The 50 most-cited articles in AJN American Journal of Nursing, 2023

ABSTRACT: Spirituality is one aspect of the human experience that is unique to each person and may become especially important in the face of life-threatening illness. While evidence supports the need to address spirituality as part of holistic palliative care nursing, it is hoped that "spiritual care" will not become another item on nurses' to-do list, but rather will be part of nurses' everyday lives and nursing practice. Taking time to assess personal needs, and consciously connecting to meaning, hope, and peace, can support nurses' return to the deeper roots of nursing. Addressing spirituality as part of palliative nursing care can also acknowledge the complex and multidimensional experiences of the patients that nurses serve. Connecting, or reconnecting, with nurses' unique sense of spirituality can serve as a powerful resource for resilience. This article highlights the relevance of spiritual care to palliative nursing and offers practical tips to incorporate spiritual care into everyday nursing practice.

ABSTRACT: There is a scarcity of nursing literature, studies, and educational materials on the assessment and early recognition of both common and serious integumentary and general health issues in people with dark skin tones. Nurses must be exposed to such learning resources to be adequately prepared to care for patients with diverse skin tones and to help reduce health disparities and promote health equity. This article provides faculty, nursing students, and clinicians with basic information about the assessment of dark skin tone and calls for action in academia and professional practice to ensure nurses and nursing students can effectively perform skin assessments in all patients.

ABSTRACT: With increased demands for inpatient care and limited nursing resources, bedside RNs at one health care system were challenged to find experienced nurse colleagues to provide mentorship when they needed assistance in executing best practices. A virtual RN (ViRN) role was created to support bedside RNs and patients on designated general care inpatient units. The ViRN provided real-time virtual clinical guidance to bedside RNs and actively surveilled patients. Bedside RNs were surveyed by email to gauge the utility and their perceptions of integrating ViRNs into the nursing care team. RNs reported that they valued the consistent availability of having the ViRNs' expert nursing knowledge and virtual assistance with nursing tasks.

BACKGROUND: As the health care workforce diversifies, understanding and addressing the lived experiences of health care professionals facing prejudice and discrimination becomes increasingly important. Previous studies have focused on physicians and medical trainees, but there remains a dearth of research exploring nurses' experiences-even though nurses make up the largest sector of the nation's health care workforce. OBJECTIVE: This qualitative study explored nurses' experiences of personally mediated workplace discrimination based on race, ethnicity, culture, or religion. METHODS: We conducted in-depth interviews with a convenience sample of 15 RNs at one academic medical center. Using an inductive thematic analysis approach, we identified several themes emerging from RNs' experiences and responses to a discriminatory event ("encounter"). Themes were grouped across three phases: pre-encounter, encounter, and post-encounter. RESULTS: Participants reported wide-ranging experiences, from insensitive joking to overt exclusion, coming from various people including patients, patients'…

ABSTRACT: Severe postoperative movement-evoked pain (MEP) can be immobilizing, instilling in patients the fear that further activity will produce unbearable pain. This impedes healing and restoration of function while also extending time to recovery. Therefore, it is critical to manage MEP effectively through timely evaluation and comprehensive care planning. This article builds on recent calls to standardize testing of MEP to inform care planning in a way that both reduces pain and improves functioning. Subsequent reassessment of MEP can guide the refinement of therapy. Although this approach may seem intuitive, it challenges common practices that focus too heavily on pain intensity, resulting in overtreating, undertreating, or not treating pain, while ignoring the risks of immobility and the importance of movement for improving functional capacity. The authors propose a multifaceted approach to overcoming MEP that nurse clinicians, educators, researchers, and compliance professionals can use to enhance the quality and safety of nursing practice.

