The Journal of the New York State Nurses Association, Volume 51, Number 2
THE JOURNAL
of the New York State Nurses Association
VOLUME 51, NUMBER 2
n Editorial: The Nurse’s Role in Empowering Patients Through Education by Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k; Simon Paul P. Navarro, MA, BSN, RN, CCRN, TCRN; Alsacia Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Coreen Simmons, PhD(c), DNP, MSN, MPH, RN
n The Jury Is Out: Effective Pathophysiology and Pharmacology Instruction in New York State Baccalaureate Nursing Education by Cindy Paradiso, PhD, RN-BC, CNE; and Elizabeth A. Berro, PhD, RN, CHSE, CNE
n Effects of Percutaneous Coronary Intervention on Health-Related Quality of Life Among Patients Living With Coronary Artery Disease by Renu Mathew, RN, FNP-BC; Sharon Stahl Wexler, PhD, RN, FNGN; and Karen Roush, PhD, RN, FNP-BC
n Nurses Advancing Equity and Inclusion Through Communication and Language by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; and Lucille Contreras Sollazzo, MSN, RN-BC, NPD
n What's New in Healthcare Literature
n CE Activity: Nurses Advancing Equity and Inclusion Through Communication and Language
THE JOURNAL
VOLUME 51, NUMBER 2
n Editorial: The Nurse’s Role in Empowering Patients Through Education
by Anne Bové, MSN, RN-BC, CCRN, ANP; Audrey Graham-O’Gilvie, DNP, RN, ACNS-BC, CCRN-k; Simon Paul P. Navarro, MA, BSN, RN, CCRN, TCRN; Alsacia Sepulveda-Pacsi, PhD, DNS, RN, FNP, CCRN, CEN; and Coreen Simmons, PhD(c), DNP, MSN, MPH, RN
n The Jury Is Out: Effective Pathophysiology and Pharmacology Instruction in New York State Baccalaureate Nursing Education
by Cindy Paradiso, PhD, RN-BC, CNE; and Elizabeth A. Berro, PhD, RN, CHSE, CNE
n Effects of Percutaneous Coronary Intervention on Health-Related Quality of Life
by Renu Mathew, RN, FNP-BC; Sharon Stahl Wexler, PhD, RN, FNGN; and Karen Roush, PhD, RN, FNP-BC
n Nurses Advancing Equity and Inclusion Through Communication and Language
by Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD; and Lucille Contreras Sollazzo, MSN, RN-BC, NPD
n
n
THE JOURNAL
of the New York State Nurses Association
n The Journal of the New York State Nurses Association Editorial Board
NewYork-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
Simon Paul P. Navarro, MA, BSN, RN, CCRN, TCRN
Clinical Nurse Bronx, NY
NewYork-Presbyterian / Columbia University Irving Medical Center New York, NY
n Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, Co-Managing Editor
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.
The Nurse’s Role in Empowering Patients Through Education
Patient education is one of the most important, if not the most important, aspects of nursing care. An informed patient is able to build their self-esteem, self-awareness, sense of responsibility, and effective coping mechanisms. Successful patient education can significantly impact positive patient outcomes, increase patient satisfaction scores, reduce readmissions and overall healthcare costs, and reduce mortality and morbidity.
For patients to take a proactive role in their own care, they need to be able to comprehend their condition and work to prevent or minimize complications from their chronic illnesses. To accomplish this, we, as nurses, must continually work to improve our patient teaching and education prior to discharge—in accordance with the age-old adage that discharge planning and teaching begins on day one of admission.
Nurses with good communication skills are experts at educating patients, which is why we’re often tasked with the responsibility of providing health education. When nurses provide quality health education, they empower patients to better serve themselves, thus activating a paradigm shift and transformation of our current healthcare system rooted in the biomedical model of care to a wellness model rooted in holistic medicine.
