The 50 most-cited articles in AJN American Journal of Nursing, 2024

Editor's note: This is the 24th 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.

ABSTRACT: This article introduces the Mountain Model, the first conceptual model for evidence-based practice quality improvement (EBPQI) initiatives. The Mountain Model merges modern evidence-based practice (EBP) and quality improvement (QI) paradigm principles into a unified conceptual framework with the goal of disseminating and sustaining EBPQI projects across health care and related settings. The model was developed within the nursing discipline, but is designed for transdisciplinary implementation through interprofessional teams.

ABSTRACT: The framework for the PICO (population, intervention, comparison intervention, outcome) question was developed for use in the field of medicine to help determine the best treatment or intervention for a patient. However, use of the PICO question often fails to make sense when the problem or issue of interest is unrelated to determining the best treatment; in such cases, PICO is a less-than-optimal framework to use in searching for evidence. Nurses undertaking an evidence-based practice quality improvement (EBPQI) initiative must begin with a full understanding of the problem by exploring both external evidence (research) and internal evidence from the local setting to support the initiative. This article presents the framework for an alternative question-PPCO, or problem, population, change, outcome-that simplifies the search for evidence and provides a universal approach to question development for EBPQI initiatives. The PPCO question was developed for use with all nursing issues that need addressing.

ABSTRACT: With nurses at the forefront of health care, the need for their active engagement in policy has never been more urgent. Numerous national and global reports call for nurses to lead policy change. The Patton Zalon Ludwick Policy Assessment Framework is intended to answer this call by serving as a foundational guide to nurses' self-assessment of their health policy actions. It includes three dimensions: engagement, partnership, and reach, each with three levels. The levels of engagement are literacy, advocacy, and influence. The partnership levels are single unit or community group, interdisciplinary team(s), and broad-based coalitions. The reach levels are based on the location of policy work: local/unit/organization, regional/state, and national/global. The dimensions are interconnected, and the levels build upon one another but are not necessarily symmetrical, linear, or prescriptive. In this article, the authors describe each dimension and level in detail, and the accompanying tables provide examples of policy goals and actions. Nurses worldwide can use this framework to…

ABSTRACT: Rural communities in the United States are frequently marginalized and misrepresented. These communities face unique challenges, such as limited access to health care, nutritious food, and clean water, that contribute to persistent health disparities. This article presents the CARE (Complex, Access, Resourceful, Extraordinary) framework, which illustrates the dichotomy of rurality-its negative and positive aspects-in order to inform the development of palliative care delivery in rural settings. Various palliative care models are described that address access gaps, bolster provider capacity, and increase the provision of specialty palliative care. However, workforce shortages and reimbursement structures restrict the expansion of these services. Nurses, the largest segment of the health care workforce and the most trusted professionals, must partner with interdisciplinary colleagues and rural communities to advocate for equitable and inclusive care.

ABSTRACT: Extracorporeal membrane oxygenation (ECMO) is a type of mechanical circulatory support that is increasingly utilized in the United States for severe respiratory and/or cardiac failure refractory to conventional therapies. It is an expensive and complex life support modality. Moreover, patients on ECMO are critically ill and require a strong multidisciplinary care team. A successful ECMO program involves a trained team consisting of physicians, perfusionists, nurses, and respiratory therapists. This article discusses the multiple roles of ECMO nurses, the various ECMO delivery care models, and the potential cost savings of an RN ECMO specialist staffing model-and introduces the novel role of the ECMO lead.

BACKGROUND: Brain drain refers to the emigration of scientists and other educated professionals from a low- or middle-income country to a high-income country for work. In recent years, this trend has increased, particularly in the health care arena. Prior studies among nurses and nursing students indicate that migration mainly occurs from low- and lower middle-income countries to high-income countries. This study aimed to explore the attitudes of Turkish nurses, nurse academics, and nursing students toward brain drain and the factors associated with these attitudes. METHODS: The study used a mixed-methods research design. The quantitative part of the study was conducted with 1,018 participants. The qualitative part was conducted with 26 participants from the larger sample who volunteered for focus group interviews. Data were collected from June through August 2022 using an online survey, the Attitude Scale for Brain Drain, and a semistructured interview guide. RESULTS: Of all participants, 84.3% indicated that they wanted to work and live abroad. Nearly 95% stated that there was a…

This is the second article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making. It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to http://links.lww.com/AJN/A133). This follow-up series will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey.