BACKGROUND: Substance use disorder (SUD) is a chronic illness, but it's often seen as an intentional choice rather than as a disease. People with SUD are frequently stigmatized, leading to disparate care. Findings from previous studies have indicated that nurses feel inadequately prepared to care for, and tend to have negative attitudes toward, patients with SUD. But it's unknown what kind of education would better prepare nurses caring for this patient population, or whether these negative attitudes vary across practice settings. PURPOSE AND DESIGN: This observational, cross-sectional, mixed-methods study sought to explore nurses' self-assessed knowledge of and attitudes toward caring for patients with SUD (whether formally diagnosed or not) in hospital settings across the United States. A secondary aim was to determine nurses' educational preferences and needs in this area. METHODS: Data were collected over a three-month period in early 2020, using the online social networking platform Facebook. All participants were nurses working in hospital settings throughout the United…

ABSTRACT: A well-known challenge in health care is integrating evidence into practice. Implementation science (IS) is a growing field that promotes the sustainable application of evidence-based practice (EBP) to clinical care. Health care organizations have an opportunity to support sustainable change by creating robust IS infrastructures that engage nurses in the clinical environment. Integrating IS into a nursing shared governance model is an ideal vehicle to empower direct care nurses to sustain EBP. Importantly, an IS infrastructure may also promote nurse retention and increase interdisciplinary collaboration. This article, the first in a series on applying IS, describes how a multisite health care organization developed a systemwide nurse-led IS Specialist program within a shared governance model.

Improving our knowledge of disability can reduce stereotypes and stigma.

ABSTRACT: Nurses have a professional and ethical responsibility to provide inclusive, affirmative palliative care to transgender and gender nonconforming (TGNC) individuals experiencing life-limiting illness or injury. In accordance with standards for professional nursing and health organizations, nurses must continue to take tangible steps to achieve a level of care that is affirming, holistic, nonprejudicial, and collaborative. Providing quality care for TGNC individuals requires informed, competent integration of palliative nursing care, gender-affirmative care, and trans-person-centered health care within nursing practice. An interdisciplinary national team of experts collaborated to identify ways nurses could better uphold their professional responsibilities to TGNC individuals with serious illness. The purposes of this article are to: 1) describe elements of TGNC-inclusive palliative nursing care; and 2) present eight concrete recommendations to achieve affirmative clinical practice for TGNC patients living with life-limiting illness and their family of origin and/or family of…

ABSTRACT: Nursing has a long history of activism, yet nurses are often heard to express their dislike of "politics" and their desire to stay away from the tense and contentious situations associated with political activism. Nurses, however, have a fundamental duty to advocate on behalf of their patients and communities. In this article, the authors discuss the rationale for and roots of political activism in nursing, the values that shape it, and the importance of nursing's stance on policies related to the health and well-being of those they serve. The authors also present exemplars of political activism and approaches nurses can use to address the pressing health care challenges of our time.

Editor's note: This is the 18th article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204.

BACKGROUND: Nurses have primary responsibility for many of the care processes and interventions intended to improve patients' health during hospital stays. Accordingly, missed nursing care can negatively impact patient safety and lead to negative clinical outcomes. Missed nursing care is standard care that is not completed, incomplete, or seriously delayed. PURPOSE: There is scant literature on nurse-reported missed care (NRMC) in Singapore. Identifying the prevalence of, types of, and reasons for missed care, including staff-related factors, is imperative to understanding the implications of missed care and identifying opportunities for improvement. METHODS: Ours is a correlation study of NRMC using convenience sampling. Nurses working on all inpatient units in an acute care hospital in Singapore were recruited to complete the MISSCARE survey, a quantitative tool measuring missed nursing care and the reasons for it. Descriptive statistics was applied to analyze demographics, types of NRMC, and reasons for NRMC. The Pearson χ2 test was used to analyze the correlation between…

Editor's note: This is the 14th article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204.