In the article “The Jury Is Out: Effective Pathophysiology and Pharmacology Instruction in New York State Baccalaureate Nursing Education,” readers are introduced to the concept that effective patient teaching can only be accomplished by providing student nurses with an academic program that fosters self-confidence and advanced knowledge of nursing’s scientific underpinnings.
In the article “Effects of Percutaneous Coronary Intervention on Health-Related Quality of Life Among Patients Living With Coronary Artery Disease,” readers are introduced to the concept that individualized patient care plans and patient teachings on the limitations and challenges they may face following a percutaneous coronary intervention procedure correlates highly to reductions in premature mortality and morbidity.
In the article “Nurses Advancing Equity and Inclusion Through Communication and Language,” readers are introduced to the idea that without a proper awareness of the impact of language, words and phrases that perpetuate disparities and othering can negatively impact nurses’ effectiveness in our patient teaching goals.
Patients are often eager to understand and know more about their medical conditions and health situations. Educating them with the most relevant, up-to-date, and consistent information helps patients and their families in the medical care and decision-making process. Patients who are well versed on their health conditions will have a higher degree of knowledge on their health literacy, and will enhance and promote informed decision-making based on the most current and updated scientific and clinical evidence. This, in turn, ensures the creation of care plans that are not only rooted in evidence-based concepts, but in patient preferences as well.
The Jury Is Out: Effective Pathophysiology and Pharmacology Instruction in New York State Baccalaureate Nursing Education
Cindy Paradiso, PhD, RN-BC, CNE
Elizabeth A. Berro, PhD, RN, CHSE, CNE
n Abstract
A solid knowledge base in pathophysiology and pharmacology is a requisite for becoming a competent and safe nurse. Despite the importance of these foundational courses, nursing programs are hard-pressed to find the most effective course delivery. Decisions faced by nursing programs include determining the optimal placement of these courses within the curriculum, allocating credit amounts, and deciding whether to present pathophysiology and pharmacology in an integrated format or keep pharmacology as a stand-alone course. This case study report presents how different accredited baccalaureate nursing programs within New York State (NYS) deliver these course offerings and the outcomes of one nursing program that transitioned to integrating both courses. Data collected included curricular placement of pathophysiology and pharmacology, credit allotment, and whether a relationship exists between delivery mode and National Council Licensure Examination for Registered Nurses (NCLEX-RN) pass rates. The findings highlight the variability in the instruction of these courses within NYS nursing programs.
With an increasing demand for primary care in the United States, related in part to an aging population, there is a great need for nurses who act responsibly and with insight to provide safe and high-quality care to patients (Kavanagh & Szweda, 2017). Nursing programs, however, struggle to prepare students for their profession despite advances in curriculum development, adherence to thoughtful and comprehensive standards, and well-defined accreditation (National Academies of Sciences, Engineering, and Medicine, 2021). In 2020, only 9% of 1,200 new graduate registered nurses from 200 unique schools of nursing scored in the acceptable competency range for a novice nurse (Kavanagh & Sharpnack, 2021). Additionally, self-reports reveal that newly graduated registered nurses lack the confidence to provide safe patient care (Murray et al., 2019). Starting nurses can experience a transition shock, defined as “the most immediate, acute, and dramatic stage in the process of professional role adaptation for the [nursing graduate]” (Duchscher, 2009, p. 1104). Several studies have shown that this transition shock and unpreparedness are associated with increased turnover intentions and decreased quality of care, including adverse patient events, such as medication errors (Asensi-Vicente et al., 2018; Treiber & Jones, 2018). From these findings, it can be understood why nursing students need to be better equipped by their training (Preston et al., 2019; Treiber & Jones, 2018).
