Complex Health Care System Research Articles

The Importance of Developing Athletic Training Leadership Behaviors

ContextHealth care professionals such as athletic trainers (ATs) and athletic training educators should embrace contemporary leadership theories and practice leadership behaviors essential to professional responsibility.ObjectiveThis commentary discusses leadership behavior trends and the need for leadership development in professional athletic training education curricula and continuing education.BackgroundTraditional leadership theories focused on trait-based and “Great Man” characteristics. These theories suggest that leaders arise only through inherent or inherited leader-like behaviors. In contrast, contemporary leadership theories suggest that leaders can be developed and better promote the collegial leader-follower exchange that is needed to motivate, encourage, and support followers as well as a profession.SynthesisContemporary leadership theories involve a leader-follower relationship that integrates a teamwork approach into the workplace setting. Athletic trainers practice leadership behaviors but are less likely to demonstrate leadership characteristics when not practicing in their AT roles. Existing evidence suggests that contemporary leadership development can be helpful in athletic training to identify and develop future leaders, to promote the profession, and to improve patient outcomes.ResultsTransformational, team-centered leadership styles provide a growing opportunity for practicing ATs and athletic training students to expand into greater organizational leadership and decision-maker roles.Recommendation(s)Athletic trainer leadership knowledge, skills, and abilities development and professional responsibility should be emphasized more in professional athletic training educational programs and continuing education.Conclusion(s)Leadership behaviors that are effectively integrated into athletic training educational programs early and often may promote the profession by concurrently improving clinical and professional practice behaviors. Athletic trainers should practice leadership behaviors with greater frequency in differing societal constructs, communities, and complex health care systems.

Medically Underserved Populations: The Athletic Trainer's Role

Context Health care cost continues to rise; the US continues to spend dramatically more money than other developed nations per individual without increased health outcomes. More individuals are finding it harder to get access to a health care provider, especially those in medically underserved areas and populations. Objective To increase the knowledge of the athletic training educator about medically underserved populations and the roles athletic trainers (ATs) play as leaders in health care delivery. Background Current and future physician shortages are known and are only going to increase as more than one-third of current primary care physicians are expected to retire in the next 10 years. Forty percent of the population lives in areas that are medically underserved and designated by the government as areas of professional medical shortage; patients in these areas are primarily served by primary care physicians. Synthesis As with access to physicians, access to ATs has been shown to be based upon socioeconomic status and presents more challenges for the medically underserved. Early access to health care providers has shown to be important in adolescents, as negative health behaviors can carry into adulthood, leading to poorer health-related outcomes throughout life. Recommendation(s) To ensure that athletic training educational programs include opportunities to provide service to the medically underserved, education on social determinates of health, and the means by which ATs can fill critical holes in providing care for these patients. More research is needed to validate ATs' roles in providing quality health care. Additionally, more research is needed around how AT education can help meet patient needs. Conclusion(s) As the athletic training profession continues to evolve and responds to the growing demands of the complex health care system, access to an AT may provide a vital bridge to overall health care for patients within medically underserved populations.

Outcomes for Somali immigrant kidney transplant recipients in a large-volume transplant center

IntroductionKidney transplantation (KT) demands that patients navigate a complex healthcare system and adhere to lifelong therapy and surveillance. Cultural and linguistic discordance between patients and providers has been identified as a barrier to successful KT. We studied KT outcomes and disparities among a native Somali population living in Minnesota. MethodsBetween 1995 and 2015, 2,385 patients underwent KT at our institution; 22 were self-designated Somali nationals. Patient and graft survival and time to first rejection were analyzed. Utilization of interpreter services was evaluated. ResultsPatient survival for the Somali cohort at 1 year was 100% and 95.5% at 5 years; compared to 97.2% at 1 year and 89.1% at 5 years for the Caucasian cohort (p = 0.40). Graft survival for the Somali cohort at 1 year was 100% and 95.5% at 5 years; for the Caucasian cohort 94.8% and 81.6% (p = 0.35). Rejection-free survival in the Somali cohort was 100% at 1 and 5 years, for the Caucasian cohort 86.2% and 82.1 (p = 0.41). Among 22 adult Somali KT recipients, 15 (68%) patients frequently utilized interpreter services in their KT-related clinical encounters. ConclusionImmigrant Somali KT recipients, appear to have comparable KT outcomes compared to a contemporaneous Caucasian cohort.