BACKGROUND: Nurses and nursing assistants given one-to-one ("sitter") assignments are placed with one patient for long periods of time. Some of these patients require a sitter for reasons that include dementia, traumatic brain injury, psychiatric disturbances such as delirium, and risk of self-harm. Some may become verbally abusive, physically violent, or both, putting the assigned staff member in danger. PURPOSE: The study purpose was to investigate workplace violence from the perspective of nurses and certified nursing assistants working one-to-one assignments who had experienced violent encounters with patients or visitors. METHODS: This qualitative cross-sectional study used a phenomenological approach. Participants were nurses and nursing assistants at one hospital in the western United States. Data were collected in five focus groups, which were conducted online; a semistructured interview guide allowed researchers to elicit participants' responses and foster discussion. Thematic analysis was used to identify themes in the data. RESULTS: A total of 13 nurses and nursing…

BACKGROUND: Medication preparation and administration are complex tasks that nurses must perform daily within today's complicated health care environment. Despite more than two decades of efforts to reduce medication errors, it's well known that such errors remain prevalent. Obtaining insight from direct care nurses may clarify where opportunities for improvement exist and guide future efforts to do so. PURPOSE: The study purpose was to explore direct care nurses' perspectives on and experiences with medication safety practices and errors. METHODS: A qualitative descriptive study was conducted among direct care nurses employed across a large health care system. Data were collected using semistructured interview questions with participants in focus groups and one-on-one meetings and were analyzed using qualitative direct content analysis. RESULTS: A total of 21 direct care nurses participated. Four major themes emerged that impact the medication safety practices of and errors by nurses: the care environment, nurse competency, system influences, and the error paradigm. These themes…

ABSTRACT: Relationship-centered palliative nursing during serious illness requires existential care. Yet, multilevel systemic barriers hinder nurses' ability to provide this care. The authors suggest ways to navigate these barriers, highlighting existential care priorities that nurses can attend to in their daily practice. These include 1) maintaining a strengths-based orientation, 2) taking a life course perspective, 3) grounding care firmly in relationships, and 4) responding moment to moment. They propose that by emphasizing existential care in palliative nursing, we can create a more compassionate and human-centered health system.

ABSTRACT: Opioid use disorder (OUD) is an important comorbidity to assess and manage in people with cancer. In this article, the authors discuss strategies for safe opioid management in individuals with OUD and cancer-related pain using a composite case example. They highlight core approaches to pain management, including motivational interviewing, harm reduction, and evidence-based treatments, as well as advocacy for person-centered end-of-life care.

ABSTRACT: A significant number of hospices in U.S. jurisdictions where medical aid in dying is legal have implemented policies that require nurses to leave the room when a patient ingests aid-in-dying medication. Two questions with ethical implications arise from these policies: (1) Is it ethically supportable for a hospice to require that staff leave the room while a patient ingests aid-in-dying medication? and (2) Does this requirement compromise the nurse's professional commitment to the patient and family?This article reviews the origins of this common policy, as well as nursing codes of ethics and professional organization policy statements as they relate to nursing commitments to patients. It finds that an institutional policy requiring nurses to leave the room while a patient ingests aid-in-dying medication risks violating professional nursing standards, reinforces stigma regarding medical aid in dying, and potentially abandons patients and loved ones at a critical time in their passage toward a desired and legal death. The authors describe a case that depicts these three…

ABSTRACT: Febrile neutropenia is a serious complication of chemotherapy treatment and may present as the only clinical sign of infection. If not addressed in a timely manner, it may progress to multisystem organ failure and may be fatal. Initial assessment of fever in those receiving chemotherapy requires prompt administration of antibiotics, ideally within one hour of presentation. Depending on the clinical status of the patient, antibiotic treatment may occur in the inpatient or outpatient setting. Nurses play an important role in the identification and treatment of patients at high risk for febrile neutropenia through assessment and adherence to clinical practice guidelines. In addition, nurses play an active role in patient education regarding risk factors, protective measures, and signs and symptoms of infection in the immunocompromised oncology patient.

Nurses can help patients separate truth from fiction.

ABSTRACT: When patients who undergo ostomy surgery do not have access to an ostomy care nurse, staff nurses must assume responsibility for providing ostomy care and educational support. However, many staff nurses may lack the necessary knowledge and skills to provide this type of care. This article details the basics of pre- and postoperative care and patient education for nurses who encounter patients with two of the most common types of ostomy surgery of the bowel: colostomy and ileostomy. It covers the care of a new stoma and provides information about emptying and changing the pouch, nutritional and lifestyle considerations, and possible complications.

