The Journal of the New York State Nurses Association, Volume 50, Number 2

THE

JOURNAL

of the New York State Nurses Association

Volume 50, Number 2

n Editorial: Supporting the Profession of Nursing Well Into the 21st Century by Meredith King-Jensen, PhD, MSN, RN

n Informed Consent: A Patient’s Right to Information and a Nurse’s Legal and Ethical Obligation by Carol Lynn Esposito EdD, JD, MS, RN-BC, NPD

n Caring for the Caregiver: Implementation of a Mindfulness Program for Mental Health Providers in an Outpatient Clinic by Hermanuella Hyppolite, DNP, PMHNP-BC, CARN

n Implementation of Escape Room Simulation Activity for Nurses Transitioning to Clinical Practice by Simon Paul Navarro, MA, BSN, RN, CCRN, TCRN, and Maria Paula B. Nolasco, MSN, RN, CCRN, HNB-BC

n What’s New in Healthcare Literature

n CE Activities: Caring for the Caregiver: Implementation of a Mindfulness Program for Mental Health Providers in an Outpatient Clinic; Informed Consent: A Patient’s Right to Information and a Nurse’s Legal and Ethical Obligation

THE JOURNAL

of the New York State Nurses Association

n The Journal of the New York State Nurses Association editorial board

Anne Bové, MSN, RN-BC, CCRN, ANP Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN Clinical Instructor Registered Nurse III New York, NY New York-Presbyterian Adult Emergency Department New York, NY

Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-K Coreen Simmons, PhD(c), DNP, MSN, MPH, RN Assistant Professor Professional Nursing Practice Coordinator

Touro College School of Health Sciences Teaneck, NJ Hawthorne, NY

Meredith King-Jensen, PhD, MSN, RN Nurse Consultant, Veterans Administration Bronx, NY Adjunct Instructor, Mercy College Dobbs Ferry, NY

nCarol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor

Lucille Contreras Sollazzo, MSN, RN-BC, NPD, Co-Managing Editor

Christina Singh DeGaray, MPH, RN-BC, Editorial Assistant

The information, views, and opinions expressed in The Journal articles are those of the authors, and do not necessarily reflect the official policy or position of the New York State Nurses Association, its Board of Directors, or any of its employees. Neither the New York State Nurses Association, the authors, the editors, nor the publisher assumes any responsibility for any errors or omissions herein contained.

The Journal of the New York State Nurses Association is peer reviewed and published biannually by the New York State Nurses Association. ISSN# 0028-7644. Editorial and general offices are located at 131 West 33rd Street, 4th Floor, New York, NY, 10001; Telephone 212-785-0157; Fax 212-785-0429; email info@nysna.org. Annual subscription: no cost for NYSNA members; $17 for nonmembers.

The Journal of the New York State Nurses Association is indexed in the Cumulative Index to Nursing, Allied Health Literature, and the International Nursing Index. It is searchable in CD-ROM and online versions of these databases available from a variety of vendors including SilverPlatter, BRS Information Services, DIALOG Services, and The National Library of Medicine’s MEDLINE system. It is available in microform from National Archive Publishing Company, Ann Arbor, Michigan.

©2024 All Rights Reserved  The New York State Nurses Association

n eDITorIAl Supporting the Profession of Nursing Well Into the 21st Century

It is not uncommon for recent graduates of nursing to question if they have chosen the right profession as they struggle to transition from classroom to bedside. Novice nurses find that the day-to-day experiences on the job can be incredibly stressful due to a multitude of reasons, including staffing shortages, the acuity of patients, and the complexity of the healthcare system. Standards of practice, laws, regulations, and policies are also complicated and frequently change, adding to nurses’ feelings of being overwhelmed.

The authors of the articles in this issue of the The Journal offer readers a look at how to bridge the gap between novice to expert, while concomitantly supporting the profession of nursing in all aspects and concepts that are of concern to nurses and nursing.

In the article “Informed Consent: A Patient’s Right to Information and a Nurse’s Legal and Ethical Obligation,” the author details knowledge that supports nurses and protects their practice by offering an overview of legal and ethical nursing mandates. Both new and experienced nurses alike will find the details, sources, and references included here beneficial—as much of this information is not always readily available.

In the article “Caring for the Caregiver: Implementation of a Mindfulness Program for Mental Health Providers in an Outpatient Clinic,” the author discusses the ability to improve capacity to focus on current moments without distractions. No matter how experienced, competent, and proficient a nurse is, no matter how confident in their actions, no matter how holistic in their nursing theory practice, or effectual in improving long-term patient outcomes, a nurse can experience cognitive overload. We are bombarded by various specialists and department representatives who are asking for information, assistance, and other needs, all the while we are overseeing the care and health of 6 to 8 patients.

Mindfulness can improve self-awareness practices and offers big payoffs for nurses, who often allow little-to-no time for themselves on any given day or shift. Lastly, the practice of mindfulness can increase life expectancy and reduce such disorders as cardiovascular conditions, anxiety, and depression. Mindfulness is a gift that offers additional benefits for anyone willing to commit to its practice—especially nurses.

While in the beginning stages of acquiring and developing nursing skills, novice nurses can experience an extreme disconnect between what they are taught as nursing students and what their expectations are on the job once hired. In the article “Implementation of Escape Room Simulation Activity for Nurses Transitioning to Clinical Practice,” the authors address the gap between theory and practice through simulation as a way to minimize pressure and complexity for new nurses putting theory into practice. Research confirms that innovative simulation design can support novice nurses’ effective transition to clinical practice. The literature finds that it can also be a lot of fun.

Anne Bové, MSN, RN-BC, CCRN, ANP

Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-K

Meredith King-Jensen, PhD, MSN, RN

Alsacia L. Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN

Coreen Simmons, PhD(c), DNP, MSN, MPH, RN

Introduction

Informed Consent: A Patient’s right to Information and a Nurse’s legal and ethical obligation

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD

n Abstract

Purpose: The purpose of this article is to analyze the extent to which there is a requirement for nurses to obtain a patient’s informed consent by comparing and contrasting the role of the nurse as a provider of treatment and care versus the role of the nurse as a witness to the informed consent process and procedure.

Rationale: The requirement for licensed healthcare providers, including registered professional nurses, to obtain informed consent prior to procedures that invade the integrity of the patient’s body or that might be otherwise considered a battery, is addressed by healthcare law and ethics. It is important for nurses to understand the legal and ethical mandates and rational behind the principles of informed consent so that they will be in full compliance with duties owed to the patient under law and ethics.

Position Statement: The legal and ethical requirement to obtain a patient’s informed consent is significantly relevant to nursing practice and care. This article will discuss the purpose of informed consent, the process of informed consent, the circumstances under which nursing care requires a patient’s informed consent, and the implications of the informed consent procedure for nurses when approaching all aspects of patient care.

Conclusion: The principles, processes, and procedures of informed consent should underlie a nurse’s approach to all nursing care procedures. Informed consent should not be a limited, automatous process that is only relevant to surgical or research procedures, but rather a way of facilitating a patient’s meaningful decision-making in all aspects of treatment and care.

Keywords: Informed consent, patient self-determination, patient autonomy, patient-centered approach, legal and ethical aspects of nursing care

“Every human being of adult years and sound mind has the right to determine what shall be done with his own body.”

—Justice Benjamin Cardozo

code of ethics. Nurses have a moral, legal, and ethical obligation to ensure that a patient’s right to autonomy has not been breached or circumvented. Nevertheless, in daily practice, the literature is replete with examples of nursing’s continued uncertainty as to whether the

Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD

Nursing Education and Practice, New York State Nurses Association, New York, New York

registered professional nurse, as a provider of nursing care and treatment, should be securing informed consent from patients in line with their own professional services, or if their role solely remains as doing the task of assisting doctors in the obtaining of informed consent documents (the administrative role in complying with hospital policy and procedure) (Axson et al., 2021).

Patient Autonomy: A Judicially Declared right State Courts Announce a Patient’s Right to Autonomy

The philosophical underpinning for autonomy, as interpreted by philosophers Immanuel Kant (1724–1804) and John Stuart Mill (1806–1873) and accepted as an ethical principle today, is that all persons have intrinsic and unconditional worth and, therefore, should have the power to make rational decisions and moral choices and be allowed to exercise his or her capacity for self-determination. This ethical principle was first captured in a New York court decision by Justice Benjamin Cardozo in 1914 with the epigrammatic dictum, “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.” (Schlendorff v. Society of New York Hospital, 1914).

The self-determination privilege continued to be affirmed in a series of court cases, starting with the New Jersey Supreme Court in the Karen Ann Quinlan case in 1975. In that case, Quinlan’s parents asked that their daughter’s respirator be removed and that she be allowed to die. Quinlan’s doctor refused, claiming that his patient did not meet the Harvard Criteria for brain death. The New Jersey Supreme Court stated, however, that an individual’s right to self-determination, embodied by the right to privacy, was most relevant to the case. The court opined although the U.S. Constitution does not expressly indicate a right to privacy, U.S. Supreme Court rulings in past cases had not only recognized this privilege but had also determined that some areas of the right to privacy are guaranteed by the Constitution.

For example, the Supreme Court had upheld the right to privacy in Griswold v. Connecticut (the right to marital privacy, or the right to use contraception, Griswold v. Connecticut, 1965) and in Roe v. Wade (the right to abortion, Roe v. Wade, 1973). The U.S. Supreme Court had further presumed that the right to privacy included a patient’s right to refuse medical treatment in some situations. The court observed that life-prolongation advances had rendered the existing medical standards ambiguous (unclear), leaving doctors in a quandary. Moreover, modern devices used for prolonging life, such as respirators, had confused the issue of “ordinary” and “extraordinary” measures. The court suggested that respirators could be considered “ordinary” care for a curable patient, but “extraordinary” care for irreversibly unconscious patients.

The court also suggested that hospitals form ethics committees to assist physicians with difficult cases like Quinlan’s. And so began the birth of legally mandated hospital ethics committees throughout the states.

U.S. Supreme Court Announces a Patient’s Right to Autonomy

In 1983, Nancy Beth Cruzan was involved in an automobile accident which left her in a “persistent vegetative state.” For almost eight years, her body was rigid and her feet and hands contracted and bent. She had occasional seizures, and while her eyes sometimes opened and moved,

she showed no sign of recognizing her family. A month after the accident, a feeding tube was implanted in Miss Cruzan’s stomach for nutrition. She breathed without assistance from a ventilator.

In 1987, Miss Cruzan’s parents went to court to ask that the feeding tube be removed and that she be allowed to die a dignified death as they said she would have wanted. But a loose coalition of euthanasia and abortion opponents describing themselves as “right to life” advocates quickly intervened into Nancy’s case. They argued that every life has meaning, even life in a vegetative state, and that removing the feeding tube and starving Miss Cruzan to death devalued life. The lower court refused the parent’s request to remove the feeding tube.

The Cruzan v. Director, Missouri Department of Health, 497 U.S. 261 (1990) case became the centerpiece of a bitter debate about how and when families can decide to withdraw nourishment or medical treatment to bring about the death of an incapacitated loved one.

In a 5-to-4 decision, and in its first ruling on the right to die, the U.S. Supreme Court recognized such a right under the right of privacy, but said the state of Missouri could nevertheless stop the Cruzans from withholding food and water from their daughter unless there was “clear and convincing” evidence that she would have wanted to die. Ultimately, the U.S. Supreme Court ruling in the Cruzan case set no uniform national guidelines on the right to die, but left it to states to set their own standards.

The ruling spurred enormous interest in living wills and other advance directives that allow people to spell out, in advance, what treatment they want and who should make decisions for them if they become incapacitated.

The case also helped to generate support for Congressional passage of the Federal Patient Self-Determination Act, effective November 1991, under which hospitals and nursing homes that receive Medicaid or Medicare funds must provide patients written information about such advance directives, explaining what right-to-die options are available under their state law. States now have laws providing a way for people to make known, in advance, their wishes about medical treatment, thus preserving patient autonomy and self-determination.

Patient Autonomy: A Right Codified in New York State Statutory Law

New York State embodies a patient’s right to autonomy and selfdetermination within three state statutes. The New York Health Care Proxy Law (Article 29-C of the New York Public Health Law) lets patients appoint a competent adult (an agent) to make decisions about their medical treatment in the event they lose the ability (capacity) to decide for themselves— including decisions to remove or provide life-sustaining treatment.

Additionally, the Family Health Care Decisions Act (FHCDA) of 2010 allows New York family members or a close friend (if there are no family members) to act as a “surrogate” or representative of the patient to make healthcare decisions, including withholding or withdrawing of life-sustaining treatment, for a patient who loses the ability to make those decisions under those circumstances where the patient has not signed a health care proxy. This law includes extensive rules and procedures to protect the patient.

Under the FHCDA, the surrogate’s role is very similar to a healthcare agent. However, a surrogate only has authority to act if the patient is in a hospital or a nursing home or if the decision is about hospice care.

Informed Consent: A Patient’s Right to Information and a Nurse’s Legal and Ethical Obligation

Informed Consent: A Patient’s Right to Information and a Nurse’s Legal and Ethical Obligation n

Conversely, a healthcare agent may make decisions wherever the patient is located.

New York State Public Health Law § 2805-d (2014) also codifies a patient’s rights to autonomy and self-determination in its informed consent statute.

Limitation of medical, dental or podiatric malpractice action based on lack of informed consent:

1. Lack of informed consent means the failure of the person providing the professional treatment or diagnosis [emphasis added] to disclose to the patient such alternatives thereto and the reasonably foreseeable risks and benefits involved as a reasonable [emphasis added] medical, dental or podiatric practitioner under similar circumstances [emphasis added] would have disclosed, in a manner permitting the patient to make a knowledgeable evaluation.

2. The right of action to recover for medical, dental or podiatric malpractice based on a lack of informed consent is limited to those cases involving either (a) non-emergency treatment, procedure or surgery, or (b) a diagnostic procedure which involved invasion or disruption of the integrity of the body.

3. For a cause of action therefore it must also be established that a reasonably prudent person in the patient’s position [emphasis added] would not have undergone the treatment or diagnosis if he had been fully informed and that the lack of informed consent is a proximate cause of the injury or condition for which recovery is sought.

4. It shall be a defense to any action for medical, dental or podiatric malpractice based upon an alleged failure to obtain such an informed consent that:

(a) the risk not disclosed is too commonly known to warrant disclosure; or

(b) the patient assured the medical, dental or podiatric practitioner he would undergo the treatment, procedure or diagnosis regardless of the risk involved, or the patient assured the medical, dental or podiatric practitioner that he did not want to be informed of the matters to which he would be entitled to be informed; or

(c) consent by or on behalf of the patient was not reasonably possible; or

(d) the medical, dental or podiatric practitioner, after considering all of the attendant facts and circumstances, used reasonable discretion as to the manner and extent to which such alternatives or risks were disclosed to the patient because he reasonably believed that the manner and extent of such disclosure could reasonably be expected to adversely and substantially affect the patient’s condition.

Patient Autonomy: A Right Codified in New York State Regulatory Law

The New York State Code of Rules and Regulations codifies a patient’s right to autonomy, self-determination, and informed consent via the following regulatory provisions:

1. 10 NYCRR §405.7(c)(6): You have a right to know the names, positions and functions of any hospital staff involved in your care and refuse their treatment, examination or observation.

2. 10 NYCRR §405.7(c)(8): You have a right to receive complete information about your diagnosis, treatment and prognosis.

3. 10 NYCRR §405.7(c)(9): You have a right to receive all the information that you need to give informed consent for any proposed procedure or treatment. This information shall include the possible risks and benefits of the procedure or treatment.

4. 10 NYCRR §405.7(c)(10): You have a right to receive all the information you need to give informed consent for an order not to resuscitate. You also have the right to designate an individual to give this consent for you if you are too ill to do so.

5. 10 NYCRR §405.7(c)(11): You have a right to refuse treatment and be told what effect this may have on your health.

6. 10 NYCRR §405.7(c)(14): You have a right to participate in all decisions about your treatment and discharge from the hospital. The hospital must provide you with a written discharge plan and written description of how you can appeal your discharge.

Patient Autonomy: A Right Codified in the Nursing Code of Ethics

The American Nurses Association (ANA) Nursing Code of Ethics with Interpretative Statements (2015) embodies a patient’s rights to autonomy and self-determination in Provision 1: “The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person”:

Autonomy is the ethical principle demonstrated when a nurse accepts the patient as a unique person with the right to his own opinions, values, beliefs, and right to make his own decisions.

Provision 1, Interpretive Statement 1.4:

The Right to Self-Determination: Demonstrating respect for human dignity requires nurses to recognize patient rights, especially the right of self-determination or autonomy. Self-determination is the basis upon which patients can engage in informed consent for healthcare services. Patients have a legal right to decide what treatments if any, will be performed on or for them. They have the right to accurate, understandable, and complete information that supports informed decision-making, allowing them to weigh the advantages and disadvantages of care. Nurses are obligated to be knowledgeable about the legal and moral rights of all patients to self-determination. Nurses must protect, preserve, and support their patient’s interests by verifying their comprehension of the education or information provided and the implications associated with their decisions. Nurses should support the patient’s right to accept, refuse, or stop treatment without undue influence, coercion, duress, or penalty. Support of self-determination includes recognizing cultural differences that may affect the patient’s decisions about care.