Emerging roles for research intensive PhD prepared nurses: Beyond faculty positions.

Research-intensive PhD programs need to prepare nurse scientists to bridge the chasms between research, and practice and policy in an increasingly complex healthcare system. In practice, nurse scientists are critical to building capacity for research, promoting excellence in patient-centered care, and achieving or exceeding national quality benchmarks. Moreover, they provide methodological expertise and insight to address pressing clinical questions. PhD-prepared nurses also leverage their research expertise and practice knowledge to transform health policy in roles as organizational executives and leaders, advocates, and communicators. Re-envisioning nursing PhD curricula is required to ensure that PhD students are capable of not only conducting rigorous and impactful science, but launching careers across sectors of healthcare. Here, we summarize viewpoints of a special session from the October 2019 PhD Summit "Re-Envisioning PhD Programs of the Future" sponsored by the University of Pennsylvania School of Nursing and literature to invigorate thinking about ways to promote career transitions into nontraditional vital positions for nurse scientists. Advancing the health of patients and communities depends on preparing the next generation of nurse scientist to pursue career trajectories outside of traditional academic institutions.

Systems Thinking for Managing COVID-19 in Health Care Systems: Seven Key Messages.

This article provides the most current guidelines for nurse educators and nurses to use systems thinking to manage COVID-19 in health systems. A working definition of systems thinking is offered, with a review of basic knowledge and care in the context of the system awareness model (SAM). Seven key messages assist nurse educators and nurses in the management of COVID-19 patients culminating in leadership of complex health care systems using systems thinking. [J Contin Educ Nurs. 2020;51(9):402-411.].

Abstract 1186: Relationships between health literacy, having a cancer care coordinator, and long-term health-related quality of life among cancer survivors

Abstract Care coordination has been identified as a strategy to reduce challenges navigating the healthcare system for cancer patients. The objective of this study was to assess the association between cancer patients having a cancer care coordinator during their treatment and their long-term health-related quality of life (HRQoL) after treatment, and whether this association differs by level of health literacy. A population-based sample of patients diagnosed with breast, prostate, or colorectal cancer in 2015 were recruited from the Iowa Cancer Registry and invited by mail to participate in an online survey conducted in 2017-2018 (N=369). Survey and Registry data were analyzed using linear regression to model the association between having a cancer care coordinator during active treatment with post-treatment physical or mental HRQoL, a mean of 2.7 years later, by varying levels of health literacy while controlling for sociodemographic and clinical factors.Most patients (81%) reported having one individual coordinating their cancer care. Overall, having a care coordinator was not significantly associated with physical HRQoL (p=0.113). However, patients (20%) with low health literacy, who had a care coordinator, had significantly higher physical HRQoL scores (mean difference 5.0, p=0.022), while those with medium (29%) and high (51%) health literacy, did not (p=0.223, and p=0.864, respectively). Mental HRQoL scores were not associated with the presence of a care coordinator overall or when stratified by health literacy level. Findings suggested care coordinators improved post-treatment physical HRQoL, particularly for patients with low health literacy. Care coordinators may be beneficial to patients struggling to navigate the complex healthcare system during cancer treatment. Future research should focus on the mechanisms by which care coordination affects post-treatment HRQoL. PROMIS Physical HRQoL and CCC by Health Literacy LevelPROMIS Physical HRQoLMultivariable-Adjusted means (95% CI)Cancer Care CoordinatorLow Health LiteracyMedium Health LiteracyHigh Health LiteracyYes49.4 (42.7-56.1)48.9 (43.5-54.3)52.5 (46.1-58.8)No or I Don't Know44.4 (36.2-52.5)46.6 (39.3-53.8)52.1 (45.9-58.4p-valuep=0.0223p=0.2231p=0.8640PROMIS Mental HRQoLMultivariable-Adjusted means (95% CI)Cancer Care CoordinatorLow Health LiteracyMedium Health LiteracyHigh Health LiteracyYes49.7 (44.2-55.1)49.0 (45.5-52.5)55.3 (50.1-60.4)No or I Don't Know47.5 (39.9-55.2)48.1 (43.0-53.3)53.3 (48.3-58.2)p-valuep=0.4099p=0.6168p=0.3360 Citation Format: Natalie J. Del Vecchio, Mary Charlton, Natoshia Askelson, Knute Carter, Elizabeth Chrischilles, Charles Lynch. Relationships between health literacy, having a cancer care coordinator, and long-term health-related quality of life among cancer survivors [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1186.

