Background: Microaggressions are recognized as harm-producing insults and slights associated with increased anxiety, acute stress, and engagement in risky health behaviors (e.g., smoking, alcohol and drug use), however the extent and impacts on chronic stress and health are not fully understood. A mixed methods approach is being utilized to investigate the self-reported health effects related to racial microaggressions and stress among female African American and Filipino registered nurses (RN) using methods designed to elicit information aimed at understanding lived microaggression experiences from respondents’ perspectives but focused on impacts that may have long term stress and health implications. Methods: A mixed methods approach to investigate female African American and Filipino RNs’ microaggression experiences and the relationship to respondents’ self-reported stress and health was utilized. Through surveys and interviews, female African American and Filipino RNs shared racial microaggression experiences, coping mechanisms used to navigate those experiences, and the self-reported effects on stress levels and health. Via survey responses and personal narratives common microaggression experiences, coping techniques, and immediate and long-term effects of those experiences were identified. Implications: Studying lived microaggression experiences and self-reported effects on stress and health using a sequential explanatory mixed methods approach was important to understand not just racial microaggression experiences and effects on stress and health but the climate and context in which racial microaggressions were able to occur. The findings of this study may provide insights that contribute to information used to develop interventions which address needs of African American and Filipino RNs.

Background: Hospital budget constraints and re-allocation of resources have led to a decrease in nurse manager positions, increasing spans of control (SOC). Large SOC can have direct impacts on nurse engagement and clinical outcomes. Nurse managers in the organization with large SOC were overwhelmed by administrative functions that took them away from daily interactions with patients, families, and staff. Management roles and responsibilities were not clearly defined, resulting in role confusion and role blending. Wide ranging SOC were worsened by the varying levels of experience and competency among managers. Additionally, there was an increase in labor activity in the organization and a notable reduction in nurse participation in hospital surveys, with Press Ganey Nurse Engagement survey scores lower than national benchmarks.

Methods: This quality improvement project examined the feasibility of a nursing leadership structure and practice-based change. The project involved conducting a needs assessment and re-designing unit leadership structure to improve SOC. A thorough needs assessment, review of past performance in standardized benchmarking surveys, and review of the literature were

utilized in the leadership redesign. Baseline measurements were established for the organization to assess the effectiveness of the change. The measurements included: 1) Leadership Access and Responsiveness domain from Press Ganey Nurse Engagement survey; 2) nurse perception of unit management and work environment using a focus group approach and Qualtrics survey with pilot unit staff; 3) patient satisfaction scores; and (4) nurse sensitive indicators.

Results: Comprehensive needs assessment, SWOT analysis, nurse manager ratios, nurse sensitive indicator performance, and patient satisfaction scores suggested the need for quality improvement project to address the gaps in unit leadership.

Conclusion: A new leadership structure was designed and new manager position was created to improve SOC. Outcome measures that include nurse engagement, patient satisfaction, and nurse sensitive indicators were established. The best evidence suggests that smaller SOC is related to higher levels of nurse engagement and ultimately to improved patient safety and staff satisfaction. Redesigning the SOC model is essential to achieving improved nurse engagement and clinical outcomes.

Autism spectrum disorder (ASD) is a developmental disability that affects 1 in 54 children in the United States. This developmental disability impacts an individual’s behavior, communication patterns, and social interactions. ASD strikes 17.9 per 1,000 Asian American and Pacific Islander children in the United States. A dearth of knowledge exists about ASD within the Filipino American community. Shame and stigma related to ASD negatively affect how Filipino Americans perceive the developmental disability, and contribute to underreporting and delayed intervention.

Grounded theory was utilized to explore Filipino American cultural beliefs and perceptions about ASD, describe how Filipino American parents manage care for children and adults with ASD, and generate an explanatory framework about processes involved in Filipino American parental management of care for children and adults with ASD. Social constructionism was used as a theoretical framework and symbolic interactionism was used as a philosophical underpinning.

Research participants partook in a personal interview to capture cultural beliefs and perceptions about ASD using Kleinman’s Explanatory Model of Illness and explore parental management of children and adults with ASD. Demographic information and levels of acculturation and parent adjustment to illness were also collected. Coding processes, memos, reflexive journals, diagrams, and field notes were utilized for data analysis.

Eighteen participants enrolled in the research study. Traditional Filipino cultural values and generational differences influenced beliefs and perceptions about ASD. Causal beliefs of ASD were attributed to environmental factors, medical conditions, pharmaceutical products, prenatal events, genetic history, and/or superstitious beliefs. Management of ASD involved recognizing signs and symptoms of ASD, seeking help, learning about ASD, organizing daily schedules, integrating into social settings, de-escalating challenging behavior, incorporating self-care, worrying about the future, navigating cultural awareness, accepting the diagnosis, defining parenting role, and being an advocate.

