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Over-rating pain is overrated: A fundamental self-other bias in pain reporting behavior. THE JOURNAL OF PAIN 2022; 23:1779-1789. [PMID: 35724938 DOI: 10.1016/j.jpain.2022.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/24/2022] [Accepted: 06/04/2022] [Indexed: 11/21/2022]
Abstract
Wide-spread cultural beliefs influence personal experiences and clinical treatment of pain, yet are often unexamined and unchallenged in the pain literature. The common cultural belief that people generally over-report or exaggerate pain is familiar, reflected in discordant patient-provider pain assessments, and compounded in the context of disparities in pain treatment. However, no studies have directly measured the prevalence of this belief among the general population, nor challenged the validity of this assumption by assessing normative pain reporting in clinical settings. Results of an initial and replication study suggest that reporting pain accurately "as-is" is the norm, yet most people still believe that others normatively over-report pain. We refer to the phenomenon by which most people report their pain as they experience it while paradoxically believing that others over-report their pain as the fundamental pain bias, and suggest this false perception may contribute to larger scale pain stigma and poor outcomes for people in pain. We also identify counter-stereotypical patterns of pain reporting among groups (i.e., women, Latinx Americans) that face more disparate care. Results reinforce the need for respecting patient pain reports, and suggest that distrust surrounding others' pain experiences is prevalent in society.
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2
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Mathur VA, Trost Z, Ezenwa MO, Sturgeon JA, Hood AM. Mechanisms of injustice: what we (do not) know about racialized disparities in pain. Pain 2022; 163:999-1005. [PMID: 34724680 PMCID: PMC9056583 DOI: 10.1097/j.pain.0000000000002528] [Citation(s) in RCA: 60] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/29/2021] [Accepted: 10/21/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Vani A. Mathur
- Department of Psychological and Brain Sciences, Texas A&M University, College Station, TX, United States
| | - Zina Trost
- Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, VA, United States
| | - Miriam O. Ezenwa
- Department of Biobehavioral Nursing Science, College of Nursing, University of Florida, Gainesville, FL, United States
| | - John A. Sturgeon
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Anna M. Hood
- Division of Psychology and Mental Health, University of Manchester, Manchester, United Kingdom
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3
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Wang KY, Puvanesarajah V, Xu A, Zhang B, Raad M, Hassanzadeh H, Kebaish KM. Growing Racial Disparities in the Utilization of Adult Spinal Deformity Surgery: An Analysis of Trends From 2004 to 2014. Spine (Phila Pa 1976) 2022; 47:E283-E289. [PMID: 34405826 DOI: 10.1097/brs.0000000000004180] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective. OBJECTIVE The purpose of this study was to assess trends in utilization rates of adult spinal deformity (ASD) surgery, as well as perioperative surgical metrics between Black and White patients undergoing operative treatment for ASD in the United States. SUMMARY OF BACKGROUND DATA Racial disparities in access to care, complications, and surgical selection have been shown to exist in the field of spine surgery. However, there is a paucity of data concerning racial disparities in the management of ASD patients. METHODS Adult patients undergoing ASD surgery from 2004 to 2014 were identified in the nationwide inpatient sample (NIS). Utilization rates, major complications rates, and length of stay (LOS) for Black patients and White patients were trended over time. Utilization rates were reported per 1,000,000 people and determined using annual census data among subpopulations stratified by race. All reported complication rates and prolonged hospital stay rates are adjusted for Elixhauser Comorbidity Index, income quartile by zip code, and insurance payer status. RESULTS From 2004 to 2014, ASD utilization for Black patients increased from 24.0 to 50.9 per 1,000,000 people, whereas ASD utilization for White patients increased from 29.9 to 73.1 per 1,000,000 people, indicating a significant increase in racial disparities in ASD utilization (P-trend < 0.001). There were no significant differences in complication rates or rates of prolonged hospital stay between Black and White patients across the time period studied (P > 0.05 for both). CONCLUSION Although Black and White patients undergoing ASD surgery do not differ significantly in terms of postoperative complications and length of hospital stay, there is a growing disparity in utilization of ASD surgery between White and Black patients from 2004 to 2014 in the United States. There is need for continued focus on identifying ways to reduce racial disparities in surgical selection and perioperative management in spine deformity surgery.Level of Evidence: 3.
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Affiliation(s)
- Kevin Y Wang
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Amy Xu
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Bo Zhang
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA
| | - Khaled M Kebaish
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
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4
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Yetman HE, Cox N, Adler SR, Hall KT, Stone VE. What Do Placebo and Nocebo Effects Have to Do With Health Equity? The Hidden Toll of Nocebo Effects on Racial and Ethnic Minority Patients in Clinical Care. Front Psychol 2022; 12:788230. [PMID: 35002881 PMCID: PMC8733207 DOI: 10.3389/fpsyg.2021.788230] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/30/2021] [Indexed: 12/21/2022] Open
Abstract
A placebo effect is a positive clinical response to non-specific elements of treatment with a sham or inert replica of a drug, device, or surgical intervention. There is considerable evidence that placebo effects are driven by expectation of benefit from the intervention. Expectation is shaped by a patient's past experience, observations of the experience of others, and written, verbal, or non-verbal information communicated during treatment. Not surprisingly, expectation in the clinical setting is strongly influenced by the attitude, affect, and communication style of the healthcare provider. While positive expectations can produce beneficial effects, negative information and experiences can lead to negative expectations, and consequently negative or nocebo effects. Key components identified and studied in the placebo and nocebo literature intersect with factors identified as barriers to quality care in the clinical setting for Black patients and other patients of color, including poor patient-clinician communication, medical mistrust, and perceived discrimination. Thus, in the context of discrimination and bias, the absence of placebo and presence of nocebo-generating influences in clinical settings could potentially reinforce racial and ethnic inequities in clinical outcomes and care. Healthcare inequities have consequences that ripple through the medical system, strengthening adverse short- and long-term outcomes. Here, we examine the potential for the presence of nocebo effects and absence of placebo effects to play a role in contributing to negative outcomes related to unequal treatment in the clinical encounter.
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Affiliation(s)
- Hailey E Yetman
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Nevada Cox
- Penn State College of Medicine, Hershey, PA, United States
| | - Shelley R Adler
- Osher Center for Integrative Health, University of California, San Francisco, San Francisco, CA, United States
| | - Kathryn T Hall
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
| | - Valerie E Stone
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Department of Medicine, Harvard Medical School, Boston, MA, United States
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5
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Vo JB, Gillman A, Mitchell K, Nolan TS. Health Disparities: Impact of Health Disparities and Treatment Decision-Making Biases on Cancer Adverse Effects Among Black Cancer Survivors. Clin J Oncol Nurs 2021; 25:17-24. [PMID: 34533532 DOI: 10.1188/21.cjon.s1.17-24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Health disparities affect cancer incidence, treatment decisions, and adverse effects. Oncology providers may hold biases in the decision-making process, which can perpetuate health disparities. OBJECTIVES The purpose of this article is to describe health disparities across treatment decisions and adverse effects, describe decision-making biases, and provide suggestions for nurses to mitigate adverse outcomes. METHODS A scoping review of the literature was conducted. FINDINGS Factors affecting health disparities stem, in part, from structural racism and decision-making biases, such as implicit bias, which occurs when individuals have unconscious negative thoughts or feelings toward a particular group. Other decision-making biases, seemingly unrelated to race, include default bias, delay discounting bias, and availability bias. Nurses and nurse navigators can mitigate health disparities by providing culturally appropriate care, assessing health literacy, providing education regarding adverse effects, serving as patient advocates, empowering patients, evaluating personal level of disease knowledge, and monitoring and managing cancer treatment adverse effects.
