Overcoming patient safety concerns and integrating early mobility into pediatric intensive care unit nursing practice.

PURPOSE: Early Mobilization (EM) in Pediatric Intensive Care Units (PICU) is safe, feasible and improves outcomes for PICU patients, yet patient safety concerns persist among nurses which limits EM adoption. The purpose of this study was to explore how nurses incorporate EM into practice and balance their concerns for patient safety with the benefits of EM. DESIGN & METHODS: This focused ethnographic study included 15 in-depth interviews with 10 PICU nurses. Data were analyzed using thematic analysis. RESULTS: Two major categories were found which describe the clinical judgement and decision-making of PICU nurses regarding EM. The nurses' concerns for patient safety was the first major category. This included patient-level factors: hemodynamic stability, devices attached, patient's strength, and risk for falls and size. In the second major category, these safety concerns were overcome by applying a multiple step process which resulted in nurses performing EM despite their concerns. That process included: gaining comfort through experience, performing patient safety checks, working with therapists, learning from adverse events, and understanding existing evidence about the benefits of EM. CONCLUSIONS: The overarching theme was nurses' determination to preserve patient safety while ensuring patients could receive the benefits of EM. This theme describes the decisions, behaviors and processes that nurses enact to become more comfortable with EM despite their concerns for patient safety and potential adverse events while performing mobility activities. PRACTICE IMPLICATIONS: Creating opportunities for nurses to participate in EM may increase their willingness to overcome safety concerns and engage in these activities.

Best practices in implementing inpatient pediatric asthma pathways: a qualitative study.

Objective: Clinical pathways (operational versions of practice guidelines) can improve guideline adherence and quality of care for children hospitalized with asthma. However, there is limited guidance on how to implement pathways successfully. Our objective was to identify potential best practices in pathway implementation.Methods: In a previous observational study, we identified higher and lower performing children's hospitals based on hospital-level changes in asthma patient length of stay after implementation of a pathway. In this qualitative study, we conducted semi-structured interviews with a purposive sample of healthcare providers involved in pathway implementation at these hospitals. We used constant comparative methods to develop a conceptual model of potential best practices in implementation.Results: Healthcare providers (n = 24) from 6 higher performing and 2 lower performing hospitals were interviewed about pathway implementation. We identified several practices that addressed barriers and promoted successful pathway implementation: (1) utilizing quality improvement (QI) methodology and a data-driven approach helped overcome inertia of current practice; (2) getting teams to commit to shared goals around asthma care helped overcome disagreements in the implementation process; (3) integrating pathways into the electronic medical record decreased some burdens of implementation; (4) leveraging multidisciplinary teams by developing protocols for nurses and/or respiratory therapists to titrate medications reduced variability in provider practice; and (5) engaging hospital leaders with pathway implementation teams helped secure crucial resources.Conclusions: We identified several potential best practices to support pathway implementation. Hospitals implementing pathways should consider applying these strategies to better ensure success in improving quality of asthma care for children.

Understanding the Long-Term Impact of Living-Related Liver Transplantation on Youth and Young Adults and their Family.

PURPOSE: The purpose of this mixed methods study was to better understand the long term impact of living-related liver donation (LRLD) on youth and young adult (YYA) recipients and their family. DESIGN AND METHODS: Semistructured interviews were conducted with YYA, aged 11-18 years, who received a living donation from a parent. Interviews were audiotaped, transcribed, and analyzed to aggregate themes that represented the participants' views as live-liver recipients. An ethnographic process was conducted to understand the participants' social behavior. At interview, participants completed a demographics questionnaire and the Youth Quality of Life Instrument-Research Version (YQOL-R). RESULTS: Thirteen adolescents were interviewed; six were re-interviewed as key informants. Three major categories were created from the data: Developing Identity, Redefining Family Relationships, Feeling Gratitude to Donors. The overarching theme was Resiliency. Findings from the YQOL-R showed no difference in overall scores or separate domains when compared with a reference population with no chronic illness. CONCLUSION: Qualitative and quantitative data highlight the positive effect that LRLD can have on pediatric patients as they transition from childhood to adolescence to young adulthood. PRACTICE IMPLICATIONS: As pediatric transplant centers in the United States soon mark 30 years of performing live-liver donation, recipients are becoming adults and understanding more clearly that the long-term effects of such donations will lead to improvements in future care.

