Sue & Bill Gross School of Nursing

Moral injury increasingly describes the distress nurses experience when systemic constraints prevent them from practicing in alignment with their professional values. Moral injury has been theoretically presented as an injury to one’s identity. Professional identity in nursing is “a sense of oneself in relationship to others” which results in an individual “thinking, acting, and feeling like a nurse.” This scoping literature review explores contemporary understandings of nursing professional or moral identity and the association between moral injury and identity among nurses in the United States.

Occupational burnout and moral injury are related, but distinct, processes with operational and relational drivers. This scoping literature review examines one key relational driver of burnout and moral injury: values conflicts between nurses and their organizational leadership. This review included a five-database search, which produced 346 citations for full-text review. Preliminary results have identified 11 relevant citations: 8 journal articles, 2 journal-published expert opinions, and 1 qualitative dissertation study. All references examined some aspect of leadership in relation to burnout and discussed values conflicts; only one investigated moral injury in relation to leadership structures and values conflicts. Six sources explicitly found that perceived differences in values between administrators and clinicians may contribute to burnout. One article discussed the betrayal of nurses' moral values by leadership in connection with moral injury. Implications suggest a potential for organizational leadership and administration interventions that address values conflicts to combat burnout, moral injury, and their myriad negative downstream consequences. These results also implicate a need for further research to better understand how nurses come to experience values conflicts in relation to their organizational leaders and administrators.

This project seeks to: (1) better understand the concept of occupational moral injury (MI) as it relates to moral distress (MD) and burnout (BO), and (2) improve the understanding of occupational MI in healthcare settings, such that healthcare systems may better develop strategies for MI assessment, prevention, and mitigation. Based on Walker and Avant's (2019) methodology, this concept analysis of occupational MI in healthcare describes the antecedents, defining attributes, and consequences of MI in relation to MD and to the oft associated phenomenon of BO. Our findings reveal a highly interconnected network of related concepts that can intensify each other and that are not mutually exclusive. MI, MD, and BO have shared antecedents and overlapping consequences that can render their delineation challenging. MI, MD, and BO in healthcare contexts all share the attribute of capturing experiences of clinician distress with varying sources, intensity, and chronicity. MI and MD introduce ethical tones to clinician distress and capture the effects of moral dissonance related to constrained moral agency and disempowerment. We suggest 3 necessary and sufficient conditions for defining occupational MI in healthcare (2 ""moral"" antecedents and 1 ""injury"" consequence): (1) a clinician's often-appropriate commitment to the expected moral responsibilities, principles, and values of their profession, and (2) a recognition of suppressed moral agency and compromised integrity from a forced violation of those principled commitments, coupled with (3) the consequence of significant and profound distress from such recognized moral violation. In short, MI in healthcare captures the injury of possessing moral responsibility while lacking commensurate moral agency. Better understanding the avoidable antecedents that drive MI is critical for guiding targeted pre-exposure mitigation efforts and solutions that proactively address this problem. We emphasize the need for preventative actions directed toward avoidable drivers of MI.