Autonomy in nursing means providing adequate information to allow patients to make their own decisions based on their beliefs and values, even if they aren’t the ones the nurse chooses.

Autonomy also relates to only providing nursing care within the scope of practice defined by state and organizational rules (ANA, 2023).

Discussion

The purpose of informed consent is to protect a patient’s autonomy and to promote meaningful decision-making using a patient-centered approach. Given the potential for nursing care interventions to infringe upon a patient’s autonomy, consent, including informed consent, is clearly a relevant notion in nursing, particularly when any touching without consent would render the nurse liable for an assault and battery action under tort law.

The concept of obtaining informed consent is not limited to the legal aspects (protection from a lawsuit) and the administrative aspects (obtain a signed document in accordance with hospital policy) of the process; rather, the concept and principle of obtaining informed consent is rooted in ethics and patient-centered care.

In accordance with the provisions of New York State Public Health Law § 2805-d, consent should be obtained by the nurse prior to nursing care procedures whenever the needs of the patient warrant a meaningful decision-making discussion (Aveyard, 2002), or whenever the procedure invades the integrity of the patient’s body (NYS PHL § 2805-d (1), (2)). Nurses should not assume that only major surgical or diagnostic procedures, or procedures that may present significant risk to the patient, can threaten autonomy. Neither should nurses assume that all nursing interventions are covered by the general consent signed by the patient upon admission to the hospital. Rather, nurses should approach all aspects of nursing care with the intention of informing patients about the proposed treatment or procedure to the level required by them to make meaningful decisions about the care and to preserve patient autonomy.

The concept of informed consent is comprised of several analytic components: disclosure of information, capacity to make healthcare decisions, comprehension of information, voluntariness to participate in the treatment or procedure, and furnishing the actual consent.

Disclosure of Adequate Information

For consent to be informed, the provider (including nurses) of the treatment or procedure [emphasis added] must disclose information that includes: (1) the nature and type treatment or procedure that is proposed, (2) the reason for the treatment or procedure, (3) the risks and benefits of the proposed treatment or procedure, (4) alternatives to the treatment or procedure that is proposed, (5) the risks and benefits of all alternative treatments or procedures, (6) what would be the likely results if the patient chooses to withhold all treatments or procedures (Shah et al., 2022), (7) the percentage of chance that the risk might occur regarding all proposed and alternative treatments or procedures, and (8) how the risks for each proposed and alternative treatments and procedures are likely to happen (Nisenholtz v. Mount Sinai Hospital, 483 N.Y.S.2d 568, 1984).

There are three acceptable legal approaches to the question of whether the information disclosed facilitated adequate informed consent. They are the: (1) Subjective standard: What would this patient need to know and understand to make an informed decision? (2) Reasonable patient standard: What would the average patient need to know to be an informed participant in the decision? (3) Reasonable physician standard: What

would a typical physician say about this procedure? In accordance with NYS PHL § 2805-d (1), healthcare practitioners in New York must adhere to all three standards—what the reasonably prudent practitioner would say about the procedure or treatment after assessing what the patient (in accordance with their age, level of education, knowledge, skills and training, and anxiety level) would want to know or need to know in order to make an informed decision.

Capacity to make Healthcare Decisions

For consent to be valid, the patient must have capacity to consent (a legal standard) and have decision-making capacity (an individual standard). Legal capacity under New York State law is presumed to be present unless a court has appointed a legal guardian to make healthcare decisions or a physician has examined the patient and declared the patient currently incapacitated. More specifically, persons who have legal capacity to consent to procedures and treatment under law include: (1) any person 18 years of age or older, (2) any person who is the parent of a child, (3) any person who is married, (4) any person who is pregnant and is consenting to prenatal care, (5) any person who is married or who has borne a child and is consenting to a treatment or procedure for their child, and (6) any person who is 16 years of age or older and is living independently (NYS PHL § 2504).

Decision-making capacity is the ability to understand and appreciate the nature and consequences of proposed treatment or procedure. If a patient loses capacity to make a decision, but made a decision in the past about the proposed health care, the nurse can act based on the patient’s previously made decision. If there is good reason to believe the patient currently lacks capacity, a doctor must make and confirm the determination following an examination.

If the patient has a healthcare proxy, the healthcare agent named in the proxy makes decisions for those patients who have lost capacity. If a patient does not have a healthcare proxy, a court appointed legal guardian, or the person highest in priority from the surrogate list, (known as “the surrogate”) makes the decisions. The persons with the highest to the lowest priority on the surrogate list are as follows: (1) the spouse, if not legally separated from the patient, or the domestic partner; (2) a son or daughter 18 or older; (3) a parent; (4) a brother or sister 18 or older; and (5) a close friend. If a surrogate highest in priority is not available to make the decision, the next available surrogate who is highest in priority makes the decision (NYS DOH, 2018).

Every patient has the right to withhold (not start) or withdraw (start and then stop) any treatment or procedure under New York State law. Agents named under a healthcare proxy have the same right as the patient. However, legal guardians and surrogates do not. A legal guardian or surrogate can only demand a withholding or withdrawing of treatment if:

• The treatment would be an extraordinary burden to the patient and:

 the patient has an illness or injury which can be expected to cause death within six months, whether or not treatment is provided; or

 the patient is permanently unconscious; or

• The provision of treatment would involve such pain, suffering or other burden that it would reasonably be deemed inhumane or

extraordinarily burdensome under the circumstances and the patient has an irreversible or incurable condition.

Comprehension of Information

For consent to be valid, the patient must fully understand both the information which has been given and the implications of giving their consent. The patient (or alternative decision-maker) must be able to explain:

(1) the physical or mental condition needing treatment; (2) the type of treatment or procedure proposed; (3) the purpose of the treatment or procedure; (4) the advantages to submitting to the treatment or procedure;

(5) the risk to health or life that submitting to the treatment or procedure may impose; (6) the risk involved if they do not submit to the treatment or procedure; (7) the available alternatives to the proposed treatment or procedure; (8) the risks and advantages involved in those alternatives; (9) the percentage of chance that the risk might occur with each treatment or procedure; and (10) how the risks associated with each treatment or procedure might occur.

Simply providing the requisite information does not satisfy the informed consent criteria regarding comprehension of information. Healthcare providers must be assured that the information imparted was actually understood. For those patients who need interpreter services, 10 NYCRR §405.7(a)(7) requires all hospitals to develop a Language Assistance Program to ensure meaningful access to the hospital’s interpreter services and reasonable accommodation for all patients who require language assistance services. One proviso that nurses should remember is that family members, friends, or non-hospital personnel may not act as interpreters, unless:

(a) the patient agrees to their use;

(b) free interpreter services have been offered by the hospital and refused; and

(c) issues of age, competency, confidentiality, or conflicts of interest are taken into account. Any individual acting as an interpreter should be 16 years of age or older; individuals younger than 16 years of age should only be used in emergent circumstances and their use documented in the medical record.

Voluntariness to Participate in Treatment or Procedure

To limit deception and coercion, the patient must voluntarily submit to the proposed treatment or procedure without undue influence from someone who might seek to alter the patient’s decision according to a different set of values. The New York State Board of Regents Rules, Part 29.1(b)(2) enumerates behaviors that constitute unprofessional conduct including, but not limited to “exercising undue influence on the patient or client, including the promotion of the sale of services, goods, appliances or drugs in such manner as to exploit the patient or client for the financial gain of the practitioner or of a third party.” In any one of the following circumstances, a patient’s autonomy would be threatened and therefore, any informed consent obtained under these situations would not be considered valid:

 accepting as a patient anyone with whom you have had a prior sexual relationship;

 forming a sexual relationship with a current or former patient;

 treating patients to whom you are related by blood or legal ties;

 bartering with patients for the provision of services;

 referring patients to services in which you have a financial relationship, without disclosing that you may stand to benefit financially from their use of the service; and

 entering into financial relationships with patients other than their paying for your professional services.

Furnishing the Actual Consent

For many years, most nurses were of the opinion that the role of the nurse in the informed consent process was restricted to two limited functions: (1) to witness a patient’s signature on the informed consent document, thus verifying that it was the actual patient who signed the document; and (2) to communicate to the physician or other provider of surgical or research treatment or procedure that the patient has further questions (the advocacy role). However, one factor that strongly influences the nurse’s new position in contemporary practice regarding the informed consent process is the continually developing scope of nursing practice itself resulting from the expansion of nursing responsibilities and increasing accountability in nursing functions (Rosse & Krebs, 1999). As indicated in NYS Public Health Law §2805-d (1), a patient can bring an action against the “person providing the professional treatment or diagnosis” [emphasis added] for failure to provide informed consent. Thus, nurses who are the provider of a nursing treatment that could foreseeably result in a patient refusing that type of treatment should accept the ethical and legal obligation to obtain informed consent from the patient (Wilkenfeld & Campbell, 2021). Table 1 enumerates some of the nursing functions that might require informed consent.

It is well understood that consent does not always need to be obtained using a document, signed by the patient, and that there are occasions when consent can be verbal or implied. What is important is that the patient has sufficient understanding of all intended treatments and procedures, including nursing treatments and procedures, and has the opportunity to raise any questions and/or objection to the care that is proposed (Aveyand et al., 2022). Nevertheless, best practices and evidence support the notion that all informed consents should be documented in the patient medical record via a narrative note or a document consistent with the hospital’s policies and procedures.

There are occasions when informed consent need not be obtained in accordance with law and usual and customary practices. Those occasions include:

1. In an emergency (See New York State Public Health Law § 2805-d (2));

2. When the procedure is likely to be continuous over the course of the hospital stay (i.e.: taking a BP, pulse, tympanic temperature) (See New York State Public Health Law § 2805-d (2));

3. The risk is obvious to most people (See New York State Public Health Law § 2805-d (4)(a));

4. The patient tells you they agree to the treatment without the need for a discussion (See New York State Public Health Law § 2805-d (4)(b));

5. The patient tells you they do not want to hear any of the risks or alternatives (See New York State Public Health Law § 2805-d (4)(b));

Informed Consent: A Patient’s Right to Information and a Nurse’s Legal and Ethical Obligation

Table 1

Types of Nursing Interventions: Best Practices Require Informed Consent*

Physical assessment

Verbal, admission consent

Taking blood Informed consent

IV therapy Informed consent

Radiography tests Informed consent

Inserting Foley catheter Informed consent

Inserting nasogastric tube Informed consent

Blood transfusion Informed consent

Starting oxytocin Informed consent

Giving an enema

Medication administration

Wound care

Dietary decisions

Injections

Immunizations

Informed consent

Informed consent

Informed consent

Verbal, medical record narrative note

Informed consent

Informed consent

Needle biopsy Informed consent

Suctioning

Dietary changes

Informed consent

Verbal, medical record narrative note

Administration of oxygen Verbal, medical record narrative note

Restraints

Isolation protocol

Pap Smear

Turning and/or positioning

Application of internal fetal monitor

Application of external fetal monitor

Irrigations

Suturing

Central line care

Glucose monitoring via fingerstick

Rectal temperature

Axillary, tympanic temperature

Urine collection

Dressing changes

Informed consent

Implied consent

Verbal, medical record narrative note

Verbal, admission consent, medical record narrative note

Informed consent

Verbal, admission consent

Verbal, medical record narrative note

Informed consent

Verbal, admission consent, medical record narrative note

Verbal, admission consent, medical record narrative note

Verbal, admission consent, medical record narrative note

Verbal, admission consent, medical record narrative note

Verbal, medical record narrative note

Verbal, medical record narrative note

Traction Verbal, admission consent, medical record narrative note

Massage therapy Verbal, medical record narrative note

Information about medical condition Informed consent

Kristeller maneuver

Episiotomy

Mechanically assisted birth

*Note. This is not an all-inclusive list.

Informed consent

Informed consent

Informed consent

6. The patient is currently incapacitated or is legally incompetent and there is no access to an agent or surrogate (See New York State Public Health Law § 2805-d (4)(c));

7. The nurse determines that a particular piece of information would be too much for this patient, taking into consideration the nature of the nurse-patient relationship, the patient’s previous behavior, the comfort level of the patient asking questions and admitting unfamiliarity of information, or any information that, in the nurse’s expert opinion, would likely adversely and substantially affect the patient’s current condition (See New York State Public Health Law § 2805-d (4)(d)).

Implications for Nursing Practice

The practice and provision of informed consent is time consuming, complex, and challenging. Indeed, the literature is replete with views that the informed consent process is culturally biased, legalistic, ritualistic, and unevenly enforced (Menendez, 2013). Nurses facilitating the informed consent process should remember that informed consent is simply the ethical and practical practice of showing respect for patients and their opinions and ways of being, knowing, and thinking.

Ensuring patient comprehension, addressing patient anxiety, identifying appropriate surrogate decision-makers when needed, advocating for the patient, and documentation are integral aspects of diagnosing patient issues, planning, intervention, evaluating care, health teaching, and health counseling of patients. Nurses who recognize that the informed consent process is an opportunity to exchange important information upon which a patient or surrogate can make autonomous, self-directed, patient-centered, crucial, and culturally appropriate healthcare choices can fully comply with their moral, legal, and ethical obligations to their patients.

Contemporary healthcare ethics rejects the old paternalistic approach to the informed consent process. Nurses are at the forefront of patient-

Nurses who are enlightened about the informed consent process can contribute meaningfully to the healthcare team.

provider interactions and advocacy and as a group are continuously rated as one of the most respected healthcare providers, which puts them in the best position to recognize when patients are genuinely informed and are not being coerced into submitting to an unwanted or misunderstood treatment or procedure.

Conclusion

The legal and ethical requirement to obtain a patient’s informed consent is significantly relevant to nursing practice and care. The principles, processes, and procedures of informed consent should underlie a nurse’s approach to all nursing care procedures. Informed consent should not be a limited, automatous process that is only relevant to surgical or research procedures, but rather a way of facilitating a patient’s meaningful decisionmaking in all aspects of treatment and care.

While exercising their important role as patient advocate, nurses who are enlightened about the informed consent process can contribute meaningfully to the healthcare team, the patient-provider relationship, and the process to elevate informed consent from a simple, ritualistic, legal document to a way of ensuring meaningful shared decision-making, autonomy, and self-determination.

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Menendez, J. B. (2013, October–December). Informed consent: Essential legal and ethical principles for nurses. JONAS Healthcare Law, Ethics and Regulation, 15(4), 140–144; quiz 145–146. https://doi. org/10.1097/NHL.0000000000000015

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Strini, V., Schiavolin, R., & Prendin, A. (2021, July). The role of the nurse in informed consent to treatments: An observational-descriptive study in the Padua Hospital. Clinical Practice, 11(3), 472–483. https://doi. org/10.3390/clinpract11030063

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Caring for the Caregiver: Implementation of a mindfulness Program for mental Health Providers in an outpatient Clinic

Hermanuella Hyppolite, DNP, PMHNP-BC, CARN

n Abstract

Background/Purpose: Mindfulness-based cognitive therapy (MBCT) is an effective method to treat anxiety and depression. Anxiety impacts physical and mental health, reduces cognitive performance, and causes memory and attention impairment—even in mental health providers. The objectives of this quality improvement (QI) project were to implement a mindfulness-based training program, assess how mindfulness may be used to improve anxiety and memory of mental health providers, and identify if participants will integrate mindfulness as an adjunct to therapy and or medication to diversify available clinical techniques and individualize treatment.

Theoretical Framework: The Mindfulness-to-Meaning Theory (MMT) guided this project.

Literature Review: Mindfulness can reduce anxiety for people with anxiety and mood disorders. Mindfulness training can enable people to engage in helpful activities to minimize distress. The review of literature also highlights that mindfulness can improve individuals’ working memory capacity.

Methods: This was an evidenced-based, single-group, pre-/post-test design. The setting was an outpatient mental health clinic on Long Island, New York. A purposeful sample of 10 mental health providers participated in the 4-week program. Prior to and at the completion of the mindfulness program, participants completed the Generalized Anxiety Disorder 7 (GAD-7) screen, the Mindful Attention Awareness Scale (MAAS), and memory test, as well as a post-program evaluation. One month post-intervention, a survey to assess if participants incorporated mindfulness into their daily practice with patients and their families was completed.

Results: There was a mean 8-point reduction in levels of anxiety, 3-point increase in memory tests scores, and a 4-point increase in the level of mindfulness. These results were statistically significant with paired sample T-test on the GAD-7, MAAS, and memory test scores, p = < .0001. Participants also integrated mindfulness as an adjunct to therapy in their patients.

Conclusion and Implications: The results were promising in this small sample and point to the importance of mindfulness training for healthcare providers. Mindfulness can effectively manage anxiety and improve memory retention in both providers and their patients.

Recommendations: Mindfulness and other self-care programs can be added into the workplace as part of wellness activities that will benefit the staff and their patients long term.