Editor's note: This is the 23rd 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 a critical role to play in achieving the United Nations' 17 Sustainable Development Goals (SDGs). While Goal 3 (good health and well-being) is of particular importance to nursing, every SDG contributes to the advancement of universal health and well-being. Yet many nurses are unfamiliar with the SDGs and how they relate to everyday nursing practices. PURPOSE: The purpose of this study was to examine RNs' knowledge of and attitudes toward the SDGs. METHODS: This study used a descriptive correlational cross-sectional design. A convenience sample of RNs from multiple countries completed an anonymous online survey that included eight demographic items and 25 items exploring participants' knowledge of and attitudes toward the SDGs. Descriptive, parametric, and nonparametric statistics were used to analyze the data. RESULTS: The majority of nurses in this study perceived themselves as lacking knowledge of the SDGs. Most wanted to know more, including how they could take action to help achieve the goals. Overall, participants agreed that the SDGs are relevant to…

BACKGROUND: During the COVID-19 pandemic, nurses have faced innumerable challenges, which have contributed to staggering increases in burnout rates. In the health care arena, burnout has been associated with the onset or exacerbation of physical illness, neglect of self-care, fatigue, decreased patient satisfaction, higher medication error rates, lack of nurse engagement, and increased nurse turnover. PURPOSE: This cross-sectional study sought to determine whether a correlation exists between self-reported physical activity and nurses' perception of burnout in a sample of hospital RNs. The secondary aim was to determine whether a correlation exists between the level of perceived burnout and the number of medication errors or near misses. METHODS: Participants were asked to provide demographic information, complete the Copenhagen Burnout Inventory (CBI) and the Godin Leisure-Time Exercise Questionnaire (GLTEQ), and self-report the number of medication errors or near misses they were involved in during the previous 12 months. Data were analyzed using Stata version 17 software.…

This article is one in a 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.

ABSTRACT: Disaster management can be difficult to teach in the classroom, yet nurses must be prepared to respond to emergency situations and feel confident doing so. Educators developed a simulated learning activity-a mock disaster drill using live volunteers as patients and emergency medical technicians-to improve disaster management preparedness, confidence, and interdisciplinary teamwork among nursing students. This article details their strategy and experience with this project.

This is the first article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making. It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to http://links.lww.com/AJN/A133). This follow-up series will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey.

Neurodivergent nurses bring unique strengths that can enhance patient care.

BACKGROUND: To improve patient safety, hospitals use alarm notification systems to increase nurses' real-time situational awareness of a patient's condition. Such alarms are critical to nurses' clinical decision-making and prioritization, thus helping to improve patient care and care efficiency. But the frequent and often simultaneous ringing of alarms, including many that are false, nonemergent, or nonactionable, has led to overwhelm, alarm distrust, and desensitization, resulting in alarm fatigue. PURPOSE: This study aimed to explore oncology nurses' lived experiences with alarms and the adaptive and maladaptive strategies they use to cope with alarm fatigue. METHODS: This qualitative, phenomenological study was guided by the theoretical framework of the Roy Adaptation Model. A purposive sample of nine nurses was recruited from two oncology units at a large midwestern Magnet hospital in the United States. Qualitative data were collected using a six-question, semistructured interview guide. Interviews were conducted either face-to-face in a private conference room on the unit or…

ABSTRACT: Substantial evidence demonstrates that plumes from uncovered toilets potentially expose nurses and other health care workers to aerosols containing infectious agents and hazardous drugs, including antineoplastic drugs. Most hospitals in the United States utilize flushometer-type toilets, which operate under high pressure and do not have a permanently attached closure or lid, which is known to reduce the aerosols generated by flushing. This article aims to raise awareness among nurses of the potential exposure risks associated with toilet plume aerosols, so they can educate other health care workers and take part in initiatives to address these risks.

