The 50 most-cited articles in AJN American Journal of Nursing, 2019

: This article examines the nature of implicit, or unconscious, bias and how such bias develops. It describes the ways that implicit bias among health care providers can contribute to health care disparities and discusses strategies nurses can use to recognize and mitigate any biases they may have so that all patients receive respectful and equitable care-regardless of their race, ethnicity, religion, sexual orientation, gender identification, socioeconomic status, disabilities, stigmatized diagnoses, or any characteristic that distinguishes them from societal norms.

: While health care often focuses on acute or chronic illness, the elements necessary for good health are far more complex than we tend to recognize. Florence Nightingale understood this complexity and wrote extensively on the myriad social and environmental factors that influence well-being. Today these factors are termed "health determinants" and undergird the United Nations 17 Sustainable Development Goals (SDGs). This article explores how nurses can contextualize the SDGs within their daily practice and create holistic plans of care for patients, families, communities, and nations.

: Sickle cell disease (SCD) is an autosomal recessive genetic condition that alters the shape and function of the hemoglobin molecule in red blood cells. While the overall survival rate among children with SCD has improved in recent years, pediatric rates of hospitalization, ED use, and mortality from complications of SCD remain high. Among patients ages 18 and older, hospital admission and ED usage are even greater-and the median age at death of people with SCD is considerably lower than that of the general population. Nurses who care for patients with SCD have an opportunity to improve health outcomes and quality of life for these patients by recognizing the major SCD-associated complications and providing patients and their caregivers with appropriate educational information. The authors discuss the genetic, hematologic, and clinical features of SCD and describe the major associated health complications. In addition, they review the nursing implications of each complication and provide online links to resources for clinicians, patients, and caregivers.

: Purpose: The purpose of this evidence-based quality improvement (QI) project was to implement an oral care protocol in the adult in-patient care areas of a level 1 trauma hospital and to evaluate its impact on the incidence of hospital-acquired pneumonia (HAP). METHODS: A standardized, evidence-based oral care protocol was implemented depending on the level of care required by each ventilated, at-risk, or short-term care patient. The QI project included the introduction of a new suction toothbrush kit for at-risk patients and, for short-term patients, a new short-term oral care kit that featured a more ergonomically appropriate toothbrush, a baking soda toothpaste, and an alcohol-free antiseptic mouthwash; the project also supported the continued use of the then current suction toothbrush kit for patients receiving mechanical ventilation. We examined medical records retrospectively and used International Classification of Diseases (ICD) 9 and ICD 10 codes for pneumonia not present on admission to determine the incidence of HAP, including nonventilator hospital-acquired pneumonia…

: Nursing students who don't specialize in ostomy care typically gain limited experience in the care of patients with fecal or urinary stomas. This lack of experience often leads to a lack of confidence when nurses care for these patients. Also, stoma care resources are not always readily available to the nurse, and not all hospitals employ nurses who specialize in wound, ostomy, and continence (WOC) nursing. Those that do employ WOC nurses usually don't schedule them 24 hours a day, seven days a week. The aim of this article is to provide information about stomas and their complications to nurses who are not ostomy specialists. This article covers the appearance of a normal stoma, early postoperative stoma complications, and later complications of the stoma and peristomal skin.

: Once considered solely as an educational tool in undergraduate education, simulation-based education (SBE) now has many uses. SBE is now embedded in both graduate and undergraduate nursing education programs and has become increasingly accepted practice in hospital orientation and transition-to-practice programs. Newer applications include ongoing professional education, just-in-time training, teamwork development, and systems testing. This article highlights the changing landscape of SBE and describes elements critical to its successful use, including facilitator competencies, the necessity of providing a psychologically safe environment to enable learning, and the importance of addressing other safety concerns, such as the possibility of accidentally introducing simulated equipment and medications into real patient care.

In Brief This article discusses the health sector's responsibility to address climate change and nurses' role in these efforts.

Nurses can prepare the public to save lives following a mass casualty event.

: Background: Acute care nurses work in highly taxing environments, and as such are vulnerable to work-related stress, burnout, and attrition. Yet some nurses appear to flourish even in the presence of such stress, perhaps because of differences in their cognitive processes. Positive thinking, a set of skills that can be learned, has been linked to increased well-being, physical health, and longevity. But at this writing, there has been scant research investigating the use of positive thinking among nurses. PURPOSE: To assess the relationship between perceptions of work-related stress and the use of positive thinking among acute care nurses. METHODS: A cross-sectional survey consisting of the Expanded Nursing Stress Scale, the Positive Thinking Skills Scale (PTSS), and a demographic questionnaire was administered to a convenience sample of 298 RNs, which included nurses already working for an eight-campus health care system and newly hired nurses during orientation. RESULTS: Compared to the established group, the incoming RNs were generally younger, had less education, and reported…

An online NIOSH course raises awareness of workplace violence and offers preventive strategies.