Critical educational components of professional nursing practice include pathophysiology, “the study of how a disease affects the functioning of the body” (Ashelford et al., 2019, p. 14), and pharmacology, “the science that examines the composition, effects, and uses of drugs” (Ashelford et al., 2019, p. 21). While some studies propose specific teaching techniques and tools for their instruction (Branney & Priego-Hernández, 2018; Mauldin, 2021; Thomas & Schuessler, 2016), consensus is yet to be achieved about the basic terms of the offerings, including whether they should be stand-alone or integrated courses, whether one’s own nursing department should offer it, and curriculum placement (sophomore, junior, or senior year) (Colsch et al., 2021; Foster et al., 2017). The aim of the present study is to use New York State as a case study of how different nursing programs offer pathophysiology and pharmacology and what is known about the results. Additionally, we provide a reflection on the experience of our nursing program.
Cindy Paradiso, PhD, RN-BC, CNE, College of Health Professions, Pace University, Pleasantville, New York
Elizabeth A.
Berro, PhD, RN, CHSE,
CNE, College of Health Professions, Pace University, Pleasantville, New York
Background
In early nursing programs, pathophysiology and pharmacology education was nonexistent, as physicians kept treatments to themselves. Nursing education predominantly focused on practical skills and hands-on experience, with little emphasis on the field’s scientific underpinnings (Egenes, 2017; Scheckel, 2009). Today, nursing students receive extensive instruction in pathophysiology and pharmacology as part of their education (Peate, 2022). This includes understanding the underlying mechanisms of various diseases and conditions, as well as the effects of medications on the body and potential side effects (National League for Nursing Commission for Nursing Education Accreditation [NLN CEA], 2021). In addition, students learn how to safely administer medications and monitor patients for adverse reactions (NLN CEA, 2021). Evidence has demonstrated that pathophysiology and pharmacology exam scores predict National Council Licensure Examination (NCLEX) success (McGahee et al., 2010; Herrera & Blair, 2015; Yeom, 2013).
Integration or Stand-Alone
In 2002, Manias and Bullock obtained the opinions of 16 lecturers and 43 nursing students about pharmacology. Lecturers felt there might be insufficient focus on pharmacology when provided in an integrated manner but nevertheless preferred it, finding it helped link theory and practice. Students, on the other hand, clearly felt better prepared when provided with a stand-alone course and did not feel the link with practice was made in the integrated courses. In 2003, Zellner and colleagues noticed the paucity of research that was able to inform nursing curriculum development. They retrospectively analyzed whether students obtained better pharmacology test results if they had received integrated pharmacology content throughout a 4-year curriculum (the method they had used in 1994–1997) or if they had been offered a stand-alone pharmacology course during the sophomore year (the method they had used in 1998–1999). They found that there were no differences in the exam scores on medication calculations and effects of medication, but the students who had followed the integrated course (n = 196) outperformed those who had followed the stand-alone course (n = 103) on principles of medication administration and performed better compared to the national norm on this component. The researchers, however, acknowledged confounding variables, including other curricular changes and reorganization of clinical hours.
No later studies have been carried out to provide further support for these early findings. Colsch et al. (2021) revealed higher satisfaction among nursing students in traditional pathophysiology (n = 31) than in blended learning (n = 25). However, no significant results were found when comparing the students’ posttest results. Foster et al. (2017) asked the opinion of 55 senior students about pharmacology education and found that students perceived that reviewing pathophysiology as part of pharmacology instruction was an effective teaching strategy. This suggests a more specific form of integration where pathophysiology and pharmacology are combined into a single course. Although this integration is offered by some universities, it has not yet been established whether or not it is more effective compared to stand-alone courses.
Instructor Characteristics
Courtenay et al. (1991) found that nurse lecturers considered their knowledge of pharmacology and biological sciences inadequate. This
made a case for biologists, pharmacologists, or physiologists to provide this fundamental instruction. On the other hand, Manias and Bullock (2002) found that nursing lecturers agreed that pharmacology instructors “needed a nursing background and science lecturers could not integrate theory and practice” (p. 12). A case study analysis in the United Kingdom (U.K.) revealed a divided opinion on who should teach pharmacology (Latter et al., 2000). Students at one research site, in which pharmacologists instructed medical and nursing students together, expressed dissatisfaction. In the same study, however, lecturers considered biological scientists and pharmacologists the most appropriate for teaching these subjects within the nursing curriculum.
