Suboptimal Communication Research Articles

Supporting cancer-related fatigue self-management: A conversation analytic study of nurse counsellor and cancer survivor consultations

PurposeCancer-related fatigue (CRF) is a prevalent and distressing symptom experienced by people affected by cancer. A breakdown of the clinician-patient partnership and suboptimal clinician communication has been identified as a significant barrier to implementing into clinical practice effective self-management strategies for CRF. This study examined the use and impact of communication practices employed by trained cancer nurse counsellors when providing CRF self-management support to cancer survivors. MethodsInteractions from 41 telehealth consultations between three nurse counsellors and 23 cancer survivors in a CRF self-management support clinic in Queensland, Australia were recorded and analysed using conversation analysis methods. ResultsAnalysis found that in instances where nurses established the agenda of a consultation from the outset of a session (e.g., focusing on fatigue self-management support), cancer survivors displayed clearer understandings of their self-management role, the tasks, and goals of a session; and displayed less difficulty engaging in supportive care discussions. Furthermore, clinicians used formulation practices, such as summarising dialogue, to sustain focus on fatigue during consultations, and to close discussion matters not ostensibly pertinent to fatigue self-management planning supporting the goals of the CRF SMS clinic consultations. ConclusionFor supportive care sessions targeting fatigue management, clinicians should ideally focus discussion on CRF support early, by clearly introducing the agenda at the outset of the consultation while also asking for client agreement. Periodically summarising patient's talk allows clinicians to maintain a focus on matters relevant for self-management fatigue planning and provide support within the typically constrained timeframes allocated for addressing CRF.

A comparative analysis of patients with breast cancer with and without language barriers.

340 Background: About 20% of Americans speak a language other than English at home, among these over one-third experience language barriers when interacting in English. These populations face additional barriers, which can lead to adverse outcomes in the case of a cancer diagnosis. Diverse older adults are at highest risk for sub-optimal care and toxicity from cancer therapies due to the intensity of treatment, their age, comorbidities, in addition to the burden of historic inequities they experience due to sub-optimal communication and insufficient communication of risk. Methods: This retrospective observational study explores the role of language barriers on patient characteristics among patients diagnosed with advanced left-side breast cancer (LSBC). LSBC requires radiotherapy which can pose a risk for cardiotoxicity. Electronic medical records for N=1795 patients were extracted at a tertiary cancer center; analyses were conducted on a secure virtual research desktop using SAS 9.4. This study was IRB approved. Results: Overall, most patients were female (99.5%) and NH White, with a large proportion of Latine patients 17.8%. Most were married or had a partner (49.6%) and were on Medicare (43.2%) or private insurance (34.7%), very few were on Medicaid (5.0%). 9.7% reported a disability that left them unable to work and 13.3% of patients requested an interpreter at their last encounter. Nearly 9% of patients reported a history of heart disease. When we compared patients by those that did and did not request an interpreter as a proxy for limited English proficiency (LEP), we found that patients who were reported Spanish as their preferred language (84.8%, p<.0001) were more likely to be request an interpreter. This group was followed closely by speakers from languages spoken in the Middle East and N. Africa (MENA) region (80.5%, p<.0001). Conversely, we observed patients on Medicaid to be more likely to request an interpreter vs other payer types (39.3%, p<.0001), finally we found significantly fewer patients with a history of heart disease experiencing language barriers. Conclusions: Our assessment demonstrates language barriers remain a significant barrier for Spanish and MENA-region breast cancer patients. Patients with language barriers may have different risk factors and unique needs that require further study. Thus, improved outcomes can be encouraged with tailored management and support for communication barriers.

Can we talk? A correspondence study to examine responsiveness of physical educators to requests for a phone call from parents of children with disabilities

ABSTRACT The Individuals with Disabilities Education Improvement Act (2004) mandates that parental input be considered when making educational decisions for children with disabilities, including in physical education. However, parents of children with disabilities often report suboptimal communication experiences with physical educators. The purpose of the current study was to examine if the initiation of a parent–physical educator relationship is influenced by whether students have a disability or not. An online message correspondence study methodology was used to detect potential disparities in the responsiveness of a sample of 320 physical educators to electronic message requests for a phone call to discuss physical education service from hypothetical parents of a child with a visual impairment (VI), autism spectrum disorder (ASD), Down syndrome (DS), or no disability. Parents of children with ASD had reduced odds of receiving a positive response as compared to parents of children without disabilities (15.8% vs 26.9% RR = .57). Similarly, parents of children with DS had reduced odds of receiving a positive response as compared to parents of children without disabilities (15.2% vs 26.9%, RR = .59). Strategies to promote parent–physical educator relationships are urgently needed, especially for parents of children with ASD and DS.