ABSTRACT: Addiction is a highly misunderstood and stigmatized chronic illness frequently encountered by health care providers during routine medical care. People with substance use disorders, in particular, face extraordinary stigma and bias when interacting with health care providers, including nurses. Stigma associated with addiction contributes to health inequities and is recognized as a significant barrier to people seeking and receiving necessary health care. Since patients often spend the most time with nurses in the clinical setting, nurses are ideally positioned to address addiction stigma. However, many nurses lack knowledge about addiction, stigma, and the impact of the words they use, whether in conversation or in clinical documentation. This article reviews the consequences of addiction stigma (labeling, stereotyping, or discrimination) and the steps nurses can take to reduce biases related to substance use. A case scenario based on our experience will be used to guide a discussion of opportunities for nurses to intervene and improve care.

It's important for nurses to join the conversation.

ABSTRACT: Social media-based groups offer a rich opportunity for nurse researchers to connect with potential study participants. However, as the authors discovered from recruitment of acute respiratory distress syndrome survivors in social media-based survivorship groups, there is a risk of enrollment of both false and duplicate participants. Nurse researchers should adopt best practices to screen out false participants and prevent duplicate participation. Lessons learned from recruitment in social media groups include avoiding the use of survey links, requiring video interviews or home visits for confirmation of identity, adoption of strategic screening questions, and avoidance of international groups (unless the aim is to recruit foreign nationals). Adoption of these practices can help to ensure that the data collected from group patrons are trustworthy. Nurses who read research and adopt findings into practice should critically examine if researchers implemented strategies to screen out false and duplicate participants to protect data integrity.

BACKGROUND AND PURPOSE: Nurse engagement in quality improvement (QI) is critical in the delivery of safe high-quality care, yet few studies have evaluated frontline nurses in this area. The purpose of this study was to identify and compare levels of self-reported QI engagement and QI competence among frontline nurses and nurse leaders. METHODS: This study used a cross-sectional descriptive design. A convenience sample of frontline nurses (bedside RNs and advanced practice nurses) and nurse leaders from acute and ambulatory care sites completed the Nursing Quality Improvement in Practice (NQuIP) tool, which measures engagement and competence (knowledge, skills, and attitudes) in QI. RESULTS: Data from 6,351 surveys completed by frontline nurses and nurse leaders representing 66 sites nationwide were analyzed. Only 52.5% of all respondents reported participating in QI. Knowledge scores were relatively high, while skills scores-especially those related to using QI tools-were low. Overall attitudes toward QI were positive. Nurse leaders scored significantly higher in engagement and…

ABSTRACT: Pediatric oncology patients are vulnerable to pain that may be caused by the disease or its treatment, and this symptom can be challenging to manage. This article focuses on the importance of pain control, pain assessment and treatment, and special considerations in pediatric oncology pain management, including preparing children for painful procedures and the family's role in managing pain.

This is the fourth article in a series on nurse innovators, which focuses whenever possible on nurse-engineer partnerships and outlines working, replicable models of collaboration between the two disciplines. In this installment, we explore the work of four engineers who are forging a path to strengthen nurse-engineer partnerships through their work in academia. Their experiences exemplify the work of nurse-engineer teams, inform ways to employ these teams, and reveal the insights that result when these disciplines collaborate in real time to solve health care problems.

ABSTRACT: The passage of the PACT Act of 2022 expanded the services veterans receive through the U.S. Department of Veterans Affairs (VA), ensuring they now qualify for benefits if they've been exposed to certain toxins during their military service. This significant expansion of VA benefits also highlights the need for nurses and other health providers working outside the VA system-who care for millions of veterans-to be well-informed about their patients' military experiences and any potential environmental exposures and health impacts. In this article, the author raises awareness of military environmental exposures and offers guidance about exposure-informed care.