Lewis (1981) and Wharrad et al. (1994) surveyed undergraduate nursing programs regarding pathophysiology and biological science instruction in the United States (U.S.) and United Kingdom, respectively. Their studies are dated but provide some perspective. Lewis queried 205 NLN-accredited nursing programs and found that nurses taught 55% of pathophysiology courses. The later study of Wharrad et al. (1994) revealed that only 15.9% of biological science lecturers had a nursing background in the United Kingdom. Altogether, study results remain unclear on whether education is most effective when provided by the nursing department or other specialists.
Placement in the Curriculum
Pathophysiology and pharmacology courses are offered at various points within nursing curricula. Foster et al. (2017) identified course placement as one of four student-perceived barriers to pharmacology education. Lewis’s (1981) study revealed that 60% of responding nursing programs offered pathophysiology in the junior year, 22%, and 11% in the sophomore and senior years, respectively. Pathophysiology course credits ranged from two to six, with 58% awarding three or four credits. In one more recent study carried out at a U.S. university that sought to improve junior nursing students NCLEX passing rates and retention, pathophysiology was deliberately and successfully moved from junior to sophomore year (Weber, 2020).
With respect to pharmacology, Manias and Bullock’s (2002) study of Australian nursing programs revealed that 49% of curricula included pharmacology in the 2nd year, followed by the 3rd year (36%). In their other publication, it was reported that the number of allocated credits/ hours ranged from about one credit to 27 hours of lectures combined with 18 hours of tutorials (Manias & Bullock, 2002). Herrman and Diefenbeck (2009) described it as a sophomore course, forming a prerequisite for clinical experience. If integrated into other courses, it is also found to be spread over 3 years, with the basics provided in the 1st year, and thereafter increasing complexities (including pharmacodynamics and -kinetics in the 2nd year and differentiation and applied reasoning in the 3rd year) (Lim & Honey, 2006). None of these studies addressed the question of the effect of placement in the curriculum in terms of NCLEX passing rates or other measures of learning outcomes.
The Present Study
The literature review demonstrates a lack of consistency and the need for more research to understand the best pathophysiology and pharmacology education practices within the nursing curriculum. These vital foundational courses require appropriate placement and delivery to
support student success in higher-level nursing courses, clinical experiences, and safe patient care. However, the evidence base is limited, consisting of outdated studies and insufficient information on the various aspects of delivery. Therefore, we explored NYS data as a case study. First, we looked at the relationship of test scores at our own site, where pathophysiology and pharmacology delivery were changed from stand-alone junior year courses to one integrated sophomore course. Second, we examined pathophysiology and pharmacology delivery in other baccalaureate-accredited NYS nursing programs. We described how it was delivered, and whether there were associations between the different delivery modes and NCLEX pass rates.
Methods
Sample and Procedure
In our nursing program, offered in a private university in the Lower Hudson Valley region, pathophysiology and pharmacology were given by the nursing department to junior students as two stand-alone courses from years 2014–2015 to 2018–2019. The pathophysiology course was subdivided into Pathophysiology I (foundational) and Pathophysiology II (complex systems). During the Fall 2018 semester, faculty voted on two undergraduate curriculum changes. We combined pathophysiology and pharmacology into one integrated course offered over two semesters (Integrated I and Integrated II) and moved it from the junior to the sophomore year. The instructors, however, were still from the nursing department. The rationale for these changes was to provide a seamless transition from anatomy and physiology offered in the first year to pathophysiology, with the goal of improving student retention (Weber, 2020). Additionally, this shift was thought to provide students with a strong pharmacology knowledge base before their first clinical experience, as suggested by Herrman and Diefenbeck (2009). We included the anonymized data of all students who completed the test(s) each year (Table 1).