S14-3: The adoption and implementation of a physical activity referral pathway integrated into a major U.S. health system

Abstract Background Regular physical activity (PA) is highly effective in improving mental, physical, and emotional health; yet, health systems experience challenges integrating PA referral pathways connecting eligible patients to health-enhancing PA resources and programs. Purpose To examine the adoption of a clinic-to-community PA referral pathway in primary care clinics in a major U.S. health system and identify provider- and patient-level barriers and facilitators associated with its implementation. Methods Exercise is Medicine Greenville® (EIMG®) is a clinic-to-community model that connects primary care patients to a 12-week, evidence-informed, PA program in community PA facilities. Resumption of EIMG® in March 2021 after COVID-19 closures provided a unique opportunity to comprehensively evaluate the PA referral pathway from inception. Referral provision, utilization, and program enrollment were tracked from reopening through September 2022 in twelve primary care clinics. Semi-structured interviews were conducted with providers (informed by the i-PARIHS framework) and referred patients who declined enrollment (informed by the COM-B model). Interviews were recorded, transcribed, and themes identified. Results Twenty-six providers completed interviews. Referral barriers included a lack of knowledge about EIMG®, a perceived time-consuming referral process, and placing incomplete referrals. Facilitators included acknowledgment of a high value for PA in healthcare, desire to incorporate EIMG® into patient visits, and the work of the EIMG® nurse navigator. Twenty-eight patients completed interviews. Enrollment barriers included time, financial constraints, inconvenient locations, disruptions due to COVID-19, and suboptimal communication. Facilitators included aligning EIMG® with patients’ health goals, enhanced trust due to provider referral, group-based format of the PA program, and friendly staff. Conclusions Improving communication, conducting refresher trainings, simplifying the referral process, and providing more resources (for providers), along with providing more program details, and offering more program times, locations, and financial support (for patients), may increase success of PA referral pathways implemented in primary care settings. Practical implications This work identifies modifiable factors that can guide improvements in the adoption and implementation of PA referral models in health settings. Funding The Duke Endowment and the National Heart, Lung, and Blood Institute (NHLBI)

Comparing Patient Perception and Physician's Records: Generative AI Performance Evaluation.

Patient perception involves a patient's thoughts and beliefs regarding their health status. It is also associated with medical compliance and outcomes. However, discrepancies often arise between patient perception and physicians' documentation within the medical records, resulting in misunderstanding and suboptimal doctor-patient communication. In this study, we assessed the efficacy of generative artificial intelligence (AI) in comparing the content of patient perception as recorded in patient questionnaires and physicians' records of the Department of Breast Surgery. We evaluated the precision and recall of the generative AI by comparison with human-created ground truth. Our results demonstrated the high performance of the generative AI in comprehending and contrasting symptoms and the entire content recorded differently by patients and physicians, with F1 scores ranging from 0.77 to 0.97. These results highlight the potential contribution of a generative AI to deeper mutual comprehension in healthcare scenarios.

2223 Older patients admitted with a fragility fracture—a review of discharge summary documentation in accordance with HIQA national

Abstract Background Fragility fractures, defined as fractures resulting from low energy trauma (1), are consistent with a diagnosis of osteoporosis. When a patient is discharged from hospital, guidelines recommend principal and additional diagnoses, relevant co-morbidities contributing to primary diagnosis, medications and relevant investigations are recorded (2). Methods This audit reviewed discharge summaries of all patients discharged from a rehabilitation unit over two months, in accordance with the Health Information and Quality Authority’s (HIQA) National Standard for Patient Discharge Summary Information (2). Patients with fragility fractures were identified through medical record review. Principal and additional diagnoses were reviewed, with cause and mechanism of falls considered relevant co-morbidities. Discharge prescriptions for anti-resorptive medications were noted. Dual-energy x-ray absorptiometry (DXA) was recorded as a relevant investigation (3). Results 33 discharge summaries met inclusion criteria. 12 patients were admitted with fragility fractures with a mean age of 81 years (69–90). 83.3% (n = 10) were female. Osteoporosis was mentioned in 50% (n = 6) of discharge summaries of patients with fragility fractures. On review of relevant co-morbidities, likely cause of the fall was documented in 58.3% (n = 7) and mechanism in 75.0% (n = 9). Bone protection was planned in 83.3% (n = 10). Plan for DXA was documented in 8.3% (n = 1). Conclusion This audit demonstrates suboptimal communication between hospital and community teams, despite chronic disease being predominantly managed in the community. In Europe, Ireland has one of the largest disease burdens relating to osteoporosis and the largest increase predicted in the next ten years (4). It is of utmost importance we improve communication to minimise disease burden.

