Research suggests that infants with poor neck and upper torso muscle tone experience lateral slouching and a compromised airway when placed in the semi-upright seating position. Studies reveal that 4-60% of premature infants (born at less than 3-7 weeks gestation) may experience oxygen desaturation events when in their child safety seats (CSS), potentially resulting in adverse neurodevelopmental outcomes. Therefore, the American Academy of Pediatrics recommends that premature infants be tested in their CSS prior to hospital discharge. However, neonatal healthcare providers are concerned that this method of testing might not be reliable. No formal studies have investigated the outcomes of repeat testing of premature infants, and little is known about the risk factors for oxygen desaturation events. Therefore, the purpose of this descriptive, non-experimental, observational study was to explore the stability of the one-point Infant Car Seat Challenge (ICSC) and risk factors that may be associated with oxygen desaturation events. A sample of 49 premature infants was used to explore the following variables: 1) pass/fail rates following two (ICSC) observation points, 2) oxygen saturation and desaturation patterns, sleep/wake activity, and a measure of head lag (using the pull-to-sit maneuver) during two ICSCs, and 3) the association between head lag, chronological age, time spent sleeping in the CSS and oxygen desaturation events. Data were analyzed by descriptive and nonparametric statistical tests. This study's findings indicated that 86% of premature infants had stable results, 8% passed rcsc 1 but not ICSC 2, and 6% failed ICSC l and passed ICSC 2. In addition the odds for oxygen desaturation events increased in infants that are born at a gestational age ≤ 34 weeks, were discharged home at a chronological age of > 7 days and had a corrected gestational age of ≤ 37 weeks. Neither head lag or sleep time influenced the ICSC outcomes. Furthermore the ICSC success rate for identifying at risk infants was equal to or better than that of other screening tests for newborn medical conditions. These findings will assist neonatal healthcare providers in making appropriate recommendations for safe travel.

Substance abuse is a relapsing chronic illness. In 2014, an estimated 27 million persons reported using illicit drugs in the United States (SAMHSA, 2014). Substance abuse negatively impacts societies, productivity, healthcare costs and families. Families play an important role in relapse prevention and sobriety. With adequate family support, substance abuse positively responds to treatment. Many individuals (about 66 million Americans) play the role as an informal caregiver for a relative with chronic illnesses such as substance abuse but few studies exist on the caregiving experiences. What we know about the family caregiving experience is restricted to data from quantitative studies which do not explain the complexities and competing challenges that exist. Different approaches are thereby needed to deepen our understanding of the family caregiver burden of living with a relative with substance abuse problems. Such studies will enable us to understand the original experience and moment of learning of a relative’s substance abuse problems, decision making and support that follows thereafter. This moment calls for major decision making and encounter with treatment services. The purpose of this study was to explore the lived experience of caregivers of relatives with alcohol and opiate dependence. This study utilized Max van Manen’s (2014) Phenomenology of Practice. Ten participants (N=10) were recruited for this study. Van Manen’s guided existential inquiry was used in the analysis of experiential material collected through interviews. Four main themes emerged from the data: (1) Being in the moment: the extension of the self; (2) The dawn of reality: the being of acceptance; (3) Deciding in the moment: the healthcare experience; (4) Uncertainties and struggle: a lifelong process. These themes described how the participants: experienced, accepted and processed a relative’s substance abuse problem, encountered treatment services and experienced the uncertainties and struggles involved in caring for a relative with substance abuse problems. Two main findings emerged from these themes; the impact of guilt and stigma on seeking care and the need to see addiction as a disease instead of as a moral character failure. This calls for coalitions with stakeholders to decrease stigma, enhance acceptance process and increase access to treatment.