: Effective pain assessment is a necessary component of successful pain management and the pursuit of optimal health outcomes for patients of all ages. In the case of children, accurate pain assessment is particularly important, because children exposed to prolonged or repeated acute pain, including procedural pain, are at elevated risk for such adverse outcomes as subsequent medical traumatic stress, more intense response to subsequent pain, and development of chronic pain.As with adults, a child's self-report of pain is considered the most accurate and reliable measure of pain. But the assessment of pain in children is challenging, because presentation is influenced by developmental factors, and children's responses to certain features of pain assessment tools are unlike those commonly observed in adults.The authors describe the three types of assessment used to measure pain intensity in children and the tools developed to address the unique needs of children that employ each. Such tools take into account the child's age as well as special circumstances or conditions, such as…

BACKGROUND: People with type 1 diabetes are at increased risk for diabetes burnout, resulting in suboptimal diabetes care and quality of life. While the existence of diabetes burnout is widely acknowledged, there is no evidence-based definition, means of measurement, or interventions to address it. OBJECTIVE: This study was aimed at increasing our understanding of the lived experiences of diabetes burnout among adults with type 1 diabetes. METHODS: A qualitative descriptive study was conducted with a sample of 18 adults with type 1 diabetes who reported a current or previous experience of diabetes burnout. Data were collected using in-depth interviews and analyzed using qualitative content analysis. RESULTS: Four main themes were identified: mental, emotional, and physical exhaustion from having diabetes; detachment from illness identity, diabetes self-care, and support systems; contributing factors to diabetes burnout; and strategies for preventing or overcoming diabetes burnout. CONCLUSION: Although exhaustion is an entry point for diabetes burnout, the findings suggest that…

: Background: Clinical research nursing is an emerging specialty practice. Clinical research nurses (CRNs) work to make protocol-related care safe for the research subjects while simultaneously maintaining protocol fidelity. They must continuously balance the needs of the research subjects and the study requirements. PURPOSE: The purpose of this qualitative study was to describe CRNs' perceptions of the value of their role. METHODS: Two focus groups were conducted with a purposive sample of 18 CRNs. An interview guide consisting of eight open-ended items was used. Data analysis used critical elements from Krueger's systematic steps for analyzing focus group data. RESULTS: Five major themes emerged from 168 coded statements contained within the focus group transcripts: comprehensive nursing care of research subjects, training and education of research subjects and staff, contributions to clinical science, unique combination of clinical and critical thinking skills, and CRN practice attributes. Subcategories were also identified. In general, participants felt strongly about the value…

Free, evidence-based resources for health care providers, patients, and consumers.

More than 67% of people diagnosed with cancer in the United States are alive five years after receiving the diagnosis; but even if they are cancer free, the effects of the disease and its treatment will remain with them for the rest of their lives. Distress, which can be of a psychological, social, physical, or spiritual nature, is common among cancer survivors. Spiritual distress is a broad concept that is not necessarily associated with any specific religious beliefs, practices, or affiliations. Both religious and nonreligious people may have a strong sense of spirituality and may experience spiritual distress at various points throughout cancer survivorship. But clinicians often neglect to explore the spiritual components of distress, and despite the well-established association between spiritual well-being and quality of life, few of the instruments designed to assess the care needs of cancer survivors address spiritual needs. Through a composite clinical case, this article illustrates how nurses can incorporate into practice evidence-based recommendations for assessing and…

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aim to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series provide simple and useful instructions that nurses should reinforce with family caregivers. This article is the first of two that provide an update on urinary incontinence and its management in older adults. The second article will contain an informational tear sheet-Information for Family Caregivers-that contains links to the instructional videos. To use this series, nurses should read the articles first, so they understand how best to help family caregivers, and then…

: This is the third article in a new series about evidence-based practice (EBP) that builds on AJN's awardwinning previous series-Evidence-Based Practice, Step by Step-published between 2009 and 2011 (to access the series, go to http://links.lww.com/AJN/A133). This follow-up series features exemplars illustrating the various strategies that can be used to implement EBP changes-one of the most challenging steps in the EBP process.