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Affiliation(s)
| | | | | | - Timiya S Nolan
- Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
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6
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Tinôco JDDS, Cossi MS, Fernandes MIDCD, Paiva AC, Lopes MVDO, Lira ALBDC. Effect of educational intervention on clinical reasoning skills in nursing: A quasi-experimental study. NURSE EDUCATION TODAY 2021; 105:105027. [PMID: 34218071 DOI: 10.1016/j.nedt.2021.105027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/24/2021] [Accepted: 06/15/2021] [Indexed: 06/13/2023]
Abstract
This study evaluated the effect of an educational intervention based on virtual clinical simulation and problem-based learning using a mobile application in a clinical nursing education context as a tool to improve clinical reasoning skills of students on the second year of nursing graduation. A prospective quasi-experimental study was conducted in the year 2018, and assessments were performed before and after the educational intervention. A random convenience sample (n = 32) of nursing students in the second year of a public university in Brazil was divided equally into experimental and control groups. The experimental group underwent educational intervention about clinical reasoning skills and measured the quality of the Diagnostician Nurse software by LORI 2.0 instrument. The control group experienced the conventional class on clinical reasoning skills. Four clinical cases were used to assess reasoning skills before and after the educational intervention. The data were analyzed using descriptive and inferential statistics. The experimental group showed a statistically significant difference regarding the prioritization of nursing diagnoses (p = 0.014) and a higher final score. There was a statistically significant difference in performance between the pre- and post-test in the grades of the students who participated in the intervention (p = 0.003). The control group also showed statistical significance in the score attributed to the clinical reasoning process (p = 0.015). In addition, the Diagnostician Nurse software had excellent usability and quality evaluations (SUS 87.81 and LORI 4.66, respectively). It is concluded that educational intervention based on virtual clinical simulation and learning problems using the Diagnostician Nurse software is effective as a tool to improve clinical reasoning skills and can support early detection of patients. The educational intervention developed was of high quality and attractive and improved students' motivation for the teaching-learning process.
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Affiliation(s)
| | - Marcelly Santos Cossi
- Nursing Department, State University of Rio Grande do Norte, Caicó, Rio Grande do Norte, Brazil
| | | | - Anderson Cruz Paiva
- Metrópole Digital Institute - IMD, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
| | | | - Ana Luisa Brandão de Carvalho Lira
- Nursing Department and in the Post-Graduate Program in Nursing, Federal University of Rio Grande do Norte, Natal, Rio Grande do Norte, Brazil
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A randomized controlled trial testing a virtual perspective-taking intervention to reduce race and socioeconomic status disparities in pain care. Pain 2020; 160:2229-2240. [PMID: 31568099 DOI: 10.1097/j.pain.0000000000001634] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
We conducted a randomized controlled trial of an individually tailored, virtual perspective-taking intervention to reduce race and socioeconomic status (SES) disparities in providers' pain treatment decisions. Physician residents and fellows (n = 436) were recruited from across the United States for this two-part online study. Providers first completed a bias assessment task in which they made treatment decisions for virtual patients with chronic pain who varied by race (black/white) and SES (low/high). Providers who demonstrated a treatment bias were randomized to the intervention or control group. The intervention consisted of personalized feedback about their bias, real-time dynamic interactions with virtual patients, and videos depicting how pain impacts the patients' lives. Treatment bias was re-assessed 1 week later. Compared with the control group, providers who received the tailored intervention had 85% lower odds of demonstrating a treatment bias against black patients and 76% lower odds of demonstrating a treatment bias against low SES patients at follow-up. Providers who received the intervention for racial bias also showed increased compassion for patients compared with providers in the control condition. Group differences did not emerge for provider comfort in treating patients. Results suggest an online intervention that is tailored to providers according to their individual treatment biases, delivers feedback about these biases, and provides opportunities for increased contact with black and low SES patients, can produce substantial changes in providers' treatment decisions, resulting in more equitable pain care. Future studies should examine how these effects translate to real-world patient care and the optimal timing/dose of the intervention.
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8
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Letzen JE, Dildine TC, Mun CJ, Colloca L, Bruehl S, Campbell CM. Ethnic Differences in Experimental Pain Responses Following a Paired Verbal Suggestion With Saline Infusion: A Quasiexperimental Study. Ann Behav Med 2020; 55:55-64. [PMID: 32421193 DOI: 10.1093/abm/kaaa032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ethnic differences in placebo and nocebo responses are an important, yet underresearched, patient factor that might contribute to treatment disparities. PURPOSE The purpose of this study was to examine ethnic differences in pain trajectories following a verbal suggestion paired with a masked, inert substance (i.e., saline). METHODS Using a quasiexperimental design, we examined differences between 21 non-Hispanic Black (NHB) participants and 20 non-Hispanic White (NHW) participants in capsaicin-related pain rating trajectories following a nondirectional verbal suggestion + saline infusion. All participants were told that the substance would "either increase pain sensation, decrease it, or leave it unchanged." A spline mixed model was used to quantify the interaction of ethnicity and time on ratings. RESULTS There was a significant Ethnicity × Time interaction effect (β = -0.28, p = .002); NHB individuals reported significantly greater increases in pain following, but not before, the verbal suggestion + saline infusion. Sensitivity analyses showed no change in primary results based on differences in education level, general pain sensitivity, or condition order. CONCLUSIONS The present results showed ethnic differences in pain response trajectories following a verbal suggestion + saline infusion and suggest that future research rigorously examining possible ethnic differences in placebo/nocebo responses is warranted.
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Affiliation(s)
- Janelle E Letzen
- Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Nathan Shock Drive, Suite, Baltimore, MD, USA
| | - Troy C Dildine
- National Center for Complementary and Integrative Health, National Institutes of Health, Bethesda, MD, USA.,Department of Clinical Neuroscience, Karolinska Institutet, Solna, Sweden
| | - Chung Jung Mun
- Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Nathan Shock Drive, Suite, Baltimore, MD, USA
| | - Luana Colloca
- Department of Pain and Translational Symptom Science, School of Nursing, University of Maryland, Baltimore, MD, USA.,Departments of Anesthesiology and Psychiatry, School of Medicine, University of Maryland, Baltimore, University of Maryland, Baltimore, MD, USA.,Center to Advance Chronic Pain Research, University of Maryland, Baltimore, MD, USA
| | - Stephen Bruehl
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Claudia M Campbell
- Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Nathan Shock Drive, Suite, Baltimore, MD, USA
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9
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Areas of Knowledge Deficit and Misconceptions Regarding Pain among Jordanian Nurses. Pain Manag Nurs 2019; 20:649-655. [DOI: 10.1016/j.pmn.2019.02.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 01/13/2019] [Accepted: 02/23/2019] [Indexed: 11/20/2022]
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10
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Salim N, Joshua R, AbuBaker N, Chehab F, Jose A. Effect of a Nursing In-Service Education Program on Nurses’ Knowledge and Attitudes towards Pain Management in a Governmental Hospital in the United Arab Emirates: Experimental Random Assignment Study. DUBAI MEDICAL JOURNAL 2019. [DOI: 10.1159/000503560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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11
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Meints SM, Cortes A, Morais CA, Edwards RR. Racial and ethnic differences in the experience and treatment of noncancer pain. Pain Manag 2019; 9:317-334. [PMID: 31140916 PMCID: PMC6587104 DOI: 10.2217/pmt-2018-0030] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Accepted: 12/12/2018] [Indexed: 12/11/2022] Open
Abstract
The burden of pain is unequal across racial and ethnic groups. In addition to racial and ethnic differences in the experience of pain, there are racial and ethnic disparities in the assessment and treatment of pain. In this article, we provide a nonexhaustive review of the biopsychosocial mechanistic factors contributing to racial and ethnic differences in both the experience and treatment of pain. Using a modified version of the Socioecological Model, we focus on patient-, provider- and system-level factors including coping, perceived bias and discrimination, patient preferences, expectations, patient/provider communication, treatment outcomes and healthcare access. In conclusion, we provide psychosocial factors influencing racial and ethnic differences in pain and highlight future research targets and possible solutions to reduce these disparities.