Chronic obstructive pulmonary disease (COPD) has been recognized as a leading cause of mortality in older adults involving acute exacerbations as life-threatening events that lead to frequent hospitalization for care. Informal caregivers have been essential to helping older adults with COPD during an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). A lack of empirical knowledge exists regarding the experience of informal caregivers of older adults with AECOPD in situation awareness for recognizing, understanding, and responding to an AECOPD in an emergent situation. This qualitative descriptive study explored situation awareness and its components of perception, comprehension and projection of next steps, including the caregiver’s confidence level during the AECOPD event. Fifteen informal caregivers, ages 31-77 years (mean age 48), who provided care for older adults with COPD were interviewed from an underserved community health center. The overarching theme derived from this study was something was wrong and something needed to be done. Subthemes emerged as a heightened sense of awareness, caregiver tipping point, planning next steps, caregiver confidence, and caregiver commitment. This study utilized situation awareness theory as a relevant guiding framework in exploring the experience of lay informal caregivers caring for older adults with AECOPD events. Study findings provided a description of the complex processes involved, including confidence level, for informal caregiver’s in situation awareness to recognize and respond to an AECOPD event in the older adult. Future targeted interventions need to address strategies to enhance individualized care for older adults with AECOPD events for managing care at home.

BACKGROUND: Breastfeeding and lactation are cited as sensitive periods in the life course that contribute to the accumulation of risks or opportunities ultimately shaping vulnerability or resilience later in life. As such, breastfeeding and lactation are critical components of health equity. Despite this, Black women in the U.S. initiate and continue to breastfeed at lower rates than White women and other groups. Underlying reasons for racial inequities in breastfeeding rates are poorly understood. Exposure to racism, one manifestation of historical oppression in the U.S. has been cited as a determinant of poor health outcomes for decades but has not been extensively described in the context of breastfeeding. AIMS: To investigate the association between experiences of racism and 1.) breastfeeding initiation 2.) breastfeeding duration 3.) and the association between selected life-course factors and breastfeeding initiation and duration among participants of the Black Women’s Health Study. METHODS: This study was a prospective secondary analysis of the Black Women’s Health Study. The sample included all participants who enrolled in 1995, responded to the racism assessment in 1997 and reported the birth of a first child following the racism assessment resulting in an N=2, 995 for the initiation outcome and N= 2,392 for the duration outcome. In addition to the racism assessment, we also included life-course factors (nativity, neighborhood segregation and social mobility). For each aim, we calculated odds ratios and 95% confidence intervals using binomial and multinomial logistic regression using two models. The first adjusted for age, the second adjusted for age, BMI, education, marital status, geographic region, neighborhood SES and occupation. RESULTS: Associations between daily and institutional summary racism variables and breastfeeding initiation and duration were small and not statistically significant. Experiences of racism in the job setting was associated with lower odds of breastfeeding duration at 3-5 months compared with 3 months 95% CI [0.60, 0.98]. Experiences of racism with the police was associated with higher odds of breastfeeding initiation and duration at 3-5 months [1.01, 1.77] and at 6 months [1.10, 1.82] compared with women who did not report this experience. The participant’s nativity and the nativity of her parents were life-course factors that predicted lower odds of breastfeeding initiation and duration. Neighborhood segregation did not reach statistical significance after adjusting for covariates but results trended toward lower odds of breastfeeding initiation and duration for women who reported living in a predominately Black neighborhood (compared with White) up to age 18 and for women who reported living in a predominately Black neighborhood in 1999. CONCLUSION: Experiences of institutional racism in the job setting was associated with lower odds of breastfeeding duration. In addition to explicit experiences of racism, this study provides preliminary evidence surrounding life-course factors and breastfeeding. Individual level interventions may mitigate harmful effects of racism but structural level interventions are critical to close the gap of racial inequity in breastfeeding rates in the U.S.

Hepatitis C virus (HCV) infection affects between 150,000 to 300,000 human immunodeficiency (HIV) positive adults in the US (Alter et al., 1999; Sherman, Rouster, Chung, & Rajicic, 2002). The majority of co-infected adults (50%-90%) have acquired HCV through substance abuse (Centers for Disease Control [CDC], 1998; CDC, 2006b). A patient's decision to begin HCV treatment is not straightforward. HCV evaluation and treatment involves a significant amount of time, energy, effort, and compliance on the part of the patient. There is limited information on how adults with HCV mono-infection make decisions about HCV evaluation and treatment (Fraenkel, McGraw, Wongcharatraee, & Garcia-Tsao, 2005). Even less is known about how adults with HIV/HCV co-infection with a history of substance abuse make treatment decisions. The purpose of this study was to describe substance abuse experiences and to explore how these related to patient decision-making about HCV treatment in HIV/HCV co-infected adults. Qualitative descriptive design and secondary data analysis were used to study these phenomena. Data were managed by using NVivo software and analyzed by secondary data analysis and qualitative content analysis. Five major themes with sub-themes emerged during the data analysis. They were: (1) The Evolution of Substance Abuse (with sub-themes: substance abuse initiation, escalation, polysubstance abuse, normalcy: a family of addicts, the enemy within, and transmission and disclosure), (2) Revolving Door: Going Back Out (with sub-themes: specific events as a trigger, emotions as a trigger, alcohol as a trigger, and destructive relationships as a trigger), and (3) Reconstructing Life (with sub-themes: defining moments in substance abuse addiction and maintaining sobriety), (4) HCV Infection Treatment Issues (with sub-themes: HCV treatment: not a priority, fear, and misinformation, and desire to use stimulated during HCV treatment), and (5) Get Clean and Try It. The participants spoke about how their substance abuse evolved from inception to sobriety, and for some it remained a problem. Relapse and recovery were fragile in nature especially in these adults with HIV/HCV co-infection. The decision-making process is influenced by substance abuse experiences, however more research is needed to uncover specific factors influencing these decisions.