Filipino American cultural beliefs and perceptions influence how ASD is understood, perceived, and managed. Integration of culturally tailored screening tools, educational programs, and interventions are essential to ensure that nurses provide comprehensive, holistic care for Filipino Americans with ASD. Raising awareness about ASD in the Filipino American community is necessary to further understand the developmental disability, which has no cure, throughout the lifespan.

High blood pressure, otherwise known as hypertension, is a major health issue for the American Indian population in the United States. Blood pressure can be described as the force of person’s blood pushing on the walls of their veins. Hypertension is a sustained high blood pressure over a long period of time, which can lead to many negative health outcomes. Hypertension is also strongly associated with other cardiovascular conditions, and may exacerbate those conditions further in an individual. The purpose of this research is to identify the prevalence of high blood pressure among American Indians/Alaska Natives (AI/ANs) in two counties in Southern California (Los Angeles and Orange), and to compare those numbers with the general population in the same region of the state. Findings conclude that AI/AN living in LA/Orange county have lower rates of high blood pressure than their rural counterparts in Southern California.

Abstract

As the eighth leading cause of death in the United States, pneumonia (PN) is relevant to the health of the elderly and the young. Accountability for readmission is part of the Affordable Care Act’s Hospital Readmissions Reduction Program (RRP), which levies penalty costs for readmissions. RRPs influence patients with pneumonia, accounting for over 1.1M discharges and comprising 18.5% of all readmissions. Since pneumonia is one of the targets of the RRP, this research proposes that purposeful communication using framing effects can motivate patients to make decisions with providers for care post discharge and can prevent readmissions. Communication strategies (CS), such as framing effects, are known to facilitate decision-making about health care choices. Framing effects as a method of reducing readmission have not been tested in the condition of pneumonia and the process of making decisions for care post discharge.

Specific Aims:

1. To compare the communication strategies (intervention) of framing effects (positive or negative messages) on the readmission outcome at 30 days post discharge.

2. To assess the extent pneumonia readmissions decrease at 30 days post discharge when communication strategies (CS) include the patient or family in decisions about transitions.

3. To determine the impact of agreement between patients and HCPs on recommendations for post hospital care.

4. To examine the potential confounding effects on the relationship between framing effects and readmission rates of age, pneumonia severity index (PSI), and the number of diagnoses.

Design and Data Analysis

This is a double-blind randomized control trial (RCT) with parallel assignment of pneumonia patients to one of three arms. The independent variable (IV) is the communication strategy (framing effects), and the dependent variable (DV) is the readmission. The sample randomized each group (N = 156); three participants were excluded: Intervention A: positive framing, n = 44, Intervention B: negative framing, n = 65, and control group, n = 44.

Conclusion: Findings suggest that framed messages aid in the reduction of pneumonia readmission rates in hospitals. The decision-making strategy incorporates education and understanding of risk by the patient, so the healthcare team can encourage and improve readmission outcomes.

The purpose of this study was to provide an analysis of the Indian Child Welfare Act of 1978 (ICWA), a landmark piece of legislation recognizing the exclusive jurisdiction of Indian tribes over the welfare of their children. This study used primary and secondary data to examine the historical events preceding the Act, the legislative history and implementation of the Act. The major problems with ICWA are twofold; there is no federal administrative body authorized to oversee ICWA implementation and compliance and there is no comprehensive and uniform collection of Indian child welfare data to measure the impact of ICWA. David Gil's social policy framework was used to analyze ICWA. The study found that although ICWA has been implemented for over 30 years, the lack of administrative oversight and compliance has impeded ICWA's objectives to reduce the overrepresentation of Indian children in child welfare systems and to place Indian children in Indian homes.