: Background: Grief and loss are significant issues for health care providers, who may witness their patients' pain and suffering, experience feelings of grief as a result of caring for sick and dying people, and reexperience their own past losses. Unaddressed grief can lead to many issues for providers, their patients, and the health care system as a whole. METHODS: Healing Loss: A Residential Workshop for Montefiore Associates is an experiential and educational program aimed at helping professional caregivers to identify and process grief and loss. Through retrospective analysis of program participation and feedback data, this study investigated the feasibility and effectiveness of offering an intensive bereavement support program to hospital employees in a large academic health system. RESULTS: Between 2013 and 2017, Montefiore Health System held nine Healing Loss workshops, serving 198 employees from diverse professions. These participants described multiple benefits, including being able to grieve more effectively, accessing support, and learning new tools for healing and…

This is the first article in a new series about evidence-based practice (EBP) that builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step-published between 2009 and 2011 (to access the series, go to http://links.lww.com/AJN/A133). This follow-up series will feature case studies illustrating the various strategies that can be used to implement EBP changes-one of the most challenging steps in the EBP process.

According to this study: Lower levels of RN staffing increase the risk of death during a hospital stay. Increasing the number of nursing assistants cannot compensate for RN shortages.

: Purpose: This quality improvement (QI) initiative aimed to promote patient safety by improving adherence to an existing hospita-approved fall prevention protocol. Specific aims of the initiative were to evaluate the impact of using a fall prevention checklist on (1) the implementation of a bundle of 14 specific interventions (the fall prevention protocol) and (2) the incidence of falls on participating units. METHODS: A QI team conducted a 26-day fall prevention initiative. Data were collected on day and night shifts for 13 days each. We evaluated the effect of using a new 14-item checklist based on the existing hospitalapproved fall prevention protocol on the nursing staff's adherence to each intervention and on the incidence of falls on the test unit. Oncoming staff used the checklist during change-of-shift handoffs to determine whether all prevention interventions were in place before accepting care of the patient. The incidence of falls was tracked daily. RESULTS: Thirty-seven nursing staff members (RNs and nursing assistants) participated in the pilot study and completed 90…

Joint Commission revises National Patient Safety Goal for suicide prevention. The revision is aimed at improving the hospital care of patients treated for behavioral health problems who are at high risk for suicide. Facilities should minimize door hinges, hooks, and anchor points that could be used for hanging. All patients should be screened for suicidal ideation with validated, population-appropriate screening tools. For patients who screen positive, use an evidence-based assessment process that asks directly about their ideation, plan, intent, self-harm behaviors, and protective factors. Explicitly document a patient's overall level of risk and plan for risk-reduction counseling and follow-up care. These new requirements take effect on July 1.

Over the past several decades, important advances have been made in the United States to ensure that our residents breathe clean air. Still, nearly 12 million homes in this country burn wood for heating. Globally, 3 billion people, or close to half of the world's population, depend on polluting solid fuels such as wood for daily cooking and heating. Unlike in the United States where stoves used for heating are vented, many homes in low-income countries use simple stoves that often lack chimneys, leading to toxic amounts of smoke inside and outside the home. Household air pollution from these fires is the 16th leading risk factor for death and disability worldwide. Childhood pneumonia, chronic obstructive pulmonary disease, and cardiovascular disease have all been associated with household air pollution globally, yet many nurses are not aware of this burden when caring for immigrants and refugees residing in the United States. Global organizations are working to provide access to clean cookstoves (those that run on electricity, solar power, or liquid fuel), and nurses can get…

: This article is one in a series on the roles of adjunct clinical faculty and preceptors, who teach nursing students and new graduates to apply knowledge in clinical settings. One of the first steps to becoming a preceptor is learning about the resources and support available within one's organization. This article offers tips to help preceptors prepare for and navigate the precepting experience.

This is the second article in a new series about evidence-based practice (EBP) that builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step-published between 2009 and 2011 (to access the series, go to http://links.lww.com/AJN/A133). This follow-up series will feature exemplars illustrating the various strategies that can be used to implement EBP changes-one of the most challenging steps in the EBP process.