Nurses have a key role in keeping patients safe from medical errors because they work at the point of care where most errors occur. Nursing work at the intersection of patients and health care systems requires high levels of cognitive activity to anticipate potential problems and effectively respond to rapidly evolving and potentially harmful situations. The literature describes nursing work at the intersection of patient and health care system as well as barriers to providing safe patient care. However, little is known about the systems knowledge nurses use to negotiate the health care system on their patients’ behalf, or how this systems information is exchanged between nurses. Using the clinical microsystem as the conceptual framework, this qualitative descriptive investigation identified and described: 1) the components of systems knowledge needed by nurses, 2) how systems information is exchanged between nurses, and 3) systems information exchanged between staff nurses and travel nurses. Data were collected from a stratified maximum variation sample of 18 nurse leaders, staff nurses, and travel nurses working within a high-functioning neonatal intensive care nursery within a large academic medical center in New England. Data collection methods included participant observation, document review, individual interviews, and a focus group session. Data were analyzed through constant comparison for emerging themes and patterns. Findings were compared for commonalities and differences within and across groups. Three components of systems knowledge emerged: structural, operational, and relational. Systems information exchange occurred through direct and indirect means. Direct means included formal and informal mechanisms. The formal mechanism of orientation was identified by each participant. Informal mechanisms such as peer teaching, problem solving, and modeling behaviors were identified by participants from each of the three nurse groups. Travel nurses’ descriptions of the common themes focused on individual efficacy. Staff nurses focused on fostering smooth unit functioning. Nurse leaders described common themes from a perspective of unit development. Four overarching domains of systems information were exchanged between staff nurses and travel nurses: practice patterns; staffing patterns and roles; tips, tricks, tidbits, and techniques; and environmental elements. Communication emerged as a common theme across nurse groups and domains of systems information exchanged. These findings have implications for nursing orientation and staff development, continuous improvement at the local level, and curriculum development.

Human patient simulation (HPS) has been used for over 40 years in medical education. A human patient simulator is a life-like, anatomically correct, computer driven mannequin with physiologic responses that mimic real patients. Since the introduction of computerized HPS in 2000, its use by medical and nursing students has grown exponentially. Approximately 500 nursing schools are using human patient simulators in nursing education. Researchers have suggested that using HPS can assist in reducing the gaps between theory and practice by improving critical thinking, decision making and patient outcomes. An increase in recognition of medical errors has dictated the need to improve education by allowing students and clinicians to learn in an environment that permits errors and do not put real patients in danger. However, there is a dearth of research on the benefits, advantages and disadvantages of HPS as well as the learning experiences of students who used HPS in their nursing education. Therefore, the purpose of this qualitative study was to describe and analyze the learning experience of baccalaureate nursing students who used HPS during their education. Focus group interviews with HPS students were recorded and transcribed for content analysis in NVIVO, a qualitative analysis software program. The results of the analysis were categorized into four major themes: Structure, Environment, Instructor and Learning. The findings revealed that HPS students felt that structure was critical to optimize learning opportunities. Students wanted to be properly oriented to the environment of the HPS sessions, and they felt that the lack of realism of the simulators did not negatively affect their learning. Students wanted knowledgeable and competent instructors who had good interpersonal communication and interaction skills. Last, students expressed that there were benefits from acting as both the nurse and the observer during HPS. The opportunity to make mistakes without harming a patient and to experience different types of nurse-to-nurse reports were viewed as positive. The findings of the study suggested that further research about student perceptions of HPS learning experiences could provide valuable information for educators and policymakers to improve the implementation of HPS in nursing and medical education.