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Affiliation(s)
- Samantha M Meints
- Department of Anesthesiology, Pain Management Center, Brigham & Women’s Hospital, Harvard Medical School, Chestnut Hill, MA 02467, USA
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Alejandro Cortes
- Orthopaedic and Arthritis Center for Outcomes Research, Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Calia A Morais
- Department of Psychology, The University of Alabama, Tuscaloosa, AL 35487, USA
| | - Robert R Edwards
- Department of Anesthesiology, Pain Management Center, Brigham & Women’s Hospital, Harvard Medical School, Chestnut Hill, MA 02467, USA
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12
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Modanloo M, Mohsenpour A, Rahmani H, Moghaddam S, Khoddam H. Impact of Implementing the Critical Care Pain Observation Tool on Nurses' Performance in Assessing and Managing Pain in the Critically Ill Patients. Indian J Crit Care Med 2019; 23:165-169. [PMID: 31130786 PMCID: PMC6521825 DOI: 10.5005/jp-journals-10071-23146] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and aims Pain management is one of the most important responsibilities of nurses in an intensive care unit (ICU). It is difficult to perform pain assessment appropriately in patients who are unable to report their pain. This study is aimed to determine the impact of implementing the critical care pain observation tool (CPOT) on the amount and frequency of analgesics' administration in ICUs. Materials and methods This interventional study was conducted in 2014. Sixty nurses and 240 patients were studied. This study was carried out in three phases: first the data about amount and frequency of analgesic administration were extracted from patients' medical files. Then the CPOT was implemented into the nursing assessment process and finally, nurses' performance regarding the amount and frequency of analgesic administration was recorded. This data obtained before and after intervention were analyzed using chi-square and independent t-test p values less than 0.05 were considered significant. Results In this interventional study, we found that there was no difference in the demography and cause of ICU admission before and after implementation of CPOT (age p = 0.937, gender p = 0.996, and the cause of admission p = 0.996). We found that after implementing the CPOT into the nursing assessment process, the amount of analgesics administered (7.95 ± 8.77 mg vs. 11.01 ± 11.04 mg, p = 0.018) and the frequency of administration (2.91 ± 1.38 vs. 4.16 ± 0.99, p <0.001) increased significantly. Moreover, there was a significant increase in the frequency of pain assessment per patient per day in nursing practice after implementation of CPOT as compared to the practice before (7.2 ± 2.48 vs. 1.03 ± 1.63, p <0.001). The mean pain scores before and after the intervention (5.5 ± 1.08 vs.2.2 ± 0.48) were also significantly different. Conclusion Applying CPOT, as an objective mean of pain assessment, was effective in improving the performance of ICU nurses in assessment and management of patients' pain. It increased the amount and frequency of analgesic administration. We can recommend that COPT is a useful tool for assessment and management of pain in ICU patients and should be implemented in all ICUs. How to cite this article Modanloo M, Mohsenpour A, et al. Impact of Implementing the Critical Care Pain Observation Tool on Nurses' Performance in Assessing and Managing Pain in the Critically Ill Patients. Indian J Crit Care Med 2019;23(4):165-169.
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Affiliation(s)
- Mahnaz Modanloo
- Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Afsaneh Mohsenpour
- Critical Care Nursing, Nursing and Midwifery School, Golestan University of Medical Sciences, Gorgan, Iran
| | - Hossein Rahmani
- Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Shahram Moghaddam
- Department of Anesthesiology, School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Homeira Khoddam
- Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran
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13
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Anastas TM, Meints SM, Gleckman AD, Hirsh AT. Social Influences on Peer Judgments about Chronic Pain and Disability. THE JOURNAL OF PAIN 2018; 20:698-705. [PMID: 30583083 DOI: 10.1016/j.jpain.2018.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 12/05/2018] [Accepted: 12/06/2018] [Indexed: 11/30/2022]
Abstract
Chronic pain is a leading cause of work absenteeism and disability compensation. Previous work demonstrates that patients with chronic illness often seek advice, such as whether or not to pursue disability benefits, from peers with similar health conditions. The current study examined the extent that social factors influence patients with chronic pain ("peers") when making disability judgments and recommendations for other patients with chronic pain. Participants (N = 71) made pain-related and disability ratings for fictional vignette patients that varied in weight (normal vs obese), fault of accident, and physical work demands. Results of repeated measures analyses of variance indicated that participants rated patients with obesity, who were not at fault, and who held a physically demanding job as experiencing more severe pain symptoms and disability and were more likely to recommend they seek disability benefits. Participants who had applied for disability benefits themselves rated patients as more disabled than participants who had not applied for disability. These data suggest that patients with chronic pain are influenced by patient and contextual factors when making pain-related and disability judgments for peers. These judgments may impact patient decision making via peer support programs and online forums. PERSPECTIVE: This study suggests that patients with chronic pain are influenced by patient weight, fault of accident, and physical work demands when making judgments about pain and disability for peers. Future studies should examine the extent such peer-to-peer recommendations influence actual disability-seeking behaviors for pain.
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Affiliation(s)
- Tracy M Anastas
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN
| | - Samantha M Meints
- Department of Anesthesiology and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.; Orthopedic and Arthritis Center for Outcomes Research, Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Adam T Hirsh
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, IN..
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Thomas EV. "Why Even Bother; They Are Not Going to Do It?" The Structural Roots of Racism and Discrimination in Lactation Care. QUALITATIVE HEALTH RESEARCH 2018; 28:1050-1064. [PMID: 29557297 DOI: 10.1177/1049732318759491] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Through semi-structured interviews with 36 International Board Certified Lactation Consultants (IBCLCs) who assist mothers with breastfeeding, this study takes a systematic look at breastfeeding disparities. Specifically, this study documents race-based discrimination against patients in the course of lactation care and links the implicit bias literature to breastfeeding disparities. IBCLCs report instances of race-based discrimination against patients such as unequal care provided to patients of color and overt racist remarks said in front of or behind patient's backs. This study connects patient discrimination in lactation to institutional inequality and offers suggestions to address these inequities.
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Affiliation(s)
- Erin V Thomas
- 1 Graduate of Georgia State University, Atlanta, Georgia, USA ORISE Research Fellow, Oak Ridge Tennesee, USA
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15
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Abstract
Pain is a complex sensation with a variety of qualities rather than a single sensation varying in intensity. People find it difficult to describe their pain mainly because its nature and intensity vary so much, not only between individuals but also for a person over time. This article provides an overview of wound pain, its causes and assessment, with a focus on the procedure of dressing change itself. The wound care industry has manufactured dressings to assist in reducing the pain experience and it is incumbent on health care professionals to make the most appropriate dressing selection for the individual patient and wound, rather than a 'one type of dressing fits all' approach. The choice of primary product is important and is the aspect of focus for this discussion. This paper discusses the use of Flaminal (an enzyme alginogel) to assist practitioners in managing painful wounds.