BACKGROUND: Oral complications from cancer treatments are among the adverse effects breast cancer survivors can face. Yet such complications are often overlooked in cancer survivorship care. Many breast cancer survivors are receiving adjuvant endocrine therapy, but there is limited understanding of potential oral complications from this therapy. PURPOSE: This study aimed to compare aspects of oral health in female breast cancer survivors who were taking adjuvant endocrine therapy with those of survivors not taking such therapy. METHODS: National Health and Nutrition Examination Survey data collected from January 2009 through March 2020 were used for the analysis. Female adults ages 20 years and older who had been diagnosed with breast cancer were included. Linear regression and χ 2 analyses were conducted to examine aspects of oral health, using IBM SPSS Complex Samples software, version 27. RESULTS: In our sample of 423 female breast cancer survivors, 7.1% were taking tamoxifen, 7.8% were taking anastrozole, 4.3% were taking letrozole, and 2.9% were taking exemestane. Compared with…

PURPOSE: Hospitals are implementing a variety of fall prevention programs to reduce the fall rates of hospitalized patients. But if patients don't perceive themselves to be at risk for falling and don't adhere to fall prevention strategies, such programs are likely to be less effective. The purpose of this study was to describe the perceptions of fall risk among hospitalized patients across four acute care specialty services. METHODS: One hundred patients who had been admitted to the study hospital and who had a Morse Fall Scale score over 45 were asked to complete the Patient Perception Questionnaire, a tool designed to explore a patient's confidence regarding their fall risk, fear of falling, and intention to engage in fall prevention activities. Morse Fall Scale scores were collected via retrospective chart review. Data were analyzed using descriptive statistics, Pearson correlation coefficients, and independent sample t tests. RESULTS: Participants' mean age was 65 years; 52% were male, 48% female. Although all 100 participants were deemed at risk for falls per their Morse Fall…

This specialty provides fertile ground for professional development.

ABSTRACT: After ileostomy surgery, patients require nutrition and hydration modifications to maintain electrolyte balances and prevent postoperative complications. In addition to becoming dehydrated, patients who have ileostomies can develop obstructions if care isn't taken to avoid certain kinds of foods. Moreover, changes to medications may be needed to manage ileostomy output or account for altered absorption. This article provides information on postoperative hydration, medication, and nutritional management to nurses caring for patients after ileostomy surgery.

LOCAL PROBLEM: Discharge teaching is essential to the self-care and successful recovery of colorectal surgery patients, yet the trend toward shorter hospital stays for patients with new ileostomies limits opportunities for patient education. As a result, discharged patients at our institution are initiating calls to providers with questions that could have been addressed prior to discharge. PURPOSE: The aim of this quality improvement (QI) project was to decrease patient-initiated postdischarge inquiries using a frequently asked questions (FAQs) handout at discharge. METHODS: A retrospective chart review of inquiries to the outpatient clinic over the six-month period between July 2020 and January 2021 revealed common concerns, among them bowel movements, home health care, medications, wound care, stoma issues, pathology reports, diet, and activity-related issues. Based on these concerns, a FAQs handout was developed to review with patients prior to discharge. Data from three postdischarge time periods (0 to 72 hours, 72 hours to 21 days, and 0 to 21 days) in the three months from…

These nurses practice where the health and legal systems intersect.

PURPOSE: A palliative care infrastructure is lacking for Latinos with life-threatening illness, especially in rural regions of the United States. The purpose of this study was to develop and evaluate a community-based palliative care lay health advisor (LHA) intervention for rural-dwelling Latino adults with cancer. METHODS: An exploratory mixed-methods participatory action research design was carried out by an interprofessional research team that included community and academic members. Fifteen Latino community leaders completed a 10-hour palliative care training program and then served as palliative care LHAs. Although 45 Latinos with cancer initially agreed to participate, four withdrew or died and six were not reachable by the LHAs, for a final total of 35 patient participants.The trained palliative care LHAs delivered information on home symptom management and advance care planning to assigned participants. Palliative care nurses led the training and were available to the LHAs for consultation throughout the study. The LHAs made an average of three telephone calls to each…

ABSTRACT: Tumor lysis syndrome is an oncologic emergency caused by the release of intracellular material, such as potassium, phosphate, and nucleic acids, into the bloodstream from the disintegration (lysis) of tumor cells. This condition, which is characterized by electrolyte imbalances, can be life-threatening, causing arrhythmias, seizures, acute kidney injury, and multiple organ failure. The prevention and treatment of tumor lysis syndrome requires immediate recognition of patients at risk for its development. With this knowledge, nurses can better manage and monitor treatments, thereby preventing complications and achieving better patient outcomes.

