Nurse decision making and the prevention of adverse events

This study describes the cues and factors that influence the decision making process used by nurses when identifying and interrupting a potential adverse event in the acute care setting. The adverse event of interest was preventable in-hospital cardiopulmonary arrest. Research Questions: (1) What cues do registered nurses use to identify that a patient is at risk for an adverse event (cardiopulmonary arrest)? (2) What factors influence the registered nurses decision to interrupt an adverse event (cardiopulmonary arrest)? The study was supported by assumptions from the nursing role effectiveness model which highlights decision making as an independent role of the nurse. This was a qualitative study using the cognitive task analysis method of the Critical Decision Method. The Critical Decision Method (CDM), derived from the recognition primed decision model (RPD) and naturalistic decision making paradigm was used to elicit nurses decision making in the complex, high stakes, real time, and real world pre-arrest period. The following cues were used by nurses to identify risk for an adverse event: physiological data including subtle changes in mental status and trends in vital signs, and knowledge about the patient in terms of history, severity of illness, information from report and knowing the patient as an individual. Factors which affected interruption of an event included organizational resources such as independent use of monitoring equipment, personnel in terms of experience, teamwork and flexibility and knowledge including knowledge about the patient, knowledge from past experiences, and knowledge about the organization. The cues and factors revealed here are also influenced by macrocognitive perspectives inherent in the study setting. The nurses in this study operated from a perspective of maintaining patient safety while balancing organization expectations. Examination of these decision situations demonstrated the complexity of clinical practice and the many factors that affect nurse\u27s ability to identify and interrupt adverse events. This study demonstrated that the patient\u27s experience of illness, severity of illness and trends over time are useful in identifying risk of clinical deterioration. Teamwork and flexibility was evident among the unit nursing staff and across disciplines. When team members knew and trusted each other, they were better positioned to share decision making and adapt to rapidly changing conditions. Lastly this study demonstrated the importance of knowledge management as an organization resource

Barriers to implementation of STRIDE, a national study to prevent fall-related injuries.

Background/objectivesEvaluations of complex models of care for older adults may benefit from simultaneous assessment of intervention implementation. The STRIDE (Strategies To Reduce Injuries and Develop confidence in Elders) pragmatic trial evaluated the effectiveness of a multifactorial intervention to reduce serious fall injuries in older adults. We conducted multi-level stakeholder interviews to identify barriers to STRIDE intervention implementation and understand efforts taken to mitigate these barriers.DesignQualitative interviews with key informants.SettingTen clinical trial sites affiliated with practices that provided primary care for persons at increased risk for fall injuries.ParticipantsSpecially trained registered nurses working as Falls Care Managers (FCMs) who delivered the intervention (n = 13 individual interviews), Research Staff who supervised trial implementation locally (n = 10 group interviews, 23 included individuals), and members of Central Project Management and the National Patient Stakeholder Council who oversaw national implementation (n = 2 group interviews, six included individuals).MeasurementsA semi-structured interview guide derived from the consolidated framework for implementation research (CFIR).ResultsWe identified eight key barriers to STRIDE intervention implementation. FCMs navigated complex relationships with patients and families while working with Research Staff to implement the intervention in primary care practices with limited clinical space, variable provider buy-in, and significant primary care practice staff and provider turnover. The costs of the intervention to individual patients and medical practices amplified these barriers. Efforts to mitigate these barriers varied depending on the needs and opportunities of each primary care setting.ConclusionThe many barriers to implementation and the variability in how stakeholders addressed these locally may have affected the overall STRIDE intervention's effectiveness. Future pragmatic trials should incorporate simultaneous implementation aims to better understand how research interventions translate into clinical care that improves the lives of older adults

Smoking Protective and Risk Factors Among Transgender and Gender-Expansive Individuals (Project SPRING): Qualitative Study Using Digital Photovoice

BackgroundTransgender and gender-expansive (TGE) adults are twice as likely to smoke cigarettes than cisgender individuals. There is a critical gap in research on effective and culturally sensitive approaches to reduce smoking prevalence among TGE adults. ObjectiveThis study aims to qualitatively examine the risk and protective factors of cigarette smoking among TGE adults through real-world exemplars. MethodsWe conducted a digital photovoice study among a purposeful sample of 47 TGE adults aged ≥18 years and currently smoking in the United States (March 2019-April 2020). Participants uploaded photos daily that depicted smoking risk and protective factors they experienced over 21 days on either private Facebook or Instagram groups. Next, we conducted separate focus group discussions to explore the experiences of these factors among a subset of participants from each group. We analyzed participants’ photos, captions, and focus group transcripts and generated themes associated with smoking risk and protective factors. ResultsWe identified 6 major themes of risk and protective factors of smoking among TGE individuals: experience of stress, gender affirmation, health consciousness, social influences, routine behaviors, and environmental cues. We describe and illustrate each theme using exemplar photos and quotes. ConclusionsThe findings of this study will inform future community-engaged research to develop culturally tailored interventions to reduce smoking prevalence among TGE individuals