Nursing Surveillance for Deterioration in Pediatric Patients: An Integrative Review.

PROBLEM: Adverse events occur in up to 19% of pediatric hospitalized patients, often associated with delays in recognition or treatment. While early detection is recognized as a primary determinant of recovery from deterioration, most research has focused on profiling patient risk and testing interventions, and less on factors that impact surveillance efficacy. This integrative review explored actions and factors that influence the quality of pediatric nursing surveillance. ELIGIBILITY CRITERIA: Original research on nursing surveillance, escalation of care, or cardiopulmonary deterioration in hospitalized pediatric patients in non-critical environments, published in English in peer reviewed journals. SAMPLE: Twenty-four studies from a literature search within the databases of CINAHL, PubMed, and Web of Science were evaluated and synthesized using a socio-technical systems theory framework. Study quality was assessed using The Mixed Methods Appraisal Tool. RESULTS: Assessment, documentation, decision-making, intervening and communicating were identified as activities associated with surveillance of deterioration. Factors that influenced nurses' detection of deterioration were patient acuity, nurse education, experience, expertise and confidence, staffing, standardized assessment and communication tools, availability of emergency services, team composition and opportunities for multidisciplinary care planning. CONCLUSIONS: Research provides insight into some aspects of nursing surveillance but does not adequately explore factors that affect clinical data interpretation and synthesis, and role integration between nurse and parents, and nurse and other clinicians on surveillance of clinical stability. IMPLICATIONS: Research is needed to enhance understanding of the contextual factors that impact nursing surveillance to inform intervention design to support nurses' timely recognition and mitigation of clinical deterioration.

Do You Know My Child? Continuity of Nursing Care in the Pediatric Intensive Care Unit.

BACKGROUND: Parents of children with complex, chronic conditions report a desire for continuity of care, but relatively little is known about the ways in which nursing continuity of care occurs and the extent to which it is delivered in the inpatient setting. OBJECTIVES: The objective of this analysis, which arose from a study on best practices in parent/nurse interactions in the pediatric intensive care unit (PICU), was to explore the delivery of continuity of nursing care in the PICU from the perspective of both parents and nurses. METHODS: A qualitative, grounded theory study using situational analysis was conducted with seven parents and 12 nurse participants from a single PICU. Data sources included in-depth interviews, observation, and organizational written materials. Data were coded and analyzed using memoing and situational and positional maps to highlight emerging themes, context, and positions within the data. RESULTS: Parents repeatedly endorsed a desire for continuity of nursing care, wanting to ensure that the bedside nurse valued their child as an individual and understood the complexities of the child's care regimen. Nurses understood this need but faced both contextual and personal challenges to achieving continuity, including fluctuations in staffing needs, training demands, fear of emotional entanglement, and concern for missed learning opportunities. DISCUSSION: Continuity of nursing care is highly valued by parents of children with complex chronic condition in the PICU, but significant barriers to optimal delivery exist within the current critical care environment. Mechanisms for supporting nurses to deliver continuity of care are needed, as are alternative ways to help parents feel that all nurses caring for their child have the knowledge necessary to deliver safe and compassionate care.

The Role of Health Advocacy in Transitions from Pediatric to Adult Care for Children with Special Health Care Needs: Bridging Families, Provider and Community Services.