BACKGROUND: In 2007 AcademyHealth published a landmark report on the U.S.-based international nurse recruitment industry. This article provides an update to that report, describing the current state of recruitment of foreign-educated health professionals (FEHPs), in particular foreign-educated nurses (FENs), to the United States. Areas covered include the regulatory landscape, economic issues, recruitment industry changes, and current demographic and migration trends. PURPOSE: To learn more, CGFNS International, Inc., formerly known as the Commission on Graduates of Foreign Nursing Schools, and its Alliance for Ethical International Recruitment Practices division conducted a study designed to elicit qualitative and quantitative data that would further illuminate the recruitment experience. METHODS: Researchers conducted a survey of FEHPs, recruited from those who used VisaScreen services between 2015 and 2017, designed to assess their recruitment experiences. They also conducted interviews with a smaller sample of FENs and recruiters to elicit greater detail. RESULTS: While there…

Evidence consistently shows that vaccines are safe, effective, and cost-efficient. Yet preventable outbreaks of infectious diseases are occurring in the United States, leading to a strong public response and intense scrutiny of the antivaccine movement and its persistent spread of misinformation. Social media has been a major platform for such misinformation, and recent examinations have found that nurses are not exempt from engaging in antivaccine discourse.By practicing evidence-based care, addressing health literacy, and becoming involved in public health policy, nurses can be excellent advocates for immunization and may help prevent additional outbreaks of preventable diseases.

: There is mounting evidence that obesity is linked to numerous types of cancer that affect both sexes. But the incidence of obesity-related cancers is particularly high among women. Obesity is implicated not only in the development of cancer, but also in cancer recurrence, treatment complications, and poor patient outcomes. Nurses, particularly those caring for women, should be aware of these associations so they may provide effective patient teaching about preventing cancer and mitigating its adverse effects. The author discusses the role of obesity in the development and recurrence of cancer in women; describes weight loss interventions that may reduce cancer risk in overweight or obese patients; and suggests interviewing techniques to help nurses sensitively address the topic of overweight and obesity with their female patients.

: In 2017, Navy Nurse Corps executives launched a new nursing professional practice model that promotes operational readiness, professional development, and transformational leadership. This directive prompted nursing leadership at Naval Hospital Jacksonville (NH JAX) to conduct a needs assessment survey to determine what kind of educational initiative nursing staff members would most welcome in support of the goals of the new practice model. Survey respondents favored case studies presented in a nursing grand rounds format. Our change implementation team designed and executed the grand rounds program, offering lunchtime presentations every other month. Topics included a wide range of "high-risk/low-volume" procedures-those infrequently performed at participants' clinical sites. Ten months after the initiation of grand rounds, surveys were distributed to NH JAX participants to assess their perceptions of the value of the sessions in terms of professional development, interdisciplinary teamwork, and strengthened institutional partnerships.Of the 161 nursing grand rounds participants,…

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aim to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series provide simple and useful instructions that nurses should reinforce with family caregivers. This article is the second of two that explain the nutritional principles nurses should consider and reinforce with caregivers. Each article includes an informational tear sheet-Information for Family Caregivers-that contains links to the instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then…

: By the 1920s, Lillian Wald's model of care, with nurses working side by side with social workers at the intersection of medicine and society, had become an important component of the U.S. health care system. Over subsequent decades, however, a confluence of historic forces resulted in its marginalization. Today, people are recognizing that medical cures alone, although important, will not reduce the epidemic of diseases of despair or the growing challenges involved in achieving health equity. Wald's approach, extended to a broader range of settings in which nurses work today, could be the missing ingredient.To provide background for the National Academy of Medicine Committee on the Future of Nursing 2020-2030, as it develops its follow-up to the Institute of Medicine's 2010 Future of Nursing: Leading Change, Advancing Health, the Robert Wood Johnson Foundation commissioned a report on nursing's historic role in advancing health. This article summarizes that report, which can be found in its entirety at www.rwjf.org/content/dam/farm/reports/reports/2019/rwjf452706.

New resources for diagnosis and treatment from the CDC.

A required postmarketing clinical trial of tofacitinib (Xeljanz, Xeljanz XR) in the treatment of rheumatoid arthritis found an increased risk of pulmonary embolism and death when patients were treated with 10 mg twice daily compared with the currently approved 5 mg twice daily dose. NPs are encouraged to follow tofacitinib's dosing guidelines when treating rheumatoid arthritis.

Nurses' dual role as migrants caring for other migrants.

