Direct Patient Care Research Articles

An educational model for special patient care in dentistry.

Dental school graduates often have a basic knowledge in the management of patients with specialized healthcare needs. As of August 2019, CODA amended their accreditation standard 2-25: dental school graduates must be competent in the assessment and management of treatment of patients with specialized healthcare needs and disabilities. While the majority of these patients require modified dental care, many dental schools lack the facilities to provide both the proper care and education. This paper identifies improvements to dental education brought on by the innovations at Penn Dental Medicines' Personalized Care Suite for Persons with Disabilities (PCARE). Patient centered care is the emphasis of the PCARE curriculum. Although the clinic has special rooms and equipment to assist in accommodating the special needs of the patients, the program focuses on teaching dental students how to provide comfortable, safe, and effective care in a typical office setting. Detailed patient assessment, non-pharmacological management techniques, and treatment plans designed to meet the needs and abilities of the patients and caregivers are taught through lecture and direct patient care. Teaching assessment and management of this population is of great importance. Including treatment in Standard 2-25 creates another challenge to dental education. Penn Dental's facility allows multidisciplinary care in a cohesive and timely manner. The experience in PCARE offers unique opportunities to educate dental professionals in developing a patient centered approach in the treatment and maintenance of oral health in those patients who require accommodation.

Physicians’ and nurses’ perceptions of the factors influencing the implementation of paediatric clinical pharmacy services in Hong Kong: a qualitative study

ObjectivesTo identify barriers and facilitators that influence the implementation of paediatric clinical pharmacy services in Hong Kong public hospitals from physicians’ and nurses’ perspectives.MethodsA qualitative study was conducted based on...

Comparisons of Clinical Competency and Job Responsibilities of Physical Therapists With and Without Postprofessional Training.

Understanding how educational pathways may influence clinical competence and work responsibilities is important in providing guidance to academic and clinic stakeholders and physical therapists (PTs) on PT career development. The purpose of this paper was to compare perceived clinical competency and job duties between PTs with formal mentored postprofessional clinical education with PTs without formal postprofessional clinical education. The understanding of self-perceived clinical competence of PTs overall in the United States is limited, especially as related to the impact of postprofessional education. Furthermore, there is limited understanding of the career pathways and development of job duties of PTs in the United States. Two thousand three hundred thirty-four PTs in the United States. An online survey was sent to licensed PTs. This survey included items measuring self-perceived clinical competency and questions related to weekly job responsibilities. Participants were categorized as residency trained, fellowship trained, or non-residency/fellowship trained. Frequency analyses and Kruskal-Wallis tests with pairwise post hoc tests were performed comparing the 3 groups. Residency-trained (P < .007) and fellowship-trained (P < .001) groups demonstrated elements of higher self-perceived clinical competency compared with the non-residency-/fellowship-trained group. Both the residency- and fellowship-trained groups spent less time with patient care and more time with other responsibilities (e.g., teaching, mentoring, and research) (P < .02) during an average workweek. Fellowship-trained PTs (P < .001) spent more time with administrative duties compared with the non-residency-/fellowship-trained group. Results from this paper demonstrate that residency- and fellowship-trained PTs have elements of higher self-perceived clinical competency and spend more of their job duties outside of direct patient care compared with PTs who were not residency or fellowship trained. These results may help guide PTs, academic institutions, and employers in planning and achieving specific career paths.

Abdominal Imaging Findings in Laboratory-Confirmed COVID-19 Patients: A Retrospective Observational Study.