BACKGROUND: Youth and young adults with special healthcare needs (YASHCN) experience challenges during transition from pediatric to adult care. Prior studies have not examined how community and healthcare resources can work together to assist YASHCN in transitioning from child-focused care and services to adult-oriented providers. OBJECTIVE: The aim of this study was to develop a theoretical understanding of how family, healthcare providers and community supports can assist YASHCN during the transition from pediatric to adult healthcare and services. DESIGN/METHODS: We conducted 41 semi-structured interviews with YASHCN aged 16-25, their family members and healthcare and community providers. We focused our interviews on support mechanisms, both within the traditional healthcare system, and those available in the community. Using grounded theory methods, we performed a multi-step analysis process. RESULTS: The theoretical code "Transition Advocacy" was developed from the data. This theoretical perspective arose from three major categories, which were developed in the analysis: "Fighting for healthcare", "Obtaining resources", and "Getting ready to transition". Transition Advocacy consists of the presence of, or need for, a healthcare "advocate" who did or can assist the YASHCN with the healthcare transition, particularly to navigate complex health or community services. The "advocate" role was performed by family members, healthcare or agency professionals, or sometimes the YASHCN themselves. If advocates were identified, youth were more likely to obtain needed services. CONCLUSIONS: Parents, health providers, and community agencies are potentially well-poised to assist transitioning YASHCN. Efforts to encourage development of strong advocacy skills will facilitate better transitions for YASHCN.

What impact do hospital and unit-based rules have upon patient and family-centered care in the pediatric intensive care unit?

Patient and family-centered care (PFCC) is the foundation for pediatric healthcare. The existence of hospital rules can, however, impact the extent to which PFCC is delivered. This qualitative, grounded theory study identified the existence of explicit and implicit rules in a pediatric intensive care unit, all of which negatively affected the family's ability to receive care that was attentive to their needs. The rules also placed the registered nurse in the challenging position of serving as rule enforcer and facilitator of PFCC. Further work is needed to explore how to adapt the hospital environment to better meet families' needs.

Parental live liver donation: a transformational experience.

BACKGROUND: Parental live liver donation is an attractive alternative to deceased donation for pediatric patients with end-stage liver disease (ESLD), yet very little has been published about the long-term emotional consequences of live liver donations on donors and their families. OBJECTIVES: To better understand the impact that a parental live liver donation has on the everyday life of the donor. METHOD: Thirteen living parental donors from 2 West Coast transplant centers participated. Data included semistructured interviews, observations, and field notes about the donors and their physical, emotional, and familial lives since their donation. The perceived impact of donation on parental donors and their intrafamilial relationships are reviewed and the social and emotional context of parental liver donation, including impacts on the predonation decisions and life after donation are analyzed. RESULTS: Thematic analysis was used to analyze this set of interviews, and after open coding, 3 major categories emerged: a self-awareness process, a clarification of familial relationships, and a change in perspectives on community. The overarching theme that was constructed from the interviews suggested that the impact the donation had on the donors' lives was one of transformation.

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.

Nursing's contribution to research about parenting children with complex chronic conditions: an integrative review, 2002 to 2012.

Children with complex chronic conditions (CCC) need extensive, costly care, usually provided at home by parents. These children often rely on technology to survive or avoid complications. Children with CCC receive nursing care in hospital, community, and home settings. An integrative review of 22 nursing studies, from 2002 to 2012, of parenting for children with CCC was conducted to synthesize nursing research addressing parenting a child with a CCC and identify promising areas for future inquiry and development of supportive interventions and policies. Criteria for sampling in these studies were reviewed, and an updated definition for children with CCC is offered to replace an outdated definition of "medically fragile" children. Findings include the extensive impacts of providing complex care at home, including the tension between the difficulties and recognition of the rewards of providing that care. Disruptions occurred in emotional, role development, social, and moral realms.

"It was pretty scary": the theme of fear in young adult women's descriptions of a history of adolescent dating abuse.

The mental health impact of abusive adolescent dating relationships has not been well described, but fear related to abuse has been reported. We elaborate the theme of fear in women's descriptions of a history of adolescent dating abuse. A sample of community-based women, ages 19-34, who experienced an abusive dating relationship during adolescence (ages 11-20) was used. Data were analyzed via thematic analysis. Fear was a consistent and resonant theme. Three types of fear were identified: fear for self, fear for other relationships, and fearful expectation. These results offer important insights into the impact of abusive adolescent relationships on women's mental health.