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Affiliation(s)
| | - Heather Williams
- Nurse Consultant & Honorary Lecturer Chronic Pain Service Royal Victoria Infirmary Newcastle upon Tyne
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16
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Nurses' Written Responses to Pain Management Values Education: A Content Analysis. Pain Manag Nurs 2016; 17:384-391. [PMID: 27756591 DOI: 10.1016/j.pmn.2016.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 08/26/2016] [Accepted: 08/26/2016] [Indexed: 11/22/2022]
Abstract
Providing optimal pain care for patients is essential to the work of nursing and a measure of patient satisfaction prompting some hospitals to offer pain management classes for clinicians. Although nurses generally do well on knowledge tests after attending a pain class, actual improvement in pain care for patients may not occur. The personal values of the clinician may be a key driver of pain-management decision making. Therefore, a segment on how clinicians' personal values influence pain care decisions was added to a large Midwestern hospital's pain management class. The purpose of this study was to examine the written answers to questions posed to nurses regarding any practice changes they have made to caring for patients with pain after participating in a class that included a segment on personal values. This study used a qualitative content analysis method. A large Midwestern healthcare system. Twenty clinical registered nurses who attended a pain class in April 2014. Participants provided written answers to two open-ended interview questions. Data were analyzed using conventional content analysis of the text. Four themes were identified among participants' answers: understanding the patient, importance of pain education, nurse's self-awareness, and interpretation of personal values. Nurses who learned how their personal values affect their pain management decisions described new insights into their own approach to pain management. More research is needed to fully understand the impact of knowing one's own values and determining which clinician values are associated with optimal pain care.
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17
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Sellers SL, Moss ME, Calzone K, Abdallah KE, Jenkins JF, Bonham VL. Nurses' Use of Race in Clinical Decision Making. J Nurs Scholarsh 2016; 48:577-586. [PMID: 27676232 DOI: 10.1111/jnu.12251] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE To examine nurses' self-reported use of race in clinical evaluation. DESIGN This cross-sectional study analyzed data collected from three separate studies using the Genetics and Genomics in Nursing Practice Survey, which includes items about use of race and genomic information in nursing practice. The Racial Attributes in Clinical Evaluation (RACE) scale was used to measure explicit clinical use of race among nurses from across the United States. METHODS Multivariate regression analysis was used to examine associations between RACE score and individual-level characteristics and beliefs in 5,733 registered nurses. FINDINGS Analysis revealed significant relationships between RACE score and nurses' race and ethnicity, educational level, and views on the clinical importance of patient demographic characteristics. Asian nurses reported RACE scores 1.41 points higher than White nurses (p < .001), and Black nurses reported RACE scores 0.55 points higher than White nurses (p < .05). Compared to diploma-level nurses, the baccalaureate-level nurses reported 0.69 points higher RACE scores (p < .05), master's-level nurses reported 1.63 points higher RACE scores (p < .001), and doctorate-level nurses reported 1.77 points higher RACE scores (p < .01). In terms of clinical importance of patient characteristics, patient race and ethnicity corresponded to a 0.54-point increase in RACE score (p < .001), patient genes to a 0.21-point increase in RACE score (p < .001), patient family history to a 0.15-point increase in RACE score (p < .01), and patient age to a 0.19-point increase in RACE score (p < .001). CONCLUSIONS Higher reported use of race among minority nurses may be due, in part, to differential levels of racial self-awareness. A relatively linear positive relationship between level of nursing degree nursing education and use of race suggests that a stronger foundation of knowledge about genetic ancestry, population genetics and the concept "race" and genetic ancestry may increase in clinical decision making could allow nurses to more appropriately use of race in clinical care. Integrating patient demographic characteristics into clinical decisions is an important component of nursing practice. CLINICAL RELEVANCE Registered nurses provide care for diverse racial and ethnic patient populations and stand on the front line of clinical care, making them essential for reducing racial and ethnic disparities in healthcare delivery. Exploring registered nurses' individual-level characteristics and clinical use of race may provide a more comprehensive understanding of specific training needs and inform nursing education and practice.
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Affiliation(s)
- Sherrill L Sellers
- *Associate Dean for Undergraduate Education and Professor, Department of Family Studies and Social Work, Miami University, Oxford, OH, USA.
| | - Melissa E Moss
- *Postbaccalaureate Intramural Research Training Award (IRTA) Fellow, Health Disparities Unit, Social and Behavioral Research Branch, Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kathleen Calzone
- Senior Nurse Specialist, Research, National Cancer Institute, Center for Cancer Research, Genetics Branch, National Institutes of Health, Bethesda, MD, USA
| | - Khadijah E Abdallah
- Research Analyst, Health Disparities Unit, Social and Behavioral Research Branch, Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jean F Jenkins
- Clinical Advisor, Office of the Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Vence L Bonham
- Associate Investigator, Health Disparities Unit, Social and Behavioral Research Branch, Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
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African Americans Have Better Outcomes for Five Common Gastrointestinal Diagnoses in Hospitals With More Racially Diverse Patients. Am J Gastroenterol 2016; 111:649-57. [PMID: 27002802 DOI: 10.1038/ajg.2016.64] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 02/01/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We sought to characterize the relationship between hospital inpatient racial diversity and outcomes for African-American patients including rates of major complications or mortality during hospitalization for five common gastrointestinal diagnoses. METHODS Using the 2012 National Inpatient Sample database, hospital inpatient racial diversity was defined as the percentage of African-American patients discharged from each hospital. Logistic regression was used to predict major complication rates or death, long length of stay, and high total charges. Control variables included age, gender, payer type, patient location, area-associated income quartile, hospital characteristics including size, urban vs. rural, teaching vs. nonteaching, region, and the interaction of the percentage of African Americans with patient race. RESULTS There were 848,395 discharges across 3,392 hospitals. The patient population was on average 27% minority (s.d.±21%) with African Americans accounting for 14% of all patients. Overall, African-American patients had higher rates of major complications or death relative to white patients (adjusted odds ratio (aOR) 1.19; 95% confidence interval (CI) 1.16-1.23). However, when treated in hospitals with higher patient racial diversity, African-American patients experienced significantly lower rates of major complications or mortality (aOR 0.80; 95% CI 0.74-0.86). CONCLUSIONS African Americans have better outcomes for five common gastrointestinal diagnoses when treated in hospitals with higher inpatient racial diversity. This has major ramifications on total hospital charges.
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Boissoneault J, Mundt JM, Bartley EJ, Wandner LD, Hirsh AT, Robinson ME. Assessment of the Influence of Demographic and Professional Characteristics on Health Care Providers' Pain Management Decisions Using Virtual Humans. J Dent Educ 2016; 80:578-587. [PMID: 27139209 PMCID: PMC4899979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/14/2015] [Indexed: 06/05/2023]
Abstract
Disparities in health care associated with patients' gender, race, and age are well documented. Previous studies using virtual human (VH) technology have demonstrated that provider characteristics may play an important role in pain management decisions. However, these studies have largely emphasized group differences. The aims of this study were to examine dentists' and physicians' use of VH characteristics when making clinical judgments (i.e., cue use) and to identify provider characteristics associated with the magnitude of the impact of these cues (β-weights). Providers (N=152; 76 physicians, 76 dentists) viewed video vignettes of VH patients varying in gender (male/female), race (white/black), and age (younger/older). Participants rated VH patients' pain intensity and unpleasantness and then rated their own likelihood of administering non-opioid and opioid analgesics. Compared to physicians, dentists had significantly lower β-weights associated with VH age cues for all ratings (p<0.001; d>0.69). These effects varied by provider race and gender. For pain intensity, professional differences were present only among non-white providers. White providers had greater β-weights than non-white providers for pain unpleasantness but only among men. Provider differences regarding the use of VH age cues in non-opioid analgesic administration were present among all providers except non-white males. These findings highlight the interaction of patient and provider factors in driving clinical decision making. Although profession was related to use of VH age cues in pain-related clinical judgments, this relationship was modified by providers' personal characteristics. Additional research is needed to understand what aspects of professional training or practice may account for differences between physicians and dentists and what forms of continuing education may help to mitigate the disparities.