Coronavirus disease 2019 (CO-VID-19) is known to predominantly present with respiratory symptoms; however, a significant proportion of patients present with digestive symptoms. These symptoms are often non-specific and as such prompt the treating physician to request further imaging evaluation. Understanding the abdominal imaging findings in COVID-19 and their possible associations is thus crucial to direct patient care and prevent misdiagnosis.The aim of this study was to describe abdominal imaging findings on both computed tomography (CT) and ultrasound scans in cases with positive COVID-19 polymerase chain reaction (PCR) tests performed at our institution, and also, to evaluate the reason for requesting these imaging studies, and to correlate these findings with patients' demographics. A retrospective observational study was conducted at Salmaniya Medical Complex, Bahrain, between February 2021 and March 2022. We examinedthe abdominal CT and ultrasound data for PCR-confirmed COVID-19 patients. The demographic data, reason for requesting imaging and imaging findings were gathered by reviewing the hospital's electronic health records and picture archiving and communicating system (PACS). The study included 97 patients, with the majority being male (57.7%). The most common reason for imaging was abdominal pain, as seen in over half of the patients (60.8%), followed by deranged liver enzymes (18.6%). More than 75% of imaging studies showed positive abdominal findings with the majority (19.6%) showing non-specific inflammatory findings, followed by gallbladder disease (13.4%). The CT studies were more likely to yield positive findings as compared to ultrasound, with only 7 (11.3%) CT scans yielding normal findings (χ2 = 14.65; P < 0.01). To our knowledge, the research conducted on the abdominal manifestations of COVID-19 is still limited, especially in our region. Our study showed that there are variable presentations of abdominal organ involvement in COVID-19 cases, and as such more data is required to direct choice of imaging study, protocol, and interpretation of findings to better guide patient management.

COVID-19 vaccine uptake before and after a vaccine mandate at a major academic hospital: Trends by race/ethnicity and level of patient contact

ObjectivesTo assess vaccine coverage rates before and after implementation of a COVID-19 vaccine mandate among Health care Personnel (HCP) and demographic characteristics associated with vaccine uptake Design, Setting, and Participants: Cohort study conducted among 10,889 hospital employees followed from Dec 16, 2020 - October 31, 2021, at a large academic hospital in Philadelphia. Main Outcome and Measures: Time to COVID-19 vaccination and vaccine series completion rates before and after implementation of a COVID-19 vaccine mandate based on age, gender, race/ethnicity, and level of patient contact/occupational group. ResultsThe vaccination series completion rate was 86.0% prior to mandate announcement, and increased to 98.7% after mandate implementation. Rates before mandate announcement were highest among Asians (96.2%), Whites (94.0%), males (89.7%), employees ≥ 65 years of age (95.2%), and employees with direct patient care (physicians, 99.0%, and nurses, 93.3%). Hospital educational initiatives (including Town Halls and discussions with Black and Hispanic employees with the lowest vaccination rates) appeared to improve uptake. The largest increase in series completion after mandate announcement occurred among Blacks, those of other/multiracial backgrounds, and Hispanics (35.6%, 22.4%, and 10.8%, respectively) as well as those with some or no direct patient contact (24.5% and 18.3%, respectively). Medical or religious exemptions were approved for 64 (<0.6%) employees and 38 (<0.4%) left their positions (8 voluntary, 30 involuntary) specifically due to the COVID-19 vaccine mandate. No clinically meaningful differences by age, gender, or race/ethnicity for those who were vaccinated under the mandate versus those who left their positions were noted. Conclusions and RelevanceThese results suggest that while mandates may be challenging to institutions and enforcement unpopular, they play an important role in reducing hesitancy and securing high vaccination rates among HCP, a group at high risk of COVID-19 given their employment and who can be a source of disease transmission to patients.

Need for additional training to be a laboratory genetic counselor-A qualitative exploration.