Introduction: Orgasm is a significant indicator of fulfillment or the centerpiece of sex. Even though women are physiologically capable of experiencing multiple orgasms due to no refractory period, research has repeatedly shown that, in heterosexual sexual interactions, men experience orgasms more frequently than women. In many cultures, the talk of sex, orgasms, masturbation, self-exploration, or sexual pleasure is still outlawed or frowned upon. Sexual pleasure and satisfaction are inherent components of the human sexual experience; nevertheless, these fundamental aspects of sexuality are rarely highlighted in sexual education programs. Consequently, sexual dysfunction and sexual health are not addressed in clinical, educational, social, cultural, or personal settings. Aim: The purpose of this project was to create orgasm awareness and to improve female sexual function and sexual assertiveness in women of reproductive, premenopausal, and menopausal age within a South-Asian women's organization. Methods: A pre-and post-intervention design was utilized and included: 1) a single in-person/ live video conference two-hour sex education session covering the topics of female anatomy, orgasm, the gendered orgasm gap, and Kegel exercises training, 2) an informative infographic flyer designed for the attendees of the sex education session to view privately and 3) a follow-up phone call by the project leader during week two meant to answer queries and reinforce teaching. Orgasm awareness and sexual assertiveness were measured using the Female Sexual Function Index-Modified (FSFI-Modified) scale and Sexual Assertiveness Questionnaire (SAQ). Results: After eight weeks, sexual assertiveness, as measured by SAQ, increased from M=86.68 to M=93.92 (p=0.002) in the in-person intervention group and M=79.19 to M=86.52 (p=0.005) in the video-conference intervention group. After eight weeks, FSFI-Modified improved from 40.6 to 43.28 (p=0.09) for the in-person intervention group. In the video-conference intervention group, the overall FSFI-Modified scores at eight weeks significantly enhanced from 33.29 to 38.24 (p=0.05). Participants reported, “I wish I had learned about all this 20 years ago!” Implication and Conclusion: In this population of South-Asian women with a conservative cultural background, which generally promotes modesty, the education session presented enhanced orgasm satisfaction and sexual assertiveness, thus positively affecting their lives and opening conversations within their families.

Background: Autism spectrum disorder (ASD) is diagnosed in early childhood and affects 1 in 68 children in the United States. ASD often creates deficits in social functioning making it difficult for children with ASD to socialize and communicate with others.

Purpose: The purpose of this review paper is to examine the effectiveness of therapeutic horseback riding (THR) on communication and social skills in children with ASD.

Methods: Articles were selected from the databases CINAHL and PubMed and were published within the last 10 years in the United States and Europe. Search terms included ASD, children, and THR. Studies with samples sizes of ten or less were excluded.

Results: Inconsistent results were found for two of the studies that used the Social Responsiveness Scale; one study found statistically significant results for improved social motivation when compared to the control group (p = .038) while another study found a significant improvement for social cognition compared to the control group (p= 0.05). The remaining outcomes tested amongst the studies were not significant.

Conclusion: Current research does not fully support the efficacy of THR on communication and social skills for children with ASD. Therefore nurses do not have enough evidence to recommended this approach to families that have a child with ASD. Future studies should be conducted using larger sample sizes so the ASD population is well represented. With more research, the findings will hopefully serve to facilitate the assimilation of this population into society.

Background: Mechanically ventilated patients in the ICU are at a high risk for ventilator-associated pneumonia (VAP), and the rate of this hospital-acquired infection (HAI) is problematic. Nursing interventions utilize evidence-based practice (EBP) VAP prevention guidelines to decrease the incidence. The purpose of this paper is to examine the effects of staff education on the reduction of VAP in the critical care setting.

Methods: Literature search was performed on two databases, CINAHL and PubMed. Search results were narrowed based on type of research article, relevance, and publication date, and eventually three studies were chosen.  

Results: In two of the studies, VAP incidence was shown to have decreased after staff education and one study had insignificant results, although there was a trend towards decreased VAP incidence. Length of stay significantly decreased post-intervention in two studies. Nurse adherence/concordance significantly increased in all studies.

Conclusions: These findings show that staff education may decrease VAP incidence in ICUs, but further research needs to be performed to confirm these findings, as well as to determine the best form of education. Nurses are the primary individuals to prevent mechanically ventilated patients from acquiring VAP, and thus the next step would be focusing on how to improve long-term nurse adherence to preventative interventions and how to implement them into bedside practice.