Impact of a codesigned and coproduced patient-centred discharge form on communication and understanding.

Adverse clinical outcomes and patient dissatisfaction with care often have elements of poor communication. Factors such as illness and pharmacotherapy can affect cognition, and overestimation of patients' health literacy may contribute to suboptimal communication with patients regarding their hospitalisation and post-discharge instructions. Improved patient understanding and recall of their diagnoses and treatment is critical for adherence to treatment, follow-up and optimal clinical outcomes. The aim of the study was to assess whether a coproduced and codesigned patient-centred discharge form (PCDF) improves patients' understanding of their discharge diagnosis, in-hospital treatment and post-discharge plan. A sample of 111 patients was enrolled through simple randomisation by admission to one of two identically operating general medicine wards. Over a 3-month period, 59 patients received the coproduced and codesigned form and 52 patients were controls. Assessment of patients' understanding of diagnosis, in-hospital management, post-discharge instructions and overall experience of care was undertaken by a blinded phone survey conducted approximately 6 days after discharge. Patients who received PCDF were significantly more likely to report adequate understanding of their hospital management (P < 0.001) and the post-discharge plan (P < 0.001). There was no statistically significant difference between the intervention and control groups in terms of understanding of diagnosis. Patients who received PCDF reported better understanding of care and recall of admission. The use of PCDF is associated with improved patient understanding with respect to their hospital management and post-discharge instructions. It is also associated with high levels of satisfaction as assessed by measures of patient experience.

Resident perspectives on the impact of program leadership communication on well-being during the COVID-19 pandemic

ABSTRACT Background The COVID-19 pandemic introduced a myriad of changes that negatively impacted resident physicians’ well-being. Communication from program leadership may mitigate resident stress during times of crisis, yet literature supporting this premise is scant, and best communication practices remain uncertain. This qualitative study aimed to identify stressors to residents and explore the influence of residency program leadership’s communication on emotional stress during the COVID-19 pandemic. Methods Informed by Kotter’s 8-step management model to support resident well-being, this qualitative study used grounded theory methods to interview 25 residents from three training programs (Pediatrics, Internal Medicine, and Medicine-Pediatrics) on a single academic medical campus from May-September 2020. Four investigators coded the data using the constant comparative analysis. Sampling continued until reaching thematic saturation. Codes were built using an iterative approach and organized into themes. Discrepancies were resolved by consensus discussion among investigators. Results Residents described increased stress levels, the all-consuming nature of COVID-19, mixed emotions about their role as healthcare providers, new coping mechanisms, and changes to their education and work environment that impacted stress. Communication from leadership to residents during the pandemic varied. Effective communication helped mitigate stress; perceived suboptimal communication exacerbated stress. Who was communicating, methods of communication, and content of communication influenced resident stress. Conclusions The COVID-19 pandemic introduced new stressors and challenges to residents. The perception of leadership communication played a critical role in mitigating or exacerbating resident stress. We propose a communication framework (“Who? What? Where? When? How?”) that residency leadership can utilize during times of crisis.

Navigating Challenges for Disaster Resilience: Insights from Department of Public Works and Highways Personnel

Disasters are unforeseen, catastrophic events that have the potential to significantly harm populations, ecosystems, and economies. Disasters can occur quickly or gradually, and the scope of their effects may range from local to regional to even global. The Department of Public Works and Highways' (DPWH) efforts in building and maintaining resilient road networks are vital for ensuring access to affected areas during disasters. This facilitates the timely arrival of emergency responders, the delivery of relief supplies, and the evacuation of affected populations. This study then seeks to examine the experiences of the DPWH-BSDEO (Benguet Second District Engineering Office) personnel in their commitment to fostering disaster resilience while navigating challenges. This study utilized a qualitative research design. Data were collected from various sources, including DPWH-BSDEO employees, Municipal of Buguias personnel, Philippine National Police-Buguias, Bureau of Fire Protection-Buguias, as well as official office reports. The responses of the participants established that the challenges faced by DPWH-BSDEO personnel encompass insufficient funding, limited resources, inadequate training among disaster volunteers, vulnerability of responders to disasters, limited community cooperation, suboptimal communication, and an ineffective drainage system. Based on these findings, the researchers concluded that it is imperative to enhance the DRRM functions within the office and significantly bolster its capabilities.