Opportunities for genetic counselors to work in the laboratory have grown exponentially, yet the professional development needed to serve in these roles had not been previously explored. This study aimed to identify competencies required for entry-level genetic counselors working in the laboratory, explore the perceived level of preparation of these competencies as noted by experts in the laboratories, and assess the perceived value of additional credentialing for genetic counselors practicing in these settings. Twenty genetic counselors working in the laboratory setting and five MD or PhD laboratory managers, identified through purposeful and snowball sampling and with at least 5 years of experience working in a laboratory, were interviewed using a semi-structured protocol. Transcripts were analyzed thematically using deductive and inductive coding. Key findings included the distinction of laboratory and industry roles as involving nondirect patient care and differing from genetic counseling roles in the clinical setting. Genetic counselors working in the laboratory feel well prepared to transition into this setting and provide a unique patient-focused perspective to laboratory roles, including variant interpretation, marketing, and product development. Practice-based competencies (PBCs) were translatable to those used in the laboratory, yet variant interpretation, limitations of genomics-based tests, and the business of health care were noted as important to these roles but not fully addressed in the PBCs. Additional skills were often developed through on-the-job training and interdisciplinary collaboration, but more exposure to diverse roles in genetic counseling programs' didactic and field training was recommended. The majority felt that requiring an additional post-master's credential to work in the laboratory setting may restrict movement into these roles. Several questioned their identity as genetic counselors as they were no longer providing direct patient care and/or had been dissuaded by others from pursuing a laboratory position. Research focused on professional identity among genetic counselors working in nondirect patient care roles is warranted.

Children's Oncology Group's 2023 blueprint for research: Pharmacy.

Children's Oncology Group (COG) pharmacists and pharmacy technicians from more than 200 COG-member institutions comprise the COG Pharmacy Discipline. Discipline members serve an essential role in the design and execution of COG clinical trials. Core activities include study drug management, study drug access, clinical trial operations, protocol harmonization, and direct patient care. Discipline members are also actively involved in continuing education, membership engagement, and research across other COG committees/domains. Future areas of committed growth for the discipline include pharmacogenomics, pharmacokinetics, pharmacoeconomics, pharmaceutics, and implementation science.

Expansion of around the clock critical care and emergency medicine clinical pharmacy services at a large urban academic medical center

AbstractThe impact of a pharmacist as a dedicated member of multidisciplinary intensive care unit (ICU) and emergency department (ED) teams has repeatedly been described in the literature for over 20 years. A 2020 position paper published by the Society of Critical Care Medicine and the American College of Clinical Pharmacy recommended the optimal practice model include critical care pharmacists providing direct patient care 24 h a day, 7 days a week. The objective of this paper is to describe the expansion and evolution of clinical pharmacy services provided in the ICU and ED at a large academic health center, beginning in 2015 and accelerated in the face of a global pandemic. This was made possible through a combination of creating new positions and reallocating existing positions to substantially increase ICU and ED clinical pharmacy coverage. Over a 7 year period, the emergency medicine and critical care clinical pharmacy team expanded from six full time equivalent (FTE) employees in 2015 to 16 FTEs in early 2022. This allowed for reduced pharmacist to patient ratios, the expansion of clinical pharmacy services from primarily weekday hours to a 24 h per day coverage model, 7 days a week, and to better support clinical pharmacy specialists providing these services. Rapid expansion of around the clock clinical pharmacy services was only possible through collaboration between clinical and operations pharmacy managers and feedback from members of the multidisciplinary team.

Perceived Barriers to Patient Mobilization Among Therapy and Nursing Acute Care Staff: A Multi-Site Survey Study

