnia symptoms and explore interventions to promote better sleep among adults with SCD, with an emphasis on recommending treatment for pain and depression. In addition, current pain and depression interventions in this population could add insomnia measures and assess the effect of the intervention on insomnia symptomatology as a secondary outcome.

Second Life simulation as a strategy to enhance decision-making in diabetes care: a case study.

AIMS AND OBJECTIVES: The case study evaluated the Second Life perceived usability and the decision-making of insulin administration via situational awareness at two different simulation freezes during Second Life simulation. BACKGROUND: Due to safety issues stemming from nursing knowledge deficits of insulin administration, the use of simulation via practice in a virtual immersive environment, Second Life was evaluated in a case study of practicing nurses. DESIGN: This case study used a single convenience group, post-test design. METHODS: Perceived usability was evaluated using the System Usability Scale. Evaluation of decision-making was evaluated via Situational Awareness Score at two simulation freezes in the Second Life simulation with practicing nurses (n = 12). RESULTS: Nurses with more years of practice reported difficulty in using Second Life. As age increased, the total Situational Awareness Score decreased. Day shift nurses were more likely to obtain a High Situational Awareness Score. CONCLUSIONS: Although usability was nearly obtained, virtual immersive environments for nurses has promise to provide practice in aiding clinical decision-making. RELEVANCE TO CLINICAL PRACTICE: Finding a new platform to allow all nurses to practice difficult clinical decisions is key. A virtual immersive environment, like Second Life, can provide simulation for nurses to practice making such difficult decisions.

The Effects of Symptoms on Quality of Life during Chemotherapy in African-American Women with Breast Cancer.

Little is known about the effects of burdensome symptoms dur- ing chemotherapy treatment in African-American women. This study explored the symptom burden occurring during chemotherapy treatment and how these symptoms impacted functional well-being and quality of life (QOL). A sample of 30 African-American women with breast cancer (BC) completed a battery of questionnaires that were used to collect the data at baseline, midpoint, and at the completion of chemotherapy. There were significant differences in the severity of symptoms for worse pain, pain inteiference with activities of daily living (ADLs), present fatigue and history offatigue, present nausea and history of nausea and insomnia as well as lower intensity of QOL measures over the course of chemotherapy treatment. All symptoms had greater intensity at midpoint and completion than at baseline. Worst pain had a significant negative effect on functional well-being. Both pain and depression each had significant negative effects on QOL.

Reduced sleep, stress responsivity, and female sex contribute to persistent inflammation-induced mechanical hypersensitivity in rats.

Studies in humans suggest that female sex, reduced sleep opportunities and biological stress responsivity increase risk for developing persistent pain conditions. To investigate the relative contribution of these three factors to persistent pain, we employed the Sciatic Inflammatory Neuritis (SIN) model of repeated left sciatic perineurial exposures to zymosan, an inflammatory stimulus, to determine their impact upon the development of persistent mechanical hypersensitivity. Following an initial moderate insult, a very low zymosan dose was infused daily for eight days to model a sub-threshold inflammatory perturbation to which only susceptible animals would manifest or maintain mechanical hypersensitivity. Using Sprague Dawley rats, maintaining wakefulness throughout the first one-half of the 12-h light phase resulted in a bilateral reduction in paw withdrawal thresholds (PWTs); zymosan infusion reduced ipsilateral PWTs in all animals and contralateral PWTs only in females. This sex difference was validated in Fischer 344, Lewis and Sprague Dawley rats, suggesting that females are the more susceptible phenotype for both local and centrally driven responses to repeated low-level inflammatory perturbations. Hypothalamic-pituitary-adrenal (HPA) axis hyporesponsive Lewis rats exhibited the most robust development of mechanical hypersensitivity and HPA axis hyperresponsive Fischer 344 rats matched the Lewis rats' mechanical hypersensitivity throughout the latter four days of the protocol. If HPA axis phenotype does indeed influence these findings, the more balanced responsivity of Sprague Dawley rats would seem to promote resilience in this paradigm. Taken together, these findings are consistent with what is known regarding persistent pain development in humans.

Biobehavioral Influences of Stress and Inflammation on Mucositis in Adolescents and Young Adults with Cancer: Results from a Pilot Study.