Assessment of Patient-Physician Interactions in Psoriatic Arthritis: National Results of the ASSIST Study.

An overarching principle for the management of psoriatic arthritis (PsA) is a shared decision-making process between physicians and patients. The aim of this study is to assess the patient-physician relationship in a group of patients with PsA, by using the Perceived Efficacy in Patient-Physician Interactions (PEPPI) and CollaboRATE instruments. This is a cross-sectional multicenter study where consecutive patients with PsA were enrolled. For each patient, the main demographic, comorbid conditions, and clinical data were collected, including the assessment of disease activity, function, quality of life, and impact of disease. PEPPI and CollaboRATE questionnaires were used, respectively, to evaluate the patient's perception of the patient-physician relationship and the shared decision-making process. A total of 81 patients with PsA were enrolled at four centers in Italy. Overall, our patients showed a high level of confidence in obtaining needed health care, with relatively high median (IQR) values of PEPPI (20; 16-23), and a good shared decision-making process, with high median (IQR) values of CollaboRATE questionnaire (7; 6-9). PEPPI and CollaboRATE scores showed a statistically significant inverse correlation with different clinical variables such as disease duration, Leeds Enthesitis Index, PsA impact of Disease, Health Assessment Questionnaire, pain, patient's global assessment of disease activity and clinical disease activity for PsA. The presence of comorbidities did not appear to be associated with lower values of PEPPI and CollaboRATE. In this study, few patients with PsA were at risk of suboptimal communication with their physician. This phenomenon appeared to be primarily related to higher disease activity and burden.

Incidental pulmonary nodule management in Canada: exploring current state through a narrative literature review and expert interviews.

Incidental pulmonary nodules (IPNs) are common and increasingly detected with the overall rise of radiologic imaging. Effective IPN management is necessary to ensure lung cancer is not missed. This study aims to describe the current landscape of IPN management in Canada, understand barriers to optimal IPN management, and identify opportunities for improvement. We performed a narrative literature review by searching biomedical electronic databases for relevant articles published between January 1, 2010, and November 22, 2023. To validate and complement the identified literature, we conducted structured interviews with multidisciplinary experts involved in the pathway of patients with IPNs across Canada. Interviews between December 2021 and May 2022 were audiovisual recorded, transcribed, and thematically analyzed. A total of 1,299 records were identified, of which 37 studies were included for analysis. Most studies were conducted in Canada and the United States and highlighted variability in radiology reporting of IPNs and patient management, and limited adherence to recommended follow-up imaging. Twenty experts were interviewed, including radiologists, respirologists, thoracic surgeons, primary care physicians, medical oncologists, and an epidemiologist. Three themes emerged from the interviews, supported by the literature, including: variability in radiology reporting of IPNs, suboptimal communication, and variability in guideline adherence and patient management. Despite general awareness of guidelines, there is inconsistency and lack of standardization in the management of patients with IPNs in Canada. Multidisciplinary expert consensus is recommended to help overcome the communication and operational barriers to a safe and cost-effective approach to this common clinical issue.

Refining a Framework to Enhance Communication in the Emergency Department During the Diagnostic Process: An eDelphi Approach