ABSTRACT: Primary palliative nursing in home health care (HHC) can be delivered to medically complex patients across the lifespan. Primary palliative nursing provides patient- and family-centered care for serious illness by alleviating the stress and symptoms of illness; coordinating care; and supporting the social, cultural, and psychological aspects of care. In this article, two case scenarios of patients in different phases of life serve as examples of primary palliative nursing in HHC. Key elements and challenges of delivering primary palliative nursing care in HHC are also highlighted.

ABSTRACT: Debridement, a mainstay of nursing clinical practice, refers to the removal of dead or unhealthy tissue from a wound to facilitate healing. Debridement is one component of the concept of wound bed preparation that has long guided the approach to wound management. The ability of a wound to heal must be determined prior to the initiation of any method of debridement. In areas where high-quality, comparative studies on the relative benefits of different debridement modalities are lacking, nurses should adopt an evidence-informed approach to care. To do this, nurses must understand the importance of following a comprehensive, holistic approach when treating chronic wounds. Nurses should have knowledge of inflammation and infection control and of the fundamentals of moisture management, recognize the need for debridement in healable wounds, and be familiar with different debridement options. This article provides nurses with a wound management framework, an overview of wound debridement options based on the potential for wound healing, and scope of practice considerations for…

ABSTRACT: The emerging field of implementation science (IS) facilitates the sustainment of evidence-based practice in clinical care. This article, the third in a series on applying IS, describes how a nurse-led team at a multisite health system used IS concepts, methods, and tools to implement a hospital-acquired pressure injury (HAPI) prevention bundle on six critical care units, with the aim of decreasing HAPI incidence.

Diane S. Aschenbrenner is a former member of the faculty at Notre Dame of Maryland University and the Johns Hopkins University School of Nursing. She coordinates Drug Watch: [email protected].

LOCAL PROBLEM: Variations in nursing practice were observed across our hospital, a 520-bed acute care teaching facility in the northeast United States, regarding the timing and frequency of insulin administration in adult patients with diabetes. Chart audits noted that RNs administered insulin more than one hour after blood glucose results were obtained 97% of the time. In addition, insulin was given at bedtime only 37% of the time. PURPOSE: The purpose of this quality improvement (QI) project was to improve the care of inpatients requiring insulin by implementing protocols and adjusting practice to align with best practice recommendations. METHODS: The clinical nurse education specialist met with a team of staff nurses, providers, nurse leaders, and patient care technicians (PCTs) to formulate protocols and design interventions to ensure improvements in the quality of care for inpatients with diabetes. A sequence of education sessions and an online learning module were developed and assigned to nurses and PCTs to address knowledge gaps, specifically in the pharmacodynamics and safe…

Research and clinical practice can inform and improve each other.

PURPOSE: This study aimed to assess the perceptions of nurses who self-identify as Black or African American regarding their workplace health and safety and to explore how these perceptions are associated with their perceived personal health. BACKGROUND: Nurses practicing in unhealthy work environments can experience poorer physical and mental health. Recent civil unrest and ongoing dialogue about structural and systemic racism have prompted calls for greater efforts to understand the workplace perceptions and experiences of ethnic minority nurses, and how these influence nurses' personal well-being. But there is a dearth of relevant evidence concerning these nurses, including Black nurses. METHODS: This cross-sectional, descriptive study involved analysis of secondary data collected from May 1, 2017, through December 31, 2019, by the American Nurses Association's HealthyNurse Survey (N = 19,131). We employed descriptive, bivariate, and multivariate analyses to examine the data for the 1,143 respondents who both self-identified as Black or African American and responded to all items…

This is the fourth article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making (EBDM). It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to https://links.lww.com/AJN/A133). This follow-up series on EBDM will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey. To access previous articles in this EBDM series, go to https://links.lww.com/AJN/A256.

This is the third article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making (EBDM). It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to http://links.lww.com/AJN/A133). This follow-up series on EBDM will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey. To access previous articles in this EBDM series, go to http://links.lww.com/AJN/A256.

Editor's note: This is the 22nd 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.