While developing a standardized approach to orient new staff in the U.S. Army Institute of Surgical Research Burn Center at Fort Sam Houston in Texas, nurse leaders identified the need to also standardize preceptor selection and instruction. A multidisciplinary research team conducted a two-year pilot project based on the evidence-based Vermont Nurses in Partnership Clinical Transition Framework, which provides a structured method for preceptor selection, development, and evaluation. Minimum preceptor qualifications; preceptor validation processes; and modifiable, unit-specific coaching tools were established. The authors previously published a description of the preceptor program implementation process and their findings. In this article, they discuss lessons learned during the project, highlighting the challenges and obstacles encountered when implementing this preceptorship program.

Advances in genetic and genomic research, combined with the rapid development of new technologies, have reshaped our understanding of health and disease processes, generating what have collectively become known as "omics" sciences. These sciences are now an integral part of health care delivery, with nurses and nurse scientists at the forefront, implementing and adapting genomic technologies in the clinical setting while advancing knowledge in these areas. With the increasing focus on precision medicine and health care, integrating genetic and genomic knowledge has become an essential competency in nursing care, research, and education, as it enables nurses to collaborate effectively with patients in improving their health and well-being.

: Background: At our institution, RNs have performed bone marrow aspiration and biopsy procedures for more than 10 years. A recent review of our institutional policies and practices regarding RN-performed bone marrow procedures was intended to ensure that we were using a safe and evidence-based approach and prompted this program evaluation. METHODS: We conducted a literature search and review of our institutional policies and practices regarding RN-performed bone marrow procedures. All elements of our clinical practice were reviewed and evaluated, including outcomes. RESULTS: Between 2010 and 2017, the RN team completed a total of 10,867 bone marrow procedures in our hospital-based ambulatory infusion center. The team included 15 nurses who completed up to eight patient procedures each weekday. Patient satisfaction rates were consistently high and complication rates were very low: less than 1% of all patients experienced postprocedure bleeding, and less than 2% required urgent medical care within 24 hours of the procedure. In an analysis of bone marrow procedures performed between…

Arterial blood gas (ABG) analysis assesses the adequacy of ventilation, oxygenation, and the acid-base status of the body by measuring the levels of pH, oxygen, carbon dioxide, and bicarbonate in arterial blood. Interpretation of ABG results, which can play a major role in diagnosis and treatment of patients with pulmonary and other critical conditions, can sometimes be difficult. This article focuses on basic ABG analysis and interpretation, discusses the combinations of imbalances that may occur, and reviews the compensatory mechanisms that arise as a result.

Chronic pain, stemming primarily from musculoskeletal conditions and severe headaches, is a growing problem in the United States, affecting as many as 43% of adults. Opioids are frequently prescribed to manage chronic pain despite limited data on their long-term efficacy and the potential risks of long-term use. In 2017, more than 47,000 people died as a result of an opioid overdose involving illicit opioids (such as heroin), illicitly manufactured opioids, diverted opioids, prescription opioids, or some combination thereof. Although it's been more than three years since the nationwide opioid crisis prompted the Centers for Disease Control and Prevention (CDC) to release a guideline outlining safe practices for prescribing opioids to patients with chronic pain (unrelated to active cancer or palliative and end-of-life care), opioid misuse remains a significant concern. Historically, physicians have been tasked with the primary responsibility for implementing opioid safety measures, but nurses in the primary care setting are being increasingly relied on to incorporate these measures…

Gestational hypertension, preeclampsia, and peripartum cardiomyopathy are among the most common and often severe pregnancy-specific cardiovascular diseases (CVDs) and causes of complications in pregnancy. This clinical review provides nurses with an overview of pregnancy-specific CVDs, outlines their pathophysiology, and discusses risk factors and assessment. It describes management interventions according to timing: the antepartum, intrapartum, and postpartum phases are each addressed.

This article is part of a series, Supporting Family Caregivers: No Longer Home Alone, published in collaboration with the AARP Public Policy Institute. Results of focus groups, conducted as part of the AARP Public Policy Institute's No Longer Home Alone video project, supported evidence that family caregivers aren't given the information they need to manage the complex care regimens of family members. This series of articles and accompanying videos aims to help nurses provide caregivers with the tools they need to manage their family member's health care at home.The articles in this new installment of the series provide simple and useful instructions regarding nutritional principles that nurses should reinforce with family caregivers. Most articles include an informational tear sheet-Information for Family Caregivers-that contains links to the instructional videos. To use this series, nurses should read the article first, so they understand how best to help family caregivers, and then encourage caregivers to watch the videos and ask questions. For additional information, see…

: This article is one in a series on the roles of adjunct clinical faculty and preceptors, who teach nursing students and new graduates to apply knowledge in clinical settings. Instructors often seek to link theory with practice during the postclinical conference, but little is known about the most effective methods of doing so. Debriefing, which is an approach primarily associated with simulation-based learning, encourages students to reflect on and improve performance. This article examines various debriefing methods and describes scenarios in which clinical instructors can utilize this approach to improve the effectiveness of the postclinical conference.