Emergency departments (EDs) are susceptible to diagnostic error. Suboptimal communication between the patient and the interdisciplinary care team increases risk to diagnostic safety. The role of communication remains underrepresented in existing diagnostic decision-making conceptual models. The authors used eDelphi methodology, whereby data are collected electronically, to achieve consensus among an expert panel of 18 clinicians, patients, family members, and other participants on a refined ED-based diagnostic decision-making framework that integrates several potential opportunities for communication to enhance diagnostic quality. This study examined the entire diagnostic process in the ED, from prehospital to discharge or transfer to inpatient care, and identified where communication breakdowns could occur. After four iterative rounds of the eDelphi process, including a final validation round by all participants, the project's a priori consensus threshold of 80% agreement was reached. The authors developed a final framework that positions communication more prominently in the diagnostic process in the ED and enhances the original National Academies of Sciences, Engineering, and Medicine (NASEM) and ED-adapted NASEM frameworks. Specific points in the ED journey were identified where more attention to communication might be helpful. Two specific types of communication-information exchange and shared understanding-were identified as high priority for optimal outcomes. Ideas for communication-focused interventions to prevent diagnostic error in the ED fell into three categories: patient-facing, clinician-facing, and system-facing interventions. This project's refinement of the NASEM framework adapted to the ED can be used to develop communications-focused interventions to reduce diagnostic error in this highly complex and error-prone setting.

Developing a Collaborative Agenda-Setting Intervention (CASI) to promote patient-centered communication in ovarian cancer care: A design thinking approach

ObjectivesPatient-centered communication (PCC) occurs when clinicians respond to patients’ needs, preferences, and concerns. While PCC is associated with better health-related quality of life in patients with cancer, patients with ovarian cancer have reported unmet communication needs. We used design thinking to develop an intervention to promote PCC in ovarian cancer care. MethodsFollowing the steps of design thinking, we empathized with stakeholders by reviewing the literature, then created stakeholder and journey maps to define the design challenge. To ideate solutions, we developed a challenge map. Finally, we developed wireframe prototypes and tested them with stakeholders. ResultsEmpathizing revealed that misaligned visit priorities precipitated suboptimal communication. Defining the design challenge and ideating solutions highlighted the need to normalize preference assessments, promote communication self-efficacy, and enhance visit efficiency. The Collaborative Agenda-Setting Intervention (CASI) elicits patients’ needs and preferences and delivers communication guidance at the point of care. Stakeholders approved of the prototype. ConclusionDesign thinking provided a systematic approach to empathizing with stakeholders, identifying challenges, and innovating solutions. Practice ImplicationsTo our knowledge, the CASI is the first intervention to set the visit agenda and support communication from within the electronic health record. Future research will assess its usability and acceptability.

Knowing the Dose to Control the Dose: Optimizing Patient-Controlled Analgesia in Adults with Sickle Cell Disease (SCD)

Introduction: Acute painful episodes are the most common cause of hospitalization in SCD. Intravenous (IV) opioids are the analgesic of choice to treat pain requiring hospitalization in adults. On-demand IV opioid dosing can be either via a patient-controlled analgesia (PCA) pump or via intermittent nurse bolus. Advantages of PCA include better analgesia accessibility and relative independence from staff. However, significant variability exists in PCA management. A multicenter, randomized-controlled trial of PCA strategies in SCD was terminated early due to slow accrual, stemming from barriers such as suboptimal communication between inpatient teams. Additional limitations with PCA include technological limitations and incomplete charting through a manual process. We initiated a quality improvement project to understand patterns of PCA use in patients hospitalized for SCD pain crises at our institution. Methods: We performed a retrospective manual chart review on all adult patients diagnosed with SCD pain crises admitted to the University of Cincinnati Medical Center (UCMC) from October 1 through December 31, 2022. Inpatient data collected included reason for admission, length of stay, and documentation of inpatient opioid usage in daily clinical notes. Hospitalizations requiring intensive care admission for severe complications were excluded. Outpatient data collected included demographics and outpatient opioid prescriptions via the state prescription drug monitoring database. The study was approved by the UCMC IRB. Results: Fifteen patients were admitted to UCMC a total of 24 times for SCD pain crises during the 3-month period. The patients ranged in age from 21 years to 73 years (median age 33 years, interquartile range (IQR) 19.5 years) and the majority (11/15) were women. Disease-modifying therapies prescribed included hydroxyurea (8/15, 53%), chronic transfusions (2/15, 13%), chronic transfusions plus hydroxyurea (1/15), voxelotor (1/15), no disease-modifying therapy (2/15). Nine patients were prescribed daily outpatient opioids that included an oral long-acting opioid plus an oral short-acting opioid. Out of the 24 hospitalizations, 11 were for an uncomplicated pain crisis, 10 were complicated by mild acute chest syndrome (mild hypoxia and/or abnormal chest imaging), and 3 patients experienced other treatable complications (2 with Staphylococcus epidermidis bacteremia, 1 with deep venous thrombosis). Five patients were admitted two or more times. Two patients, admitted a total of 5 times, were maintained on nurse-administered IV bolus opioids during their admissions, in addition to oral opioids. The remainder of the patients were treated with a hydromorphone PCA pump with on-demand bolus dosing only, in addition to home long-acting oral opioids when applicable. Two patients were ultimately transitioned from PCA onto nurse-administered bolus IV opioids, due to failure to achieve adequate analgesia with PCA. In 9 out of the 19 admissions using a PCA, daily MME or the equivalent was charted in at least one progress note (47%). The median LOS in the subgroup in which PCA use was charted at least once was 7 (IQR 3.5) days. In the 10 admissions on a PCA in which daily MME was never charted (53%), the median LOS was 11 (IQR 6.25) days. Among patients not receiving outpatient opioids, daily MMEs from the PCA in the first few days of hospitalization (when recorded) ranged from 24 to 520 (median 178, IQR 241) MME. In patients who had daily chronic pain on outpatient opioid therapy, daily inpatient MME from PCA ranged from 360 to 1020 (median 545, IQR 418) MME. In patients with multiple admissions during the study period, the recorded daily opioid use was about two times that in the single admission group (median 673, IQR 500 MME in the multiple admissions group; vs median 329, IQR 351 MME in the single admission group). Conclusions: Our data suggest that length of stay is shortened by ~4 days when clinicians quantify daily opioid use for patients on PCA. In addition, patients with frequent admissions tend to have higher inpatient daily opioid use. This hints that readmission may be partly driven by mild withdrawal when on outpatient opioids at lower MME. A major barrier to data collection was inconsistent documentation of daily opioid use. The next step in our quality improvement project is an educational curriculum on inpatient opioid management for residents and hospitalists.