An urgent need to make pregnancy, birth, and the postpartum period safer.

Editor's note: From its first issue in 1900 through to the present day, AJN has unparalleled archives detailing nurses' work and lives over more than a century. These articles not only chronicle nursing's growth as a profession within the context of the events of the day, but also reveal prevailing societal attitudes about women, health care, and human rights. Today's nursing school curricula rarely include nursing's history, but it's a history worth knowing. To this end, From the AJN Archives highlights articles selected to fit today's topics and times. In the 1980s, Barbara J. Braden and Nancy Bergstrom developed the Braden Scale for Predicting Pressure Sore Risk. The scale consists of six subscales that evaluate a patient's sensory perception, activity level, mobility, and nutrition status and the skin's exposure to moisture, and friction and shear forces. The Braden Scale was adopted internationally and has since served as a foundation for decades of subsequent pressure injury research. In this June 2005 article, Braden and Joann Maklebust provided an update about the scale,…

ABSTRACT: Nurse suicide is an alarming issue that remains largely underexplored and underaddressed. Moreover, rates of suicide among nurses, which are higher than those in the general population, may increase due to additional stressors caused by the COVID-19 pandemic. There is a decided lack of data regarding nurse suicide or the efficacy of evidence-based prevention programs. This article examines the state of nurse suicide and explores the latest statistics on nurse suicide rates; contributing factors to nurse suicide; and current suicide prevention programs, such as the Critical Incident Stress Management and Healer Education Assessment and Referral programs.

ABSTRACT: The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recently updated the adult pneumococcal vaccine recommendations to include two new pneumococcal conjugate vaccines (PCVs): PCV15 and PCV20. The authors review the updated guideline recommendations, their advantages and disadvantages, and nursing implications.

ABSTRACT: Nonsuicidal self-injury (NSSI) is an area of growing concern for the health care community, as evidenced by its identification as a Healthy People 2030 objective and as a condition for further study in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. In the past, nurses may have identified patients who cut or harmed themselves as having suicidal intent, yet NSSI is increasingly recognized and investigated as a separate disorder. This article provides an overview of NSSI, including information about risk factors, clinical assessment, and preventive efforts.

Building trust in the nurse-patient relationship.

Resources for health care workers, leaders, and organizations.

ABSTRACT: There were 36,136 new HIV diagnoses in the United States and dependent areas in 2021, despite a 12% reduction in estimated HIV incidence from 2017 to 2021. The burden of HIV remains disproportionately high among certain populations, including gay and bisexual men, Black/African American individuals, and Hispanic/Latino individuals, and racial and ethnic health care disparities persist. The Ending the HIV Epidemic initiative aims to significantly reduce new infections, with a focus on HIV prevention, particularly the use of preexposure prophylaxis (PrEP). However, challenges remain in achieving equitable PrEP distribution. As frontline health care providers, nurses play a pivotal role in this battle against HIV. This article provides an update on PrEP screening recommendations, the types of PrEP available, dosing, adverse effects, and the role of nurses in patient support and monitoring.

ABSTRACT: Nursing research is essential to improving patient care, yet barriers may hinder bedside nurses from participating in research and evidence-based practice (EBP) activities. This article describes a nursing research residency program that aimed to inspire direct care nurses to participate in research and EBP projects. The program described may be a potential solution to bridge the gap between clinical work and research.

These nurses conduct activities to support clinical research.

This is the first article in a new series from Press Ganey-a health care performance improvement organization-that will discuss the many facets of the human experience in health care. Using the latest national data, the series will explore the intersections of safety, reliability, experience, and service, and their impact on engagement, work culture, and nurse-sensitive outcomes. Each installment will be designed as a "deep dive" into the most recent thinking and evidence-based approaches to improvement of the patient experience with a particular focus on practical and implementable tactics in each of the above subject areas.

Editor's note: This is the 16th article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204.

These nurses leverage technology to improve health.