Keywords: Anxiety, depression, memory, mindfulness

Hermanuella Hyppolite, DNP, PMHNP-BC, CARN Statewide Peer Assistance for Nurses, New York, New York

Introduction background

Anxiety and mood disorders are some of the most common psychiatric disorders diagnosed today, each being distinctive in their symptomology and treatment. Individuals with anxiety disorders are characterized by intense, persistent, and excessive worry and fears. In addition, patients with anxiety disorders often encounter repeated panic attacks that entail recurrent episodes of sudden and intense anxiety or feelings of fear that quickly peak (Eser et al., 2018). On the other hand, mood disorders encompass both depression and bipolar disorders. This includes major depression that leads to loss of interest in everyday activities, feelings of sadness, and hopelessness, among other symptoms (Frey et al., 2020). According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), for an individual to be diagnosed with clinical depression, they must experience five of the following symptoms lasting for two weeks and leading to significant impairment in their occupational or social functioning. These symptoms also are present without any medical conditions or a diagnosis of substance use disorder: depressed mood most of the day, nearly every day; loss of interest in previously enjoyable activities; change in appetite leading to unintentional weight gain or weight loss; psychomotor agitation or retardation; fatigue or loss of energy nearly every day; feelings of worthlessness or excessive or inappropriate guilt almost every day; poor concentration and indecisiveness; and recurrent suicidal thoughts, plan, or acts.

Mood disorders also include dysthymia, which involves chronic, depressed, and irritable moods that last for several years. Bipolar disorders are mood disorders in which patients encounter periods of depression that alternate with periods of elevated moods or mania (American Psychiatric Association [APA], 2013).

Previous research has established increased comorbidity of anxiety and mood disorders. Anxiety disorder is a common mental health condition that affects approximately 40 million adults in the United States (Eser et al., 2018). Anxiety accounts for 18.1% of the U.S. population every year. While anxiety disorders can be treated, data shows that only 36.9% of people suffering from the disorder receive treatment (Eser et al., 2018). Furthermore, patients with anxiety disorders are six times more likely to be hospitalized than those without anxiety. The complex risk factors of anxiety disorders such as genetic factors, brain chemistry, life experiences, and personality make anxiety a common psychiatric condition. The comorbidity of anxiety and mood disorders has been established. It is common for people with anxiety to suffer from depression associated with increased symptom severity and a high likelihood of suicidal ideations (Eser et al., 2018). Mood disorders and anxiety are accountable for significant causes of disability in the United States. About 26.0% or about 1 in 4 American adults are diagnosed with a mental disorder each year, with many people suffering from more than one psychiatric condition, including anxiety and depression, at any given time (Frey et al., 2020). These psychiatric conditions have significant effects on both physical and mental health. Various studies have shown that individuals diagnosed with mental illnesses such as anxiety and depression have a lower life expectancy of more than 13 years when compared to the general population, and a greater risk of developing cardiovascular disease.

Mental health is a fundamental component of health linked to individual and family well-being. The pervasiveness of mental disorders, particularly anxiety and mood disorders, has imposed an enormous health burden due

to the high degree of suffering caused to patients and families (Burrone et al., 2020). Anxiety prevalence is 18.1% compared to mood disorders, accounting for 9.5% of the population. It is estimated that psychiatric mental disorders are a leading cause of disability worldwide (Burrone et al., 2020). Specifically, anxiety and mood disorders significantly contribute to a global disability, with depression and anxiety being the third and the ninth leading causes of years lived with disability, respectively (Frey et al., 2020).

Anxiety and mood disorders have significant economic implications, with approximately $317 million being spent treating mental health illnesses in the United States. The costs of treating mental health illnesses are related to direct and indirect costs associated with disability and lack of productivity (Frey et al., 2020). Moreover, major depressive disorders are linked to severe and persistent health conditions and have been established as significant risk factors for cardiovascular morbidity and mortality (Frey et al., 2020). Individuals with anxiety and mood disorders have reduced quality of life for symptomatic and non-symptomatic periods (Frey et al., 2020). In addition, anxiety and mood disorders have significant long-term effects on cognition and functioning. There is strong research consensus to suggest that anxiety and mood disorders contribute to difficulties in focusing on work or other tasks and the ability of individuals to think clearly (Frey et al., 2020). Moreover, anxiety can lead to poor memory, while mood disorders are associated with short-term memory loss. Therefore, patients suffering from anxiety and mood disorders can have difficulties retaining information or remembering essential critical details for performing routine activities and daily tasks.

History of mindfulness

The term “mindfulness” has been continually used over the years to refer to the state of psychological self-awareness, practices which promote awareness, a mode for processing information, and a character trait. It refers to the process of sustained attention and understanding toward present moment sensations and awareness with a nonjudgmental attitude and stance. Mindfulness is an evidence-based therapy borrowed from Buddhist and yoga-based practices. It can be defined as a process that results in a mental state characterized by paying attention to the current moment and experience, including thoughts, body state, sensations, consciousness, and the environment (Rodrigues et al., 2017). Mindfulness involves being attentive purposely, open-mindedly, and particularly to the present moment. It is conceptualized as a two-component concept involving self-regulation of the awareness of the encounters of the current moment and adopting an orientation to accept and be open to one’s experiences (Shapero et al., 2018). Thus, mindfulness emphasizes skills to improve intentional awareness to develop and maintain a particular relationship with one’s thoughts and mainly practice ways to address distressing emotions and thoughts.

Mindfulness is associated with psychotherapeutic practices such as mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR) programs. This process has become a standard treatment intervention in contemporary psychotherapy to offer intensive meditation therapy to help people with psychosocial conditions such as pain, stress, anxiety, and depression (Shapero et al., 2018). Mindfulness in psychology is considered one of the most effective ways to ensure that patients get the chance to experience pleasure, wisdom, and connectedness. Experts believe that if practiced effectively and adequately, it may play an essential role in

improving the mental and physical health of the patient. Mindfulness-based therapy has been adopted through experiential practices and exercises in which individuals learn to disengage from previous thoughts by developing meta-awareness (Shapero et al., 2018). The application of mindfulnessbased therapy has found widespread application. On some occasions, mindfulness-based therapy has been used to prevent relapse rather than reduce acute symptoms. In other cases, mindfulness has been used as a symptom-focused therapy to relieve acute symptoms during treatment. Thus, it is imperative to explore how mindfulness can reduce anxiety and retain information for individuals with anxiety and mood disorders.

Mindfulness-based therapy has been suggested as a potential intervention to mediate memory function and improve information retention among patients suffering from anxiety and mood disorders. Research indicates that these psychosocial interventions can help reduce anxiety and mood disorders such as depression (Rodrigues et al., 2017; Shapero et al., 2018). By learning how to respond and adapt to stress and being aware of what is happening in the present moment, patients can be taught to address their physical and mental states to reduce their psychiatric symptoms and improve their cognitive functioning (Shapero et al., 2018). However, the effectiveness of mindfulness-based therapy in reducing anxiety and improving information retention is poorly understood, and research is warranted to inform the use of this intervention.

Significance of Clinical Problem

Anxiety and mood disorders are common psychiatric conditions with significant physical and mental health impacts on patients and their families. Anxiety and mood disorders are among the leading causes of disability and impose a substantial economic burden on patients—and healthcare providers are not immune. Among the many impacts of anxiety and mood disorders are reduced cognitive performance and impaired attention and memory that may affect a provider’s ability to retain or remember important information needed to perform daily and routine activities and tasks. Conversely, increasing research suggests that mindfulness-based therapy can help reduce anxiety symptoms, boost memory, and improve information retention (Rodrigues et al., 2017; Shapero et al., 2018). This evidence-based project will help establish evidence of the use of mindfulness to reduce anxiety and improve cognitive function.

Purpose

The intention is to addressing the health and well-being of providers, and better understand whether effective and supportive healthcare team members ultimately provide better patient care and are more present with patients and families, and if this in turn leads to better patient outcomes. Furthermore, consistent with the aim of this research, finding an appropriate solution for addressing memory and information retention can help patients improve the cognitive functioning necessary to maintain daily and routine activities and other tasks. This is relevant in providing an evidence-based intervention in mental health practice. This study contributes to an increased understanding of the benefits of mindfulnessbased therapy in managing anxiety disorders and improving information retention. This information is helpful to mental health practitioners in improving their practice in the treatment of patients with psychiatric conditions.

Clinical Questions

To guide the evidence, search a PICOT question was developed. For this search, the PICOT question is: In (P) mental health providers, does (I) mindfulness training compared to (C) no training (O) influence anxiety and information retention over a (T) two-month period? Clinical questions are:

1. In mental health providers, does mindfulness training compared to no training influence anxiety and information retention over a two-month period?

2. Will participants integrate mindfulness as an adjunct to therapy and or medication in order to diversify available clinical techniques and individualize treatment?

Project Aims

This evidence-based practice (EBP), single-group, pre-/post-test design research project aims to implement a mindfulness-based training program that will improve symptoms of anxiety and mood disorders and improve memory retention in mental health providers.

review of literature Search Strategy

The search strategy for the articles for the literature review encompassed the currency, relevance, authority, accuracy, and purpose (CRAAP) criterion (Lenker, 2017).

Overall, the inclusion criteria encompassed primary articles published in the last decade that addressed mindfulness and how it reduces anxiety and improves information retention. Articles that did not contain relevant information on mindfulness were eliminated. It is imperative to highlight that the search process yielded 41 articles. The abstracts and titles of the articles were then screened to make sure that only articles with detailed information about the topic were picked. After screening, ten articles were selected. The themes of the articles included anxiety and mood disorders, mindfulness training, information retention, and anxiety reduction.

Information retention

Evidence from studies conducted over the years shows that mindfulness helps activate the brain area vital to executive function and attention. Improved control of attention has also been identified as an essential factor in improving patients’ quality of life with anxiety and depression (McComb et al., 2003). This skill helps guarantee that the individual focuses better on their present task, rather than constantly being distracted by worry or anxiety or their state of depression.

evidence from studies conducted over the years shows that mindfulness helps activate the brain area vital to executive function and attention.

The study by Sevinc et al. (2019) explored the impact of mindfulness training on the strengthening of hippocampal circuit underlies. The authors explained that the hippocampus helps with recall extinction, which is the gradual inability to recall information. Despite this role being well recognized, the authors noted that little research had been conducted to understand how hippocampal network changes induced by interventions helped enhance extinction learning. Sevinc et al. (2019) hypothesized that mindfulness training was a precursor to heightened awareness and attention. This reduces anxiety symptoms, enhances emotion regulation, and improves learning. Mindfulness training is associated with hippocampalcortical reorganization. Mindfulness training also facilitates the primary sensory cortex’s hippocampal connectivity for enhanced extinguished stimuli retrieval (Sevinc et al., 2019). Based on the findings, the article can build the foundation of research on mindfulness’s impact on information retention and anxiety reduction.

The research by Quach et al. (2016) was based on a randomized controlled trial (RCT), and it was used to evaluate mindfulness meditation effects on individuals’ working memory capacity. Working memory capacity is involved in reading comprehension, language, mathematical problem-solving, and reasoning ability, among other processes. The authors highlighted that brief mindfulness training positively impacts standardized test scores, mind wandering, and working memory capacity. For this particular study, the authors used a wait-list control group, hatha yoga, and mindfulness meditation practices for comparison (Quach et al., 2016). The participants were to complete self-reports and computerized measures to help understand their anxiety and stress levels before and after the intervention. It was established that mindfulness meditation played a crucial role in improving individuals’ working memory capacities. Quach et al. (2016) noted that most researchers discuss the general benefits of mindfulness, such as improving psychological and physical functioning.

However, the study failed to emphasize specific benefits that individuals could gain from particular mindfulness practices. For example, mindfulness’s effect on working memory among older adults is unexplored in modern research studies. There is a research gap regarding specific mindfulness practices that enhance working memory capacity more than others. Working memory is considered a mental building block for information retention, comprehension, and reasoning. The article examines how mindfulness practices can help people’s brains shift information stored in short-term memory to long-term memory.

Impact on mental Illness

The relationship between mindfulness and patients with schizophrenia spectrum disorders (SSD) has been explored. Bergmann et al. (2021) looked at the relationship between mindfulness and quality of life, anxiety, and depression for people with SSD. People with SSD were chosen as study participants since they experience comorbid anxiety and depressive symptoms, which mindfulness aims to eliminate or reduce. Individuals with SSD also experience affective symptoms and cognitive dysfunctions. They may also experience disorganized thinking, hallucinations, and delusions. Mindfulness is hypothesized to improve psychosocial and cognitive functioning. With this in mind, mindfulness training can be a game changer in reducing depressive symptoms linked to SSD and enhancing the quality of life for patients.

The study by Bartels-Velthuis et al. (2016) conducted mindfulnessbased training for psychiatric outpatients. The goal was to enable them to live with compassion. The research developed a new compassion-based training dubbed the Mindfulness-Based Compassionate Living (MBCL). This training program helped examine changes in compassion, mindfulness, anxiety, and depression when used for populations in a heterogeneous psychiatric outpatient setting. Unlike other studies that do not specify the duration of mindfulness training, the research by Bartels-Velthuis et al. (2016) focused on 2.5-hour sessions weekly. These sessions were conducted for nine consecutive weeks to facilitate the examination of MBCL on stress, compassion, and anxiety levels among patients. However, despite specificity in the duration of the training, the research has research gaps and limitations. For instance, the study is based on a small sample size, making the results nonrepresentative of all psychiatric outpatients. The study also had no control group, making any comparison of the novel MBCL challenging to achieve.

Machado et al. (2020) focused on linking mindfulness to outpatient substance abuse disorder treatment in another patient population. The researchers focused on symptoms of anger, anxiety, and depression and substance use behavior. However, for this particular research, the focus is on the impact of a mindfulness-based intervention on anxiety symptoms. Mindfulness is a promising non-pharmacological treatment intervention for substance use disorders. Specifically, its ability to enable patients to acquire nonjudgmental, kind, and curious attributes makes it a promising candidate for anxiety reduction (Machado et al., 2020). Hence, the study aimed to explore and understand how mindfulness-based interventions work to achieve the ultimate goal of anxiety reduction. The study can be used for further research, as it provides foundational knowledge on mindfulness and how it helps to reduce anxiety.

Mindfulness therapy for anxiety and depression is also essential in regulating emotions, which improves an individual’s quality of life. Emotional regulation plays a critical role in improving depression and anxiety symptoms. Common symptoms usually reduced from mindfulness practice include rumination, non-acceptance, worry, and reappraisal. This perspective is based on the general understanding that emotional regulation through mindfulness helps stimulate mental health. Emotional regulation refers to how individuals temper their emotions in response to the different environmental factors likely to impact their feelings. It aims to guarantee that a person can better handle challenges they encounter, which might negatively impact their emotions. The evidence primarily supports the idea that mindfulness helps in the regulation of the negative emotions that are associated with anxiety. Studies also show that rumination is a crucial contributor to anxiety, mainly due to repetitive negative thoughts about the future (Immink, 2016). Many patients with anxiety and depression are likely to engage in negative repetitive thoughts about the past and the future consequences of their actions.

Studies show that individuals with recurrent depression are especially vulnerable to depressogenic cognitions (Williams et al., 2018). The main implication of this is that, in most cases, stressful events that one may encounter through life can trigger negative thinking that impacts the patient’s mental well-being. The individual may show signs of worry, selfcriticism, and rumination, which affects the likelihood of depressive relapse. The focus of MBCT will be on identifying these negative thinking patterns, which will prove to be the most effective approach in determining the

the Caregiver: Implementation of a Mindfulness Program for Mental Health Providers in an Outpatient Clinic

specific issues affecting the individual and thereby impacting the outcome of the entire therapy process.

Ultimately, mindfulness helps in improving concrete critical thinking and self-questioning, which all form an essential part of reducing anxiety and depression symptoms.

Physical Health

Mindfulness plays an essential role in changing one’s perception of themselves and teaches that nothing in this life is static or permanent. This also applies to one’s current medical condition. It also helps change someone’s perspective on the different issues they may encounter throughout life (Hedman et al., 2014). A few months of meditation will effectively increase the self-esteem and self-acceptance of the patient. Finally, there is also the public benefit that comes with improving the individual’s physical health. Evidence from studies conducted over the past few years has shown that one of the health benefits of practicing mindfulness is that it helps reduce blood pressure and cortisol levels. Based on this understanding, it is vital to consider recommending mindfulness practice and meditation to reduce the stress levels that anxiety and depressed patients may be dealing with.

According to Barratt (2017), people with chronic diseases require compassionate care to help them improve outcomes. Without compassionate care, individuals with chronic conditions are likely to exhibit adverse psychosocial effects, with high stress levels among them. Barratt (2017) explained that self-compassion and mindfulness practices had been found to improve individual well-being. Furthermore, it helps to enhance resilience among students and professionals in the healthcare environment. The authors suggested that healthcare professionals practice mindfulness to improve their health and well-being. Mindfulness can also enhance the productivity needed to provide holistic care for patients, leading to improved psychological and physical health outcomes. Further studies will be required to establish a connection between mindfulness, compassionate care, and reduced stress among healthcare stakeholders such as patients and professionals.

Neurology is also an essential part of MBCT interventions in treating anxiety and depression and has been analyzed over the years through brain imaging studies which are both structural and functional. The structural aspect aims to show brain imaging, which will help show how the brain reacts to different stimuli introduced (Collins & Wamsley, 2020). The imaging also shows the impact of long-term meditation on brain mechanisms, which has a vital role in determining whether it is relevant in helping patients with anxiety and depression. Some of the possible brain regions likely to be affected by meditation and mindfulness include memory consolidation, brain awareness, and emotion regulation. These ideas support the need for mindfulness practices in helping patients dealing with anxiety and depression possibly change their brain patterns for the better.