Chronic conditions among children admitted to U.S. pediatric intensive care units: their prevalence and impact on risk for mortality and prolonged length of stay*.

OBJECTIVE: To estimate the prevalence of chronic conditions among children admitted to U.S. pediatric intensive care units and to assess whether patients with complex chronic conditions experience pediatric intensive care unit mortality and prolonged length of stay risk beyond that predicted by commonly used severity-of-illness risk-adjustment models. DESIGN, SETTING, AND PATIENTS: Retrospective cohort analysis of 52,791 pediatric admissions to 54 U.S. pediatric intensive care units that participated in the Virtual Pediatric Intensive Care Unit Systems database in 2008. MEASUREMENTS: Hierarchical logistic regression models, clustered by pediatric intensive care unit site, for pediatric intensive care unit mortality and length of stay >15 days. Standardized mortality ratios adjusted for severity-of-illness score alone and with complex chronic conditions. MAIN RESULTS: Fifty-three percent of pediatric intensive care unit admissions had complex chronic conditions, and 18.5% had noncomplex chronic conditions. The prevalence of these conditions and their organ system subcategories varied considerably across sites. The majority of complex chronic condition subcategories were associated with significantly greater odds of pediatric intensive care unit mortality (odds ratios 1.25-2.9, all p values < .02) compared to having a noncomplex chronic condition or no chronic condition, after controlling for age, gender, trauma, and severity-of-illness. Only respiratory, gastrointestinal, and rheumatologic/orthopedic/psychiatric complex chronic conditions were not associated with increased odds of pediatric intensive care unit mortality. All subcategories were significantly associated with prolonged length of stay. All noncomplex chronic condition subcategories were either not associated or were negatively associated with pediatric intensive care unit mortality, and most were not associated with prolonged length of stay, compared to having no chronic conditions. Among this group of pediatric intensive care units, adding complex chronic conditions to risk-adjustment models led to greater model accuracy but did not substantially change unit-level standardized mortality ratios. CONCLUSIONS: Children with complex chronic conditions were at greater risk for pediatric intensive care unit mortality and prolonged length of stay than those with no chronic conditions, but the magnitude of risk varied across subcategories. Inclusion of complex chronic conditions into models of pediatric intensive care unit mortality improved model accuracy but had little impact on standardized mortality ratios.

Day-to-Day Decision Making by Adolescents and Young Adults with Cancer.

Background: Adolescents and young adults (AYAs) with cancer must negotiate the transition between childhood and adulthood while dealing with a life-threatening illness. AYA involvement in decision making varies depending on the type of decision and when decisions occur during treatment, and evidence suggests that AYAs want to be involved in decision making. Objective: To explore involvement of AYAs with cancer in day-to-day decisions affected by their cancer and treatment. Methods: This qualitative study used interpretive focused ethnography within the sociologic tradition, informed by symbolic interactionism. Semi-structured interviews and informal participant observation took place at two quaternary pediatric oncology programs. Results: Thirty-one interviews were conducted with 16 AYAs ages 15 to 20 years. Major day to day decision-making categories identified included: (1) mental mindset, (2) self-care practices, (3) self-advocacy, and (4) negotiating relationships. Participants described how they came to grips with their illness early on and decided to fight their cancer. They described decisions they made to protect their health, how they advocated for themselves and decisions they made about relationships with family and friends. Conclusions: Through day-to-day decisions, participants managed the impact of cancer and its treatment on their daily lives. Research should focus on developing and implementing interventions to empower AYAs to participate in day-to-day decisions that will affect how they manage their cancer, its treatment and ultimately their outcomes. Implications for Practice: Healthcare providers can facilitate AYA's participation in day-to-day decision making through encouraging autonomy and self-efficacy by providing support and through effective communication.

Strategies for sustaining high-quality pediatric asthma care in community hospitals.