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Affiliation(s)
- Jeff Boissoneault
- Dr. Boissoneault is Research Assistant Professor, Department of Clinical and Health Psychology, University of Florida; Ms. Mundt is Graduate Assistant, Department of Clinical and Health Psychology, University of Florida; Dr. Bartley is Research Assistant Professor, Department of Community Dentistry and Behavioral Science, University of Florida; Dr. Wandner was Graduate Assistant, Department of Clinical and Health Psychology, University of Florida at the time of this study; Dr. Hirsh is Assistant Professor, Department of Psychology, Indiana University-Purdue University Indianapolis; and Dr. Robinson is Professor, Department of Clinical and Health Psychology, University of Florida
| | - Jennifer M Mundt
- Dr. Boissoneault is Research Assistant Professor, Department of Clinical and Health Psychology, University of Florida; Ms. Mundt is Graduate Assistant, Department of Clinical and Health Psychology, University of Florida; Dr. Bartley is Research Assistant Professor, Department of Community Dentistry and Behavioral Science, University of Florida; Dr. Wandner was Graduate Assistant, Department of Clinical and Health Psychology, University of Florida at the time of this study; Dr. Hirsh is Assistant Professor, Department of Psychology, Indiana University-Purdue University Indianapolis; and Dr. Robinson is Professor, Department of Clinical and Health Psychology, University of Florida
| | - Emily J Bartley
- Dr. Boissoneault is Research Assistant Professor, Department of Clinical and Health Psychology, University of Florida; Ms. Mundt is Graduate Assistant, Department of Clinical and Health Psychology, University of Florida; Dr. Bartley is Research Assistant Professor, Department of Community Dentistry and Behavioral Science, University of Florida; Dr. Wandner was Graduate Assistant, Department of Clinical and Health Psychology, University of Florida at the time of this study; Dr. Hirsh is Assistant Professor, Department of Psychology, Indiana University-Purdue University Indianapolis; and Dr. Robinson is Professor, Department of Clinical and Health Psychology, University of Florida
| | - Laura D Wandner
- Dr. Boissoneault is Research Assistant Professor, Department of Clinical and Health Psychology, University of Florida; Ms. Mundt is Graduate Assistant, Department of Clinical and Health Psychology, University of Florida; Dr. Bartley is Research Assistant Professor, Department of Community Dentistry and Behavioral Science, University of Florida; Dr. Wandner was Graduate Assistant, Department of Clinical and Health Psychology, University of Florida at the time of this study; Dr. Hirsh is Assistant Professor, Department of Psychology, Indiana University-Purdue University Indianapolis; and Dr. Robinson is Professor, Department of Clinical and Health Psychology, University of Florida
| | - Adam T Hirsh
- Dr. Boissoneault is Research Assistant Professor, Department of Clinical and Health Psychology, University of Florida; Ms. Mundt is Graduate Assistant, Department of Clinical and Health Psychology, University of Florida; Dr. Bartley is Research Assistant Professor, Department of Community Dentistry and Behavioral Science, University of Florida; Dr. Wandner was Graduate Assistant, Department of Clinical and Health Psychology, University of Florida at the time of this study; Dr. Hirsh is Assistant Professor, Department of Psychology, Indiana University-Purdue University Indianapolis; and Dr. Robinson is Professor, Department of Clinical and Health Psychology, University of Florida
| | - Michael E Robinson
- Dr. Boissoneault is Research Assistant Professor, Department of Clinical and Health Psychology, University of Florida; Ms. Mundt is Graduate Assistant, Department of Clinical and Health Psychology, University of Florida; Dr. Bartley is Research Assistant Professor, Department of Community Dentistry and Behavioral Science, University of Florida; Dr. Wandner was Graduate Assistant, Department of Clinical and Health Psychology, University of Florida at the time of this study; Dr. Hirsh is Assistant Professor, Department of Psychology, Indiana University-Purdue University Indianapolis; and Dr. Robinson is Professor, Department of Clinical and Health Psychology, University of Florida.
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Boissoneault J, Mundt JM, Bartley EJ, Wandner LD, Hirsh AT, Robinson ME. Assessment of the Influence of Demographic and Professional Characteristics on Health Care Providers’ Pain Management Decisions Using Virtual Humans. J Dent Educ 2016. [DOI: 10.1002/j.0022-0337.2016.80.5.tb06118.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Emily J. Bartley
- Department of Community Dentistry and Behavioral Science; University of Florida
| | - Laura D. Wandner
- Department of Clinical and Health Psychology; University of Florida
| | - Adam T. Hirsh
- Department of Psychology; Indiana University-Purdue University Indianapolis
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Azarpazhooh A, Dao T, Ungar WJ, Da Costa J, Figueiredo R, Krahn M, Friedman S. Patients' Values Related to Treatment Options for Teeth with Apical Periodontitis. J Endod 2016; 42:365-70. [DOI: 10.1016/j.joen.2015.11.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 11/23/2015] [Accepted: 11/29/2015] [Indexed: 10/22/2022]
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Development and validation of a virtual human vignette to compare nurses' assessment and intervention choices for pain in critically ill children. Simul Healthc 2015; 10:14-20. [PMID: 25514587 DOI: 10.1097/sih.0000000000000061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION As virtual experiences are increasingly used in health care training and research, it is important that adequate processes are applied for developing valid scenarios. We describe the development and validation of virtual human (VH) vignettes, computer-generated scenarios with animated patients and clinical information, for a mixed-methods study regarding nurses' assessment and intervention choices for critically ill children's pain. METHODS We followed the case development and review process for high-fidelity simulation case scenarios, including the use of validated written vignettes and content experts. Forty nurses described their pain assessment and intervention choices for the newly derived VH vignettes and completed a pain questionnaire. Nurses' reports of VH vignette consistency with their professional experience and recognition of VH facial expressions were evaluated to establish face validity. Their pain ratings for the VH and written (questionnaire) vignettes were evaluated for convergent validity. Qualitative content analysis, descriptive statistics, correlations, and paired t tests were used. RESULTS Most nurses (68.4%) supported vignette consistency with their professional experience. Facial expression recognition was 98.4%. Smiling children's pain was rated significantly lower than grimacing children in both VH and written vignettes. Pain was rated significantly lower for grimacing children in the VH vignettes than the written vignettes. Virtual human vignette pain ratings were strongly correlated with their written counterparts. CONCLUSIONS This process was effective for developing VH vignettes that demonstrated good face validity with participants and convergent validity with written vignettes. Virtual human vignettes may be useful in studying the influence of facial actions on nurses' choices for children's pain assessment and treatment.
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Hollingshead NA, Meints S, Middleton SK, Free CA, Hirsh AT. Examining influential factors in providers' chronic pain treatment decisions: a comparison of physicians and medical students. BMC MEDICAL EDUCATION 2015; 15:164. [PMID: 26427937 PMCID: PMC4591590 DOI: 10.1186/s12909-015-0441-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 09/12/2015] [Indexed: 05/23/2023]
Abstract
BACKGROUND Chronic pain treatment guidelines are unclear and conflicting, which contributes to inconsistent pain care. In order to improve pain care, it is important to understand the various factors that providers rely on to make treatment decisions. The purpose of this study was to examine factors that reportedly influence providers' chronic pain treatment decisions. A secondary aim was to examine differences across participant training level. METHODS Eighty-five participants (35 medical students, 50 physicians) made treatment decisions for 16 computer-simulated patients with chronic pain. Participants then selected from provided lists the information they used and the information they would have used (had it been available) to make their chronic pain treatment decisions for the patient vignettes. RESULTS Frequency analyses indicated that most participants reported using patients' pain histories (97.6 %) and pain description (95.3 %) when making treatment decisions, and they would have used information about patients' previous treatments (97.6 %) and average and current pain ratings (96.5 %) had this information been available. Compared to physicians, medical students endorsed more frequently that they would have used patients' employment and/or disability status (p < 0.05). A greater proportion of medical students wanted information on patients' use of illicit drugs and alcohol to make treatment decisions; while a greater proportion of physicians reported using personal experience to inform their decisions. DISCUSSION This study found providers use patients' information and their own experiences and intuition to make chronic pain treatment decisions. Also, participants of different training levels report using different patient and personal factors to guide their treatment decisions. CONCLUSIONS These results highlight the complexity of chronic pain care and suggest a need for more chronic pain education aimed at medical students and practicing providers.