Calm Application

A study by Huberty et al. (2019) explored the effect of Calm, a mindful meditation mobile application, on reducing stress among college students. The authors based their study on the fact that most college students often

experience high levels of stress due to academic workload and study-work balance. The goal of the study was to see if the Calm app was effective in managing anxiety. A randomized control trial involved a group of selected students to the experimental group, which involved the use of the app for 8 weeks. The control group was treated with mindfulness sessions on mindfulness, stress, and self-compassion. The outcome of the application was measured by observing the health outcomes among the participants, which included alcohol consumption, sleep disturbance, healthy eating, and physical activity. Other outcomes observed included the acceptability and feasibility of the application.

Data was collected prior to initiating the study, at the end of the intervention at the eight weeks, and four weeks after the intervention was over. The third data collection was essentially a follow-up to examine whether the effectiveness of the intervention persisted after the experiment. The intervention was done through a 10-minute meditation every day. The eligibility criteria of the students were that they were full-time, were 18 years and over, willing to be randomized, and were English speakers.

A total of 88 participants were included in the study. Comparing the pre- and post-intervention data, the study found a significant difference in all the outcomes: self-compassion, stress, and mindfulness (P < 0.04). The results further indicated that the outcomes persisted at follow-up, pointing to evidence that the Calm application has a prolonged effect on the users.

Huberty et al. (2021) conducted another study to explore how the use of the Calm application influenced the users’ sleep quality and mental health. The authors posited that despite adequate evidence on the effectiveness of the application, there is limited evidence regarding its impact on sleep quality. They also claimed that lack of adequate sleep or sleep disturbance is one of the most notable or observable features of patients suffering from mental health disorders such as anxiety and depression. Half of the participants recruited for the study indicated that they had experienced episodes of sleep disturbance and/or mental health issues. The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality among the participants. In addition to sleep quality, the questionnaire captured information on other mental health issues, including depression, anxiety, and post-traumatic stress disorder (PTSD). The results indicated that an overwhelming majority of participants associated the use of the application with ease in falling asleep, staying asleep, and having a restful sleep. The study found that the use of the application was associated with improvement in all aspects of sleep disturbance. For participants who had mental health problems, the results indicated that a majority of participants reported that the use of the application helped them improve symptoms of depression and anxiety.

Professional Impact

Darby and Beavan (2016) investigated mindfulness-integrated cognitive behavior therapy (MiCBT) to determine how it helps professionals provide the best care to patients with chronic mental illnesses. Mindfulness training enables healthcare professionals to improve patients’ well-being and health by reducing stress. It also helps healthcare professionals to enhance their clinical skills for improved psychosocial care. The most commonly used mindfulness training programs in the healthcare profession include MBSR and MBCT. Mindfulness training has shown numerous benefits for healthcare professionals. These benefits include increased empathy and

self-compassion, enhanced well-being, and a sense of shared humanity. One particular research gap identified in this study is the lack of knowledge and literature about the modalities of MiCBT despite being widely practiced in North America, Europe, and Australia (Darby & Beavan, 2016). Mindfulnessbased treatment also helps enhance the level of compassion that therapists have toward their patients and the emotions they may be going through. Compassion in this context implies that the therapist is more likely to listen to what the patient has to say in a nonjudgmental and nonreactive way, which helps patients feel better about sharing more information about their conditions. Compassion is vital to improving the quality of the relationship between patient and therapist, and thereby improving the likelihood of better patient outcomes in the long term. Mindfulness practice also the probability of therapists improving their counseling skills, and thus positively impacting patient outcomes.

Darby and Beavan (2016) highlighted that healthcare professionals experience many challenges in their careers. Most healthcare professionals report drowsiness, intrusive thoughts, and anxiety, which jeopardize the quality of care given to patients. As a result, patients experience adverse health outcomes, such as increased stress levels and deterioration of their physical conditions. With MiCBT, challenges facing healthcare professionals can be eliminated or reduced. Specifically, the focus of the research is how MiCBT is linked to reduced stress levels among healthcare professionals. The knowledge acquired is instrumental in examining mindfulness as a prelude to decreased anxiety and improvement of information retention.

Song and Lindquist (2015) pointed out that nursing students experience psychological challenges such as stress, anxiety, and depression. The identified research gap is that there is little evidence of the effectiveness of MBSR for nursing students. Mindfulness is considered an already existing internal resource among people who await “reawakening,” or becoming mindful of life by learning to experience it fully in the present (Song & Lindquist, 2015). For this reason, the use of MBSR, if integrated and practiced by nursing students, can help to improve both academic performance and future nursing practice. MBSR acts as an alternative treatment for depressive disorder and comorbid anxiety symptoms. In addition to using MBSR for clinical populations, the program should also be extended to nursing students in order to help manage their stressful and demanding work and educational environment.

Song and Lindquist (2015) explained that anxiety is a common psychological issue among nursing students. Emotion-oriented coping mechanisms cause it. These mechanisms include, but are not limited to, fantasizing reactions, self-preoccupation, and emotional responses. Based on this revelation, the MBSR program strives to alleviate psychological issues by decreasing stress, anxiety, and depression—which are all interrelated. Since anxiety is a psychosocial factor, it directly impacts nursing students’ educational process and performance. Knowledge about the management of stress among nursing students is vital in healthcare for improved patient and health professional outcomes. Breedvelt et al. (2019) conducted a meta-analysis study on the impact of mindfulness, yoga, and meditation on psychological disorders among tertiary education students. Admittedly, Breedvelt et al. (2019) asserted that about 16% of tertiary education students have anxiety or mood disorders. These disorders are responsible for severe or moderate stress levels. Most universities depend on counseling and conventional medication to treat mental health problems among students. However, these methods have many challenges, such

as lack of awareness and the potential for stigma. Mindfulness teaching can help overcome the difficulties experienced in conventional treatment for anxiety. It is a self-administered practice that eliminates the possibility of stigmatization because it can be conducted privately. Additionally, mindfulness practices share spirituality and religion’s common therapeutic elements and principles. In this regard, their chances of being rejected by students are minimal.

The objectives of the research by Seidel et al. (2021) were to examine the short-term and long-term effects of a condensed mindfulness practice course intended for nurses and other healthcare workers on well-being, burnout, and mindful awareness. The study, which focused on the mindfulness practice course for healthcare providers, encompassed two phases: The first phase included a single-set pre- and post-test research design that adopted a model size of 25 nursing employees in an academic medical center, while the second was a randomized controlled experiment that encompassed 83 healthcare professionals. Both designs focused on the participants who studied mindfulness. The findings of the research by Seidel et al. (2021) demonstrated a significant rise in attentive awareness as well as a decrease in at least one measure affiliated with mental burnout. The nurses in the study reported that they experienced a general improvement in their quality of life. These findings affirmed the hypothesis set by the researchers, which sought to examine briefly how a mindfulness curriculum had a short-term and long-term impact on mindful awareness, quality of life, and features of burnout among healthcare practitioners (Seidel et al., 2021).

Mbachu (2020) suggests that the rate American healthcare personnel experiences burnout or depletion of their energy in the course of their career is a common instance that has been negatively influencing the costs of health care in the United States, and that healthcare burnout is a key factor in lower productivity and higher staff turnover rates. The objectives of Mbachu’s (2020) research was to ascertain whether or not the practice of mindfulness may help minimize mental states that result to burnout among psychiatric professionals. The outcomes of the t-test suggests statistical significance variance between the participants’ pre-intervention and postintervention burnout levels (Mbachu, 2020).

Gilmartin et al. (2017) examined the effect of mindfulness practice among healthcare professionals focusing on burnout. They determined that variables such as anxiety and depression through the development of nonjudgmental awareness, mindfulness, and tolerance of a given situation while concentrating one’s attention on that environment to be the key determiners of burnout. The authors tested a brief mindfulness intervention with hospital practitioners and measured change in well-being (for example, stress) or behavior (for example, duties of awareness or decline of diagnostic or clinical errors) that were selected for a summary of the findings. These studies were looked at to ascertain whether or not mindfulness can decrease clinical or diagnostic errors. Nine out of the 14 pieces of literature adopted in the study research indicated a significant reduction in anxiety and depression and an overall improvement in the providers’ mindfulness and endurance.

research Findings and Scholarly Project relationship

The existing literature reviewed provides foundational knowledge regarding the impact of mindfulness training on decreasing anxiety and

improving information retention among healthcare providers. The ROL helps establish the link between mindfulness, anxiety, and information retention. Specifically, this ROL has revealed that mindfulness training helps to enhance hippocampal connectivity in an individual’s primary sensory cortex. The ROL also highlights that mindfulness can improve individuals’ working memory capacity. Mindfulness is also helpful in eliminating cognitive dysfunctions, such as disorganized thinking, hallucinations, and delusions that affect the memory of patients who have schizophrenia. Furthermore, mindfulness can enhance individuals’ reading comprehension, reasoning ability, and analytical problem-solving skills (Machado et al., 2020).

It has also been established that mindfulness can reduce anxiety for people with anxiety and mood disorders. Mindfulness training can enable people to engage in helpful activities to minimize distress. It is also established that mindfulness facilitates compassionate care among people, which helps overcome adverse psychosocial outcomes such as high-stress levels and anxiety. It also helps people to be resilient and to enhance their psychological health (Darby & Beavan, 2016).

Addressing Research Gaps in Current Knowledge or Practice

The ROL has established many existing gaps in the literature as far as mindfulness, anxiety, and memory are concerned. For example, it has been revealed that there are inadequate studies on the mindfulness training process. Monshat et al. (2013) identified such a research gap in that most studies have focused on quantitative benefits associated with mindfulness, but have given little focus to the mindfulness training process. As a result, there is very little knowledge about how people, particularly youths, can engage with mindfulness practices and ideas. Without proper mindfulness training, the participants reported increased destructive activities that made them susceptible to anxiety. Participants enrolled in the mindfulness training said they experienced being in control, balanced, and calm (Monshat et al., 2013). Hence, mindfulness has the potential to restore confidence and help avert future distress. Despite the in-depth analysis of mindfulness, the article failed to specify the duration needed to reduce stress. Thus, mindfulness practice studies need to further explore the time required to achieve improved emotional regulation.

Another research gap is that there are no studies on specific mindfulness practices or activities to improve working memory capacity (Quach et al., 2016). In addition, no studies adequately show how to integrate cognitive behavioral therapy into mindfulness training (Darby & Beavan, 2016). Breedvelt et al. (2019) established the existence of low-quality studies on mindfulness and how they achieve anxiety reduction. The side effect of this is the lack of evidence-based decisions on mindfulness application to reduce anxiety and improve mental health in hospitals. Although it has been established that mindfulness can help reduce anxiety, further research will be needed to understand the best techniques to be adopted as evidence-based practices.

Seidel et al. (2021) found that a most mindfulness programs were not feasible for frontline healthcare personnel due to the requirement of extensive, off-site initial training and the continuous practice commitment required by these programs. The authors, therefore, had to condense a training curriculum specifically catered to suit healthcare practitioners.

Intended Impact of the ebP on Patient/Population

The EBP is aimed at directly impacting patient or population outcomes. With mindfulness training, patients will experience improved psychological well-being that is cost-effective. The comorbid risks of cardiovascular mortality and morbidity may also be reduced with the reduction of anxiety, leading to improved quality of life and productivity among patients. Over the years, mindfulness has received considerable attention in research, mainly due to the desirable effects associated with this treatment. Growing support for this form of therapy for anxiety and depression helps in explaining their incorporation into Western world medicine. Despite its short history in the field, mindfulness-based treatment has garnered a lot of support based on its effectiveness in treating psychiatric disorders such as depression and anxiety. These treatments help with the minimization of the symptoms associated with such disorders. Still, they have also been proven to help significantly improve individuals’ quality of life. With improved information retention due to mindfulness training, providers will also be better able to complete daily tasks, thus leading to enhanced productivity both at home and work and improvement in patient outcomes for their patients.

Conceptual Framework

mindfulness-to- meaning Theory (mmT)

Hanley et al. (2021) mentioned that mindfulness training positively correlates with emotional distress alleviation and well-being promotion. The mindfulness-to-meaning theory (MMT) holds that the relationship between mindfulness and well-being is due to emotion regulation. According to Garland et al. (2017), practicing mindfulness enables flexible awareness and the capability to suspend automatic thoughts, emotions, and spontaneous moments. By doing so, mindfulness separates negative emotional experiences and judgments from the thoughts that can usually result. MMT comprises a comprehensive action framework that illuminates modifications in downward noncognitive predispositions and emotion regulation methods that develop from being in a mindful state.

According to Garland et al. (2015), MMT holds that engaging in attentional control during stressful periods encourages a shift from stress assessments into a metacognitive mode that results in awareness expansion to include formerly unattended interoceptive exteroceptive bodily information. The information is later incorporated into new, adaptable reassessments of individuals and the world, eventually leading to longlasting, useful feelings and sense of relevance in life (Garland et al., 2017). According to Garland et al. (2017), there are different processes in linking mindfulness to reassessing psychological responses.

The first step is attention control, which refers to sustaining attention on an element in the distraction setting and intentionally shifting focus (Garland et al., 2015; Garland et al., 2017). The second process is decentering. According to Garland et al. (2017), decentering denotes detaching from mental and emotive phenomena to attain a psychological remoteness relating to internal experiences. The mindful reappraisal hypothesis argues that decentering removes stress judgments in short-term memory and reduces attentional prejudice toward undesirable stimulants. The process reduces downward perceptive and interactive intelligibility (Hanley et al., 2021). Garland et al. (2017) argues that decentering allows consciousness disengagement from typical cognitive sets.

The notion of extended consciousness of internal and external stimuli information denotes an increase in the access of discernments of the interior and exterior setting, which results from decentering. The third process of MMT allows contextual information controlled previously by the constricted attentional viewpoint resulting from stress and adverse affective situations. The awareness growth enables the facilitation of appraisals reconfiguration by incorporating positive contextual features that were previously unattended (Garland et al., 2017). Broadened awareness is influential in the contributive reassessment of stressful situations. The unification of these processes creates the mindful reappraisal hypothesis.

According to Hanley et al. (2021), broadening awareness will expand perspective and interpretative opportunities. In situations where negative contextual factors prevail under stressful conditions, broadening awareness brings a more stable situation illustration that combines helpful and impartial essentials with harmful elements of the stressful environment. According to MMT, mindfulness can clear working memory of familiarized understandings of life situations. New and unanticipated information is expected to appear when information is no longer sifted to follow a distressing description (Hanley et al., 2021).

linking Theory

This evidence-based project aims to investigate the effects of mindfulness on anxiety and memory retention. The impact of mindfulness

on physical, cognitive, and mental health has long been documented. Anxiety is a stressful life event that is usually appraised negatively. However, if individuals have access to an invasion of new stimuli, these stressful situations may be reassessed as harmless and thus would affect a person’s emotions or behavior differently. Participants were enrolled in a mindfulness training to modify how they attended to situations that cause anxiety.

Many elements affect the ability to learn and recall new information. External noises decrease attention span, and lack of motivation may affect memory retention (Lueke & Lueke, 2019). Proactive interference reduces the effectiveness of the working memory. MMT’s attention control and decentering concepts were used to understand memory retention (Lueke & Lueke, 2019). Learning new things may be difficult because of the interference with memories (Lueke & Lueke, 2019). According to MMT, decentering allows broad awareness that increases the access to perceptions of the internal and external environment (Garland et al., 2017). It becomes easier to remember things through this process because the mind is not clogged with information from previous events.

Summation of literature

There has been growing clinical interest in using mindfulness interventions to treat psychological issues such as anxiety and mood disorders. Mindfulness refers to the capacity to focus on the current

Note. Adapted from “Mechanisms of

by P. Malinsowski, February 4, 2013, Frontiers in

Figure 1

The Liverpool Mindness Model

moment without any distractions. According to Hanley et al. (2021), mindfulness techniques are efficient in clinical settings. Therefore, having an understanding of the theoretical framework for mindfulness intervention enable practitioners to have a comprehension of how they work. The current study utilizes MMT to observe the effects of mindfulness on anxiety and memory retention.

methods

Design

This evidence-based practice (EBP), single group, pre-/post-test design focusing on reducing anxiety symptoms and improving memory in mental health providers by implementing an evidence-based mindfulness program.

Setting

The evidence-based project took place at an outpatient clinic located in Freeport, New York. The clinic provides various “comprehensive” mental health services to both children and adults and has been in operation since 1959. Due to the current COVID-19 pandemic, the clinic at the time of the study was being run using a hybrid model, with most services being rendered via telehealth, including group therapy. Services include counseling, crisis intervention, preventive services, medication management, and chemical dependency and alcohol abuse treatment. The clinic is open seven days a week. Both the medical and clinical directors agreed to the project and other stakeholders, such as therapists, mental health counselors, and case managers, were essential in the participant recruitment process. The project was implemented through the Adult Services Program, which employs one psychiatrist who also serves as the department director, one psychiatric nurse practitioner, and seven therapists.