ABSTRACT: The emerging field of implementation science (IS) facilitates the sustainment of evidence-based practice in clinical care. This article, the second in a series on applying IS, describes how a nurse-led IS team at a multisite health system implemented the Brøset Violence Checklist-a validated, evidence-based tool to predict a patient's potential to become violent-in the system's adult EDs, with the aim of decreasing the rate of violence against staff. The authors discuss how they leveraged IS concepts, methods, and tools to achieve this goal.

How to address these behaviors to promote health equity and inclusion.

ABSTRACT: The youth mental health crisis in the United States was exacerbated by the COVID-19 pandemic, as well as in part by widespread, frequent use of the internet and social media. Schools provide an opportune setting for delivering prompt preventative interventions to actively mitigate this crisis. The purpose of this project was to identify policy recommendations for improving school-based mental health services and reducing inequities in care, as well as to produce guidelines on how to advocate for better policies for school mental health services. School policies were analyzed in 3 states at 3 different levels: the state level, district level, and school level. To augment the policy reviews, unstructured interviews were conducted with 5 school nurses from the 3 states. Recommendations for just and sustainable policies for school-based mental health care and strategies on how to advocate for such policies are outlined. This project exemplifies the need for strong policies to support school mental health, with a focus on the role of the school nurse.

BACKGROUND: Health-harming legal needs are legal burdens that negatively affect a person's overall health. Medical-legal partnerships (MLPs) are a cost-effective way for health care systems to improve overall health and access to health care and empower health care providers to become more active in addressing health-harming legal needs and social determinants of health. This article describes the implementation of a referral pathway to an MLP in a nurse-managed community health center. This pathway was used by the health center's clinical team to help connect patients who had burdensome legal needs with legal professionals who could further help evaluate those needs. METHODS: An MLP team developed a referral pathway in which all adult patients were asked to complete a legal screening tool to assess whether they had legal needs that could be addressed by an MLP's intervention. If a legal need was identified, the patient would meet with the community health worker for further assessment. The community health worker would then present these cases for further review to the MLP team.…

Nurses can play a crucial role as trusted advocates.

Common misunderstandings about nursing regulation.

ABSTRACT: The second victim phenomenon describes the distress frequently experienced by health care providers after an unintentional medical error or unexpected adverse event. However, few health care institutions have initiatives that proactively address this phenomenon. The pilot project discussed in this article aimed to create a peer support program for health care providers experiencing the second victim phenomenon. The project team validated the need for such a program among health care providers in the perioperative departments of two facilities within a large health care organization in the southeastern United States. To do this, they used a survey, the Second Victim Experience and Support Tool. Among survey respondents in the two departments, 80% and 87.6% indicated a strong desire to discuss their emotional challenges with a respected peer colleague after a traumatic event. The project team then developed and implemented a peer support program in three phases to 1) educate staff across the facility on second victimization, 2) recruit and train volunteer peer supporters,…

But inadequate staffing remains a factor driving some nurses away.

Excluding this population perpetuates health inequities.

ABSTRACT: Patients who have Parkinson disease require individualized medication regimens to optimize care. A review of the medication management of patients admitted to a tertiary care hospital with a secondary diagnosis of Parkinson disease found significant departures from the patients' home regimen. Medication regimens are often altered by health care teams unfamiliar with Parkinson disease-specific care in order to conform to standard hospital medication orders and administration times, potentially resulting in increased patient falls, delirium, and mortality.A nurse-led multidisciplinary team consisting of pharmacy, nursing, informatics, neurology, and quality personnel implemented a quality improvement (QI) project between July 2020 and July 2022 to identify patients with Parkinson disease, including those with a secondary diagnosis and those undergoing deep brain stimulation, and customize medication management in order to reduce length of stay, mortality, falls, falls with harm, and 30-day readmissions. The QI project team also evaluated patient satisfaction with medication…

LOCAL PROBLEM: In 2019 and the first half of 2020, our facility experienced an increase in the number and severity of hospital-acquired pressure injuries (HAPIs) among our cardiothoracic surgery population. Fifty percent of these HAPIs occurred within 72 hours of surgery. A review of the literature revealed that alternating pressure overlays (APOs) have been successfully used to prevent HAPIs in surgical patients. PURPOSE: The primary purpose of our quality improvement (QI) project was to measure perioperative HAPI rates in cardiothoracic surgery patients after the addition of APOs to our HAPI prevention protocol. Our secondary purpose was to identify common factors among those patients who developed HAPIs. METHODS: This QI project collected both pre- and postintervention data and compared the findings. A nurse-led team was responsible for measuring HAPI rates during the intervention-from July through October 2020-which involved placing an APO under cardiothoracic surgery patients during the 72-hour perioperative period. APOs were placed on all operating room (OR) tables and…

Recognizing bias as the biggest hidden threat to patient safety.