Perceptions of Use of Names, Recognition of Roles, and Teamwork After Labeling Surgical Caps

Communication failures in perioperative areas are common and have negative outcomes for both patients and clinicians. Names and roles of teammates are difficult to remember or discern contributing to suboptimal communication, yet the utility of labeled surgical caps with names and roles for enhancing perceived teamwork and connection is not well studied. To evaluate the use of labeled surgical caps in name use and role recognition, as well as teamwork and connection, among interprofessional perioperative teammates. In this quality improvement study, caps labeled with names and roles were distributed to 967 interprofessional perioperative clinicians, along with preimplementation and 6-month postimplementation surveys. Conducted between July 8, 2021, and June 25, 2022, at a single large, academic, quaternary health care center in the US, the study comprised surgeons, anesthesiologists, trainees, and all interprofessional hospital staff who work in adult general surgery perioperative areas. Labeled surgical caps were offered cost-free, although not mandatory, to each interested clinician. Quantitative survey of self-reported frequency for name use and role recognition as well as postimplementation sense of teamwork and connection. The surveys also elicited free response comments. Of the 1483 eligible perioperative clinicians, 967 (65%; 387 physicians and 580 nonphysician staff; 58% female) completed preimplementation surveys and received labeled caps, and 243 of these individuals (51% of physicians and 8% of staff) completed postimplementation surveys. Pre-post results were limited to physicians, due to the low postsurvey staff response rate. The odds of participants reporting that they were often called by their name increased after receiving a labeled cap (adjusted odds ratio [AOR], 13.37; 95% CI, 8.18-21.86). On postsurveys, participants reported that caps with names and roles substantially improved teamwork (80%) and connection (79%) with teammates. Participants who reported an increased frequency of being called by their name had higher odds for reporting improved teamwork (AOR, 3.46; 95% CI, 1.91-6.26) and connection with teammates (AOR, 3.21; 95% CI, 1.76-5.84). Free response comments supported the quantitative data that labeled caps facilitated knowing teammates' names and roles and fostered a climate of wellness, teamwork, inclusion, and patient safety. The findings of this quality improvement study performed with interprofessional teammates suggest that organizationally sponsored labeled surgical caps was associated with improved teamwork, indicated by increased name use and role recognition in perioperative areas.