Racial color-blindness is a meritocratic ahistorical false belief surrounding the denial, minimization, and distortion of the existence of racism that has detrimental effects on health. Critical race theory effectively centered race for this analysis. Faculty of all races except African American/Black had higher racial color-blindness than students on all 3 of the following sub-concepts of the Color-Blind Racial Attitudes Scale: Unawareness of Racial Privilege, Institutional Discrimination, and Blatant Racial Issues. These are all disadvantages to student success and show that nursing faculty may not be optimally poised to speak on the social determinants of health. Findings also showed that Latina/o/Hispanic students and students of “All Other Races” were less aware of racial privilege than White and Black/African American students. Students with lower GPAs were less aware of racial privilege and those with higher GPAs were more racially color-blind on the sub-concept of Institutional Discrimination. The sample for this study, comprised of nursing students and nursing faculty in a selection of California Community Colleges across Southern California was much more diverse than those in other similar studies where the sample was comprised predominantly of White people. A cross sectional within-subjects descriptive research design was used. Participants completed the Color-Blind Racial Attitudes Scale. While the Everyday Discrimination Scale was completed to control for experiences of discrimination in their level of racial color-blindness, it did not show a statistically significant relationship. Of the faculty in the sample, 52% were non White compared to the national average of 15.9% non-White for nursing faculty. The findings related to first language and language spoken at home are a strong indicator of the high diversity of the sample. English was the first language for 58% of the students and 86% of the faculty. English was the language spoken at home for 73% of the students and 91% of the faculty, while 67% of students and 65% of faculty were born in the United States. The year 2020 had unique historical events surrounding the dual pandemic of COVID-19 and racism. The heightened sensitivity to racism and police brutality as a result of the murder of George Floyd surely had some influence on the data collected for this study. The results support interventions related to raising awareness about color-blind racial attitudes.

Statement of the Problem. Approximately 2.5 million individuals suffer traumatic injuries that demand admission to an acute care hospital. Safe, effective pain management is a priority of care for hospitalized patients receiving opioids for acute trauma-related pain. Opioids remain the primary approach for management of moderate to severe pain. The persistent use of an opioid-only approach to pain management is alarming given that an estimated 0.3% to 46% of hospitalized patients receiving opioids experience serious opioid-related adverse events, such as life-threatening respiratory depression. Opioid-induced respiratory depression (OIRD) among trauma patients hospitalized on general care floors had not been previously described. In this preliminary analysis the incidence and characteristics of OIRD monitored by continuous capnography and pulse oximetry, as well as, nursing assessment is reported. Methods. From July through October 2019 patients who presented to the emergency department following traumatic injury and admitted to general care floors were continuously monitored with bedside capnography and pulse oximetry for signs of respiratory depression. The Principal Investigator (PI), an advanced practice registered nurse with expertise in pain management and critical care, also assessed every patient within 5 minutes prior to opioid administration and every 10 minutes for 60 minutes thereafter. The adjusted Wald method was used to calculate the incidence of respiratory depression. STOP-BANG and PRODIGY risk scores were calculated. Time of admission to the ward and time of first OIRD were determined and displayed on a 24-hour radar plot for visual inspection of peak occurrence of events. Summary of findings. Nineteen patients were admitted for a traumatic injury to a general care floor and underwent continuous monitoring with capnography and pulse oximetry. Indications for admission were orthopedic trauma (n=15), chest trauma (n=3), or abdominal (n=1) trauma. Twelve patients required surgical management. High-risk STOP-BANG and PRODIGY scores were calculated for 5 (26.3%) and 8 (42.1%) patients, respectively. The median duration of monitoring was 7.0 [6.4, 7.4] hours. All patients received intravenous opioids in the emergency department and general care floors. Median morphine equivalents in the emergency department were 17.5 MME (IQR 24) and 18MME (IQR 24) for patients who later experienced >1 respiratory event on the GCF as compared to those patients who did not experience a respiratory event on the GCF. Median morphine equivalents (MME) on the general care floor were 7 MME (IQR 8) and 7 MME (IQR 3.5) for patients with >1 respiratory depression event or without, respectively. Respiratory depression was detected in 14 patients (incidence 71 [95%CI 50.9 – 88.6] cases per 100 patients) with apnea (n=12) and hypoxemia (n=10) the most detected abnormalities and hypopnea (n=5) and low expired end-breath carbon dioxide level (n=4) less common. The median time to first detected OIRD was 108 (24, 275) minutes. Majority of admissions were between 1600 and 2400 (n=9, 64%) and the majority of first OIRD episodes were from 1800 to 2400 (n=9, 64%). 42.8% (n=6) of respiratory events occurred prior to the administration of intravenous or oral opioids on the general care ward. Using the Pasero Opioid-Induced Sedation Scale, sedation was observed in 78% (n=11) of patients. Fifty percent (n=7) of respiratory events were recognized by the PI. No patient received an opioid receptor antagonist (naloxone) or was transferred to a higher level of care. Conclusion. These findings revealed that respiratory depression detected by bedside capnography and pulse oximetry was common among trauma patients hospitalized on general care floors. Importantly, OIRD typically was first observed early in the hospital course. Furthermore, respiratory depression and apnea were commonly recognized by changes in exhaled carbon dioxide (ETCO2) and oxygen saturation while undetected with nursing assessment. These results offer compelling evidence of the un-met need for continuous monitoring in this patient population.