Background: The Theory of Cultural Distress offers a framework for understanding the potential outcomes in patients who do not receive care that incorporates their cultural beliefs (DeWilde & Burton, 2017).This study represents initial steps in researching the theory byexploring the layering of stressors that place the patient at risk for Cultural Distress. Methods: Utilized aCross-sectional descriptive correlational analysis of intersecting identities (Structural Stressors), ethnicity-related stressors (Otherness) and ethnic-identity (Otherness) to develop understanding of the potential effects of these variables on psychological stress. Independent variables included intersecting identities, perceived ethnic discrimination, concern for stereotype confirmation, own group conformity pressure, and group membership. The dependent variable was perceived stress. Participants were also asked to define the word culture. Results: Stereotype confirmation concern, perceived ethnic discrimination, group membership, and own group conformity pressure were significantly associated with perceived stress. Intersectionality was not significantly associated with perceived stress but was significantly associated with perceived ethnic discrimination. Regression analysis revealed stereotype confirmation concern, own group conformity pressure, and group membership as significant predictors of perceived stress. Participant definitions of culture primarily fell under two themes, Collectiveness and Individualness, indicating that the way we live is highly influenced by our shared experiences, and also a product of individual choices. Discussion: Results indicated that structural stressors had no influence on psychological stress but were associated with perceptions of discrimination. The experience of otherness significantly influenced psychological stress. Additional research and tool development is needed to better understand how structural stressors may influence psychological stress.

Anesthesia is a health care specialty fraught with high workload demands, stressful work environments, increased production pressure, work areas with many distractions, an increasing use of advanced technology, and the constant need to prioritize work actions. Effective clinical judgment in this dynamic environment necessitates that the provider demonstrate the ability to project what may occur secondary to actual or potential condition changes. These key elements operationalize situation awareness (SA). High level SA is an important characteristic for the successful development of student registered nurse anesthetists (SRNAs). With Endsley’s “Theory of Situation Awareness” as the foundation, the goal of this study was to adapt and validate the “Situation Awareness Global Assessment Technique” (SAGAT), to quantify SRNAs' SA during a specific simulated anesthesia event. With IRB approval, purposeful sampling identified a group of CRNA, nurse educator subjects and an exploratory sequential mixed methods design utilized. Delphi methods during qualitative data collection and validation used a seven-member sample. Content analysis resulted in items for the adapted SAGAT. Quantitative methods utilized data collected from a second 40-member sample yielding item content validity and scale content validity indices (S-CVI/Ave. 0.92). Additionally, exploratory factor analysis provided further reliability with a Cronbach’s alpha of 0.937. Findings revealed that a SAGAT specific to the anesthesia domain and the SRNA subgroup was amenable to adaptation and validation, providing positive implications in SRNA education and training. Additionally, results support the further adaptation, validation, and use of this instrument in other anesthetic content areas, as well as other health care domains.

Hospital readmissions are a major burden for patients with end stage renal disease (ESRD). On average, one in three hospital discharges among patients with ESRD are followed by a readmission within 30 days. Currently, dialysis facilities are held accountable for readmissions via the ESRD Quality Incentive Program standardized readmission ratio (SRR) clinical measure. However, little is known about facility-level factors associated with readmission. Additionally, unlike other standardized measures of quality in the dialysis setting, incident patients within their first 90-days of dialysis are included in the performance calculation. This study analyzed CMS Dialysis Facility Report data from 2013 to 2016 to examine dialysis facility and incident patient factors associated with SRR using multivariate mixed models. Among 5,419 dialysis facilities treating 104,768 incident patients, the mean SRR remained stable across all four study years at 0.99. Factors significantly associated with a lower SRR (p<0.0001) included Western geographic region and higher patient care technician ratios. Several incident patient pre-dialysis nephrology care characteristics were associated with lower SRRs including higher percentages of patients with a fistula present at first dialysis treatment, higher percentages of patients receiving 6-12 months or greater than 12 months of nephrology care prior to dialysis and higher facility average hemoglobin. Factors significantly associated with a higher SRR (p<0.0001) included Northeastern geographic region, higher registered nurse ratios, higher percentage of incident patients, and higher facility average GFR. Understanding facility-level and patient-level factors associated with higher SRRs may inform interventions to reduce 30-day hospital readmission among patients receiving dialysis.