Sample

Participants were recruited during the first week of the fall semester. An informational flyer (Appendix L) was posted throughout the clinic, and copies were given to clerical staff to distribute to various staff. Participants who showed an interest and met the criteria were then enrolled in the program. The project consisted of a convenience sample and was open to all employees and contractors at the clinic. The project consisted of ten participants (I = 10) (see Table 1). Of the ten participants that took part in the project, seven (7) identified as females, and three (3) as males. The project consisted of one (1) psychiatrist, eight (8) therapists, and one (1) psychiatric nurse practitioner. The ages of the participants were between 35 and 54. Six (6) of the participants identified as Black/African American, one (1) identified as Hispanic/Latinx, and three (3) identified as white. The mean baseline GAD-7 score was M = 17.20 (SD = 3.190), which is considered to be severe anxiety; the MAAS score was M = 8.40 (SD = 1.713), and memory test scores were M = 4.20 (SD = 1.398). All scores were recorded prior to the intervention for comparison. All participants who attended all four sessions received a self-care journal and a $5 Dunkin’ Donuts gift card.

measurement Instruments

All participants completed a Mindfulness, Attention, and Awareness Scale (MAAS) assessment, which is a 6-point Likert-type response scale ranging from 1 (almost always) to 6 (almost never), which assesses the

Table 1

Demographics Data

frequency an individual is mindful or is in the present (see Appendix C). Higher scores indicated greater mindfulness. A Generalized Anxiety Disorder 7 (GAD-7) item scale, which is a seven-item questionnaire used to assess anxiety, was used to measure how often, during the most-recent two weeks, individuals experienced anxiety symptoms (see Appendix E). Severity of anxiety was scored as 1 to 4 minimal symptoms, 5 to 9 mild symptoms, 10 to 14 moderate symptoms, and 15 to 21 severe symptoms. Participants were also given a memory test (see Appendix F) before their first mindfulness session. GAD-7 and MAAS are both available in the public domain with no permission required to reproduce, translate, display, or distribute with good reliability and validity results. All group sessions were scheduled in person, but because the ongoing COVID-19 pandemic and at the request of all participants, group sessions were changed to Zoom. Participants were emailed all necessary questionnaires and tools. Participants participated in four 30-minute sessions while using the Calm application software over four weeks. At the end of the four weeks they then repeated the MAAS, GAD-7, and memory tests post-intervention. A post-program evaluation was distributed in order to determine if the mindfulness program was effective and contributed to participants’ learning,

as well as a one-month post-intervention survey to assess if participants had incorporated mindfulness into their daily practice with patients and/ or their families. The Calm application is valued at $1 billion and is the most downloaded and used health and fitness application globally with over 50 million downloads worldwide. Subscriptions in the United States are available for $69.99, which amounts to less than $0.19 per day. The application offers meditations led by experts in their fields that target various issues, including stress, anxiety, anger, and pain, or to improve focus and attention. Calm is currently available in five languages, including German, French, English, Korean, and Spanish.

ethical Considerations and Human Subjects’ Protections

The Molloy College (now known as Molloy University) Institutional Review Board (IRB) approval form was completed to determine if IRB approval was necessary before starting the project (Appendix I). The project lead completed and passed the collaborative institutional training initiative (CITI) that provided education on IRB protocols, as well as protecting the rights and safety of all participants (Appendices I & J). Ethical considerations and protections were considered for all participants enrolled in the project and participation was voluntary. Participants identified either verbally or through email that they wanted to participate.

Intervention and Procedures

The project lead implemented a mindfulness-based training program that took place over four weeks. On day one, participants were given background information on the history and benefits of incorporating mindfulness into their daily lives, instructions on completing all tools and surveys, the number and length of sessions, and the requirements for participation. Participants completed a participant demographic questionnaire and were also given the opportunity to ask questions and receive feedback.

Week one consisted of a presentation on the following topics: stress, defining mindfulness, history, mindfulness benefits, and understanding mindfulness, and concluded with a 30-minute mindfulness exercise from

the Calm app titled “A Heart Less Heavy” by Tamara Levitt. Week two consisted of a presentation on the following topics: what mindfulness is not, neuroplasticity, neurophysiology of anxiety, and tone the vagal nerve with breath, and concluded with a deep breathing exercise and a mindfulness exercise from the Calm app titled “Calming Anxiety” by Tamara Levitt. Week three consisted of a presentation on the following topics: effectiveness in depression treatment, role of compassion, and manage negative selftalk with awareness of thoughts: Self-compassion break and concluded with a 30-minute mindfulness exercise from the Calm app titled “Anxiety Release” by Elisha Goldstein. Week four consisted of a presentation on the following topics: mindfulness, diversity & cultural humility; compassion fatigue; recognize risks; and stop, drop and roll, and concluded with a 30-minute mindfulness exercise from the Calm app titled “Saying Yes to Life” by Tara Bach.

Data collection

An informational flyer was posted and distributed throughout the clinic. Participants who showed an interest and met the criteria were then enrolled in the program. Participants met with the project lead and were given a QR code to complete demographic questionnaires, screening tools, and a one-month post-intervention evaluation. Personal identified (PI) information was removed and an encrypted identification (ID) was assigned to each participant. The ID code consisted of the first letter of the participant’s mother’s first name, followed by the participant’s birthday. All data was password protected and hard copies were scrubbed of all identifying information.

Data Analysis

Analysis of Data results

The project lead compiled descriptive statistics of the sample pre- and post-test scores obtained from the GAD-7, MAAS, and memory test using Statistical Product and Service Solutions (SPSS) software. A paired t-test was performed using SPSS. Mean and standard deviation were used on demographics, such as age and occupation, and percentages were used on variables such as race and gender.

Table 2

Mindful Attention Awareness Scale (MAAS) Scores Pre- and PostIntervention Descriptive Statistics

Discussion

The resulting data helped interpret the percentage of change in the participants’ levels of mindfulness, anxiety, and ability to recall information after taking part in the program. The post-intervention results consisted of a GAD-7 score with an M = 8.90 (SD = 1.663), a MAAS score with M = 13.10 (SD = 3.784), and a memory test with M = 7.00 (SD = 1.155) (see Tables 3 & 4). The means for pre-intervention and post-intervention anxiety levels were also compared using a paired sample t-test, and the result was p = < .0001 (see Table 5). This result indicated a statistically significant difference between pre- and post-anxiety, MAAS, and memory test scores.

Implications Research

The resulting data analysis shows that mindfulness can be effective in both decreasing anxiety and improving memory retention among mental health providers. Effectiveness of wellness programs on nurses’ physical and mental health can help inform and improve the design and implementation of future programs.

Generalized Anxiety Disorders 7 Scores, Pre- and Post-Intervention Descriptive Statistics

Memory Test Scores Pre- and Post-Intervention Descriptive Statistics

Paired T Test on Memory, MAAS, and GAD-7 Scores

Table 3

Table 4

Table 5

Clinical Practice

The resulting data shows significant improvement in providers’ ability to recall information and reducing their anxiety symptoms. This will impact clinical practice to decrease burnout, improve job satisfaction, and improve patient outcomes.

Policy

The results of this study can serve as a prototype to adapt mindfulness in the plan of care, not only for the providers, but also for the patients whom they treat. The project will impact policy since similar wellness programs can be included in healthcare policies to ensure that nurses have access to the necessary resources and support needed to maintain their health and well-being.

Education

Wellness programs can be incorporated into nursing education to help equip nurses with the skills and strategies needed to manage their own physical and mental health in the workplace. Educating current and incoming staff on the importance of self-care is vital for patient outcomes.

Sustainability

Mindfulness can effectively manage anxiety and improve memory retention in both providers and their patients. There is sufficient evidence

that mindfulness can enhance individuals’ reading comprehension, reasoning ability, and analytical problem-solving skills (Machado et al., 2020). The practice can be added into the workplace as part of wellness activities that will benefit the staff and their patients over the long term.

Conclusion

The EBP is aimed at directly impacting patient or population outcomes. With mindfulness training, patients can experience improved psychological well-being. The comorbid risks of cardiovascular mortality and morbidity may also be reduced with anxiety reduction, leading to improved quality of life and productivity among both providers and patients. The reduction in overall anxiety, increase in memory test scores, as well as increase in the level of mindfulness in the participants who took part in the program shows the effectiveness of mindfulness in managing anxiety and improving memory. The resulting data helps to substantiate the role that mindfulness can play for both providers and their patients, as all participants reported one-month post training that they had started to incorporate mindfulness as an adjunct in their care plans. Practicing mindfulness allowed participants to navigate moments of increased stress by redirecting their thoughts and focusing on essential tasks. This impacted clinical practice by decreasing burnout, improving job satisfaction, and improving patient outcomes. The project will impact policy and education as administrations begin to look at how they can offer more wellness activities for their staff onsite and educate future staff on the importance of self-care as way to show up and be present for patients.

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the Caregiver: Implementation of a Mindfulness Program for Mental Health Providers in an Outpatient Clinic

Appendix A

Evidence Table

Citation Type of study

Level of evidence Statistical tests and results Summary statements for practice

Author/s, year, title, journal, pages What design did they use Hierarchy of evidence (Polit & Beck Hierarchy of Evidence)

Monshat, K., Khong, B., Hassed, C., Vella-Brodrick, D., Norrish, J., Burns, J., & Herrman, H. (2013).

“A conscious control over life and my emotions:” Mindfulness practice and healthy young people. A qualitative study. Journal of Adolescent Health, 52(5), 572–577. https://doi.org/10.1016/j. jadohealth.2012.09.008

Barratt, C. (2017). Exploring how mindfulness and self-compassion can enhance compassionate care. Nursing Standard (2014+), 31(21), 55. http://dx.doi.org.molloy.idm. oclc.org/10.7748/ns.2017.e10671

Darby, M., & Beavan, V. (2017). Grist to the mill: A qualitative investigation of mindfulnessintegrated cognitive behavior therapy for experienced health professionals. Australian Psychologist, 52(6), 491–502. https://doi.org/10.1111/ap.12215

Morgan, P., Simpson, J., & Smith, A. (2015). Healthcare workers’ experiences of mindfulness training: A qualitative review. Mindfulness, 6(4), 744–758. https://doi.org/10.1007/s12671014-0313-3

Henry, B. J. (2014). Nursing burnout interventions: What is being done? Clinical Journal of Oncology Nursing, 18(2), 211–214.

A single qualitative study.

Level 6

What tests were run on the data?

A 6-week mindfulness training program was given to a group of participants ages 16–24. Participants were then followed and interviewed eight times over three months. Participants reported greater calm, balance, and control and a clearer understanding of themselves and others.

Correlation between mindfulness and the ability to improve a provider’s compassionate care.

Two-stage qualitative analysis that analyzed the experience of healthcare workers during mindfulness training.

Level 7 None

Why does it matter?

By utilizing mindfulness, participants improved emotion regulation and gained greater confidence in their ability to manage life challenges. The result supported the literature as well as similar studies conducted on older participants.

A review of published qualitative papers on the experiences of health care workers who attended mindfulness training.

Level 5

An analysis of the recorded experiences of healthcare workers who took part in an introductory mindfulness training in Australia 21 months post-training.

Level 5 None

The article provided various interventions for reducing compassion fatigue.

Level 7

None

Based on the data collected, mindfulness is helpful in minimizing staff burnout in healthcare providers.

Results suggest that the method of delivery for the training, individual’s job description, as well as their level of functioning, played a significant role in the outcome of the training.

Participants who participated in a mindfulness training program reported an overall increased personal well-being and selfcompassion.

Organizations that implement burnout interventions such as an 8-week mindfulness-based stress reduction program may experience increased retention, reduced turnover, and increased patient satisfaction.

Appendix b

Synthesis Table

Topic: Implementation of a Mindfulness Program for Patients Diagnosed with Depression and Anxiety to Decrease Stress and Improve Memory

Article number

1

2

3

Evidence supports levels of anxiety decreasing post mindfulness training

Evidence supports levels of depression reducing post mindfulness training

33 participants enrolled in nine weeks of 2.5-hour sessions of mindfulness. Participants completed post-training questionnaires that showed the level of depression decreased while anxiety remained the same.

Six-week mindfulness training program with a non-clinical group of 11 young people (ages 16–24).

Participants were then followed and interviewed eight times over three months.

Participants reported greater calm, balance, and control, and a clearer understanding of themselves and others.

Participants reported greater confidence in their ability to manage life challenges.

A systematic review of 21 randomized controlled trials was reviewed for the effectiveness of mindfulness-based stress reduction and mindfulnessbased cognitive therapy. Results showed that mindfulness reduced the risk of depressive relapse.

Evidence supports improved the wellbeing and resilience of participants

Evidence supports an increase in memory/ cognitive function

Caring for the Caregiver: Implementation of a Mindfulness Program for Mental Health Providers in an Outpatient Clinic

4

Evidence supports levels of anxiety decreasing post mindfulness training

Evidence supports levels of depression reducing post mindfulness training

Evidence supports improved the wellbeing and resilience of participants

Evidence supports an increase in memory/ cognitive function

5

6

There was no statistical significance in anxiety between the meditation, hatha yoga, and the wait-list group.

8

7

A randomized control trial of 50 nursing students in South Korea showed that participants enrolled in a mindfulness training program reported significantly decreased depression compared to those who did not participate.

A literature review of 24 articles shows that mindfulness effectively treats mood and anxiety disorders.

Found significant improvement in anxiety post mindfulness training program.

Participants reported significantly decreased depression compared to students who did not participate.

Mindfulness is an effective tool for the treatment of mood disorders.

Significant improvement in mood post mindfulness training program.

198 teens were enrolled and randomly assigned to a mindfulness meditation program, hatha yoga, or a waitlist. Participants completed a computerized measure of working memory test and selfreported perceived stress during pre-intervention and postintervention/wait-list. Participants in the mindfulness meditation group showed significant improvements in working memory compared to those in the hatha yoga and wait-list control groups.

Significant increase in executive functioning and attention.

The literature reviewed shows that participants demonstrated increased cognitive function up to five months post mindfulness training.

Legend:

1. Bartels-Velthuis et al. (2016)

2. Monshat et al. (2013)

3. Quach et al. (2016) 4. Song & Lindquist (2015)

5. Rodrigues et al. (2017) 6. Rodrigues et al. (2017) 7. Dunning et al. (2019) 8. Gallant, S. N. (2016)

Appendix C

MAAS-Short

Instructions: Below is a collection of statements about your everyday experience. Using the 1-6 scale below, please indicate how frequently or infrequently you currently have each experience. Please answer according to what really reflects your experience rather than what you think your experience should be.

Please treat each item separately from every other item.

1. It seems I am “running on automatic,” without much awareness of what I’m doing.

2. I rush through activities without really being attentive to them.

3. I get so focused on the goal I want to achieve that I lose touch with what I’m doing right now to get there.

4. I do jobs or tasks automatically, without being aware of what I’m doing.

5. I find myself doing things without paying attention.

Appendix D

Over the last two weeks, how often have you been bothered by the following problems?

If you checked off any problems, how difficult have these made it for you to do your work, take care of things at home, or get along with other people?

Extremely difficult

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. No permission is required to reproduce, translate, display or distribute.

Appendix e

Pre-Memory Test

Appendix F Post-Memory Test

Implementation of escape room Simulation Activity for Nurses Transitioning to Clinical Practice

Simon Paul Navarro, MA, BSN, RN, CCRN, TCRN, and Maria Paula B. Nolasco, MSN, RN, CCRN, HNB-BC

n Abstract

Background: Transitioning into clinical practice can be challenging for newly registered nurses, especially when it comes to developing critical clinical decision-making skills, which are crucial for providing quality patient care and achieving organizational goals.

Purpose: This project explores the effectiveness of incorporating an escape room as an innovative, evidence-based simulation design into the unit-based nursing orientation for new hires.

Methods: The escape room consisted of two phases: simulation development and simulation testing. This study used a pre- and post-test design. To describe and analyze activity outcomes, means and standard deviations were employed.

Results: A total of 10 nurse-participants voluntarily completed the escape room activity. Participants agreed that the escape room activity was engaging and helpful in standardizing their clinical knowledge and skills.

Conclusion: Utilization of the escape room scenario as a simulation learning activity could support new nurses in transitioning more effectively to clinical practice, which can support optimal patient care delivery.

Keywords: Escape room, simulation, nurses

Acknowledgments

The authors thank Maxy Escalante DNP, MSN, RN, CCRN, the patient care director of Surgical Anesthesia Intensive Care Unit (SAICU) at NewYork-Presbyterian/Columbia for supporting the Clinical Escape Room Scenario Activity. We also thank Lovie Marie Amolo MSN, RN, ACCNS-AG, CCRN, SCRN, CEN, the unit's clinical nurse specialist, as well as clinical nurses Caitlin Frawley, BSN, RN, CCRN, and Iasmina McAleese, BSN, RN, for their assistance in successfully facilitating and implementing the said learning activity.

Introduction

Application of theoretical knowledge into the clinical setting can prove to be a challenge for many nurses despite their proficiency and clinical competency level. Multiple factors, such as new hires’ varying knowledge and critical thinking skills due to the new work environments, limited clinical exposures, varying preceptorships, and lack of experiences in unitspecific scenarios, contribute to safe practice issues among new graduate nurses (Ankers et al., 2018; McLaughlin et al., 2021; Pertiwi & Hariyati, 2019). This creates a theory-practice gap, which hinders a nurse’s ability to integrate professionally in the nursing and medical practice (Blevins,

Simon Paul Navarro, MA, BSN, RN, CCRN, TCRN

2018; Cant et al., 2020; Koukourikos et al., 2021). Treiber and Jones (2018) reported that medication errors committed by new graduate nurses were linked to various factors such as lack of clinical experience, time management skills, technological equipment, staffing ratio, and levels of patient acuity. Similarly, Murray et al. (2019a) found that there’s a decreased self-reported clinical safety knowledge and attitudes among new graduate nurses regarding medical errors, suggesting that a gap between theory and practice persists for transitioning new nurses. These transitional hardships precipitate the presence of theory-practice gap among new nurses in the profession, which may create a negative impact on overall patient safety

NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York

Maria Paula B. Nolasco, MSN, RN, CCRN, HNB-BC

NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York

and nursing outcomes (Koukourikos et al., 2021; Labrague et al., 2019; Murray et al., 2019a).