ObjectiveTo identify differences in perceived barriers to patient mobilization in acute care among therapy and nursing clinicians, and among hospitals of different sizes and types. DesignCross-sectional survey study. SettingEight hospitals of various sizes and types (teaching vs non-teaching; urban vs rural), from 2 different states in the Western region of the United States. ParticipantsA nonprobability sample of 568 acute care clinicians (N=586) involved in direct patient care were surveyed. Clinicians indicated a clinical role within the branch of therapy (physical therapy or occupational therapy) or nursing (registered nurse or nurse assistant). Main Outcome MeasuresThe Patient Mobilization Attitudes and Beliefs Survey (PMABS) was used to assess perceived barriers to early patient mobilization among therapy and nursing staff. A PMABS total score and 3 subscale scores (knowledge, attitudes, or behaviors associated with barriers to mobilization) were calculated, with higher scores indicative of greater mobilization barriers. ResultsMean PMABS total scores were significantly lower (better) for therapy providers (24.63±6.67) than nursing providers (38.12±10.95), P<.001. Additionally, therapy providers had significantly lower scores than nursing providers on all 3 subscales (all P<.001). Item-specific analyses revealed significant differences in responses between therapy and nursing staff on 22 of 25 items, with nursing staff indicating greater perceptions of barriers than therapy staff on 20 of the 22 items. The top 5 items with the largest response differences between therapy and nursing clinicians included adequate time to mobilize patients, understanding appropriate referral to therapy staff, knowledge on when it is safe to mobilize patients, confidence in the ability to mobilize patients, and receiving training on methods of safe mobilization. While hospital type did not affect perceived barriers to early mobilization, PMABS scores were significantly higher for large and small hospitals when compared to medium-sized hospitals. ConclusionPerceived barriers to patient mobilization exist among therapy and nursing acute care clinicians, with greater barriers noted among nursing staff for knowledge, attitudes, and behaviors associated with patient mobility practices. Findings suggest future work is warranted, with opportunities for therapy providers to collaborate with nursing providers to address barriers to implementing patient mobility.

How new clinical roles in primary care impact on equitable distribution of workforce: a retrospective study.

There are inequalities in the geographical distribution of the primary care workforce in England. Primary care networks (PCNs), and the associated Additional Roles Reimbursement Scheme (ARRS) funding, have stimulated employment of new healthcare roles. However, it is not clear whether this will impact inequalities. To examine whether the ARRS impacted inequality in the distribution of the primary care workforce. A retrospective before-and-after study of English PCNs in 2019 and 2022. The study combined workforce, population, and deprivation data at network level for March 2019 and March 2022. The change was estimated between 2019 and 2022 in the slope index of inequality (SII) across deprivation of full-time equivalent (FTE) GPs (total doctors, qualified GPs, and doctors-in-training), nurses, direct patient care, administrative, ARRS and non- ARRS, and total staff per 10 000 patients. A total of 1255 networks were included. Nurses and qualified GPs decreased in number while all other staff roles increased, with ARRS staff having the greatest increase. There was a pro- rich change in the SII for administrative staff (-0.482, 95% confidence interval [CI] = -0.841 to -0.122, P<0.01) and a pro- poor change for doctors-in-training (0.161, 95% CI = 0.049 to 0.274, P<0.01). Changes in distribution of all other staff types were not statistically significant. Between 2019 and 2022 the distribution of administrative staff became less pro-poor, and doctors-in-training became pro-poor. The changes in inequality in all other staff groups were mixed. The introduction of PCNs has not substantially changed the longstanding inequalities in the geographical distribution of the primary care workforce.

Early Doffing among Frontline Healthcare Workers Working in the COVID Areas in Resource-Limited Settings: Lessons Learned and Interventions Taken.

In the fight against the pandemic, personal protective equipment (PPE) has played a vital role. However, working with PPE has its own difficulties and problems. The aim of this study was to find out the reasons of early doffing, that is, in doffing in emergency situations before the shift among healthcare workers (HCWs) working in PPE in the COVID areas in resource-limited settings. This cross-sectional, survey-based study was carried out on healthcare workers involved in direct care of patients with COVID-19 in tertiary care COVID center, India. The questionnaire was sent as a Google form through email and social media platforms like WhatsApp and Facebook. The data was reported as the mean ± SD for continuous variables and as the percentage for categorical variables. Among 252 healthcare workers who participated in the survey, 145 (57.5%) participants doffed early on 300 occasions. Out of these 145, 50% doffed early only once and rest doffed early multiple times. The most common reason of early doffing was found to be breach in PPE (15.33%) followed by fogging (14%) and headache (12%), and most commonly, breach was in mask or coverall/gown (32.6% each). Although PPE decreases the risk of infection, it is challenging for HCWs to work in PPE leading to instances of early doffing. The most common reason for early doffing in our study was the breach in PPE and the most common component of breach was found to be mask and coverall/gown. Therefore, we suggest that the proper sizes of the PPE should be made available and proper training in donning should be imparted to HCWs working in PPE.