OBJECTIVE: To identify strategies associated with sustained guideline adherence and high-quality pediatric asthma care in community hospitals. DATA SOURCES: Primary qualitative data from clinicians in hospitals across the United States (collected December 2019-February 2021). STUDY DESIGN: Pathways for Improving Pediatric Asthma Care (PIPA) was a national quality improvement (QI) intervention. In a prior quantitative study, data from 23 community hospitals in PIPA were analyzed to identify sites with the highest and lowest performance in sustaining improvements for 2 years. In this qualitative study, we conducted semi-structured interviews with multidisciplinary clinicians from these hospitals to identify strategies associated with sustainability. DATA COLLECTION/EXTRACTION METHODS: We purposefully sampled and interviewed participants involved in clinical care of children hospitalized with asthma at the identified hospitals (those with the highest/lowest sustainability performance). We transcribed and analyzed interview data using constant comparative methods. PRINCIPAL FINDINGS: Clinicians (n = 19) from five higher- and three lower-performing hospitals participated. In higher-performing hospitals, dedicated local champions more consistently provided reminders of evidence-based practices and delivered ongoing education. They also modified/developed electronic health record (EHR) tools (e.g., order sets with decision support). Higher-performing hospitals had a collaborative culture receptive to practice change and set firm expectations that evidence-based practices would be followed without exception. In lower-performing hospitals, participants described unique barriers, including delays in modifying the EHR and lack of automation of EHR tools (requiring clinicians to remember new EHR tasks without automated prompts). Barriers to sustainability for all hospitals included challenges with quality monitoring, decreasing focus of local champions over time, and ongoing difficulties developing consensus around evidence-based practices. CONCLUSIONS: To better ensure sustained high-quality care for children with asthma and greater returns on QI investments, QI leaders should prioritize: designating long-term local champions to continue reminders and educational efforts and developing electronic order sets to provide ongoing decision support.

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.

Relationships and betrayal among young women: theoretical perspectives on adolescent dating abuse.

AIMS: Adolescent dating abuse is not specifically described by any current nursing theory, and this article presents discussion of some existing theories that could inform a nursing theory of adolescent dating abuse. To account for the effects of gender, this discussion is limited to young women. BACKGROUND: Adolescent dating abuse is an important and understudied international issue for nursing. Theoretical frameworks can support development of nursing scholarship for such issues. No single theory yet exists in nursing to explain the experiences and health ramifications of dating abuse among young women. DATA SOURCES: A summary table of theories is provided. Literature was gathered via database search and bibliographic snowballing from reference lists of relevant articles. Included literature dates from 1982 through 2010. DISCUSSION: Theories of relationship formation and function are discussed, including attachment, investment, feminist and gender role conflict theories. Betrayal trauma theory is considered as a mechanism of injury following an abusive dating experience. IMPLICATIONS FOR NURSING: Gender, relationship and adolescence combine in a complex developmental moment for young women. To improve nursing care for those at risk for or in the throes of abusive relationships, it is critical to develop specific nursing approaches to understanding these relationships. CONCLUSION: Existing theories related to relationship and traumatic experiences can be combined in the development of a nursing theory of adolescent dating abuse among young women.

3 Dimensions of Treatment Decision Making in Adolescents and Young Adults With Cancer.

BACKGROUND: Adolescents and young adults (AYAs) experience treatment nonadherence rates as high as 60%, which can increase the risk of cancer relapse. Involvement of AYAs in treatment decisions might support adherence to medical treatment. OBJECTIVE: The aim of this study was to explore the involvement of AYAs, aged 15 to 20 years, in cancer treatment decision making (TDM). METHODS: Using interpretive focused ethnography, we conducted interviews with 16 AYAs (total of 31 interviews) receiving cancer treatment within 1 year of diagnosis. Participants reflected on a major recent TDM experience (eg, clinical trial, surgery) and other treatment decisions. RESULTS: Participants distinguished important major cancer treatment decisions from minor supportive care decisions. We identified 3 common dimensions related to AYAs' involvement in cancer TDM: (1) becoming experienced with cancer, (2) import of the decision, and (3) decision-making roles. The preferences of AYAs for participation in TDM varied over time and by type of decision. We have proposed a 3-dimensional model to illustrate how these dimensions might interact to portray TDM during the first year of cancer treatment for AYAs. CONCLUSIONS: As AYAs accumulate experience in making decisions, their TDM preferences might evolve at different rates depending on whether the decisions are perceived to be minor or major. Parents played a particularly important supportive role in TDM for AYA participants. IMPLICATIONS FOR PRACTICE: Clinicians should consider the AYAs' preferences and the role they want to assume in making different decisions in order to support and encourage involvement in their TDM and care.