This is the sixth article in a series on nurse innovators, which focuses on nurse-engineer partnerships and outlines working, replicable models of collaboration between the two disciplines. In this installment, we describe the role of academia in building the next generation of nurse-engineers, highlighting three novel academic programs that have reimagined nursing and engineering education to promote interdisciplinary partnership and innovation.

BACKGROUND: Nurse staffing committees offer a means for improving nurse staffing and nursing work environments in hospital settings by giving direct care nurses opportunities to contribute to staffing decision-making. These committees may be mandated by state law, as is the case currently in nine U.S. states, yet little is known about the experiences of staff nurses who have served on them. PURPOSE AND DESIGN: This qualitative descriptive study was conducted to explore the experiences of direct care nurses who have served on nurse staffing committees, and to better understand how such committees operate. METHODS: Participants were recruited by sharing information about the study through online nursing organization platforms, hospital nurse leadership, state chapters of national nursing organizations, social media, and nonconfidential nursing email lists. A total of 14 nurses from five U.S. states that have had nurse staffing committee legislation in place for at least three years were interviewed between April and October 2022. RESULTS: Four themes were identified from the data-a…

Decreased vaccine coverage and waning immunity are cited as factors.

ABSTRACT: This is the fifth article in a new series designed to provide readers with insight into educating nurses about evidence-based decision-making (EBDM). It builds on AJN's award-winning previous series-Evidence-Based Practice, Step by Step and EBP 2.0: Implementing and Sustaining Change (to access both series, go to https://links.lww.com/AJN/A133). This follow-up series on EBDM will address how to teach and facilitate learning about the evidence-based practice (EBP) and quality improvement (QI) processes and how they impact health care quality. This series is relevant for all nurses interested in EBP and QI, especially DNP faculty and students. The brief case scenario included in each article describes one DNP student's journey. To access previous articles in this EBDM series, go to https://links.lww.com/AJN/A256.

Actions nurses can take to ensure accurate and appropriate care.

The roles of PhD- and DNP-prepared nurses are very different.

BACKGROUND: Total knee arthroplasty (TKA) is a surgical procedure to improve the quality of life of patients with osteoarthritis. However, postoperative recovery can be difficult due to sleep disturbance, such as poor sleep quality, and postsurgical pain. PURPOSE: The aim of this systematic review was to examine recent evidence regarding changes in sleep quality after TKA and to explore factors affecting the postoperative recovery process. METHODS: This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We screened the PubMed, Google Scholar, ScopeMed, and Science Direct databases in December 2022 using the keywords sleep, total knee replacement surgery, knee arthroplasty, and sleep disruptions for relevant articles published between 2011 and 2022. Seven studies met all inclusion criteria and were included in the final sample for analysis. RESULTS: Findings revealed that sleep disturbance was common during the early stages of the TKA recovery period and may be related to pain. After three months,…

Implementation science is the process of integrating an intervention into practice within an organization or health system and is a useful strategy to improve practice, affect patient outcomes, and promote practice sustainability. In this series, AJN and the journal JBI Evidence Implementation have partnered to deliver examples of how health care facilities from around the world have worked to solve common patient care problems. Through this partnership, we strive to create awareness and share knowledge and experiences by publishing summaries of studies that have appeared in JBI Evidence Implementation. These summaries are designed to provide nursing teams with an overview of the barriers faced and the strategies and resources needed to improve practice and drive change at the unit level. Our goal is to ensure that AJN readers have access to important evidence-based information designed to influence patient outcomes and nursing practice.-Carl A. Kirton, DNP, MBA, RN, ANP, FAAN.