Nurse educators play an important role in creating new hire orientation programs that are engaging and informative to adequately prepare newly hired staff nurses transitioning into their professional roles (Ayed & Khalaf, 2018; Labrague et al., 2019; Murray et al., 2019a; Persico et al., 2021; Pornsakulpaisal et al., 2023). High-fidelity healthcare simulation activity is one method that is widely recognized as an effective educational strategy that enhances student outcomes by allowing them to practice and apply their theoretical knowledge in a controlled environment that closely resembles a hospital setting. This grants them an opportunity to gain clinical experiences before entering the workforce as healthcare professionals (Hanshaw & Dickerson, 2020). In 2018, nurse educators from three educational systems in the rural Midwest collaborated to facilitate a disaster response simulation among healthcare students and military trainees. They found out that students have positive learning experiences, enhanced their clinical reasoning and technical skills, and fostered interprofessional collaboration using simulation (Murray et al., 2019b). Findings from the hermeneutic phenomenological study done by Anker et al. (2018) found that positive experiences of graduate nurses are strongly connected to the support they receive from their educators and senior nurses during the transition program. In the specific context of critical care, a well-designed orientation program plays a crucial role in preparing new nurses to provide high-quality patient care. Monforto et al. (2020) emphasizes that such transition programs equip nurses with standardized knowledge that enables them to deliver optimal care.

In the surgical and anesthesia intensive care unit (SAICU) of a large academic medical center, clinical preceptors have observed varying levels of knowledge and skills among newly hired nurses. Feedback from new nurses who completed the unit-based clinical orientation revealed a significant desire for a more comprehensive and engaging clinical transition activity that focuses on the practical application of different nursing procedures in accordance with the institution’s policies and protocols. The current clinical nursing orientation program of the unit consists of an interactive online module followed by one-on-one preceptorship. The investigators created an escape room simulation activity in the hopes that it would address the gap between theory and practice during the clinical transition phase of newly hired nurses in the SAICU. It is also believed that the escape room activity would be an effective teaching strategy to improve the critical thinking skills and reinforce didactic learning on new hires through exposure to real-world clinical scenarios. By doing so, it can promote patient safety and standardize the quality of care provided.

Using escape room scenarios as a simulation design is considered an innovative experiential learning activity in nursing orientation programs. It offers higher educational value by guiding new hires during their clinical and non-clinical orientation in consolidating theoretical learning and strengthening of critical thinking skills relevant to their new professional role (Cant et al., 2020; Lewis et al., 2019; Monforto et al., 2020; Pertiwi & Hariyati, 2019). Furthermore, escape room scenarios serve as a flexible simulation strategy that effectively bridges the theory-practice gap, while enhancing collaborative skills among newly hired nurses (Ayed & Khalaf, 2018; Murray et al., 2019b; Pornsakulpaisal et al., 2023). To successfully integrate newly hired nurses into organizational processes and promote standardized delivery of safe, quality patient care, nurse educators and

leaders must implement experiential learning strategies in a structured transitional program. It is also essential that these educational strategies must be delivered in a supportive and respectful manner as this approach has been shown effective and is supported by several studies (Ankers et al., 2018; Blevins, 2018; McLaughlin et al., 2021; Treiber & Jones, 2018).

Previous research has examined the significance of simulation activities in healthcare settings (Ayed & Khalaf, 2018; Hanshaw & Dickerson, 2020; Koukourikos et al., 2021), but there is currently limited knowledge about the efficacy of escape room scenarios as a simulation design within the realm of professional nursing practice. The inclusion of the escape room scenarios as a simulation activity in clinical nursing orientation programs design for new nurses transitioning into professional practice has not been extensively adopted by most of the hospitals across the country, despite the potential benefits (Cant et al., 2020; Curry-Lourenco et al., 2022; Lewis et al., 2019; Pertiwi & Hariyati, 2019). This study highlights the urgent need for nurse educators and nursing professional development specialists to determine strategies that can improve the transitional program for new nurses in professional practice. The goal is to provide adequate support to new nurses and for them to perceive a better experience in delivering optimal patient care.

By analyzing the use of escape room scenarios at an institutional unitlevel, we can gain insight into its usefulness as an innovative experiential learning strategy for supporting new nurses in the present and future practice of professional nursing. In this paper, the investigators examined the implementation and outcomes of incorporating an escape room simulation activity into an existing unit-based clinical orientation program designed for newly hired nurses transitioning to professional clinical practice.

Specific Aim

The purpose of this simulation activity is to improve the critical thinking skills, communication skills, and collaborative abilities of newly hired SAICU nurses. The objectives were twofold: (a) to evaluate the current knowledge and skills of new hires, and (b) to educate staff about common critical-care scenarios and nursing procedures in the SAICU. Upon completion of the escape room scenario, participants were expected to demonstrate their understanding on the appropriate implementation of nursing procedures based on institutional policies, as proven by passing the post-tests with a score of 70% or higher. The long-term goals of escape room simulation activity are to promote patient safety, elevate standard patient care, and improve the overall professional nursing practice.

methods

The theoretical underpinning for this study was drawn from utilizing the International Nursing Association for Clinical Simulation and Learning or INASCL guidelines for simulation-based experiences and principles of experiential learning theory within the context of nursing education. New nurses can hone their critical thinking, decision-making, and problemsolving skills through immersive, hands-on escape room scenarios, which promote the integration of theoretical knowledge with practical skills (Kolb et al., 2014; Persico et al., 2021; Watts et al., 2021). By incorporating realistic patient scenarios, ethical dilemmas, and interdisciplinary collaboration within the controlled escape room environment design, nursing educators and professional development practitioners can ensure that new nurses can develop comprehensive skill sets while fostering a deeper understanding

n Implementation of Escape Room Simulation Activity for Nurses Transitioning to Clinical Practice

of the professional nursing practice standards. The experiential learning cycle of structured educational experience, reflective observation, abstract conceptualization, and active experimentation serve as a guiding framework for the escape room simulation activity (Kolb et al., 2014; Persico et al., 2021; Watts et al., 2021).

The preparation for the escape room scenario was initially done by securing approval and leadership support from the unit’s patient care director, clinical nurse manager, clinical nurse specialist, and nurse educators. Ethics approval from the target institution was not required for this educational project since the risk to the participant’s privacy was minimal and no sensitive information was obtained. Moreover, the pre-test, post-test, and post-evaluation survey forms did not involve any potential identifiers to ensure subjects’ anonymity and confidentiality. Activity implementation, outcomes, and timelines were defined accordingly prior to program initiation. To describe the activity learning outcomes, a 5-point Likert scale was employed in the 15-item anonymous post-evaluation survey forms with response options of strongly agree (5), agree (4), undecided (3), disagree (2), and strongly disagree (1). Mean scoring and standard deviations were used to descriptively analyze and evaluate data from the aggregated pre-test and post-test scores. The creation of the clinical escape room simulation activity involved two phases: simulation development and simulation testing.

Escape Room Client Patient Condition Scenario

Simulation Development

The team decided to incorporate an escape room scenario into the unit-based clinical orientation program to assist newly hired registered nurses as they transition to clinical practice. The goal was to provide an active simulation strategy that would support these new hires during their transition into clinical, critical-care nursing practice. To ensure the effectiveness of the simulation activity, the investigators followed the simulation-based experience framework from INACSL guidelines to carefully identify the key tasks that the new hires would need to complete in the escape room scenario (Persico et al., 2021; Watts et al., 2021). The given hypothetical client scenario utilized a commonly experienced medical diagnosis and complication in the target unit setting—gastrointestinal (GI) bleeding, which is considered a significant cause of mortality and morbidity worldwide as it can be life-threatening if not managed early (Mujatba et al., 2020). The escape room activity incorporated puzzle themes and educational objectives based on the institution’s policies and staff nurses’ educational needs. Topics such as liver transplant protocol, train of four, bladder pressure monitoring, and massive transfusion protocol were selected for this purpose. Furthermore, these topics were also discussed during the nursing skills day. Figure 1 narrates the client scenario with clues embedded and rules provided prior to entering the escape.

Introduction Scenario

Rick Shaw is a 45-year old male, full code, no known allergies, post-operative day 2 from liver transplant. He is ready for transfer from SAICU; introducer sheath, indwelling foley catheter, and arterial line have been removed. Night shift RN is giving you an unremarkable report and there is wind that a bed will be made available late afternoon. Morning laboratory results are pending and waiting review.

Background

History of gastrointestinal bleed and esophageal varices–clipped 6 months ago. Alcoholic liver cirrhosis with portal vein hypertension. Large volume paracentesisi–a month ago prior to liver transplant.

He seems like a straightforward patient but with all things ICU, he’ll be a PUZZLE to deal with. Good luck PIECING together the info in this room!

Rules of the Escape Room

1. You have 30 minutes to “escape” the room.

2. You will be provided with a two-minute sneak peek of the room. Use this time to familiarize yourself with the set-up environment.

3. There will be facilitators present during “the escape.” They will not talk and only communicate through writing. They can also provide 3 free clues at no cost to you–just ask!

4. Please do not force open any items.

5. Be efficient and accurate. Follow all the steps appropriately. No shortcuts or skipping steps to “escape” sooner.

6. Absolutely no cellphone use during “the escape.”

7. Please do not share your answers with the other participants outside of your group until debriefing.

8. Timer will start after your 2-minute sneak peek of the room.

9. Best of luck and have fun!

Figure 1

Simulation Testing

The clinical content of the escape room scenario was based on pre-briefing, briefing, and debriefing frameworks for simulation-based experiences (Decker et al., 2021; McDermott et al., 2021). These models are considered as vital simulation processes in ensuring successful learning experience of trainees at their respective level of knowledge and competency (Watts et al., 2021). The PEARLS or Promoting Excellence and Reflective Learning in Simulation script (Eppich & Cheng, 2015) was specifically used to cognitively aid the escape room scenario post activity. During the pre-briefing and briefing phases, nurse-participants were oriented to the simulation environment and familiarized with rules and processes, while post-activity debriefing was conducted to facilitate cognitive discussion about participants’ learning experiences (Decker et al., 2021; McDermott et al., 2021; Persico et al., 2021). Ten (10) out of the twenty (20) staff nurses who attended the nursing skills day voluntarily participated in the escape room simulation activity. The pilot group of ten (10) nurse-participants were divided into three (3) groups: two groups (group A and group B) of three (3) participants, and one group (group C) of four (4) participants. Group A and B consisted of newly hired nurses in the unit with less than a year of experience and who were not board-certified in critical care, whereas Group C was composed of four staff nurses with more than a year of experience and who were nationally board-certified critical care nurses.

Interventions

The escape room simulation activity was added in the unit-based clinical orientation program for newly hired nurses from March 2023 to September 2023. It was facilitated during the annual nursing skills day program as a conclusive, team-based active learning strategy to augment clinical skills and assess knowledge retention on critical-care nursing procedures discussed with the nurse-participants during the said skills program. A 10-minute pre-briefing was done to orient the participants in the simulation rules, environment, and equipment. The 30-minute timed escape room scenario was initially started through a brief narrative history of the fictional client, and was then followed by a beginning scenario leading to the first puzzle task that gave prompts and cues to which participants could respond to in order to proceed to the next succeeding clinical puzzle tasks.

Figure 2 shows the summary flow of the puzzle games in the escape room scenario. A 20-minute debriefing was conducted post simulation activity to help initiate discussion and feedback about participants’ experiences of the escape room scenario. The debriefing focused more on reviewing the flow processes and procedures in the escape room scenario, explaining the rationale for each of the clue cards and puzzle tasks. Additionally, nurseparticipants voluntarily completed the anonymous post-evaluation survey after the simulation activity. These post-activities allowed the participants to reflect on their learning experiences in completing the escape room scenario.

Figure 3 displays the map layout of the escape room clinical scenario as well as the selection of equipment to be used (e.g., lockboxes, flashlights, and USB drives) and various unit-based decoy items (e.g., hospital supplies). All materials needed in the simulation activity were available and purchased for previous training projects, hence, there was no additional costs for equipment affecting the unit’s operational budget. The average completion time for the whole escape room scenario was approximately 60 minutes. To evaluate and promote knowledge retention among nurse participants, re-administration of post-test and follow-up teachings about the escape room scenario’s clinical content were done one (1) month and three (3) months after the initial implementation of the simulation activity.

results

The 30-minute timed escape room scenario gathered a total of ten (10) nurse-participants who voluntarily completed the simulation activity. In Table 1, the pre-test that was administered prior to the implementation of the escape room scenario garnered a total mean score of 10.7 (SD = 1.77), whereas the total mean score for the series of post-tests was 12.6 (SD = 1.26). With a setting of 70% passing score, which is 11 out of 15 items, a minimal increase of scores and variations were observed between the pre- and post-test results.

Based on the cumulative results of the anonymous post-evaluation survey done by the nurse-participants, the course objectives of the hands-on simulation activity were met accordingly (M = 4.11, SD = 1.17) and executed efficiently (M = 4.20; SD = 1.19) as seen in Table 2. Overall, the findings from the evaluation survey were positive with minimal variations.

Clue Card 1: Found by opening the lockbox#1 that has the USB drive containing institution’s policies such as liver transplant protocols.

Clue Card 2: Matching game: connecting the six main functions of the liver to its clinical findings and corresponding laboratory values.

Clue Card 5: Multi-step code card: arterial and central line insertions, train of

Clue Card 6: Monitoring of bladder pressure in intra-abdominal hypertension and compartment syndrome.

Clue Card 4: Assisting in rapid sequence intubation and invasive mechanical ventilation.

Clue Card 7: Competencies Massive Transfusion Protocol (MTP).

Clue Card 3: Differential diagnoses and anticipated interventions.

Congratulations! You “escaped” the room and kept your patient alive! Now DEBRIEF!

Introduction – Finding and solving the (9) PUZZLE PIECES together!

four skill, and catheter-associated UTI (CAUTI) protocols.

Figure 2

Flow Chart of the Escape Room Puzzles

After the completion of the escape room scenario, debriefing was initiated by the activity facilitators. During the session, subjective remarks from the participants were noted and collected. This promoted open communication and feedback between participants and facilitators, allowing them to reflect on their overall learning experience from the simulation activity. One of the barriers found in the escape room activity was the limited 30-minute time frame given to finish the whole scenario. In the qualitative comment section from the anonymous post-evaluation survey, one of the participants commented that the activity should “have more time on skill.” Another narrative response noted from the participant was, “Nurses should be setting up and doing the skills.” These annotations from the participants were asked for evaluation purposes to facilitate quality improvement of such an active teaching strategy for future use and research. In general, facilitators noted that nurse-participants were challenged and engaged doing the escape room scenario and gave positive feedback regarding its implementation as a conclusive learning activity incorporated in the nursing skills day.

Discussions

Formulating an escape room simulation activity was an innovative, descriptive, active learning strategy that provided an avenue for newly hired nurses to demonstrate and evaluate their comprehension with regards to critical thinking and collaboration as components of evidence-based practices (EBPs) and culture of safety. The general feedback from clinical nurses has been positive about the escape room simulation activity. With high overall mean scores with minimal variations as seen on post-evaluation surveys and post-tests, results from this study can clearly support the findings from multiple studies suggesting that escape room scenarios can be considered as an interactive, flexible simulation activity in orientation programs for bridging the theory-practice gap for both new graduates and experienced nurses (Ayed & Khalaf, 2018; Cant et al., 2020; Monforto et al., 2020; Murray et al., 2019a; Pertiwi & Hariyati, 2019; Pornsakulpaisal et al., 2023).

Utilizing escape rooms scenarios as a simulation-designed teaching method is an educational opportunity that increases knowledge retention and decreases the risk of novice nurses compromising patient safety during clinical transition (Ankers et al., 2018; Blevins, 2018; Labrague et al., 2019; Lewis et al., 2019; Murray et al., 2019a; Pertiwi & Hariyati, 2019). It also provides an avenue for nurse managers and educators to promote their supportive role towards new hires during their transition to clinical practice, which nurtures high-performing work environments that influence overall patient and nursing outcomes (Ayed & Khalaf, 2018; Cant et al., 2020; Curry-Lourenco et al., 2022; McLaughlin et al., 2021).

Findings from this study highlighted the integral advantages of adding escape room scenarios in critical-care onboarding programs designed for newly hired nurses. This flexible and cognitively challenging healthcare simulation activity can shape learning in a more powerful innovative way than the traditional, conventional teaching method. The implications of this learning strategy have been confirmed and supported in previous literature (Cant et al., 2020; Koukourikos et al., 2021; Lewis et al., 2019; McLaughlin et al., 2021; Monforto et al., 2020; Pertiwi & Hariyati, 2019). The use of escape room scenarios in clinical nursing practice is an emerging area of research and education. It is imperative for nursing professional development leaders and specialists to provide additional studies in the future that examine the implications of escape room scenarios as an incorporated interactive teaching strategy, which can enhance and support the successful transition of newly hired nurses in the clinical environment of a certain healthcare organization.