Implementation of Digital-Based Approaches in Early Childhood Education Supervision Amidst the COVID-19 Pandemic

In the context of early childhood education, education plays a crucial role in shaping a child’s development. The COVID-19 pandemic has transformed the education landscape entirely, including early childhood education. School principals and early childhood educators have faced challenges in providing effective supervision, guidance, and evaluation in digital-based learning environments. This research aims to analyze the implementation of digital-based approaches in early childhood education supervision during the COVID-19 pandemic. Employing a survey method with a mixed-method approach, the results indicate that digital-based supervision in early childhood education exhibits limited effectiveness due to educators' lack of digital literacy, institutional unpreparedness, and suboptimal communication channels. Emphasizing digital literacy training, ensuring digital infrastructure, establishing continuous communication, and adopting user-friendly applications are crucial to enhancing educator competencies and enriching children learning experience.

Model of Stakeholder Engagement in Halal Tourism Ecosystems in Rural Areas

This study aims to explore stakeholder engagement models in halal tourism ecosystems in rural areas. The research focuses on understanding how stakeholders’ involvement in production, services, infrastructure, and human resources (HR) in the field of halal tourism in rural areas contributes to building an ecosystem. The analysis, based on the concept of Halal in the tourism industry, aims to provide clarity to the Halal ecosystem within hotel, culinary, and tourist destination businesses. The urgency of this research lies in identifying, analyzing, and evaluating the involvement of each stakeholder as a component of the halal tourism ecosystem, with particular emphasis on government regulations. The research adopts a qualitative method using a case study approach within a constructivist paradigm. In-depth interviews and focus group discussions (FGDs) are conducted to gather data. The primary objectives of this research are to develop a model of the Halal Tourism Ecosystem and provide recommendations for synergizing and optimizing the potential of halal tourism from each stakeholder. Four villages in West Java, namely Dayeuh Kolot Village, Alam Endah Village, Cisayong Village, and Sukalaksana Village, were selected as research locations using purposive sampling. Informants representing various sectors, such as hotels, restaurants, tourist attractions, halal centers, the Indonesian Ulema Council (MUI), regional governments, and elected village heads, were involved in the research. The findings reveal that the construction of a halal tourism ecosystem involves six stakeholder components that interact and relate to each other during implementation. These stakeholders include the Ministry of Tourism of the Republic of Indonesia as the ”leading sector” responsible for regulating tourism development in various regions. The Indonesian Ulema Council (MUI) issues Fatwas to align tourism activities with the principles of the Qur’an and Hadith. Regional leaders play a vital role in policymaking, providing infrastructure, and supporting human resource development and funding for halal tourism initiatives. Tourism business actors, such as hotel owners, managers, tourist attractions, restaurants, and tourism bureaus, commit to capitalizing on halal tourism opportunities within their business operations. While the ideal halal tourism industry ecosystem relies on active involvement and proper execution of roles by all stakeholders, the study identifies challenges. Awareness and achievement of the vision and mission among stakeholders in developing halal tourism remain low due to suboptimal communication, coordination, and collaboration. Therefore, the government’s role is vital in acting as a conductor, harmonizing the efforts of stakeholders in the development of Indonesia’s halal tourism industry.&#x0D; Keywords: engagement model, halal ecosystem, tourism stakeholders

Effects of DementiaNet's Community Care Network Approach on Admission Rates and Healthcare Costs: A Longitudinal Cohort Analysis.

People with dementia are increasingly living at home, relying on primary care providers for most healthcare needs. Suboptimal collaboration and communication between providers could cause inefficiencies and worse patient outcomes. Innovative strategies are needed to address this growing disease burden and rising healthcare costs. The DementiaNet programme, a community care network approach targeted at patients with dementia in the Netherlands, has been shown to improve patient's quality of care. However, very little is known about the impact of DementiaNet on admission risks and healthcare costs. This study addresses this knowledge gap. A longitudinal cohort analysis was performed, using medical and long-term care claims data from 38 525 patients between 2015-2019. The primary outcomes were risk of hospital admission and annual total healthcare costs. Mixed-model regression analyses were used to identify changes in outcomes. Patients who received care from a DementiaNet community care network showed a general trend in lower risk of admission for all types of admissions studied (ie, hospital, emergency ward, intensive care, crisis, and nursing home). Also, the intervention group showed a significant reduction of 12% in nursing days (relative risk [RR] 0.88; 95% CI: 0.77- 0.96). No significant differences were found for total healthcare costs. However, we found effects in two sub-elements of total healthcare costs, being a decrease of 19.7% (95% CI: 7.7%-30.2%) in annual hospital costs and an increase of 10.2% (95% CI: 2.3%-18.6%) in annual primary care costs. Our study indicates that DementiaNet's community care network approach may reduce admission risks for patients with dementia over a long-term period of five years. This is accompanied by a decrease in nursing days and savings in hospital care that exceed increased primary care costs. This improvement in integrated dementia care supports wider scale implementation and evaluation of these networks.