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Affiliation(s)
- Nicole A Hollingshead
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
| | - Samantha Meints
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
| | - Stephanie K Middleton
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
| | - Charnelle A Free
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
| | - Adam T Hirsh
- Department of Psychology, Indiana University - Purdue University Indianapolis, 402 N Blackford, Indianapolis, IN, 46202, USA.
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Al-Quliti KW, Alamri MS. Assessment of pain. Knowledge, attitudes, and practices of health care providers in Almadinah Almunawwarah, Saudi Arabia. ACTA ACUST UNITED AC 2015; 20:131-6. [PMID: 25864065 PMCID: PMC4727624 DOI: 10.17712/nsj.2015.2.20140546] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Objective: To present data on knowledge and attitudes toward pain assessment among health care providers in Almadinah Almunawwarah, Saudi Arabia. Methods: This exploratory study required at least 100 participants to attain an effect size of 0.2 or larger. A convenience sample was recruited from the major hospitals in Almadinah Almunawwarah, Saudi Arabia; King Fahad Hospital, Ohud Hospital, Alansar Hospital, Almeqat Hospital, and the Maternity Hospital. Data collection occurred between January and April 2014. Knowledge of pain assessment was examined by administering the Knowledge and Attitudes Survey Regarding Pain. Results: Data from 105 participants was collected. Seventy-three participants scored 44% or below (69.5%), and 32 participants scored 45% and above (30.5%). Additionally, only 6 participants (5.7%) scored above 60%. There were significant differences between male and female scores (p=0.05), physicians’ and nurses’ scores (p=0.001), and level of education (p=0.009). There were no significant differences in the passing scores across means of nationality, the department where participants worked, years of experience, and age of participants. Conclusion: There is a deficit in pain assessment knowledge, and pain management in the study group. Continuous education on pain assessment is required to increase the health care providers’ knowledge, and enhance their practices regarding pain assessment and treatment.
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Affiliation(s)
- Khalid W Al-Quliti
- Department of Medicine, College of Medicine, Taibah University, Almadinah Almunawwarah, Kingdom of Saudi Arabia. E-mail:
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ten Ham W, Ricks EJ, van Rooyen D, Jordan PJ. An Integrative Literature Review of the Factors That Contribute to Professional Nurses and Midwives Making Sound Clinical Decisions. Int J Nurs Knowl 2015; 28:19-29. [DOI: 10.1111/2047-3095.12096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Wilma ten Ham
- Department of Nursing Science; Nelson Mandela Metropolitan University; Port Elizabeth South Africa
| | - Esmeralda J. Ricks
- Department of Nursing Science; Nelson Mandela Metropolitan University; Port Elizabeth South Africa
| | - Dalena van Rooyen
- School of Clinical Care Sciences; Faculty of Health Sciences; Nelson Mandela Metropolitan University; Port Elizabeth South Africa
| | - Portia J. Jordan
- Department of Nursing Science; Nelson Mandela Metropolitan University; Port Elizabeth South Africa
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Ethnic Differences in Nonverbal Pain Behaviors Observed in Older Adults with Dementia. Pain Manag Nurs 2015; 16:692-700. [PMID: 25962546 DOI: 10.1016/j.pmn.2015.03.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 03/12/2015] [Indexed: 11/24/2022]
Abstract
Research supports using nonverbal pain behaviors to identify pain in persons with dementia. It is unknown whether variations exist among ethnic groups in the expression of nonverbal pain behaviors in this special population. The purpose of this descriptive study was to examine ethnic differences in the presentation and intensity of nonverbal pain behaviors among African American, Caucasian, and Hispanic older adults with dementia when screened for pain by certified nursing assistants. Six certified nursing assistants were trained to review and score 28 video recordings of subjects with dementia for nonverbal pain behaviors using the Non-Communicative Patient's Pain Assessment Instrument. Chi-square was used to examine differences among ethnic groups with regard to the display of nonverbal pain behaviors, and ANOVA was used to evaluate differences in the intensity of overall pain across ethnic groups. Of the 168 assessments, pain words (28%), pain noises (29.8%), and pain faces (28%) were observed most often as indicators of pain. Rubbing, bracing, and restlessness were rarely noted. Chi-square analysis revealed ethnic differences in the expression of pain words (χ(2) = 19.167, p < .001). No significant differences were noted across ethnic groups with regards to overall pain intensity. These findings are the first to examine ethnic differences in nonverbal pain behaviors for older adults with dementia. However, future work should examine assessment tendencies of providers in a larger, more diverse sample.
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Hollingshead NA, Matthias MS, Bair MJ, Hirsh AT. Impact of Race and Sex on Pain Management by Medical Trainees: A Mixed Methods Pilot Study of Decision Making and Awareness of Influence. PAIN MEDICINE 2015; 16:280-90. [DOI: 10.1111/pme.12506] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bartley EJ, Boissoneault J, Vargovich AM, Wandner PhD LD, Hirsh AT, Lok BC, Heft MW, Robinson ME. The influence of health care professional characteristics on pain management decisions. PAIN MEDICINE (MALDEN, MASS.) 2015; 16:99-111. [PMID: 25339248 PMCID: PMC5555370 DOI: 10.1111/pme.12591] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Evidence suggests that patient characteristics such as sex, race, and age influence the pain management decisions of health care providers. Although this signifies that patient demographics may be important determinants of health care decisions, pain-related care also may be impacted by the personal characteristics of the health care practitioner. However, the extent to which health care provider characteristics affect pain management decisions is unclear, underscoring the need for further research in this area. METHODS A total of 154 health care providers (77 physicians, 77 dentists) viewed video vignettes of virtual human (VH) patients varying in sex, race, and age. Practitioners provided computerized ratings of VH patients' pain intensity and unpleasantness, and also reported their willingness to prescribe non-opioid and opioid analgesics for each patient. Practitioner sex, race, age, and duration of professional experience were included as predictors to determine their impact on pain management decisions. RESULTS When assessing and treating pain, practitioner sex, race, age, and duration of experience were all significantly associated with pain management decisions. Further, the role of these characteristics differed across VH patient sex, race, and age. CONCLUSIONS These findings suggest that pain assessment and treatment decisions may be impacted by the health care providers' demographic characteristics, effects which may contribute to pain management disparities. Future research is warranted to determine whether findings replicate in other health care disciplines and medical conditions, and identify other practitioner characteristics (e.g., culture) that may affect pain management decisions.