This flexible and cognitively challenging healthcare simulation activity can shape learning in a more powerful innovative way than the traditional, conventional teaching method.

Table 2: Supplies Table 3: Equipment Laptop Computer with Timer

Figure 3

Escape Room Scenario Layout Map

Table 1

Comparison of Participant Pre-Test and Post-Test Results

Table 2

Distribution of Participant Responses on Escape Room Evaluation Survey

limitations

Formulating an escape room simulation activity was the first descriptive active learning strategy that provides an avenue for newly hired criticalcare nurses to demonstrate and evaluate their comprehension with regards to critical thinking and collaborative skills as components of EBPs and culture of safety. However, few limitations were observed and found in the implementation of this educational project. First, the location of the escape room scenario was not big enough to accommodate more participants. Furthermore, nursing management must plan the schedule of the predetermined nursing skills day in respect to appropriately staffing the unit. Second, the time for post-activity debriefing was also shortened in the interest of time. Alterations in the simulation activity, such as refining the clinical scenario, must be made for future suitable implementation. Study findings also cannot be generalizable to other healthcare work settings, since the number of participants was small and the study took place in one specific nursing unit. Objectives of the designed escape room scenario were based on the unit-specific educational needs of the newly hired nurses, which was identified prior to simulation development and testing. Additional buy-in and financial considerations from nurse leadership and educators will be needed to be considered for institution-wide adoption. Should other units want to adopt a similar escape room scenario, proper staffing, resource allocation, and unit-specific educational needs must be made initially. The team is hopeful that this project can be expanded to other participants in intensive care units so that more work can be done to validate study findings and provide evidence with regards to the use of escape room simulation activity in clinical knowledge and skills retention

among newly hired nurses. Investigators recommend further exploration on the application of escape room simulation activities for onboarding programs designed for new nurses, as well as its potential usefulness for other clinical specialty nursing units.

Conclusions

The escape room scenario as a simulation activity offers a promising and innovative evidence-based approach for supporting newly registered nurses transitioning into the realities of clinical practice. Nurse-participants who completed the escape room scenario found that such simulation design was a fun, interactive learning experience to conclude the clinical skills day for new hires. Building and evaluating gamification teaching strategies such as escape room simulation activities is considered to be an innovative, experiential learning strategy that can be incorporated into any orientation or onboarding program for newly hired licensed nurses. Such simulation activity can also be used to improve new hires’ engagement and to evaluate their knowledge retention. For nurse managers and executives, employing such a structured approach in any transition program for new hires will serve as an innovative educational resource in the context of developing a culture of safe practice, effective communication, and collaborative learning practice environment that may positively impact overall patient and organizational outcomes. Moreover, healthcare educators and leaders specializing in nursing professional development should explore the integration of these immersive escape room simulation designs as a learning tool that can be refined and reused long-term for future generations of registered nurses.

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Koukourikos, K., Tsaloglidou, A., Kourkouta, L., Papathanasiou, I. V., Iliadis, C., Fratzana, A., & Panagiotou, A. (2021). Simulation in clinical nursing education. Acta informatica medica: AIM: Journal of the Society for Medical Informatics of Bosnia & Herzegovina: casopis Drustva za medicinsku informatiku BiH, 29(1), 15–20. https://doi. org/10.5455/aim.2021.29.15-20

Labrague, L. J., McEnroe-Pettite, D., & Leocadio, M. C. (2019). Transition experiences of newly graduated Filipino nurses in a resource-scarce rural health care setting: A qualitative study. Nursing forum, 54(2), 298–306. https://doi.org/10.1111/nuf.12330

Lewis, K. A., Ricks, T. N., Rowin, A., Ndlovu, C., Goldstein, L., & McElvogue, C. (2019). Does simulation training for acute care nurses improve patient safety outcomes: A systematic review to inform evidence-based practice. Worldviews on Evidence-Based Nursing, 16(5), 389–396. https://doi.org/10.1111/wvn.12396

McDermott, D. S., Ludlow, J., Horsley, E., & Meakim, C. (2021). Healthcare simulation standards of best practiceTM prebriefing: Preparation and briefing. Clinical Simulation in Nursing, 58, 9–13. https://doi. org/10.1016/j.ecns.2021.08.008

McLaughlin, J. L., Reed, J. A., Shiveley, J., & Lee, S. (2021). Escape room blueprint: Central orientation contagion crisis. Simulation & Gaming, 52(1), 24–30. https://doi.org/10.1177/1046878120954493

Monforto, K., Perkel, M., Rust, D., Wildes, R., King, K., & Lebet, R. (2020). Outcome-focused critical care orientation program: From unit based to centralized. Critical Care Nurse, 40 (4), 54–64. https://doi. org/10.4037/ccn2020585

Mujtaba, S., Chawla, S., & Massaad, J. F. (2020). Diagnosis and management of non-variceal gastrointestinal hemorrhage: A review of current guidelines and future perspectives. Journal of Clinical Medicine, 9(2), 402. https://doi.org/10.3390/jcm9020402

Murray, B., Judge, D., Morris, T., & Opsahl, A. (2019b). Interprofessional education: A disaster response simulation activity for military medics, nursing, & paramedic science students. Nurse Education in Practice, 39, 67–72. https://doi.org/10.1016/j.nepr.2019.08.004

Murray, M., Sundin, D., & Cope, V. (2019a). New graduate nurses’ clinical safety knowledge by the numbers. Journal of Nursing Management, 27(7), 1384–1390. https://doi.org/10.1111/jonm.12819

Persico, L., Belle, A., DiGregorio, H., Wilson-Keates, B., & Shelton, C. (2021). Healthcare simulation standards of best practiceTM facilitation. Clinical Simulation in Nursing, 58, 22–26. https://doi.org/10.1016/j. ecns.2021.08.010

Pertiwi, R. I., & Hariyati, R. T. S. (2019). Effective orientation programs for new graduate nurses: A systematic review. Enfermeria clinica, 29, 612–618. https://doi.org/10.1016/j.enfcli.2019.04.094

Pornsakulpaisal, R., Ahmed, Z., Bok, H., de Carvalho Filho, M. A., Goka, S., Li, L., Patki, A., Salari, S., Sooknarine, V., Yap, S. W., & Moffett, J. (2023). Building digital escape rooms for learning: From theory to practice. The Clinical Teacher, 20 (2), e13559. https://doi.org/10.1111/ tct.13559

Treiber, L. A., & Jones, J. H. (2018). After the medication error: Recent nursing graduates’ reflections on adequacy of education. Journal of Nursing Education, 57(5), 275–280. https://doi.org/10.3928/0148483420180420-04

Watts, P. I., McDermott, D. S., Alinier, G., Charnetski, M., Ludlow, J., Horsley, E., Meakim, C., & Nawathe, P. A. (2021). Healthcare simulation standards of best practiceTM simulation design. Clinical Simulation in Nursing, 58, 14–21. https://doi.org/10.1016/j.ecns.2021.08.009

IN HEALTHCARE LITERATURE

n Three ‘Synergistic’ Problems When Taking blood Pressure

n Loewy, M. (2023, June 7). https://www.medscape.com/viewarticle/992902

Hypertension has been a known leading cause of preventable morbidity and mortality worldwide for decades. Among those patients who do have encounters with healthcare providers, accurate and consistent blood pressure measurement occurs less frequently than expected. The diagnosis and effective blood pressure management for the general population could improve if every patient has their vital signs, specifically their blood pressure correctly obtained and analyzed at every patient encounter. A consensus document signed by 25 experts from 13 institutions in the United States, Australia, Germany, the United Kingdom, Canada, Italy, Belgium, and Greece attest to this enduring problem and call for proper standardized blood pressure measurement. Several factors complicate the realization of obtaining universally accurate and consistent blood pressure measurement.

A study in Argentina reviewed almost 3,000 visits to doctor’s offices across nine healthcare centers. Findings reveal that blood pressure readings were taken only once in every seven encounters. Dr. Judith Zilberman, MD, PhD told Medscape, “Several factors can come into play: lack of awareness, medical inertia, or lack of appropriate equipment. But it is not for lack of time. How long does it take to take blood pressure three times within a 1-minute interval, with the patient seated and their back supported, as indicated? Four minutes. That’s not very much,”

López-Jaramillo, who is one of the researchers of the PURE epidemiologic study added, “Medical schools are also responsible for this. They go over this topic very superficially during undergraduate and, even worse, postgraduate training. The lack of time to take correct measurements, or the lack of appropriate instruments, is secondary to this lack of awareness among most healthcare staff members.” Since 2002, the PURE (Prospective Urban and Rural Epidemiologic) study has followed a cohort of 225,000

participants from 27 high-, mid-, and low-income countries in order to investigate the impact of modernization, urbanization and globalization, on various health measures. Blood pressures should be recorded every time a patient visits a provider, regardless of their reason for the visit.

In addition to frequent blood pressure measurement, correct technique and equipment must be utilized. Inaccurate results can lead to underdiagnosis, overdiagnosis, or a poor assessment of the patient’s response to prescribed treatments. “At least two readings separated by a minimum of 30 seconds should be taken. The two readings should then be averaged out. The patient should be asked not to smoke, exercise, or consume alcohol or caffeine for at least 30 minutes beforehand. He or she should rest for a period of 3 to 5 minutes without speaking or being spoken to before the measurement is taken. Lastly, clinically validated automated measurement devices should be used rather than manual devices.” Blood pressure should be monitored at all clinical office visits as well as at home.

A new fact sheet lists the following eight requirements for obtaining an accurate reading:

 Don’t have a conversation

 Support the arm at heart level

 Put the cuff on a bare arm

 Use the correct cuff size

 Support the feet

 Keep the legs uncrossed

 Ensure the patient has an empty bladder

 Support the back

n osteoporosis management and Fracture Prevention Clinical Practice Guidelines

n Osteoporosis Canada (2023, November 22). https://reference.medscape. com/viewarticle/998741

Osteoporosis Canada published an update to clinical practice guidelines on osteoporosis, with recommendations on management and fracture prevention in October 2023 in the Canadian Medical Association Journal. The guidelines below apply to postmenopausal females and to males aged 50 years or older.

It is recommended that adults engage at least twice weekly in balance and functional training in order to reduce fall risk. Targeting the abdominal and back extensor muscles, difficulty, pace, frequency, volume (sets, reps), or resistance should be increased over time.

Bisphosphonates (alendronate, risedronate, or zoledronic acid) are recommended for people in whom the criteria for pharmacotherapy initiation have been met. A 3- to 6-year duration is suggested for initial therapy in patients on bisphosphonates. Bisphosphonate treatment is indicated for those who meet any of the following criteria:

 Sustained a previous fracture of the hip or vertebra or suffered at least two osteoporosis-related fractures

 Have a 10-year risk of 20% or more that they will suffer a major osteoporotic fracture

 Have, at age 70 years or older, a T-score of -2.5 or less (femoral neck, total hip, or lumbar spine)

n We Know a Healthy Gut Fights Infection. New Study reveals How

n Szalinski, C. (2023, December 20). https://www.medscape.com/ viewarticle/we-know-healthy-gut-fights-infection-new-study-revealshow-2023a1000w2k?src=

Use of antibiotics to treat bacterial infection has been known to also reduce or destroy “helpful” microbes within individuals and across populations. The microbiome are microorganisms in a particular environment, body, or part of the body. In 2022, the FDA approved the first microbiota pharmaceutical (Rebyota). Taken orally, it prevents recurrence of Clostridioides difficile infection in adults. Vowst, approved in April 2023, is now used to treat C. difficile.

A new study published in Science indicates that when a great quantity of diverse species of gastrointenstinal bacteria reside together, infectious disease may be prevented. This may be attributed to the diverse nutrient consumption patterns. Greater established bacterial diversity means a greater chance that any invading pathogen would be limited in its competition for overlapping nutrients. “It’s kind of no surprise that competition for resources is what is providing the colonization resistance,” said Thomas Schmidt, PhD, professor of microbiology and immunology at the University of Michigan, Ann Arbor. Among the first of its kind to

systematically address competition between pathogens and specific host microbes, this study may bring us closer to knowing which microbes may be useful in treating infections.

In microbial culture based experiments, researchers evaluated 100 common strains of human gut bacteria to individually against the pathogens Klebsiella pneumoniae and Salmonella typhimurium. While some strains were associated with reduced pathogen growth better than other strains, Escherichia coli performed the best. No single strain could prevent infection. Protection was more robust when the top ten pathogen fighters were grouped together. When E. coli was included, combining 50 species worked even more effectively. In a population of germ-free mice, experimentally colonized similarly to the test-tube blends, similar results occurred. “Increasing the number of species in the community tended to increase the communities’ protectiveness,” Dr. Spragge said. The researchers discovered that the combined bacteria consumed more of the same nutrients as the competing pathogen.

While much research lies ahead, these findings indicate there may be future microbiota-based treatments to target other pathogens without the microbiome-reducing effect of traditional antibiotics.

n Chronic Coronary Disease Clinical Practice Guidelines

n American Heart Association and American College of Cardiology (2023, December 4). https://reference.medscape.com/viewarticle/998892

In July 2023, the American Heart Association (AHA), the American College of Cardiology (ACC), and other specialty societies updated their guidelines on the management of patients with chronic coronary disease (CCD). Changes regarding the use of beta-blockers, revascularization, and routine functional and anatomic testing have been made. Consolidation and updates of ACC/AHA 2012 and 2014 recommendations for the management of those with stable ischemic heart disease are also included.

To lower lipids in certain patient groups with CCD, adjunctive therapies, such as ezetimibe, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, inclisiran (clinical outcomes data unavailable), or bempedoic acid, may be used; statins continue to be first-line therapy. First-line antianginal therapy is now recommended to be either a calcium channel blocker or beta-blocker as first-line antianginal therapy. Unless a patient has had a myocardial infarction (MI) within the past year, left ventricular ejection fraction (LVEF) ≤ 50%, or another primary indication for beta-blocker therapy, long-term beta-blocker treatment is no longer recommended for improving outcomes in patients with CCD.

The AHA/ACC recommends use of sodium glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists for select CCD patient groups, including those without diabetes to improve outcomes. Particularly when there is a high risk of bleeding and a low to

moderate risk of ischemia, the AHA/ACC considers shorter durations of dual antiplatelet therapy as safe and effective.

The guidelines recommend revascularization for patients with CCD who meet the following criteria:

 Those with lifestyle-limiting angina despite guideline-directed medical therapy (GDMT) and with coronary artery stenoses that are willing to undergo revascularization, for symptomatic improvement

 Those with significant left main disease or multivessel disease with severe LV dysfunction (LVEF ≤ 35%), for whom coronary artery bypass grafting (CABG) plus medical therapy is recommended over medical therapy alone, for survival improvement

Cardiac rehabilitation for eligible patients is recommend to reduce morbidity and mortality from cardiovascular events. The AHA/ACC does not recommend use of nonprescription or dietary supplements (e.g., fish oil, omega-3 fatty acids, vitamins) for those with CCD citing lack of demonstrated benefit in reducing cardiovascular events. Unless there has been a change in clinical or functional status, routine anatomic or ischemic testing is not recommended for risk stratification or therapeutic decision making. While e-cigarettes improve the chance of successful smoking cessation, there has not been enough data on long-term safety and risks associated with routine use. For that reason, e-cigarettes are not first-line recommendation for smoking cessation.

n Thiazide Diuretics may Promote Hyponatremia

n Splete, H. (2023, December 18). https://www.medscape.com/viewarticle/ thiazide-diuretics-may-promote-hyponatremia-2023a1000vu3

Thiazide diuretics are usually well-tolerated by patients undergoing routine treatment of uncomplicated hypertension. A recent study of more than 180,000 adults found that those who used thiazide diuretics for hypertension were more likely than were those who used non-thiazide medications to develop hyponatremia within 2 years of beginning treatment.

Although hyponatremia is a known potential side effect to thiazide treatment, it may be more extensively experienced among those taking it for uncomplicated hypertension. Since hyponatremia has a wide range of symptoms, providers should maintain clinical awareness. Especially during the early months of treatment, patients should be aware of hyponatremiarelated symptoms and report to their prescriber. Older age and a greater number of comorbidities increased the cumulative hyponatremia in new users of thiazide-based hypertensives.

n last of the HIV Vaccine Trials Fails, Scientists regroup

n Frellick, M. (2023, December 18). https://www.medscape.com/viewarticle/ last-hiv-vaccine-trials-fails-scientists-regroup-2023a1000vot

The HIV vaccine trial began in 2018 testing two experimental combination regimes. Planned to prevent HIV infection, the vaccines contained non-neutralizing antibodies and a new form of preexposure prophylaxis. These trials have stopped because they did not demonstrate efficacy.

For an HIV vaccination to succeed, HIV infection must be prevented. Authors describe that a large amount of HIV antibody or a robust immune response to vaccine would facilitate immunity. Whereas it seems that the COVID 19 vaccines were developed quickly, it is because its success is a function of the way it prevents people from becoming very sick with the virus. People still become infected but experience less illness and mortality. However, with HIV, infection is not an option.