Free-text patient experience data inform service development.

Understanding patients' experiences of treatment and care is essential to effective service development, and is therefore a common topic of investigation for clinicians and health-service researchers. For service development, different kinds of investigation may be useful for a different purpose. Closed measures of patient satisfaction (e.g. rating scales) are useful in providing reproducible measures in specified domains; however, they are often limited both by the scope of predefined questions and by the level of detail that they provide on processes affecting reported outcomes. Free-text data are therefore often collected alongside such measures, to provide further descriptive detail on patient experience and identify emergent issues that are not covered by closed questions (Bracher et al. BMJ Open 2016;6:e011830). Izzet-Kay et al. present a rigorous and systematic exploration of women's experiences and concerns following mesh-augmented prolapse surgery (BJOG 2021; 128:131–139). The study also provides an exemplar of how free-text analysis can inform service development in more general ways: first, by exploring how patients evaluate treatment success in the context of everyday life; second, by investigating how patients understand costs/risks and benefits of treatment; and third, by identifying issues for further investigation. Findings from the study give us descriptions of experiences as both outcomes (i.e. what happened) and processes (i.e. what factors affected the outcome). This distinction is important, because different types of knowledge can serve distinct but complementary functions in service development: the former identifying areas of concern (e.g. postoperative uncertainty, decision regret), the latter describing mechanisms contributing to the outcome and hence potential points of intervention (e.g. improved information provision, communication and shared decision-making processes) (Elwyn et al. BMJ 2010;341:c5146). Navigating complex healthcare systems (such as treatment pathways involving multidisciplinary teams) involves patients, clinicians and (often) carers in varied kinds of physical, emotional and cognitive work that includes making sense of information, identifying preferences and appraising risk (May et al. BMC Health Serv Res 2014;14(281)). Free-text data can provide important insights into both processes and outcomes that may not be visible through other means such as clinical audit. Findings can be used to complement those from closed measures (as Izzett-Kay et al. have done), inform development of new questions for wider systematic exploration (e.g. through a population-level survey) or identify areas for more detailed qualitative investigation (e.g. through in-depth interviews or longitudinal diaries exploring experiences over time). More detailed qualitative studies may, for example, focus on key points of communication or information provision within treatment pathways, to better understand how presentation and discussion of information affect risk perception and decision-making (Mills et al. J Clin Epidemiol 2011;64:1127–36). Readers of this journal undertaking service evaluation and development activity may wish to consider using free-text data as one additional tool to inform this work, a helpful demonstration of which has been provided by Izzett-Kay et al. None declared. A completed disclosure of interests form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

How Do Caregivers of Children with Congenital Heart Disease Navigate the Health Care System in Ethiopia?