Decreasing Technology Burdens to Bedside Staff Through the Introduction of a Patient Technology Technician Role: A Quality Improvement Project.

With increased technology integration into health care, the focus and time of nurses are often shifting toward technology and away from direct patient care. The goal of this quality improvement project was to implement a patient technology technician role on 3 acute care units in order to reduce the time burden of technology to nurses. During this quality improvement project, the patient technology technician role focused on addressing technology issues and ensured adequate, functioning technology supplies were available on nursing units. Outcomes assessed included self-reporting of the technology time burden, the satisfaction associated with technology, and the impact on telemetry calls from the virtual telemetry monitoring center. In the pretest survey, only 10% to 14% of bedside staff were somewhat satisfied or very satisfied with the time spent managing technology. In the posttest survey, that number increased from 92% to 96%. In the pretest survey, 64% to 83% of bedside staff reported often or frequently fixing, managing, or looking for technology. In the posttest survey that number decreased from 4% to 16%. There was also a reduction in telephone calls from the virtual telemetry monitoring center after implementation. The patient technology technician role was able to successfully relieve the technology time burden for bedside staff.

Understanding Facilitators and Barriers to Providing Equity-Oriented Care in the NICU.

The current study examined the use of immersive technology as a way to improve access to high-quality interpersonal breastfeeding interactions in an undergraduate clinical lactation course. In particular, we investigated the impact of immersive consultation videos and related activities on student self-efficacy, motivational beliefs, and perceived skill level. Results indicate that usability was high, with participants rating videos, interactives, and activities positively. Although no significant improvements in their level of interest or perceived skill were found, students did report a significant increase in self-efficacy and their perceived ability to meet the course learning objectives. Our results demonstrate that high-quality immersive videos can be an important learning tool for teaching clinical skills when access to direct patient care is limited or absent.

Role, Knowledge, and Readiness of Medical Undergraduate Students and Factors Influencing their Willingness to Participate in the COVID-19 Pandemic

Background: The COVID-19 pandemic placed a high demand for health-care professionals coupled with their decreased availability. In this study, we aimed to determine the medical students’ perception of their role and preparedness during the COVID-19 pandemic and their knowledge of the same. We also determined the factors influencing the knowledge scores and willingness of medical students to help during the COVID-19 pandemic. Materials and Methods: This cross-sectional study was conducted in June 2021. Medical students in any year of their M.B.B.S, enrolled in various medical colleges across India, who spoke English and were able to fill out the predesigned online questionnaire, were eligible for participation after an implied informed consent. Results: Seven hundred and sixty-four responses were obtained from undergraduate medical students (32.5% 1st preclinical, 17.8% 2nd para-clinical, 29.1% 3rd clinical, and 20.6% 4th clinical) with representations from 20 different states of India. Among the respondents, 57.2% wanted to contribute to the management of the pandemic, although only 50.8% felt mentally ready and a paltry 2.2% felt knowledge ready. While 69.8% of respondents were ready to help in ways not requiring direct patient contact, 35.5% were willing to engage in direct patient contact. The average total knowledge score was 12.67/20. Students in Government Institutes (P &lt; 0.00001), senior years (P &lt; 0.0001), who received online training (P &lt; 0.00006) and referred to reliable sources of information (P = 0.001) had better knowledge scores. Those in senior years (P &lt; 0.0001), better knowledge scores (P = 0.0026), lesser fear of infecting themselves (P = 0.0004), and better mental readiness (P &lt; 0.0001) were more willing to fight against the pandemic. Conclusions: Medical students may be deployed in tasks not involving direct patient contact amid the COVID-19 pandemic. Those who volunteer may be involved in supervised direct patient care. Students may be better equipped to fight the pandemic by online training and dissemination of knowledge through reliable sources with an emphasis on methods to protect self.