For the second part of the study, the data from 32 Commission on Collegiate Nursing Education (CCNE)-accredited 4-year nursing programs in New York State were retrieved. Data was obtained from program documents published on university websites, including student handbooks, curriculum plans, and course descriptions. Data collected included the position of the pathophysiology and pharmacology courses in the curriculum, the number of credits, the department responsible for teaching the courses, and the 2020 NCLEX results.
National Council Licensure Examination
The NCLEX is designed to evaluate the knowledge and skills necessary for safe and effective nursing practice at the entry level and is updated periodically to reflect changes in nursing practice and ensure that it remains relevant to the field. The exam is computer-adaptive, meaning that the difficulty of the questions is adjusted based on the test-taker’s responses. This helps to ensure that each test is tailored to the individual’s knowledge level and provides an accurate assessment of their abilities. The NCLEX includes pharmacology and pathophysiology aspects of Physiological Integrity. Pharmacological and Parenteral Therapies, as a subcategory of Physiological Integrity, account for 13%–19% of the exam content, while physiological adaptations, including pathophysiology, account for 11%–17% of the exam content.
Department Responsible, Place in the Curriculum, and Credits
Our research included the department responsible for offering the course; however, we did not examine the faculty’s qualifications. Place in the curriculum was determined by year (sophomore, junior, senior, or other). Finally, study credits were registered for pathophysiology and pharmacology separately if possible, and otherwise for the combination.
Table 1
Number of Students Participating in Each Test
Year
and subject
Data Analysis
Data were analyzed with IBM SPSS Statistics 28.01. For the analyses of the test scores at our own site, two analyses of variance were used. In the first analysis, we examined if the subject delivery (integrated vs separate course) significantly predicted test scores. In the second analysis, we examined if academic year placement predicted test scores. Further, we also checked the percentage of students who failed exams (less than C+). It is noted that this threshold was not used for each course and year, as will be further explained in the discussion.
Because of deviations from normality and the small sample size, nonparametric tests were used for the analysis of the overall NYS data. A Mann-Whitney U test was carried out to test whether the 2020 NCLEX scores were different when the courses were stand-alone or combined/ integrated. We used Spearman Rho correlations to verify if placement in the curriculum and credits were associated with test scores. We further used descriptive statistics to describe how the courses were offered most.
Results
Effects of the Nursing Program Changes
Figure 1 demonstrates the test scores of the students at our program. Analysis of variance showed that there was a significant effect of subject, F(4, 1,624) = 30.74, p < .001, ŋp2 = .07. The highest average test scores were obtained for Pharmacology (M = 3.37, SD = 0.42) and Integrated II (M = 3.31, SD = 0.61). These scores were significantly higher than all other test scores (p < .05) while not significantly different from each other, p = .156. This was followed by the test scores obtained in Pathophysiology II (M = 3.20, SD = 0.45), which were significantly lower compared to Pharmacology (p < .001) and Integrated II (p = .028) but higher compared to Integrated I and Pathophysiology I, p < .001 for both comparisons. In contrast to the second part of the integrated course, Integrated I was not done as well (M = 3.02, SD = 0.74), with students obtaining similar scores compared to Pathophysiology I (M = 2.96, SD = 0.58), p = .236. However, it is noted that the lower average scores on Integrated I were mostly due to the lower scores obtained in the Fall of 2019.
The second analysis of variance showed an effect of academic year, F(7, 1621) = 36.49, p < .001, ŋp2 = .03. Pairwise comparisons revealed that in the first academic year that the integrated course was provided, students obtained the best average scores (M = 3.33, SD = 0.50), although the difference with 2014–2015 (M = 3.24, SD = 0.53) and 2017–2018 scores (M = 3.24, SD = 0.48) did not reach significance, p = .132 and p = .096 respectively. The net results obtained in the years thereafter, with M = 3.06, SD = 0.81 in 2020–2021 and M = 3.03, SD = 0.83 in 2021–2022 returned to similar scores compared to in the years 2015–2016 with M = 3.09, SD = 0.49 and 2016–2017 with M = 3.08, SD = 0.56, with no significant differences in these scores.