Research ObjectiveGlobal surgery is becoming an increasingly important global health agenda. Cardiovascular disease is the major cause of mortality around the world, and congenital heart disease is the leading cause of morbidity in children. This study aimed to investigate and illustrate the caregivers’ experiences of accessing the health care system and undergoing pediatric cardiac surgery for children with congenital heart disease (CHD).Study DesignA qualitative study was conducted. Interviews were conducted in December 2019 in Amharic, then translated into English using trained local interpreters. Data were transcribed verbatim and analyzed according to the principles of interpretive thematic analysis, informed by the candidacy framework, using NVivo. The candidacy framework explores the access to health care utilization by seven elements: candidacy, navigation, the permeability of services, appearances at health services, adjudications, offers and resistance, and operating conditions and the local production of candidacy.Population StudiedInterviews were conducted with 13 caregivers of 10 patients with congenital heart disease that received cardiac surgery during the week of the interview.Principal FindingsThe following three themes emerged from the interviews: (a) Recognition of CHD mostly took place at birth, but for those born at home, they found out much later (max 14 years); (b) CHD was misdiagnosed multiple times prior to seeking care at a large hospital; and (c) patients were waiting for the surgery for more than a year, (d) being scheduled for surgery induced both anxiety and hopefulness. In the discussion, caregivers had financial difficulties and struggled in a fragmented delivery system and experienced poor service quality such as the inaccuracy of diagnosis while navigating the Ethiopian health care system.ConclusionsMajor care‐seeking delays were related to the inefficient and complex health care system, largely due to lack of early CHD recognition and financial hardships. Financial protection is low despite the availability of fee waivers for medications. Low education attainment and distance to hospitals are contributing to this challenge.Implications for Policy or PracticeOverall, Ethiopia needs to prioritize policies that protect the financial status of low‐income households that need health care services. Along with increasing health care workforce capacity for pediatric cardiac surgeries in Ethiopia, there is a need to strengthen the district‐level screening capacity to facilitate earlier diagnosis at easily accessible health care settings.Primary Funding SourceSearch Results Web results Korea International Cooperation Agency.

Novice OTs’ Perceptions of Competency

Abstract Date Presented 03/28/20 Research within the self-perceived state of workplace competence provides areas of necessary growth in the journey of novice OT competency. Continual self-assessment is essential for attaining OT competency and impacts the profession’s role as effective leaders in the complex healthcare system. Analysis of fluctuating competence of current novice OTs provides necessary development tools in the novice OT’s transition to competent practitioner. Primary Author and Speaker: Kaitlin Rotella Additional Authors and Speakers: Betsey Smith

Measuring the Scale of Hospital Health Record System Fragmentation in England

Many patients experience a fragmented health care journey that involves transitions of care between different hospitals. Ineffective sharing of health data between hospitals can impair the delivery of safe, high‐quality care. This study aimed to identify the unmet need for interhospital data sharing by quantifying the movement of patients between acute hospital trusts and health record systems in the NHS in England.This retrospective observational review examined Hospital Episode Statistics (HES), a national hospital administrative dataset relating to patient encounters with the NHS in England. Outcome measures included the frequency of patient encounters with multiple hospital trusts and the frequency of consecutive encounters with hospitals using different health record systems.All adult patients with inpatient, emergency department, or outpatient encounters at acute hospitals in the NHS in England during the 12‐month period from April 2017 to April 2018 were included.21,286,873 patients were involved in 121,351,837 encounters at 152 included NHS trusts over the one‐year period. There was limited regional alignment of electronic health record (EHR) systems in the 117 (77.0%) hospital trusts that were using EHR systems. 15,736,863 (73.9%) patients had two or more encounters with the included trusts and 3,931,255 (25.0%) of those attended two or more trusts. Over half (53.6%) of these patients had encounters shared between just 20 pairs of hospitals. Only two of these pairs of trusts used the same EHR system. On 11,017,767 (9.1%) occasions, patients presented to a hospital using a different EHR, or paper record system, to their previous hospital attendance.This study found that nearly four million patients accessed care at two or more different NHS hospital trusts over the one‐year study period, highlighting the demand for effective interhospital data sharing. Most of the pairs of hospital trusts that commonly share patients do not use the same health record systems. The fragmented distribution of health record systems that exists in the NHS in England represents a significant barrier to interhospital data sharing and interoperability.To make informed and safe decisions for patients negotiating increasingly complex health care systems, clinicians need the right information about the right patient in the right place at the right time. The findings from this study provide guidance for policy makers, clinicians, service managers, researchers, software providers, and patients to better understand and improve how data may be shared between hospitals. The methods used in this research could be applied to health care systems in other settings to guide the procurement and coordination of EHR systems to promote interoperability and effective data sharing.National Institute for Health Research (UK).