Perceptions and experiences of female nurses when confronted with expressing a conscientious objection towards end-of-life care in Greece

BackgroundConscientious objection in nursing has been a topic of much discussion in recent years. Healthcare providers’ conscientious objection has been included in Greek legislation. However, little is known about the real experiences of nurses who want to apply conscientious objections in their practice. This study aimed to contribute to filling that gap.MethodsThis qualitative study was conducted with eighteen experienced female nurses. Data were collected through semi-structured in-depth qualitative interviews conducted with purposively selected nurses during the period from October 2019 to January 2020. Interviews were transcribed verbatim and analysed thematically. The ethical principles of anonymity, voluntary participation and confidentiality were considered.ResultsEight major themes and seven subthemes emerged from the thematic data analysis. Oppressive behaviors in the workplace and subservient interactions between nurses and physicians, suboptimal communication and inadequate support of nurses, perceived ineffectiveness of nurses’ conscientious objections, missing legal protection against job insecurity, provision of care labeled ‘futile’, nurses’ false knowledge and perceptions on medical situations related to conscientious objections, nurses’ fears of isolation bullying and negative gossip in the workplace and a trivial amount of nurses’ involvement in medical decisions emerged as barriers to nurses raising conscientious objection. Furthermore, from data analysis, it emerged that some nurses had false knowledge and perceptions on medical situations related to conscientious objections, some nurses experienced mild uncertainty distress about their ethical concerns, nurses considered their remote contribution as participation that can give rise to conscientious objection, a collective conscientious objection raised by nurses might have increased chances of being effective, and upbringing, childhood experiences, education and religion are factors shaping the nurses’ core values.ConclusionA total of fifteen themes and subthemes emerged from this study. Most of the findings of this study were previously unknown or undervalued and might be helpful to inform nurses and nursing managers or leaders as well as healthcare policy makers. The results of this study might contribute to addressing the need for creating ethically sensitive health care services and ensuring nurses’ moral integrity and high quality of patient care.

Pediatric Resident Communication of Hospital Discharge Instructions.

Suboptimal provider-parent communication contributes to poor parent comprehension of pediatric discharge instructions, which can lead to adverse outcomes. Residency is a critical window to acquire and learn to utilize key communication skills, potentially supported by formal training programs or visual reminders. Few studies have examined resident counseling practices or predictors of counseling quality. Our objectives were to (1) examine pediatric resident counseling practices and (2) determine how formal training and presence of discharge templates with domain-specific prompts are associated with counseling. We conducted a cross-sectional survey of a convenience sample of residents in the American Academy of Pediatrics Section on Pediatric Trainees. Outcomes included resident self-report of frequency of (1) counseling in domains of care and (2) use of health literacy-informed counseling strategies (pictures, demonstration, Teach Back, Show Back) (6-point scales; frequent = often/usually/always). Predictor variables were (1) formal discharge-related training (e.g., lectures) and (2) hospital discharge instruction template with space for individual domains. Logistic regression analyses, utilizing generalized estimating equations when appropriate to account for multiple domains (adjusting for resident gender, postgraduate year), were performed. Few residents (N = 317) (13.9%) reported formal training. Over 25% of residents infrequently counsel on side effects, diagnosis, and restrictions. Resident reported use of communication strategies was infrequent: drawing pictures (24.1%), demonstration (15.8%), Teach Back (36.8%), Show Back (11.4%). Designated spaces in instruction templates for individual domains were associated with frequent domain-specific counseling (adjusted odds ratio [aOR] 4.1 [95% confidence interval: 3.5-4.8]). Formal training was associated with frequent Teach Back (aOR 2.6 [1.4-5.1]) and Show Back (aOR 2.7 [1.2-6.2]). Lack of formal training and designated space for domain-specific instructions are associated with suboptimal counseling at discharge by pediatric residents. Future research should focus on determining the best mechanisms for teaching trainees communication skills and optimizing written instruction templates to support verbal counseling. [HLRP: Health Literacy Research and Practice. 2023;7(4):e178-e186.].