In 2010, men who have sex with men (MSM) represented 4% of the population in the United States (US) and accounted for 78% of all new Human Immunodeficiency Virus (HIV) infections among Hispanic men. Hispanic men who have sex with men (HMSM) accounted for the third largest number of new HIV infections (6,700 cases). This dissertation explored the effects of age, loneliness, substance use, depression, and social support on high risk sexual behaviors that predispose middle aged HMSM to sexually transmitted infections (STIs) and HIV infection risk. A sample of 150 urban HMSM aged 40 to 65 were surveyed in this study. Singer’s Syndemics Theory (1996) provided this study’s theoretical framework. Data was analyzed using a variety of parametric and non-parametric statistics. Loneliness, social support, depressive symptoms, alcohol/drug use, and sexual risk behaviors were found to have an influence on HIV infection status in this study. Partner status, religious affiliation and age did have an influence on alcohol use in this study’s participants. Also, participants with increased age had increased depressive symptoms in this study. Lastly, depressive symptoms, substance use, social support, and loneliness did have an influence on sexual risk behaviors in this study’s participants, specifically alcohol use and illicit drug use. The findings from this study should be used to assess, diagnose, plan, implement and evaluate prevention strategies geared to reduce STI and HIV infection in this population. Future research should build on these findings and develop tailored risk reduction interventions addressing HMSM, with particular attention to the understudied age group of the middle aged HMSM.

Purpose LGBTQ patients experience marginalization and discrimination when seeking healthcare in the Southern Region of the United States. As a result, they experience negative healthcare outcomes. Collecting sexual orientation/gender identity (SOGI data) is vital in decreasing health disparities and improving hospitalized LGBTQ patients’ quality of care. Providers cannot adequately assess health risk factors or deliver culturally competent care without SOGI data knowledge. Aims The aim is to collect SOGI data during intake to implement a standard of care to promote LGBTQ health outcomes and decrease marginalization. Processes To understand how to provide high-quality care to LGBTQ patients, providers receive instruction on the importance of collecting SOGI data and cultural competency training using the Gay and Lesbian Medical Association (GLMA) guideline. After IRB determined the project as not research involving human subjects, SOGI data questions (your current gender identity is and describe your sexual orientation) were added to the EHR demographic health history section. Provider adoption of collecting SOGI data is measured by extracting data from the EHR. Results Results will determine the providers’ responsiveness to implementing SOGI data questions into the EHR. Limitations Provider having a choice of collecting SOGI data, the small sample size of providers, and the project’s location are limitations. Conclusions LGBTQ individuals have more health inequities and face marginalization when accessing healthcare. SOGI data collection is essential for assessing health risk factors, improving health outcomes, and creating a safe and inclusive healthcare environment for LGBTQ patients.

The United States continues to be affected by a severe, long-standing nursing shortage that is not projected to resolve within the next 10 or more years. Unsuccessful passage of the National Council Licensure Examination for Registered Nurses (NCLEX-RN) among graduate nurses remains one of several key contributors to the nursing shortage. The goal of this study was to identify if either cumulative fall semester GPA; the overall prenursing science, mathematics, and English GPA; type of high school background; TOEFL score; clinical pass or fail; and on-time program completion best predicted passage of NCLEX-RN. Archived records from the academic years of 2006-2010 of students/graduates of a small, private BSN program were analyzed. A nonconcurrent, prospective design of secondary data was guided by the theoretical implications of the Seidman retention formula that surmises that early identification of academic problems is a necessary precursor to implementations that promote academic success. Significant, positive correlations were found between GPA of prenursing courses and achievement in clinical courses and on-time nursing program completion. Forward and backward, logistic regression procedures revealed that clinical performance was the strongest predictor of NCLEX-RN success but with an inverse relationship. Implications for positive social change include retention of BSN students to improve graduation rates. This ultimately will foster achievement on the NCLEX-RN, resulting in more graduates will be able to competently serve the health care needs of individuals and communities and alleviation of the nursing shortage.

Background: “Nurses provide essential care to the millions of people who are hospitalized each year as a result of illness or injury” (Smith, 2012, p. 172). The Institute of Medicine reported approximately 44,000-98,000 patients die annually resulting from a medical error, and health care errors ranked among the top 10 for the leading causes of death in the United States (Smith, 2012). Problem: Nurse competence impacts safe and quality nursing, and several research studies investigated the measurement of nurse competence among nurses in various nursing settings (Flinkman et al., 2016). However, a review of the research revealed limited studies in the emergency department (ED) setting and in the United States (O’Leary, 2012). Method: This study implemented a quantitative nonexperimental research design using the combination of an instrumental case study and a cross-sectional survey for this study’s sample. An Internet-based SurveyMonkey questionnaire collected data on nurse competence from registered nurses (RNs) working in the ED at a San Francisco Bay Area hospital. Part I of the questionnaire integrated Meretoja, Isoaho, and Leino-Kilpi’s (2004) Nurse Competence Scale (NCS) consisting of 73 closed-ended clinical indicators divided into seven competence areas. Participants rated their level of competence and frequency of use for each clinical indicator. Part II of the questionnaire obtained background information about participants. A total of 21 out of 110 potential participants completed the survey. Results: The data analysis using Statistical Package for Social Sciences (SPSS) provided descriptive and nonparametric correlation statistics. Descriptive statistics described survey respondents. The least and most competent areas were ensuring quality and managing situations, respectively. The most frequent length of nursing experience was at least 60 months and the most frequent number of hours worked was at least 65 hours per 2-week period. Nonparametric correlation statistics, including Kendell’s tau-b and Spearman’s rho, identified significant relationships. A significant relationship existed between the frequency of using clinical skills and level of competence for four of the seven competence areas. A significant relationship existed between the background factor of experience, both as an RN and an ED RN, and level of competence for many clinical indicators. A significant relationship existed between the background factor of hours worked and level of competence for one clinical indicator. Conclusion: Despite the small sample size of 21 survey respondents, this study revealed findings consistent with the existing research on nurse competence. This study offers implications and recommendations for practice relative to nurse competence, nurse competence assessment, and transitions to new settings of nursing practice to support the nursing profession and safe and quality nursing.