Researchers cite how difficult it is to determine which part of the HIV virus to target. Larry Corey, MD, virologist and principal investigator of HIV Vaccine Trials Network said, “There is a small group of people who have

really high immune responses to a part of the virus we call the V1V2 loop, but the frequency of people with that immune response is only 8%–10% of the population. If this trial, using a different vector, shows the same thing, then we have to spend a lot more time making an immunogen that gets 100% of the people to the levels of immunity that might be correlated with the V1V2 loop, and we’d walk out of this with a really good insight as to what to do next.”

So far, he said, scientists working to develop a vaccine haven’t determined which part of the virus to target.

“The clinical trial was very well done, and that’s the success,” Corey said.

Second, PREP (Pre Exposure Prophylaxis) works well to prevent sexually transmitted HIV infection when taken regularly, as directed. It requires individuals’ risk recognition, medication acceptance, intake and adherence to treatment. Between 40% and 50% of the cases of HIV globally are in people who don’t self-identify as high risk. “Just because it’s hard, doesn’t mean you give up,” says Corey.

n FDA Approves First Gene Therapies to Treat Patients with Sickle Cell Disease

n United States Food and Drug Administration. (2023, December 8). https://www.fda.gov/news-events/press-announcements/fda-approvesfirst-gene-therapies-treat-patients-sickle-cell-disease

The United States Food and Drug Administration has approved two drugs (Casgevy and Lyfgenia) for the treatment of transfusion-dependent beta-thalassemia and severe sickle cell disease in patients 12 years or older who are appropriate candidates for hematopoietic stem cell transplantation but a suitable donor is not available. For the first time, a novel genome editing technology is being utilized (Casgevy).

Beta-thalassemia and sickle cell disease are genetically inherited blood disorders affecting nearly 100,000 people in the United States. In patients with beta-thalassemia, low hemoglobin production results in low red blood cell count and symptoms like fatigue, shortness of breath, and irregular heartbeats. In patients with sickle cell disease, the hemoglobin produced by the body causes the irregular “sickle” shaped red blood cells. These cells obstruct blood vessels, reducing the oxygen supply to tissues and leading to a very painful condition and organ damage called vaso-occlusive events (VOE) or vaso-occlusive crises (VOC). Until recently, effective treatment for both conditions was limited to stem cell or bone marrow transplantation. Challenges to find suitable donors and well-equipped care facilities for bone marrow transplant leave people suffering with the disease.

Casgevy is a relatively new cellular therapy that uses CRISPR/Cas9 technology and contains exagamglogene autotemcel, a hematologic agent, as its active substance. Stem cells are obtained from the patient’s blood for modification. In the lab, cells are edited by CRISPR/Cas9 technology at the erythroid-specific enhancer region of the BCL11A gene. Casgevy is intended for one-time administration and its effects are thought to last a lifetime. The most common side effects for Casgevy are attributed to the medications needed for the engineered blood cells to engraft and replace the unmodified stem cells. Side effects of these medications include low white blood cell counts, including febrile neutropenia, low platelet levels, liver disease, nausea, vomiting, headache, and mouth sores. The medications needed for the modified blood cells to engraft and replace the unmodified stem cells are behind these adverse events.

Lyfgenia is a cell-based gene therapy. Lyfgenia uses a gene delivery vehicle for genetic modification and is approved for the treatment of patients 12 years of age and older with sickle cell disease and a history of vaso-occlusive events. With this therapy, the patient’s blood stem cells are genetically modified to produce HbAT87Q. Red blood cells containing HbAT87Q have a lower risk of sickling and occluding blood flow. These

modified stem cells are then delivered to the patient during a single stem cell transplant infusion. The most common side effects included stomatitis (mouth sores of the lips, mouth, and throat), low levels of platelets, white blood cells, and red blood cells, and febrile neutropenia (fever and low white blood cell count), consistent with chemotherapy and underlying disease. Hematologic malignancy has occurred in patients treated with Lyfgenia. A black box warning is included in the label for Lyfgenia with information regarding this risk. Patients receiving this product should have lifelong monitoring for these malignancies.

In preparation for infusion, the patient spends time receiving myeloablative conditioning (high-dose chemotherapy), a process that removes cells from the bone marrow so they can be replaced with the modified cells in Casgevy and Lyfgenia. The treated cells take hold in the bone marrow. Here, they begin to provide functioning hemoglobin.

Data Supporting Casgevy

The safety and effectiveness of Casgevy were evaluated in an ongoing single-arm, multi-center trial in adult and adolescent patients with SCD. Patients had a history of at least two protocol-defined severe VOCs during each of the two years prior to screening. The primary efficacy outcome was freedom from severe VOC episodes for at least 12 consecutive months during the 24-month follow-up period. A total of 44 patients were treated with Casgevy. Of the 31 patients with sufficient follow-up time to be evaluable, 29 (93.5%) achieved this outcome. All treated patients achieved successful engraftment with no patients experiencing graft failure or graft rejection. The most common side effects were low levels of platelets and white blood cells, mouth sores, nausea, musculoskeletal pain, abdominal pain, vomiting, febrile neutropenia (fever and low white blood cell count), headache, and itching.

Data Supporting Lyfgenia

The safety and effectiveness of Lyfgenia is based on the analysis of data from a single-arm, 24-month multicenter study in patients with sickle cell disease and history of VOEs between the ages of 12- and 50-years old. Effectiveness was evaluated based on complete resolution of VOEs (VOE-CR) between 6 and 18 months after infusion with Lyfgenia. Twentyeight (88%) of 32 patients achieved VOE-CR during this time period.

Both the Casgevy and Lyfgenia applications received Priority Review, Orphan Drug, Fast Track, and Regenerative Medicine Advanced Therapy designations.

Notice From NYS DoH

Notice From NYS DoH,

Notice From NYS DoH,

Notice From NYS DoH

Notice From NYS DoH, continued

n Ce Activity: Informed Consent: A Patient’s right to Information and a Nurse’s legal and ethical obligation

Thank you for your participation in “Informed Consent: A Patient’s Right to Information and a Nurse’s Legal and Ethical Obligation,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

INSTRUCTIONS

In order to receive the contact hour (CH) for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test, evaluation form, and earn 80% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made payable to NYSNA) or credit card. The completed answer sheet and evaluation form may be emailed, mailed, or faxed back to NYSNA; see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This program has been awarded 1.0 contact hour through the New York State Nurses Association Accredited Provider Unit.

The New York State Nurses Association is accredited by the International Accreditors for Continuing Education and Training (IACET) and offers IACET CEUs for its learning events that comply with the ANSI/ IACET Continuing Education and Training Standard. IACET is recognized internationally as a standard development organization and accrediting body that promotes quality of continuing education and training.

The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program.

In order to receive CHs and CEUs, participants must read the entire article, fill out the evaluation, and get 80% or higher on the post-test.

Presenters disclose no conflict of interest.

NYSNA wishes to disclose that no commercial support was received.

NYSNA Program Planners, Presenters, and Content Experts declare that they have no financial relationship with an ineligible company. Declaration of Vested Interest: None.

INTRODUCTION

In clinical practice, the role of the registered nurse during the informed consent process remains ambiguous. A range of questions arise when considering whether a registered nurse providing care services to a patient should secure informed consent from the patient. Nurses lack clarity over whether they should simply assist the physician with the administrative task of obtaining informed consent documents for specific procedures and treatment or to ensure that modern informed consent practices are applied throughout a patient encounter. Participants will incorporate the principles, processes, and procedures of informed consent as they facilitate patients’ meaningful decision-making in all aspects of treatment and care.

LEARNING OUTCOMES

Participants will identify the requirements for nurses to obtain a patient’s informed consent as they provide treatment and care.

OBJECTIVES

By completion of the article, the reader will be able to:

1. Identify the purpose of informed consent.

2. Identify the process of informed consent.

3. Identify implications of informed consent in daily nursing practice. Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 CH and 0.1 CEU for this program will be offered until January 31, 2027.

1) The only purpose of informed consent is to protect the healthcare provider against liability for adverse outcomes following treatment or intervention.

a. True

b. False

2) A component of the process of informed consent is that the patient has the ability to understand and appreciate the nature and consequences of proposed treatment or procedure.

a. True

b. False

3) The use of restraints requires informed consent.

a. True

b. False

4) Patients can consent to treatment, retaining the right to tell a provider that they do not wish to know risks or alternatives.

a. True

b. False

5) A document signed by the patient is always required as evidence of consent.

a. True

b. False

6) Nurses offering treatment that has the potential for patient refusal must obtain informed consent from the patient.

a. True

b. False

7) If a nurse determines that the informed consent process might adversely and significantly affect the patient’s current condition, informed consent may not need to be obtained.

a. True

b. False

8) Federal law requires that Medicaid or Medicare funded hospitals and nursing homes must provide patients with written information about advance directives.

a. True

b. False

9) In New York State, any person who is pregnant and consenting to prenatal care has the legal capacity to consent, regardless their age.

a. True

b. False

10) Healthcare providers must provide interpreter services for all patients who need language assistance when discussing plans of care with a patient.

a. True

b. False

The Journal of the New York State Nurses Association, Vol. 50, No. 2 Answer Sheet

Informed Consent: A Patient’s right to Information and a Nurse’s legal and ethical obligation

Note: The 1.0 CH and 0.1 CEU for this program will be offered until January 31, 2027.

Please print your answers in the spaces provided below. There is only one answer for each question.

Please print legibly and verify that all information is correct.

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Currently Licensed in NY State? Y / N (Circle one)

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ACTIVITY FEE: Free for NYSNA members/$10 nonmembers

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Please complete the answer sheet above and course evaluation form on reverse. Submit both the answer sheet and course evaluation form along with the activity fee for processing.

Email to: journal@nysna.org

Or mail to: NYSNA, attn. Nursing Education and Practice Dept. 131 West 33rd Street, 4th Floor, New York, NY 10001 Or fax to: 212-785-0429

Informed Consent: A Patient’s right to Information and a Nurse’s legal

and ethical obligation

Please use the following scale to rate statements 1–7 below:

Poor Fair Good Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test? ____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias? Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

n Ce Activity: Caring for the Caregiver: Implementation of a mindfulness Program for mental Health Providers in an outpatient Clinic

Thank you for your participation in “Caring for the Caregiver: Implementation of a Mindfulness Program for Mental Health Providers in an Outpatient Clinic,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity, and you do not need to be a resident of New York State.

INSTRUCTIONS

In order to receive the contact hour (CH) for this educational activity, participants are to read the article presented in this issue of The Journal, complete and return the post-test, evaluation form, and earn 80% or better on the post-test.

This activity is free to NYSNA members and $10 for nonmembers. Participants can pay by check (made payable to NYSNA) or credit card. The completed answer sheet and evaluation form may be emailed, mailed, or faxed back to NYSNA; see the evaluation form for more information.

The New York State Nurses Association is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

This program has been awarded 1.0 contact hour through the New York State Nurses Association Accredited Provider Unit.

The New York State Nurses Association is accredited by the International Accreditors for Continuing Education and Training (IACET) and offers IACET CEUs for its learning events that comply with the ANSI/ IACET Continuing Education and Training Standard. IACET is recognized internationally as a standard development organization and accrediting body that promotes quality of continuing education and training.

The New York State Nurses Association is authorized by IACET to offer 0.1 CEU for this program.

In order to receive CHs and CEUs, participants must read the entire article, fill out the evaluation, and get 80% or higher on the post-test.

Presenters disclose no conflict of interest.

NYSNA wishes to disclose that no commercial support was received.

NYSNA Program Planners, Presenters, and Content Experts declare that they have no financial relationship with an ineligible company. Declaration of Vested Interest: None.

INTRODUCTION

Anxiety and mood disorders such as depression are prevalent among the general population. 18.1% of the U.S. population suffers from anxiety, while 8.9% suffer from a mood disorder. Consequences include impaired memory, concentration, cardiovascular disease, and reduced life expectancy. Anxiety and mood disorders negatively impact professional performance and consequently patient outcomes. Healthcare workers consistently have higher rates of anxiety and depression than the general population. Lost productivity heavily burdens individuals, families, and the healthcare setting in which providers work. As a result, patients may experience suboptimal provider-patient relationships and may be at risk from medical errors. The

majority of those suffering from anxiety and mood disorders, including mental health workers, are unaware of their predicament or how to overcome it. While the practice of mindfulness is known to reduce anxiety and improve memory, healthcare workers do not routinely incorporate practices into their lives. Mindfulness practices can help people gain the insight needed to more effectively recognize anxiety within themselves and among peers as clinicians, educators, and leaders. Through incorporation of tools such as mindfulness and the Calm application, anxiety and mood disorders may give way to increased productivity, attention, and memory. This, in turn, can support therapeutic provider-patient relationships and health outcomes.

LEARNING OUTCOMES

Participants will identify that mindfulness practices can address anxiety and memory retention.

OBJECTIVES

By completion of the article, the reader will be able to:

1. Identify the scope and significance of anxiety and mood disorders in the United States.

2. Identify influence of mindfulness training on anxiety and information retention.

Please answer either True or False to the questions below. Remember to complete the answer sheet by putting the letter of your corresponding answer next to the question number. Each question has only one correct answer.

The 1.0 CH and 0.1 CEU for this program will be offered until January 31, 2027.

1) Individuals challenged by mental illness such as anxiety and depression have a life expectancy 13 years shorter than the general population.

a. True

b. False

2) Recall extinction is the gradual inability to recall information.

a. True

b. False

3) Mindfulness training can enhance working memory.

a. True

b. False

4) Use of the application Calm failed to improve users’ self-compassion, stress, or mindfulness.

a. True

b. False

5) Mindfulness-based stress reduction and mindfulness-based cognitive therapy are the most commonly used training programs in the healthcare profession.

a. True

b. False

6) The Mindfulness, Attention and Awareness Scale (MAAS) measures how often someone experienced anxiety symptoms.

a. True

b. False

7) Participants had improved anxiety (GAD-7), mindfulness usage frequency (MAAS), and memory test scores following a 4-week mindfulness training program.

a. True

b. False

8) Utilization of mindfulness practices can reduce burnout and improve job satisfaction.

a. True

b. False

9) The author concludes that short-term investment in mindfulness practices effectively improve psychological well-being and physical health.

a. True

b. False

10) The author suggests that including wellness programs in nursing education would help enable new nurses to manage their physical and mental health in the workplace.

a. True

b. False

The Journal of the New York State Nurses Association, Vol. 50, No. 2 Answer Sheet

Caring for the Caregiver: Implementation of a mindfulness Program for mental Health Providers in an outpatient Clinic

Note: 1.0 CH and 0.1 CEU for this program will be offered until January 31, 2027.

Please print legibly and verify that all information is correct.

First Name:

Street Address:

MI:

Last Name:

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Daytime Phone Number (Include area code):

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Profession:

NYSNA Member # (if applicable):

PAYMENT METHOD

Currently Licensed in NY State? Y / N (Circle one)

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ACTIVITY FEE: Free for NYSNA members/$10 nonmembers

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Date: / /

Please print your answers in the spaces provided below. There is only one answer for each question.

Please complete the answer sheet above and course evaluation form on reverse.

Submit both the answer sheet and course evaluation form along with the activity fee for processing.

Email to: journal@nysna.org

Or mail to: NYSNA, attn. Nursing Education and Practice Dept.

131 West 33rd Street, 4th Floor, New York, NY 10001 Or fax to: 212-785-0429

learning Activity evaluation

Caring for the Caregiver: Implementation of a mindfulness Program for mental Health Providers in an outpatient Clinic

Please use the following scale to rate statements 1–7 below:

Poor Fair Good Very Good Excellent

1. The content fulfills the overall purpose of the CE Activity.

2. The content fulfills each of the CE Activity objectives.

3. The CE Activity subject matter is current and accurate.

4. The material presented is clear and understandable.

5. The teaching/learning method is effective.

6. The test is clear and the answers are appropriately covered in the CE Activity.

7. How would you rate this CE Activity overall?

8. Time to complete the entire CE Activity and the test? ____ Hours (enter 0–99) _____ Minutes (enter 0–59)

9. Was this course fair, balanced, and free of commercial bias? Yes / No (Circle one)

10. Comments:

11. Do you have any suggestions about how we can improve this CE Activity?

THE JOURNAL

of the New York State Nurses Association

Call for Papers

The Journal of the New York State Nurses Association is currently seeking papers.

Authors are invited to submit scholarly papers, research studies, brief reports on clinical or educational innovations, and articles of opinion on subjects important to registered nurses. Of particular interest are papers addressing direct care issues. New authors and student authors are encouraged to submit manuscripts for publication.

Information for Authors

For author’s guidelines and submission deadlines, go to the publications area of www.nysna.org or write to journal@nysna.org

Call for Editorial Board Members

Help Promote Nursing Research

The Journal of the New York State Nurses Association is currently seeking candidates interested in becoming members of the publication’s Editorial Board.

Members of the Editorial Board are appointed by the NYSNA Board of Directors and serve one 6-year term. They are responsible for guiding the overall editorial direction of The Journal and assuring that the published manuscripts meet appropriate standards through blinded peer review.

Prospective Editorial Board members should be previously published and hold an advanced nursing degree; candidates must also be current members of NYSNA. For more information or to request a nomination form, write to journal@nysna.org