Developing a Preclinical Nurse-Nurse Communication Framework for Clinical Trial Patient-Related Safety Information.

Clinical trial trials have become increasingly complex in their design and implementation. Investigational safety profiles are not easily accessed by clinical nurses and providers when trial participants present for clinical care, such as in emergency or urgent care. Wearable devices are now commonly used as bridging technologies to obtain participant data and house investigational product safety information. Clinical nurse identification and communication of safety information are critical to dissuade adverse events, patient injury, and trial withdrawal, which may occur when clinical care is misaligned to a research protocol. Based on a feasibility study and follow-up wearable device prototype study, this preclinical nurse-nurse communication framework guides clinical nurse verbal and nonverbal communication of safety-related trial information to direct patient care activities in the clinical setting. Communication and information theories are incorporated with Carrington's Nurse-to-Nurse Communication Framework to encompass key components of a clinical nurse's management of a trial participant safety event when a clinical trial wearable device is encountered during initial assessment. Use of the preclinical nurse-nurse communication framework may support clinical nurse awareness of trial-related wearable devices. The framework may further emphasize the importance of engaging with research nurses, patients, and caregivers to acquire trial safety details impacting clinical care decision-making.

Pharmacist-Led Management of HIV PrEP Within the Veterans Health Administration.

Uptake and access to HIV preexposure prophylaxis (PrEP) is key to reducing incident HIV infections. Pharmacists are one of the most accessible health care professionals in the United States and are well suited to address this need. We describe a model of care at the Veterans Affairs Greater Los Angeles Healthcare System in which clinical pharmacist practitioners developed and implemented a pharmacy-led PrEP clinic colocated within an infectious disease clinic. Veterans Health Administration clinical pharmacists provide direct patient care under a scope of practice that includes ordering and interpreting laboratory tests and providing PrEP prescriptions. To improve access and patient acceptability, we also used novel telemedicine modes of care to ensure flexible appointment scheduling. This model can be used by other federal and community-based health care organizations to implement interdisciplinary pharmacist-managed PrEP clinics and expand telehealth modalities to deliver outpatient services.

Immersive Videos Improve Student Self-Efficacy in Clinical Lactation.

The current study examined the use of immersive technology as a way to improve access to high-quality interpersonal breastfeeding interactions in an undergraduate clinical lactation course. In particular, we investigated the impact of immersive consultation videos and related activities on student self-efficacy, motivational beliefs, and perceived skill level. Results indicate that usability was high, with participants rating videos, interactives, and activities positively. Students did report a significant increase in self-efficacy and their perceived ability to meet the course learning objectives; no significant changes in the level of interest or perceived skill were found. Our results demonstrate that high-quality immersive videos can be an important learning tool for teaching clinical skills when access to direct patient care is limited or absent.

New graduate nurses' delivery of patient care: A focused ethnography.

To explore factors influencing newly graduated nurses' delivery of direct care in acute care hospital settings. Qualitative study using focused ethnography. During the period from March to June 2022, a total of ten newly graduated nurses were purposively sampled, and data were collected through 96 h of participant observation as well as ten semi-structured interviews. This research took place in a large hospital located in Denmark. Data were analysed using LeCompte and Schensul's ethnographic content analysis. Three main structures were developed from the data: 'Contrasting Intentions and Actions for care delivery', 'Organizational Constraints Block Interpersonal Aspects of Nursing Care' and 'Newly Graduated Nurses' Suppressed Need for Support Constitutes Delay in Care Actions'. Newly graduated nurses were committed to delivering high-quality care but were aware they sometimes provided compromised care. The paradox between a commitment to care and compromised care delivery was borne out of tensions between newly graduated nurses' professional beliefs and nursing values, a desire to integrate patients' needs and preferences, and organizational constraints on everyday practices where newly graduated nurses often worked alone without the support of a more experienced nurse. Critical reflection on cultural, social and political forces that influence direct care delivery might support newly graduated nurses to deliver direct patient care more intentionally. Establishment of onboarding programs and other support activities for newly graduated nurses to cope with contrasting intentions and actions that must address organizational constraints is essential. These development programs should include how critical reflection competency is supported to address value inconsistencies and emotional distress to ensure high-quality patient care. The reporting adhered to the COREQ guidelines. PATIENT OR PUBLIC CONTRIBUTION: 'No Patient or Public Contribution'.