Living-related donors' quest for information before donation.

CONTEXT: Providing potential living-related liver donors with all the necessary information before donation can be challenging. What information donors need and are not getting during the evaluation phase has not been defined. OBJECTIVE: To increase understanding of the everyday life of living-related liver donors and to suggest educational strategies that could be used by transplant centers during the evaluation process. DESIGN: An interpretive ethnographic study based on a symbolic interactionism approach. All participants were interviewed; some were reinterviewed in order to better understand their experience as a donor. SETTING: Interviews took place in the clinic, the donor's home, the donor's workplace, and in coffee shops depending on each donor's preference. PARTICIPANTS: A total of 13 parents who had donated the left lower lobe of their liver to their son or daughter at least 1 year ago. MAIN OUTCOME MEASURES: Interviews were analyzed by using qualitative research methods of coding, summarizing, and discussing concepts. RESULTS: The donors viewed the donation as a life-changing event, and 11 of 13 donors described seeking further information in addition to the information given to them by the transplant center. Searching the Internet, reading research articles, and speaking to other donors were activities demonstrated by the participants.

Facilitators and Barriers to Interdisciplinary Communication between Providers in Primary Care and Palliative Care.

BACKGROUND: Community-based palliative care (CBPC) plays an integral role in addressing the complex care needs of older adults with serious chronic illnesses, but is premised on effective communication and collaboration between primary care providers (PCPs) and the providers of specialty palliative care (SPC). Optimal strategies to achieve the goal of coordinated care are ill-defined. OBJECTIVE: The objective of this study was to understand the facilitators and barriers to optimal, coordinated interdisciplinary provision of CBPC. METHODS: This was a qualitative study using a constructivist grounded theory approach. Thirty semistructured interviews were conducted with primary and palliative care interdisciplinary team members in academic and community settings. RESULTS: Major categories emerging from the data that positively or negatively influence optimal provision of coordinated care included feedback loops and interactions; clarity of roles; knowledge of palliative care, and workforce and structural constraints. Facilitators were frequent in-person, e-mail, or electronic medical record-based communication; defined role boundaries; and education of PCPs to distinguish elements of generalist palliative care (GPC) and more complex elements or situations requiring SPC. Barriers included inadequate communication that prevented a shared understanding of patients' needs and goals of care, limited time in primary care to provide GPC, and limited workforce in SPC. CONCLUSIONS: Our findings suggest that processes are needed that promote communication, including structured communication strategies between PCPs and SPC providers, clarification of role boundaries, enrichment of nonspecialty providers' competence in GPC, and enhanced access to CBPC.

Treatment Decision-Making Involvement in Adolescents and Young Adults With Cancer.

PROBLEM IDENTIFICATION: Involvement in treatment decision making (TDM) is considered a key element of patient- and family-centered care and positively affects outcomes. However, for adolescents and young adults (AYAs) with cancer, little is known about the current state of knowledge about their perspective on and involvement in TDM or the factors influencing AYAs' TDM involvement. LITERATURE SEARCH: Integrative review focused on AYAs aged 15-21 years, their involvement in TDM, and factors influencing their involvement using the MEDLINE®, PsycINFO®, CINAHL®, and Web of Science databases. DATA EVALUATION: 4,047 articles were identified; 21 met inclusion criteria. SYNTHESIS: Five factors were identified. IMPLICATIONS FOR RESEARCH: Research is needed to understand AYAs' preferences for TDM, the type and degree of their involvement, and the interactions between factors that contribute to or impede TDM.