Nurses are often the first members of the health care team with whom patients interact. The initial impression of the nurses’ receptiveness to the patients’ needs influences the patients’ views of their overall care. Researchers have suggested that understanding communication between individuals can provide the human link, or social element, to the successful implementation and use of electronic health records, including documentation (Lanham, Leykum, & McDaniel, 2012). Zadvinskis, Chipps, and Yen (2014) identified that the helpful features of bedside documentation systems were offset by the mismatch between the system and nurse’s workflow. The purpose of this micro-ethnography study was to explore the culture of nurse-patient interaction associated with electronic documentation at the bedside. Data were collected through passive participant observation, audio-taping of the nurse-patient interactions, and informal and semi-structured interviews with the nurses. A total of twenty-six observations were conducted on three nursing units at an urban healthcare facility in New England. These three units were occupied by similar patient populations and all patients required cardiac monitoring. Three themes consistently emerged from qualitative data analysis: the nurses paused during verbal communication, the nurses played a game of tag between the patient and the computer, and the nurses performed automatic or machine-like actions. The participants described these themes in the informal and semi-structured interviews. The nurses’ actions were observed during passive participant observation, and the audio-taped interactions supported these themes. Understanding the adaptation of caregiving necessitated by bedside electronic documentation will have a positive impact on developing systems that interface seamlessly with the nurses’ workflow and encourage patients’ active participation in their care.

The characteristics of nurses acting as organizational champions, as well as the ways that clinical leaders systematically harness the energy of these champions in support of innovation, were explored in this qualitative descriptive study. The specific aims were guided by prior empirical evidence and identified research needs. Semi-structured interviews were conducted with 14 formal nursing leaders (e.g. managers, educators, administration) in an academic medical center. This study, including the interview guide, was informed by Kouzes and Posner’s (2007) Five Practices of Exemplary Leadership. Two models were developed to describe the data. Overall, participants echoed prior empirical findings identifying a need for organizational champions’ support of innovation and explained how some nurses seem to have “innate” characteristics that make them champions. Participants identified the champion as the “go to” person who can see the bigger picture and who seems to “own their own practice”. They described the importance of being truly present on the unit in order to harness the energy of these champions. Once champions are identified, leaders match the champions’ talents to the innovation planned, secure buy in from the champions, and actively work to support champions and get a culture of innovation “in the drinking water.” This work enhances the leader’s experience and makes him/her feel inspired and engaged. The two models developed based on the participants’ description of their experience working with staff nurses acting as organizational champions provide a framework for clinical leaders to identify and engage organizational champions in their clinical areas in support of innovation.

The purpose of this study was to explore the feasibility of using human patient simulation (HPS) to teach Type 1 diabetes (T1DM) management to grandparents of grandchildren with T1DM. Thirty grandparents (11 male, 19 female) of young grandchildren (aged 12 and under) with T1DM were recruited from an urban medical center. Experimental group (n = 14) grandparents received hands-on visual T1DM management education using an HPS intervention, and control group (n = 16) grandparents received similar education using a non-HPS intervention. Post-intervention, researchers interviewed twelve grandparents (50% HPS, 50% non-HPS) who scored highest and lowest on the Hypoglycemia Fear Survey. Using a mixed-method design, researchers integrated study instrument data and post-intervention interview data to describe grandparent’s experience learning T1DM management. Post-intervention, grandparent scores for knowledge, confidence, and fear showed no significant difference by group assignment, however, all grandparent scores showed improvement from Time 1 to Time 2. Grandparents described how taking part in T1DM education heightened their awareness of T1DM risks. GP T1DM knowledge gains aided GPs to make sense of T1DM risks. Newfound T1DM knowledge enhanced GP T1DM management confidence. Improved T1DM knowledge and confidence helped to defuse T1DM management fear. Although study instruments did not measure significant difference between grandparents who received the HPS intervention and those who did not, the consistency of larger HPS-taught grandparent score improvement is suggestive of a benefit for HPS.