An Integrated Review of Hypertrophic Cardiomyopathy in Black Populations

Background Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiac disorder globally, affecting 0.2% to 0.5% of individuals. Existing clinical HCM guidelines do not address diverse populations, specifically minority groups who often experience health disparities. Objective The aim of this study was to describe the state of the science of HCM in black populations. Methods This integrated review guided by Whittemore and Knafl's methodology included literature search of multiple databases, data evaluation, and analysis. Publications between 2000 and 2020 were included if they addressed HCM cardiac anatomic manifestations, disease course, symptoms, quality of life, or outcomes in black populations. Results Six articles met the inclusion criteria. Overall, blacks are underrepresented in HCM research. Certain HCM structural phenotypes are more commonly exhibited in blacks, and physiology drives HCM treatment. Sudden death events and all-cause mortality do not differ between blacks and whites with HCM. Fewer blacks with HCM undergo genetic testing than whites with HCM. The lack of diversity in general genomic databases has resulted in reclassification of several genetic variants identified as more common in blacks. Conclusions Blacks are underrepresented in HCM research, even those focused on elucidating HCM manifestations, disease course, and outcomes in black populations. This may be due in part to HCM research that is largely generated from specialty centers that can require patients to navigate complex healthcare systems to reach expert HCM care. Longitudinal studies with large samples of blacks with HCM are necessary to elucidate how HCM affects this population.

Caring for the Deaf: Nursing Students' Knowledge and Awareness.

Navigating an increasingly complex health care system is challenging for marginalized populations, including the Deaf and hard of hearing who rely heavily on nurses' and hospital-provided interpreters' knowledge of the American Sign Language. This study examined Deaf culture knowledge and awareness among undergraduate and graduate nursing students in the United States. Study findings indicated low knowledge regarding cochlear implants, use of interpreters, and parental newborn hearing test rights. Integrating care of the deaf into all levels of nursing education will serve to promote patient health literacy and health outcomes while advancing the science of nursing education.

Exploring Family Caregiver Communication Difficulties and Caregiver Quality of Life and Anxiety.

When family caregivers are involved in patient care, both patients and caregivers experience better clinical outcomes. However, caregivers experience communication difficulties as they navigate a complex health care system and interact with health care providers. Research indicates that caregivers experience a communication burden that can result in topic avoidance and distress; however, little is known about how burden stemming from communication difficulties with health care providers relates to caregiving outcomes. To investigate how family caregiver communication difficulties with health care providers influence caregiver quality of life and anxiety. Data were collected in a cross-sectional online survey of 220 caregivers with communication difficulties resulting from caregiver avoidance of caregiving-related topics, inadequate reading and question-asking health literacy, and low communication self-efficacy. Caregiver outcomes were not affected by reading health literacy level but did differ based on question-asking health literacy level. Adequate question-asking health literacy was associated with lower anxiety and a higher quality of life. Caregivers who avoided discussing caregiving topics reported higher anxiety and lower quality of life and caregivers with increased communication self-efficacy reported a higher quality of life. Involvement of family caregivers in care is likely to require tailored approaches that address caregiver communication and health literacy skills. Findings from this study suggest that hospice and palliative care providers should identify and provide support for caregiver communication difficulties in order to positively influence caregiver quality of life and anxiety.

Ultrastretchable, Self‐Healable, and Wearable Epidermal Sensors Based on Ultralong Ag Nanowires Composited Binary‐Networked Hydrogels

AbstractStretchable and biocompatible flexible electronic devices are essential to meet the increasing demands of complex and multifunctional personal healthcare systems. To detect various external stimuli, noninvasively epidermal sensors with reliable and sustainable performances are desirable. Herein, ultrastretchable, self‐healable, and wearable epidermal sensors based on ultralong Ag nanowires (AgNWs) composited binary‐networked hydrogels are fabricated. The flexible hydrogel sensors can monitor dynamic strains in a wide range (4–3000%), realize high healing efficiency (94.3%) and strong adhesiveness, which is attributed to the strong covalent bond and reversible physical interaction structured binary‐network. The ultralong AgNWs network remains in direct contact under strain, ensures a rapid response to external stimuli. The strong interactions between polymer matrix and the nanowires endow the hydrogel sensors excellent sensitivity (gauge factor of 4.59) within a wide sensing range (0–850%). The cycling stability of the hydrogel sensors is further improved by the composition of AgNWs, presenting negligible degradation both on tension and compression. Based on the advantageous performances, the flexible stain sensors can differentiate complicated human motions and realize phonation recognition precisely, showing promising application in next‐generation wearable epidermal sensors with ultrabroad working range and high sensitivity.