Aim. The aim of this study was to examine the relationship of advance care planning protocols with hospitalization, rehospitalization, and emergency department use rates in U. S. home health agencies (HHA). Background. Since 2003, CMS has required HHAs to report on quality outcomes such as hospitalization, rehospitalization, and emergency department use rates, made publicly available online. Advance care planning (ACP) is a conversation about beliefs, goals, values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on ACP have taken place outside of HHAs among populations with serious illnesses such as HIV/AIDS, cancer, dementia, and end stage renal disease. Meanwhile, the U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses. Effective January 1, 2016, the Center for Medicare and Medicaid Innovation implemented the Home Health Value-Based Purchasing (HHVBP) Model among home health agencies (HHAs) in nine states representing each geographic region in the United States. Agencies in these states began competing on value in the HHVBP model, and reimbursement rates began to be tied to quality performance (innovation.cms.gov). As part of HHVBP, CMS implemented an additional process-level mandate requiring them to report on ACP, though this data is not publicly available. It is currently unknown how ACP protocols in HHAs may affect agencies’ overall rates of acute care services use. Methods. Electronic surveys about ACP protocols were distributed to HHAs. Existing data about demographics, diagnoses, hospitalization, rehospitalization, and ED use were accessed online via CMS websites. Descriptive and regression analyses were conducted using the electronic survey results and the existing data. Results. Associations between the variables were observed and compared to the hypotheses. Statistical significance was found in the relationship between ACP protocols and hospitalization, where one increased the other increased. Several trends were found: Agencies with increased total percentage of cardiac and pulmonary diagnoses tended to have increased hospitalization rates; agencies with increased average age of patients tended to have increased ACPP scores; and agencies with increased proportion of Black patients tended to have higher hospitalization rates.

Regardless of the setting, medication errors are of great concern when associated with an individual’s health outcomes, along with the increased costs to society, healthcare institutions, and providers. Current research focuses on medication error data primarily in acute and extended care facilities. However, there is a paucity of research examining the causes of medication errors that occur post hospital discharge when individuals transition to the home. The purpose of this integrative literature review is to examine risk factors for medication errors outside of these settings, specifically in the home. A systematic literature search was conducted using multiple databases for relevant articles in the English language between 2006 to 2017, including CINAHL, MEDLINE, PubMed, and PsycINFO. Search terms included ‘medication errors’, ‘home care’, ‘post-discharge’, ‘hospital readmission’, and ‘medication error risks in the home’. Exclusion criteria included medication errors in acute and extended care settings. The integrative review involved reading, analyzing and selecting articles, and summarizing on a matrix. Findings on occurrences of medication errors in the home included impaired client mental status, confusion related to medication names, limited understanding of medication purpose in the care plan and its side effects, level of health literacy, and client-provider miscommunication in discharge planning. Consistent and conflicting findings are discussed along with gaps in the literature. Limitations and implications for nursing practice, policy, research, and education are also noted.

The primary purpose of this research was to examine the effects of HRT in women with acute estrogen deficiency from surgically induced menopause. The secondary purpose was to evaluate how HRT improves symptoms of acute estrogen deficiency and quality of life (QOL) in women using hormone supplementation. Peer reviewed articles published from 2000 to 2017 that were written in the English language with a focus on the use of HRT in women with acute estrogen deficiency after surgical menopause were evaluated for relevance. Evidence suggests the primary reason for decreased use of HRT is the associated risks outweighing the benefits; however, this is not reflected in health care provider's (HCP's) clinical experience. HCP's were more likely to prescribe HRT for themselves or family members if they were experiencing the negative side effects of estrogen deficiency due to surgical menopause, but not to women in their care with similar clinical manifestations of menopause. Additionally, serious risks associated with HRT for acute estrogen deficiency remain incongruent with HRT for women experiencing natural menopause; although risk for breast cancer due to HRT was a universal concern. Risks of HRT related to thromboembolism, stroke and heart disease, were discussed with comparison to the undesirable clinical manifestations of menopause. Results indicate further education and research is needed that explores the risks and benefits for HRT in women with sudden onset of estrogen deficiency from surgical menopause.