Dementia, a progressive cognitive impairment, is the fifth leading cause of death in California with no effective treatments. This disease not only affects those diagnosed but also affects their family caregivers who experience intense emotional and physical strain. Despite this immense stress, there is an insufficient number of interventions focused on the well-being of these family caregivers. The purpose of this pilot study is to provide a mindfulness-based stress reduction intervention to family caregivers. Trained research assistants visited participants’ homes weekly for a month and introduced mindfulness techniques (i.e., deep breathing exercises, caregiving education). A modified version of the Positive Affect (PA) and Negative Affect (NA) Scale was used to measure caregivers’ emotions before and after the intervention. Twenty participants were recruited from Vietnamese and Korean communities, an Alzheimer’s research center, and an academic medical center. The mean age of family caregiver participants was 62.5(SD=4.98) ranging from 26 to 82 years old, of which 19 (95%) participants were females and 10 (50%) were spouses. Ethnic backgrounds of participants varied: 9 Vietnamese, 7 Korean, 3 Caucasian, and 1 African American. The stages of dementia included those in the early (35%), middle (50%), and late-stage (15%) stages. Our findings showed a trend of increase in positive affect (Pre-intervention=16.25 (SD=4.67), Post-intervention=17.45 (SD=4.05), t(df)=-1.45(19), p=.163) and decrease in negative affect, (Pre-intervention=5.9 (SD=2.97), Post-intervention = 4.95 (SD=1.28), t(df)=1.57(19), p=.133). Self-rated happiness displayed slight improvement (Pre-intervention=4.10 (SD=.912), Post-intervention=4.35 (SD=.745), t(df)=-1.23(19), p=.234). The mindfulness intervention showed the potential to improve dementia family caregivers’ emotional wellbeing.

Introduction: Infants in the NICU often suffer from physiologic stress related to bradycardia, apneic spells, and oxygen desaturations. This review analyzes the effect of KC on the frequency of cardiopulmonary events.

Methods: Databases utilized include PubMed, Google Scholar, and CINAHL. These papers were selected based on their publication in the last ten years, and focus on examining effects of skin-to-skin care on the NICU infant as measured by the infant’s physiological stability.

Results: All three studies showed that infants in the treatment groups had a significantly decrease in bradycardic events compared to control group. Two studies found that infants in the treatment group had significantly fewer oxygen desaturations while being held skin-to-skin versus the time they spent in the warmer.

Discussion: The studies used high fidelity of intervention, and two of the three used randomized controlled trails designs. The small sample size of the studies was a weakness and warrants further research.

Conclusion: Nurses should develop policies for increased encouragement for kangaroo care for preterm infants in NICUs.

Introduction: The Nurse Family Partnership (NFP) attempts to combat the lack of resources and knowledge in high-risk families and women who are pregnant for the first time. This paper assesses the effect of the NFP on child development.

 Methods: Google Scholar, CINAHL, PubMed, and Trip were used to conduct a literature review. Articles chosen were randomized control trials and involved implementation of the NFP with a longitudinal follow-up of the children.

 Results: Two out of three studies demonstrated that the NFP positively affected academic success of the children; two out of three studies demonstrated that children who received the intervention had less emotional/behavior issues.

 Discussion: All studies were randomized control trials without dropout. Studies utilizing objective data had more accurate results than those utilizing self-report. There was a discontinuity of care in one study and no way to measure visit content and conduct in any of the studies.

 Conclusion: Results were most pronounced in low-resource and school-age children. Nurses should recruit high-risk clients and advocate for programs such as the NFP. Further research should strive to standardize measurements, include additional follow-ups, and consider pregnancy and parental outcomes.

Background: Type 2 diabetes is a growing problem across the world. Diabetes leads to increased levels of hemoglobin A1c (A1C), and if left untreated, can lead to further chronic disease. This review examines the effectiveness of group-based diabetes self-management education (DSME) on lowering A1C levels and increasing diabetes knowledge.

Methods: Databases used for this review include PubMed, CINAHL, Google Scholar, and Web of Science. The three studies chosen for this review include two randomized controlled trials (RCT's) and one quasi-experimental study, which were peer-reviewed and published in the past 5 years.

Results: All studies demonstrated a slight decrease in A1C levels; however, one study found a significant decrease between pre-and-post intervention (p<0.0001). The two RCT's also reported a significant increase in diabetes knowledge.

Discussion: The strengths found across all studies were the study design used, fidelity of the intervention, and validity of the methods used to measure the primary outcome. All three studies took a different DSME approach; however, their end-goal was the same as they measured similar outcomes.

Conclusion: DSME is a feasible approach in improving diabetes education and attempting to reduce A1C levels. Further research is needed to develop a standardized curriculum that maximizes the benefits of DSME.