Dynamics of a specialized and complex health care system: Exploring general practitioners' management of multimorbidity.

To explore general practitioners' (GPs') experiences of cooperation with hospital-based physicians regarding multimorbid patients and to identify challenges as well as strategies in managing such challenges.Study setting: Three medical practices in a provincial town in Denmark. A qualitative methodological design was used with explorative data collection among GPs.Data collection/Extraction methods: Participant observation, qualitative interviews and a focus group interview were conducted. Interpretive description was used as the analytical framework.Principal findings: The GPs appreciated cooperating with physicians in optimizing treatment of multimorbid patients. However, three main challenges were experienced: insufficient communication and coordination; unclear divisions of roles and responsibilities; and differences in the way of approaching patients. The GPs navigated these challenges and complexities by taking advantage of their personal relationships and by developing creative and patient-centred ad hoc solutions to difficulties in cross-sectorial cooperation. A hospital initiative to support care for multimorbid patients has not been adopted by the GPs as a preferred strategy. The structures of the health care system severely challenged cooperation regarding multimorbid patients; nevertheless, these GPs were aware of the advantages of cooperation, and their mainstay strategy in this involved personalized solutions and flexibility.

Transitioning to a Competency‐Driven Curriculum

AbstractThe role of the pharmacist is evolving with pharmacists’ taking more direct responsibility for patient outcomes. As a result, pharmacy education must be designed to ensure graduates are competent and prepared to function within a complex healthcare system. Transitioning to a competency‐driven curriculum, can ultimately place the focus of the learner and faculty on outcomes specific to the skills and abilities needed for graduates to provide desired levels of care.

Assessing Health Literacy Knowledge and Practice for a PACE Program.

The complexity of health care systems requires coordination among multiple health care providers to adopt strategies that are congruent with patients' levels of health literacy. In the current study, 12 interdisciplinary members of a Program of All-Inclusive Care of the Elderly (PACE) completed the Assessment Questionnaire from the Agency for Healthcare Research and Quality (AHRQ) Health Literacy Universal Precautions Toolkit. Once the questionnaire was complete, organizational priorities were identified and the AHRQ Toolkit was used to develop next steps. Of the five subsets included in the Toolkit, the organization identified three as priorities: (a) development of a health literacy team; (b) improving spoken communication with patients and caregivers; and (c) improving written information given via letters and home instructions. Organizations, nurses, and quality care leaders may find these results useful as they seek to assess organizational literacy and develop improvement plans. [Journal of Gerontological Nursing, 46(6), 12-18.].

Extrapolation of indications and drug interchangeability as barriers to use trastuzumab-dkst biosimilar in Brazil.