Don\u27t talk to them about goals of care : Understanding disparities in advance care planning

BACKGROUND: Structurally marginalized groups experience disproportionately low rates of advance care planning (ACP). To improve equitable patient-centered end-of-life care, we examine barriers and facilitators to ACP among clinicians as they are central participants in these discussions. METHODS: In this national study, we conducted semi-structured interviews with purposively selected clinicians from six diverse health systems between August 2018 and June 2019. Thematic analysis yielded themes characterizing clinicians\u27 perceptions of barriers and facilitators to ACP among patients, and patient-centered ways of overcoming them. RESULTS: Among 74 participants, 49 (66.2%) were physicians, 16.2% were nurses, and 13.5% were social workers. Most worked in primary care (35.1%), geriatrics (21.1%), and palliative care (19.3%) settings. Clinicians most frequently expressed difficulty discussing ACP with certain racial and ethnic groups (African American, Hispanic, Asian, and Native American) (31.1%), non-native English speakers (24.3%), and those with certain religious beliefs (Catholic, Orthodox Jewish, and Muslim) (13.5%). Clinicians were more likely to attribute barriers to ACP completion to patients (62.2%), than to clinicians (35.1%) or health systems (37.8%). Three themes characterized clinicians\u27 difficulty approaching ACP (Preconceived views of patients\u27 preferences; narrow definitions of successful ACP; lacking institutional resources), while the final theme illustrated facilitators to ACP (Acknowledging bias and rejecting stereotypes; mission-driven focus on ACP; acceptance of all preferences). CONCLUSIONS: Most clinicians avoided ACP with certain racial and ethnic groups, those with limited English fluency, and persons with certain religious beliefs. Our findings provide evidence to support development of clinician-level and institutional-level interventions and to reduce disparities in ACP

Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well-Being: The STRIDE Study.

Background/objectivesIn the Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study, a multifactorial intervention was associated with a nonsignificant 8% reduction in time to first serious fall injury but a significant 10% reduction in time to first self-reported fall injury relative to enhanced usual care. The effect of the intervention on other outcomes important to patients has not yet been reported. We aimed to evaluate the effect of the intervention on patient well-being including concern about falling, anxiety, depression, physical function, and disability.DesignPragmatic cluster-randomized trial of 5,451 community-living persons at high risk for serious fall injuries.SettingA total of 86 primary care practices within 10 U.S. healthcare systems.ParticipantsA random subsample of 743 persons aged 75 and older.MeasurementsThe well-being measures, assessed at baseline, 12 months, and 24 months, included a modified version of the Fall Efficacy Scale, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression scales, and Late-Life Function and Disability Instrument.ResultsParticipants in the intervention (n = 384) and control groups (n = 359) were comparable in age: mean (standard deviation) of 81.9 (4.7) versus 81.8 (5.0) years. Mean scores were similar between groups at 12 and 24 months for concern about falling, physical function, and disability, whereas the intervention group's mean scores on anxiety and depression were .7 points lower (i.e., better) at 12 months and .6 to .8 points lower at 24 months. For each of these outcomes, differences between the groups' adjusted least square mean changes from baseline to 12 and 24 months, respectively, were quantitatively small. The overall difference in means between groups over 2 years was statistically significant only for depression, favoring the intervention: -1.19 (99% confidence interval, -2.36 to -.02), with 3.5 points representing a minimally important difference.ConclusionsSTRIDE's multifactorial intervention to reduce fall injuries was not associated with clinically meaningful improvements in patient well-being

Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well‐Being: The STRIDE

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/166230/1/jgs16854.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/166230/2/jgs16854-sup-0001-Supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/166230/3/jgs16854_am.pd

Effect of a Multifactorial Fall Injury Prevention Intervention on Patient Well- Being: The STRIDE Study

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/166230/1/jgs16854.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/166230/2/jgs16854-sup-0001-Supinfo.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/166230/3/jgs16854_am.pd