Purpose: Chemotherapy-induced mucositis is a prevalent and burdensome toxicity among adolescent and young adults (AYAs) with cancer and impedes the delivery of optimal therapy. Its development is not well understood, but baseline stress and inflammation may be contributory factors. This pilot study evaluates stress and inflammation as risk factors for mucositis, identifies effect size estimates, and evaluates the feasibility of a prospective study to investigate mucositis development. Methods: Thirty AYAs receiving chemotherapy with substantial risk of mucositis completed baseline stress measures, and serum was collected for inflammatory biomarker analysis. Regression and mediation analyses determined the relationship between stress/inflammation and mucositis. Results: Stress appears to be a significant risk factor for incidence of mucositis (odds ratio 1.13, p = 0.125) and predicts total mucositis score (ß = 0.281, p = 0.023) as well as peak incidence (ß = 0.052, p = 0.018). Baseline levels of interleukin (IL)-1a and epidermal growth factor (EGF) predicted mucositis development, and EGF and IL-8 may mediate the relationship between stress and mucositis. Findings suggest that stress-induced inflammation exacerbates symptom development. Conclusion: Results from this pilot study inform mucositis symptom models, suggesting that psychosocial and physiologic factors are involved in development. Importantly, this pilot study provides initial effect size estimates, including magnitude and direction of relationships, that are essential to informing larger, more robustly powered studies. High enrollment, low attrition, and minimal missing data in this study suggest this model is feasible for research in this population. Importantly, this work is a first step in identifying new risk factors for mucositis and targets for nurse-led interventions to prevent toxicity development.

Nonpharmacologic Pain Management for Patients in Ambulatory Extended Recovery After Minimally Invasive Gynecologic and Urologic Surgery.

PURPOSE: To determine the effectiveness of an evidence-based postoperation nonpharmacologic pain management bundle for patients recovering from minimally invasive gynecologic and urologic surgeries. PARTICIPANTS & SETTING: This study focused on patients recovering from minimally invasive gynecologic and urologic surgery at a comprehensive cancer center. The first cohort consisted of patients three months preimplementation (n = 96) and the second consisted of those three months postimplementation (n = 86). METHODOLOGIC APPROACH: The project used a pre- and postintervention design and deployed the bundle as a nursing order. Nurses and patients were educated about the bundle and comprehensive postoperation pain management strategies. FINDINGS: Postimplementation, the documented use of nonpharmacologic pain management interventions significantly increased and postoperation opioid use significantly decreased without negatively affecting pain scores or lengths of stay. IMPLICATIONS FOR NURSING: Nonpharmacologic pain interventions can decrease the need for postoperation opioids, and ordering a bundle of interventions alongside analgesia is an effective way patients can manage pain.

The Suprasellar Meningioma Patient-Reported Outcome Survey: a disease-specific patient-reported outcome measure for resection of suprasellar meningioma.

OBJECTIVE: Suprasellar meningioma resection via either the transcranial approach (TCA) or the endoscopic endonasal approach (EEA) is an area of controversy and active evaluation. Skull base surgeons increasingly consider patient-reported outcomes (PROs) when choosing an approach. No PRO measure currently exists to assess quality of life for suprasellar meningiomas. METHODS: Adult patients undergoing suprasellar meningioma resection between 2013 and 2019 via EEA (n = 14) or TCA (n = 14) underwent semistructured interviews. Transcripts were coded using a grounded theory approach to identify themes as the basis for a PRO measure that includes all uniquely reported symptoms. To assess content validity, 32 patients and 15 surgeons used a Likert scale to rate the relevance of items on the resulting questionnaire and the general Patient-Reported Outcomes Measurement Information System-29 (PROMIS29). The mean scores were calculated for all items and compared for TCA versus EEA patient cohorts by using unpaired t-tests. Items on either questionnaire with mean scores ≥ 2.0 from patients were considered meaningful and were aggregated to form the novel Suprasellar Meningioma Patient-Reported Outcome Survey (SMPRO) instrument. RESULTS: Qualitative analyses resulted in 55 candidate items. Relative to patients who underwent the EEA, those who underwent the TCA reported significantly worse future outlook before surgery (p = 0.01), tiredness from medications 2 weeks after surgery (p = 0.001), and word-finding and memory difficulties 3 months after surgery (p = 0.05 and < 0.001, respectively). The items that patients who received a TCA were most concerned about included medication-induced lethargy after surgery (2.9 ± 1.3), blurry vision before surgery (2.7 ± 1.5), and difficulty reading due to blurry vision before surgery (2.7 ± 2.7). Items that patients who received an EEA were most concerned about included blurry vision before surgery (3.5 ± 1.3), difficulty reading due to blurry vision before surgery (2.4 ± 1.3), and problems with smell postsurgery (2.9 ± 1.3). Although surgeons overall overestimated how concerned patients were about questionnaire items (p < 0.0005), the greatest discrepancies between patient and surgeon relevance scores were for blurry vision pre- and postoperatively (p < 0.001 and < 0.001, respectively) and problems with taste postoperatively (p < 0.001). Seventeen meningioma-specific items were considered meaningful, supplementing 8 significant PROMIS29 items to create the novel 25-item SMPRO. CONCLUSIONS: The authors developed a disease- and approach-specific measure for suprasellar meningiomas to compare quality of life by operative approach. If demonstrated to be reliable and valid in future studies, this instrument may assist patients and providers in choosing a personalized surgical approach.