Finally, looking at the number of students who obtained scores below C+, we find percentages between 0% and 12.2%, with the highest percentages for Pathophysiology I in 2016–2017 (10.6%) and the integrated course in the last two years (10.6%–12.2%), as shown in Table 2.
Descriptions of Pathophysiology and Pharmacology Education in NYS Nursing Programs
Integration or Stand-Alone
Pathophysiology and pharmacology were most commonly (57.9%) provided as stand-alone courses (Figure 2). In 21.1% of instances, combined pathophysiology and pharmacology instruction were integrated into a combined course, and another 21.1% were integrated into other nursing courses (e.g., medical-surgical nursing).
Mann-Whitney U test revealed that NCLEX 2020 scores were not significantly lower when the courses were delivered as stand-alone rather than combined or integrated, U = 100, z = -1.20, p = .229. However, it was noted that the lower ranges of NCLEX 2020 scores were only present in the stand-alone courses, which ranged from 3,300 to 10,000, M = 7,604.21, SD = 1,957.70, and showed some negative skewness (skew = -0.63, SE = 0.52). In contrast, the NCLEX 2020 scores ranged from 6,670 to 9,890, M = 8,535.00, SD = 1,034.89 in the combined or integrated courses and skewness was small (skew = -0.30, SE = 0.60).
Figure 1
Average Test Scores on Each Test in Each Year
Subject Pathophysiology l Pathophysiology ll Pharmacology Integrated l Integrated ll
Department Responsible
The nursing department almost exclusively taught pharmacology (90.9% of the cases). It was not always clear which department was responsible for pathophysiology (26.3% missing). However, from those schools that provided conclusive information, it appeared that it was the nursing department in 67.9% of the cases. Of the nine cases where nurses did not teach pathophysiology, eight were stand-alone courses. This small subsample makes it impossible to conclude any potential associations with the NCLEX 2020 scores.
Table 2
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Placement in Curricula and Credit Load
Schools most frequently provided courses in the first two years (90.0% for pathophysiology and 85.7% for pharmacology). In half of the programs (50%), both were provided in the junior year. If not provided in the same year, the students typically first learned pathophysiology then pharmacology. The Spearman’s rho correlations between placement in the curriculum NCLEX 2020 scores were negative, but did not reach significance, p = -.26, p = .229 for pathophysiology and p = -.15, p = .447 for pharmacology.
Pathophysiology was given three credits, except in one school with only two credits and one school with six credits. Due to missing data, information remains unknown for the other programs. In contrast, there was more variation in the credits given for pharmacology. Half of the schools gave three credits, 7.9% gave two credits, 15.8% gave four credits, and one school (2.6%) gave six credits (not the same program as the one that gave six credits for pathophysiology). The total amount of credits was most commonly six (in 47.4% of the programs) and ranged from three to nine. Although the association between the credits provided for pharmacology and NCLEX 2020 scores was positive, Spearman’s Rho correlation could not confirm this was significant, p = .28, p = .174. There did not appear to be an association between credits for pathophysiology and NCLEX 2020 scores, p = .06, p = .803.
Figure 2
Percentage of Pathophysiology and Pharmacology Courses Provided Combined, Stand-Alone, or in Another Form of Integration
Combined or independent
Discussion
Pathophysiology and pharmacology are essential foundational courses in nursing programs to prepare nursing students for professional clinical practice. Our data highlights the variability in the instruction of these two core courses within NYS nursing programs. Although no associations were found between NYS NCLEX-RN results and pathophysiology and pharmacology course delivery, more research with larger sample sizes is needed to reveal any associations between curricular design and NCLEX results.