Psychological Impacts of the COVID-19 Pandemic on Canadian Healthcare Workers: A Case Control Comparison From Three Cross Sectional Surveys.

The aim of the study is to describe mental health impacts of the COVID-19 pandemic and identify roles that predict distress among Canadian healthcare workers (HCWs). Using data from three cross-sectional Canadian surveys, we compared 799 HCWs to demographically matched controls and compared HCWs with and without COVID-19 patient contact. Participants completed validated measures of depression, anxiety, trauma-related stress, alcohol problems, coping self-efficacy, and sleep quality. Non-HCWs reported more depression and anxiety in Fall 2020 and more alcohol problems in Fall/Winter 2021 than HCWs. In Winter 2020-2021, HCWs reported more trauma-related stress than non-HCWs. As of early 2021, HCWs with direct patient contact reported worse symptoms across nearly all measures than HCWs without. Although Canadian HCWs did not report worse mental health than demographically similar peers, mental health supports are needed for HCWs providing direct patient care.

Experiences of US Clinicians Contending With Health Care Resource Scarcity During the COVID-19 Pandemic, December 2020 to December 2021

The second year of the COVID-19 pandemic saw periods of dire health care resource limitations in the US, sometimes prompting official declarations of crisis, but little is known about how these conditions were experienced by frontline clinicians. To describe the experiences of US clinicians practicing under conditions of extreme resource limitation during the second year of the pandemic. This qualitative inductive thematic analysis was based on interviews with physicians and nurses providing direct patient care at US health care institutions during the COVID-19 pandemic. Interviews were conducted between December 28, 2020, and December 9, 2021. Crisis conditions as reflected by official state declarations and/or media reports. Clinicians' experiences as obtained through interviews. Interviews with 23 clinicians (21 physicians and 2 nurses) who were practicing in California, Idaho, Minnesota, or Texas were included. Of the 23 total participants, 21 responded to a background survey to assess participant demographics; among these individuals, the mean (SD) age was 49 (7.3) years, 12 (57.1%) were men, and 18 (85.7%) self-identified as White. Three themes emerged in qualitative analysis. The first theme describes isolation. Clinicians had a limited view on what was happening outside their immediate practice setting and perceived a disconnect between official messaging about crisis conditions and their own experience. In the absence of overarching system-level support, responsibility for making challenging decisions about how to adapt practices and allocate resources often fell to frontline clinicians. The second theme describes in-the-moment decision-making. Formal crisis declarations did little to guide how resources were allocated in clinical practice. Clinicians adapted practice by drawing on their clinical judgment but described feeling ill equipped to handle some of the operationally and ethically complex situations that fell to them. The third theme describes waning motivation. As the pandemic persisted, the strong sense of mission, duty, and purpose that had fueled extraordinary efforts earlier in the pandemic was eroded by unsatisfying clinical roles, misalignment between clinicians' own values and institutional goals, more distant relationships with patients, and moral distress. The findings of this qualitative study suggest that institutional plans to protect frontline clinicians from the responsibility for allocating scarce resources may be unworkable, especially in a state of chronic crisis. Efforts are needed to directly integrate frontline clinicians into institutional emergency responses and support them in ways that reflect the complex and dynamic realities of health care resource limitation.