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Affiliation(s)
- Emily J. Bartley
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, Florida, USA
| | - Jeff Boissoneault
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, Florida, USA
| | - Alison M. Vargovich
- Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Laura D. Wandner PhD
- Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
| | - Adam T. Hirsh
- Oral and Maxillofacial Surgery, University of Florida, Gainesville, Florida, USA
| | - Benjamin C. Lok
- Department of Psychology, Indiana University-Purdue University, Indianapolis, Indiana, USA
| | - Marc W. Heft
- Computer and Information Science and Engineering, University of Florida, Gainesville, Florida, USA
| | - Michael E. Robinson
- Clinical and Health Psychology, University of Florida, Gainesville, Florida, USA
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Twigg OC, Byrne DG. The influence of contextual variables on judgments about patients and their pain. PAIN MEDICINE 2014; 16:88-98. [PMID: 25280115 DOI: 10.1111/pme.12587] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Professional judgments about persistent pain are influenced by contextual variables, which are features relating to the patient, the assessor, or the broader situation. Such judgments directly inform assessment and treatment and therefore represent an important area of research. While current formulations of persistent pain adopt a biopsychosocial framework, contextual variables relating to psychosocial information have not been well examined in the literature. DESIGN We employed a within-subjects experimental vignette paradigm to investigate the influence of four contextual variables, 2 (medical evidence: present vs absent) × 2 (pain behavior: present vs absent) × 2 (referral to a psychologist: yes vs no) × 2 (responsibility: onset controllable vs onset uncontrollable), on perceptions of pain. Judgments about patients with chronic low back pain were made across several dimensions. SUBJECTS One hundred sixteen medical and nursing students. RESULTS Main findings revealed that identifiable pain pathology led to increased ratings of pain intensity and emotional distress, and decreased perceived likelihood of malingering. Pain behavior and referral to a psychologist were also found to increase ratings of pain intensity and emotional distress. Encouragingly, psychological referral was not found to increase the perceived likelihood of malingering. Responsibility for the initial injury was found to influence judgments, but this occurred in interaction with medical evidence as well as pain behavior. CONCLUSIONS These findings suggest that contextual variables have an important influence on medical and nursing students' perceptions of patients and their pain. Theoretical and practical implications for provider training and community education are discussed.
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Affiliation(s)
- Olivia Charlotte Twigg
- Research School of Psychology, Australian National University, Canberra, Australian Capital Territory, Australia
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Pronina I, Rule N. Inducing bias modulates sensitivity to nonverbal cues of others' pain. Eur J Pain 2014; 18:1452-7. [DOI: 10.1002/ejp.510] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2014] [Indexed: 11/06/2022]
Affiliation(s)
- I. Pronina
- Department of Psychology; University of Toronto; Toronto ON Canada
| | - N.O. Rule
- Department of Psychology; University of Toronto; Toronto ON Canada
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Paradies Y, Truong M, Priest N. A systematic review of the extent and measurement of healthcare provider racism. J Gen Intern Med 2014; 29:364-87. [PMID: 24002624 PMCID: PMC3912280 DOI: 10.1007/s11606-013-2583-1] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2012] [Revised: 04/10/2013] [Accepted: 08/01/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although considered a key driver of racial disparities in healthcare, relatively little is known about the extent of interpersonal racism perpetrated by healthcare providers, nor is there a good understanding of how best to measure such racism. OBJECTIVES This paper reviews worldwide evidence (from 1995 onwards) for racism among healthcare providers; as well as comparing existing measurement approaches to emerging best practice, it focuses on the assessment of interpersonal racism, rather than internalized or systemic/institutional racism. METHODS The following databases and electronic journal collections were searched for articles published between 1995 and 2012: Medline, CINAHL, PsycInfo, Sociological Abstracts. Included studies were published empirical studies of any design measuring and/or reporting on healthcare provider racism in the English language. Data on study design and objectives; method of measurement, constructs measured, type of tool; study population and healthcare setting; country and language of study; and study outcomes were extracted from each study. RESULTS The 37 studies included in this review were almost solely conducted in the U.S. and with physicians. Statistically significant evidence of racist beliefs, emotions or practices among healthcare providers in relation to minority groups was evident in 26 of these studies. Although a number of measurement approaches were utilized, a limited range of constructs was assessed. CONCLUSION Despite burgeoning interest in racism as a contributor to racial disparities in healthcare, we still know little about the extent of healthcare provider racism or how best to measure it. Studies using more sophisticated approaches to assess healthcare provider racism are required to inform interventions aimed at reducing racial disparities in health.
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Affiliation(s)
- Yin Paradies
- Centre for Citizenship and Globalisation, Faculty of Arts and Education, Deakin University, Burwood Hwy, Burwood, 3125, Victoria, Australia,
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Torres CA, Bartley EJ, Wandner LD, Alqudah AF, Hirsh AT, Robinson ME. The influence of sex, race, and age on pain assessment and treatment decisions using virtual human technology: a cross-national comparison. J Pain Res 2013; 6:577-88. [PMID: 23901291 PMCID: PMC3724685 DOI: 10.2147/jpr.s46295] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Studies in the United States have found that patients' sex, race, and age influence the pain assessment and treatment decisions of laypeople and medical professionals. However, there is limited research as to whether people of other nationalities make pain management decisions differently based on demographic characteristics. Therefore, the purpose of the following study was to compare pain assessment and treatment decisions of undergraduate students in Jordan and the United States as a preliminary examination of nationality as a potential proxy for cultural differences in pain decisions. METHODS Virtual human (VH) technology was used to examine the influences of patients' sex (male or female), race (light-skinned or dark-skinned), and age (younger or older) on students' pain management decisions. Seventy-five American and 104 Jordanian undergraduate students participated in this web-based study. RESULTS American and Jordanian students rated pain intensity higher in females and older adults and were more likely to recommend medical help to these groups, relative to males and younger adults. Furthermore, Jordanian participants rated pain intensity higher and were more likely to recommend medical help for all patient demographic groups (ie, sex, race, age) than American participants. CONCLUSION This is the first cross-national study that compares pain decisions between undergraduate students. The results suggest that sex, race, and age cues are used in pain assessment and treatment by both Americans and Jordanians, with Jordanians more likely to rate pain higher and recommend medical help to patients. Additional research is needed to determine the cultural determinants of these differences.
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Affiliation(s)
- Calia A Torres
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Emily J Bartley
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Laura D Wandner
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Ashraf F Alqudah
- Department of Psychology, The University of Jordan, Amman, Jordan
| | - Adam T Hirsh
- Department of Psychology, Indiana University–Purdue University, Indianapolis, IN, USA
| | - Michael E Robinson
- Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
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Combine or separate future pain? The impact of current pain on decisions about future dental treatments. PLoS One 2013; 8:e64057. [PMID: 23704972 PMCID: PMC3660337 DOI: 10.1371/journal.pone.0064057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 04/08/2013] [Indexed: 11/19/2022] Open
Abstract
Patients are often given the option of undergoing future painful treatments in one or multiple sessions (e.g., extracting two wisdom teeth on one or two different days). In a randomized controlled field experiment, we investigated the impact of transient pain on patients’ decision to combine or separate future periodontal treatments. The main results show that most patients preferred to have the future treatments take place in one session when they made their choice after a painless examination (i.e., general clinical exam). However, the patients’ preference for combining the future treatments did not differ from chance when the choice was made immediately following a painful examination (i.e., pocketing and bleeding on probing exam). The impact of pain on decision making is observed within and between participants. Current pain seems to lead patients to question their ability to endure future painful treatments in one session.