Mastery of pathophysiology and pharmacology is the foundation for nursing knowledge. These two courses are essential to critical thinking and are the golden thread that provides the framework for medical-surgical interventions. Nurses must have a strong foundation in pathophysiology, medications, and adverse effects and treatments (Von Colln-Appling & Giuliano, 2017). Despite limited guidance provided by the regional data on the most effective delivery of pharmacology and pathophysiology, offering a combined course appears to be a more practical option than the standalone course. Christensen et al. (2015) found that students valued the contextualization of pathophysiology. Furthermore, a combined or integrated format may also be more cost-efficient. The results of our own site revealed that while not necessarily resulting in better outcomes, the average scores obtained when delivering an integrated course remained the same.
The data show that most programs teach pathophysiology in the junior year. The placement of these courses should be further examined in conjunction with upper-division nursing courses. Foster (2017) found that students can become overwhelmed when taking pharmacology simultaneously with medical-surgical nursing, leading to memorizing medications instead of deeper learning of content. Alternatively, when pharmacology is placed in the sophomore year, medications are discussed without the context of clinical practice to reinforce learning and critical thinking. However, this is theoretically safer, as students will have basic pharmacology knowledge before administering medications in the clinical setting.
Limitations
This study has several limitations, including sample size, as the data are limited to NYS CCNE-accredited 4-year traditional baccalaureate
Nursing educators and researchers must identify the best educational practices to support undergraduate nursing students and meet the increasing demand for professional nurses.
nursing programs. The data regarding the program curriculum were obtained from the publicly available website, which may not reflect recent curricular changes. Furthermore, there is a lack of prior research in this area. Within our program, there were confounding variables potentially impacting our data. Such variables include changing course faculty, alterations in credit allotment, and the effects of COVID-19 on student engagement and performance.
Conclusion
Pathophysiology and pharmacology instruction is an essential aspect of undergraduate nursing education. There is a long history of including this material in the nursing curriculum. Nearly 30% of the NCLEX test reflects this material. Despite the value of this instruction for future professional nurses, there is little known at a curricular level about best practices in pathophysiology and pharmacology instruction. This research does little to shed light on best practices but highlights a gap in curricular delivery and pedagogy of two essential nursing courses. In NYS, 4-year undergraduate nursing programs offer various pathophysiology and pharmacology educational practices. Nursing educators and researchers must identify the best educational practices to support undergraduate nursing students and meet the increasing demand for professional nurses. Further studies should examine pathophysiology and pharmacology delivery at a regional or national level and the relationship between pathophysiology and pharmacology instruction and clinical performance.
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Effects of Percutaneous Coronary Intervention on Health-Related Quality of Life Among Patients Living With Coronary Artery Disease
Renu Mathew, RN, FNP-BC
Sharon Stahl Wexler, PhD, RN, FNGNA
Karen Roush, PhD, RN, FNP-BC
n Abstract
Objective: The objective of this integrative review was to summarize what is known about the effects of percutaneous coronary intervention (PCI) on health-related quality of life (HRQoL) among patients living with coronary artery disease (CAD).
Background: CAD is the third leading cause of mortality and disability-adjusted life years (DALYs) worldwide. Its management prolongs survival and improves quality of life. Accessing HRQoL after PCI could help providers better understand patient outcomes and recognize early signs of disability.
Design: An integrative review was conducted to summarize the relevant literature published from 2018 and 2023.
Methods: Databases searched were Medline/PubMed, CINAHL, PsycInfo, ProQuest Central, Cochrane, and Google Scholar using the following key terms: “percutaneous coronary intervention,” “coronary artery disease,” and “health-related quality of life.” Identified studies were reviewed for content and relevance and selected studies were appraised using Bowling’s criteria. Twelve studies met the inclusion criteria and were included in the review.