A new program in pain medicine for medical students: integrating core curriculum knowledge with emotional and reflective development.

OBJECTIVE: Improvements in clinical pain care have not matched advances in scientific knowledge, and innovations in medical education are needed. Several streams of evidence indicate that pain education needs to address both the affective and cognitive dimensions of pain. Our aim was to design and deliver a new course in pain establishing foundation-level knowledge while comprehensively addressing the emotional development needs in this area. SETTING: One hundred eighteen first-year medical students at Johns Hopkins School of Medicine. OUTCOME MEASURES: Performance was measured by multiple-choice tests of pain knowledge, attendance, reflective pain portfolios, and satisfaction measures. RESULTS: Domains of competence in pain knowledge included central and peripheral pain signalling, pharmacological management of pain with standard analgesic medications, neuromodulating agents, and opioids; cancer pain, musculoskeletal pain, nociceptive, inflammatory, neuropathic, geriatric, and pediatric pain. Socio-emotional development (portfolio) work focused on increasing awareness of pain affect in self and others, and on enhancing the commitment to excellence in pain care. Reflections included observations on a brief pain experience (cold pressor test), the multidimensionality of pain, the role of empathy and compassion in medical care, the positive characteristics of pain-care role models, the complex feelings engendered by pain and addiction including frustration and disappointment, and aspirations and commitments in clinical medicine. The students completing feedback expressed high levels of interest in pain medicine as a result of the course. DISCUSSION: We conclude that a 4-day pain course incorporating sessions with pain specialists, pain medicine knowledge, and design-built elements to strengthen emotional skills is an effective educational approach. SUMMARY: Innovations in medical education about pain are needed. Our aim was to design and deliver a new course for medical students addressing both the affective and cognitive dimensions of pain. Combining small-group sessions with pain specialists, active-learning approaches to pain knowledge, and design-built elements to strengthen emotional skills was highly effective.

Integrating Culturally Competent Advance Care Planning for Korean Immigrants: An Integrative Review.

AIMS: This review aims to explore the extant literature on the current utilization of ACP in Kisin order to obtain a comprehensive understanding of their health disparities and to determineevidence-based best practices to integrate culturally-competent ACP for EOL care of KIs. DESIGN: A systematic integrative review of the literature Data Sources:  Four electronic databases including PubMed, the Cumulative Index of Nursing and Allied Health Literature, the Cochrane Library, and Embase. METHOD: The detailed search strategy for databases implicated a combination of MeSHkeywords and associated terms, which can be found in Table A.Results: Three themes emerged in relation to fundamental components in the integration of culturally-competent ACP for EOL of KIs: (1) cultural characteristics of KIs; (2) disparities in ethnic-oriented ACP and EOL care resources in KIs; and (3) KIs' perspectives on ACP. CONCLUSION: The findings of this review indicate that culturally-competent ACP resources for KIsare presently quite insufficient. It is determined that much future research is needed on howculturally-competent ACP can best augment the quality of EOL care for KIs, and on howspecific interventions can effectively implement ACP in community settings. Impact: Such ongoing research dedicated to the development of feasible culturally competent practice guidelines is anticipated to markedly reduce health disparities and promote ACP in KIs. The recommendations in this review may support Korean primary HCPs, Korean health care center administrators, Korean health maintenance organizations (HMOs), Korean advance care nurse practitioners in hospice and palliative care, and nurse researchers in their work.