: Background: Intravenous patient-controlled analgesia (IV PCA), which typically involves opioids, has become widely used in clinical settings as an effective method of pain management. Identifying errors in the administration of these drugs is essential to improving patient outcomes. This study sought to describe and analyze the errors associated with postoperative IV PCA. METHODS: Relevant data were collected from the medical records of all patients who received IV PCA at a large academic medical center in South Korea during a three-year period. The study sample comprised 45,104 patients who used one of four types of IV PCA delivery devices. RESULTS: Errors occurred in 406 cases (0.9%). Operator error was the most common type of error (54.7%), followed by device malfunction (32.3%), prescription error (12.3%), and patient error (0.7%). Of the 222 operator errors, the most frequent type was failure to begin IV PCA drug administration (28.8%), followed by programming errors by non-anesthesia providers who weren't authorized to program the device (24.8%) and wrong infusion rates set…

: The purpose of this article is to describe and analyze nurse involvement in hospital bedside rounding from 1873 to 1973. Interdisciplinary rounding is touted as a collaborative activity between nurses and physicians. Understanding the historical trends in nurse involvement in this process can shed light on the opportunities and barriers that clinical rounding presents today. This research was gathered using historical sources, both primary and secondary, and a social history framework. Primary sources included manuals for head nurses, nursing journals, and nursing student diaries.

A new form of the opioid sufentanil has been approved under the trade name Dsuvia. It is administered sublingually using a special applicator. The drug can only be sold and administered in certified medically supervised health care settings. Dsuvia carries a black box warning that it may cause respiratory depression; addiction, abuse, and misuse; and drug interactions with benzodiazepines and other central nervous system depressants. The warning also states that concomitant use of Dsuvia with cytochrome P-450 (CYP) isoenzyme CYP3A4 inhibitors (or, conversely, discontinuing drugs that induce this isoenzyme), can dangerously increase the circulating levels of Dsuvia and be fatal. Approval of Dsuvia has been controversial, with critics claiming that a new opioid is not warranted given the deaths from the current opioid epidemic.

: Clinical nurses develop a program to strengthen professional relationships and practice.

A new boxed warning has been added to the labeling of tofacitinib (Xeljanz, Xeljanz XR) based on preliminary safety data from an ongoing postmarketing trial showing an increased risk of thrombosis and death in patients with at least one cardiovascular risk factor who were taking the 10-mg twice-daily dose. Tofacitinib 10 mg twice daily is approved as induction treatment for ulcerative colitis; the dose is not approved to treat rheumatoid arthritis or psoriatic arthritis. NPs should adhere to the dosing regimens listed on tofacitinib's labeling. Patients should be assessed for thrombosis and taught to seek emergency help if they develop signs or symptoms of this condition.

Bremelanotide (Vyleesi) is now approved for the treatment of generalized hypoactive sexual desire disorder in premenopausal women. The drug may transiently increase blood pressure, induce focal hyperpigmentation, and produce nausea. Nurses and NPs should confirm that a patient's blood pressure is under control prior to starting bremelanotide.

For many leaders, giving positive feedback comes easily, but giving negative feedback can be more challenging. This article provides best-practice strategies for giving effective feedback-through building trust, promoting a growth mindset, and developing the courage to tackle difficult performance conversations.

Discerning patient preferences for care at the end of life is a mainstay of caring for patients and families. Ideally, these discussions should happen early in a patient's care trajectory. In fact, we would be surprised by how eager many patients are to talk about their desires, their fears, and their goals as death draws near, and how eager many family members are to hear these preferences. When this doesn't happen, it is often necessary to have discussions with surrogates, as Chicca describes. We need to assure families that even though certain nonbeneficial treatments may be discontinued, our care for their loved one will never end. Palliative care includes aggressive symptom management that continues through the lives of patients even when disease-focused therapies might not. Margaret M. Mahon, PhD, CRNP, FAAN, FPCN Bethesda, MD