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Abstract
PURPOSE The purpose of the study was to measure knowledge and attitudes of nursing about pain management in patients before education, immediately after, and 6 months later. The end-point measure was Hospital Consumer Assessment of Healthcare Providers and Systems quarterly scores and percentile rank. DESIGN This longitudinal, quasi-experimental, quantitative study used survey method with pretest and posttest scores to measure immediate learning and 6 months later to measure sustained changes in knowledge and attitudes for nurses in this facility. SETTING The setting was a 360-bed acute care community hospital in the midsouth. SAMPLE The sample consisted of approximately 206 bedside nurses who worked in an acute care facility and 164 final posttest participants. METHODS The survey was used in a group setting immediately prior to a didactic learning experience. Immediately after the session, a posttest survey was administered. The 6-month follow-up occurred via an online module developed by the principal investigator. A repeated-measures analysis of variance, a pairwise comparison with a paired t test, and a Bonferroni correction were performed to determine if sustained knowledge and attitudes have changed. FINDINGS Posttest scores were significantly higher than pretest scores on the Knowledge and Attitudes Survey Regarding Pain immediately after a didactic education session and 6 months later (P < .017). CONCLUSIONS Six months later, scores remained higher than pretest or immediate posttest scores. IMPLICATIONS Nurses with a stronger knowledge base may lead to better pain management, improved outcomes, and higher patient satisfaction scores.
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Penner LA, Hagiwara N, Eggly S, Gaertner SL, Albrecht TL, Dovidio JF. Racial Healthcare Disparities: A Social Psychological Analysis. EUROPEAN REVIEW OF SOCIAL PSYCHOLOGY 2013; 24:70-122. [PMID: 25197206 PMCID: PMC4151477 DOI: 10.1080/10463283.2013.840973] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Around the world, members of racial/ethnic minority groups typically experience poorer health than members of racial/ethnic majority groups. The core premise of this article is that thoughts, feelings, and behaviors related to race and ethnicity play a critical role in healthcare disparities. Social psychological theories of the origins and consequences of these thoughts, feelings, and behaviors offer critical insights into the processes responsible for these disparities and suggest interventions to address them. We present a multilevel model that explains how societal, intrapersonal, and interpersonal factors can influence ethnic/racial health disparities. We focus our literature review, including our own research, and conceptual analysis at the intrapersonal (the race-related thoughts and feelings of minority patients and non-minority physicians) and interpersonal levels (intergroup processes that affect medical interactions between minority patients and non-minority physicians). At both levels of analysis, we use theories of social categorization, social identity, contemporary forms of racial bias, stereotype activation, stigma, and other social psychological processes to identify and understand potential causes and processes of health and healthcare disparities. In the final section, we identify theory-based interventions that might reduce ethnic/racial disparities in health and healthcare.
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Affiliation(s)
- Louis A. Penner
- Population Studies and Disparities Research Program, Karmanos Cancer Institute, Department of Oncology, Wayne State University
| | - Nao Hagiwara
- Department of Psychology, Virginia Commonwealth University
| | - Susan Eggly
- Population Studies and Disparities Research Program, Karmanos Cancer Institute, Department of Oncology, Wayne State University
| | | | - Terrance L. Albrecht
- Population Studies and Disparities Research Program, Karmanos Cancer Institute, Department of Oncology, Wayne State University
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Stamp KD. How nurse practitioners make decisions regarding coronary heart disease risk: a social judgment analysis. Int J Nurs Knowl 2012; 23:29-40. [PMID: 22613752 DOI: 10.1111/j.2047-3095.2011.01196.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE Understanding how nurse practitioners use clinical decision skills in practice has the potential to guide education programs to ensure safe, competent, and high quality advanced nursing practice. This study used the lens of social judgment theory to examine the clinical decision making of 60 nurse practitioners. METHODS A three-group pretest-posttest comparison design was used to evaluate how much insight nurse practitioners had into their clinical decision-making process. FINDINGS Nurse practitioners had modest insight into their clinical decision-making process. CONCLUSION Self-insight has implications for enhancing nurses' decision making, improving education, and fostering agreement among advanced practice nurses. IMPLICATIONS FOR NURSING PRACTICE Self-insight has implications for developing professional decision making and promoting appropriate educational opportunities for advanced practice nurses.
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Affiliation(s)
- Kelly D Stamp
- Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts, USA.
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Dovidio JF, Fiske ST. Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. Am J Public Health 2012; 102:945-52. [PMID: 22420809 PMCID: PMC3483919 DOI: 10.2105/ajph.2011.300601] [Citation(s) in RCA: 202] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2011] [Indexed: 12/16/2022]
Abstract
Several aspects of social psychological science shed light on how unexamined racial/ethnic biases contribute to health care disparities. Biases are complex but systematic, differing by racial/ethnic group and not limited to love-hate polarities. Group images on the universal social cognitive dimensions of competence and warmth determine the content of each group's overall stereotype, distinct emotional prejudices (pity, envy, disgust, pride), and discriminatory tendencies. These biases are often unconscious and occur despite the best intentions. Such ambivalent and automatic biases can influence medical decisions and interactions, systematically producing discrimination in health care and ultimately disparities in health. Understanding how these processes may contribute to bias in health care can help guide interventions to address racial and ethnic disparities in health.
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Affiliation(s)
- John F Dovidio
- Department of Psychology, Yale University, New Haven, CT, USA.
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Stamp KD. How Nurse Practitioners Make Decisions Regarding Coronary Heart Disease Risk: A Social Judgment Analysis. ACTA ACUST UNITED AC 2011. [DOI: 10.1111/j.1744-618x.2011.01196.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nurses' psychosocial barriers to suicide risk management. Nurs Res Pract 2011; 2011:650765. [PMID: 21994837 PMCID: PMC3169808 DOI: 10.1155/2011/650765] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2010] [Accepted: 03/25/2011] [Indexed: 11/17/2022] Open
Abstract
Suicide remains a serious health care problem and a sentinel event tracked by The Joint Commission. Nurses are pivotal in evaluating risk and preventing suicide. Analysis of nurses' barriers to risk management may lead to interventions to improve management of suicidal patients. These data emerged from a random survey of 454 oncology nurses' attitudes, knowledge of suicide, and justifications for euthanasia. Instruments included a vignette of a suicidal patient and a suicide attitude questionnaire. Results. Psychological factors (emotions, unresolved grief, communication, and negative judgments about suicide) complicate the nurse's assessment and treatment of suicidal patients. Some nurses (n = 122) indicated that euthanasia was never justified and 11 were unsure of justifications and evaluated each case on its merits. Justifications for euthanasia included poor symptom control, poor quality of life, incurable illness or permanent disability, terminal illness, and terminal illness with inadequate symptom control or impending death, patient autonomy, and clinical organ death. The nurses indicated some confusion and misconceptions about definitions and examples of euthanasia, assisted suicide, and double effect. Strategies for interdisciplinary clinical intervention are suggested to identify and resolve these psychosocial barriers.
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van Ryn M, Burgess DJ, Dovidio JF, Phelan SM, Saha S, Malat J, Griffin JM, Fu SS, Perry S. THE IMPACT OF RACISM ON CLINICIAN COGNITION, BEHAVIOR, AND CLINICAL DECISION MAKING. DU BOIS REVIEW : SOCIAL SCIENCE RESEARCH ON RACE 2011; 8:199-218. [PMID: 24761152 PMCID: PMC3993983 DOI: 10.1017/s1742058x11000191] [Citation(s) in RCA: 194] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians' behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians' behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations.
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Affiliation(s)
- Michelle van Ryn
- Department of Family Medicine and Community Health, University of Minnesota
| | - Diana J Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center and Department of Medicine, University of Minnesota
| | | | - Sean M Phelan
- Department of Family Medicine and Community Health, University of Minnesota
| | - Somnath Saha
- Section of General Internal Medicine, Portland VA Medical Center and Division of General Internal Medicine and Geriatrics, Oregon Health and Science University
| | | | - Joan M Griffin
- Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center and Department of Medicine, University of Minnesota
| | - Steven S Fu
- Center for Chronic Disease Outcomes Research, Minneapolis VA Medical Center and Department of Medicine, University of Minnesota
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