e13010 Background: Brazil has a complex health-care system which comprises 76% of population in the public unified health system (SUS) and only 24% in private system. Even with most of the population in the public system low resources has been allocated SUS by the government compared with that in private system. Breast cancer (BC) is the more frequent malignant neoplasm in Brazilian women, including HER2 overexpression, and the most are treated in SUS. Although, the HER2 blockage benefits in overall survival have been demonstrated since 2005, the adjuvant and neoadjuvant HER2 blockage was included in SUS protocols only 2013 while the metastatic only 2018. Brazil and development countries have limited accesses to biological drugs and target therapies due to the high cost. The biosimilar technology would improve the patient access to these drugs, health-care savings with efficacy and safety. In 2017, Brazil has approved the first biosimilar in oncology, the anti-HER2 monoclonal antibody trastuzumab-dkst. Our aim is understanding the reasons that hampered the Brazilian oncologists changing practice about biosimilars. Methods: We submitted an on-line survey with 12 questions to 144 Brazilian oncologists which are registered in Brazilian Clinical Oncology Society from North, Northeast, Center east, Center west and Southeast regions in Brazil. The questions were about the anti-HER2 biosimilars knowledge, the manufacturing process, the costs, the biosimilars-based clinical trial, the drug efficacy and safety. Results: We observed that all responders have 9 years experienced oncologist with mean of care 15 patient with HER2 BC per month. In total, 95% of oncologist knows biosimilar definition and 96% assume prescribe biosimilars without doubts. However, 81% oncologists would prescribe biosimilars to all patients, 82% would interchanges and 63% would extrapolate the indication. Conclusions: This survey was conducted to understand the Brazilian oncologist knowledge about biosimilar. We demonstrated a high knowledge of biosimilar definition, however with high percentage indicated adherence barriers. The pharmacovigilance, clinical trials that support biosimilar approval and extrapolation concepts are the main aspects to be addressed. The opportunity of patient access with biosimilars is real and it is the oncologist’s duty to engage in medical education programs. This study could highlight a crucial need for greater strategies to educate physicians, to disseminate biosimilars and provide more informed decision making.

Moral distress perspectives among interprofessional intensive care unit team members.

To examine interprofessional healthcare professionals' perceptions of triggers and root causes of moral distress. Qualitative description of open-text comments written on the Moral Distress Scale-Revised survey. A subset of interprofessional providers from a parent study provided open-text comments that originated from four areas of the Moral Distress Scale-Revised, including the margins of the 21-item questionnaire, the designated open-text section, shared perceptions of team communication and dynamics affecting moral distress, and the section addressing an intent to leave a clinical position because of moral distress. Open-text comments were captured, coded, and divided into meaning units and themes using systematic text condensation. Twenty-eight of the 223 parent study participants completing the Moral Distress Scale-Revised shared comments on situations contributing to moral distress. All 28 participants working in the four medical center intensive care units reported feelings of moral distress. Feelings of moral distress were associated with professional anguish over patient care decisions, team, and system-level factors. Professional-level contributors reflected clinician concerns of continuing life support measures perceived not in the patient's best interest. Team and unit-level factors were related to poor communication, bullying, and a lack of collegial collaboration. System-level factors included clinicians feeling unsupported by senior administration and institutional culpability as a result of healthcare processes and system constraints impeding reliable patient care delivery. Approval was obtained from the Institutional Review Board (IRB) of the University of Texas Health IRB and the organization in which the study was conducted. Moral distress was associated with feelings of anguish, professional intimidation, and organizational factors that impacted the delivery of ethically based patient care. Participants expressed a sense of awareness that they may experience ethical dilemmas as a consequence of the changing reality of providing healthcare within complex healthcare systems. Strategies to combat moral distress should target team and system interventions designed to improve interprofessional collaboration and support professional ethical values and moral commitments of all healthcare providers.

Communication and Cultural Sensitivity for Families and Children With Life-Limiting Diseases: An Informed Decision-Making Ethical Case in Community-Based Palliative Care.

The health care decisions of families of children who have life-limiting genetic diseases are impacted by multiple factors including religious and ethical values, education and knowledge, emotional trauma, availability of support, and accessibility of care. Palliative care nurses must practice the highest standards by delivering nonbiased, nonjudgmental support to patients and families; however, nurses may experience moral distress if their personal values conflict with a family's decisions and needs. This case focuses on a family receiving community-based palliative care for a child with a genetic life-limiting disease. They had a family history of this disease, which had caused the deaths of previous children, and the mother had a current unplanned pregnancy. The care team overcame language barriers and cultural obstacles to establish a trusting relationship with the vulnerable pregnant mother. They were able to support her decision to terminate her pregnancy safely by helping her to navigate a complex health care system. Using 5 crucial pillars to assist health care members with the delivery of nonjudgmental family-centered palliative care is recommended: (1) identification of biases, (2) utilization of a culturally safe approach, (3) effective communication, (4) assessment and support, and (5) knowledge of community resources.