Findings: HRQoL ranged from poor to moderate among patients within 1 month, 3 months, 6 months, and 12 months after PCI. Understanding the factors that decrease HRQoL is essential. The factors influencing HRQoL after PCI were grouped into five categories: patient characteristics, social factors, physical factors, emotional factors, and premature mortality.
Conclusion: Knowledge and awareness about patients’ challenges when undergoing PCI must be improved and appropriate referral services must be implemented to reduce disability, premature mortality, and morbidity. Nurses should enhance communication among patients and providers, encourage understanding of disease processes and progression, and influence attitudes toward self-care among patients. This can be attained by improving health literacy on the expected outcomes and risk factors after PCI and recognizing and implementing primary preventive measures for CAD.
Keywords: coronary artery disease (CAD), health-related quality of life (HRQoL), percutaneous coronary intervention (PCI), patient outcomes, disability-adjusted life years (DALYs)
Renu Mathew, RN, FNP-BC, Montefiore Health System, New York, New York
Sharon Stahl Wexler, PhD, RN, FNGNA, College Health Professions, Pace University, New York, New York
Karen Roush, PhD, RN, FNP-BC, College Health Professions, Pace University, New York, New York
Cardiovascular disease (CVD) is the leading cause of death globally, accounting for 32% of deaths and claiming about 41 million lives yearly (Joseph et al., 2017). It is a significant contributor to disability, reduced quality of life (QoL), premature mortality, and increasing healthcare costs. CVD-related costs are expected to rise to $818.1 billion by 2030, and loss in productivity is projected to cost around $275.8 billion (Heidenreich et al., 2011). According to Tsao et al. (2023), CVD is the leading cause of mortality in the United States (U.S.), responsible for one in every five deaths. Among the types of CVD, such as ischemic heart disease and stroke, the most common type that increases mortality is coronary artery disease (CAD).
Coronary Artery Disease (CAD)
CAD is the third leading cause of mortality and disability-adjusted life years (DALYs) worldwide. One in 20 adults is diagnosed with CAD. From 2018 to 2019, the medical expenses related to CAD averaged about $239.9 billion (Tsao et al., 2023). According to the World Health Organization (n.d.), having 1 DALY represents losing 1 full year of health. The DALY for a disease is the sum of years of life lost due to premature mortality and the sum of years lived with disabilities. Managing CAD prolongs survival and improves the QoL; it aims to reduce cardiac death, non-fatal ischemic events, progression of atherosclerosis, symptoms, and functional-limiting factors (Virani et al., 2023).
According to the Centers for Disease Control and Prevention (2021), CAD is caused by the narrowing of the coronary arteries by plaque deposits (atherosclerosis); over time, these plaque deposits could grow or become stable. A fibrous cap grows over the lesion in a stable plaque and calcifies it, hindering blood and oxygen supply to the myocardium. CAD can be classified as stable ischemic heart disease or acute coronary syndrome (ACS). Its risk factors can be categorized as either modifiable or nonmodifiable. As CAD develops over time, symptom presentation depends on the stage of illness. The most common symptoms are dyspnea (at rest and with activity) and angina during exertion. These symptoms can limit patients from having a good health-related quality of life (HRQoL). Enhanced awareness and knowledge regarding CAD could help providers decide on the best treatment modality based on the patient's presentation and the level of disease progression.
The risk of CAD can be minimized through medical management, which is the cornerstone of CAD treatment, including medication, lifestyle changes, self-care, adequate nutrition, and referral to specialists when needed (Neumann et al., 2019). Anti-ischemic treatment mainly aims to control symptoms and improve QoL by eliminating the mechanical restriction of blood flow in the coronary arteries (Santucci et al., 2020). According to Doenst et al. (2022), there are three therapeutic principles in treating CAD: treating symptoms, preventing disease progression, and preventing adverse events. Conservative therapy aims to cover all three principles. The efficacy of this therapy can be improved by using invasive procedures such as angioplasty (stent placement), also known as percutaneous coronary intervention (PCI), and coronary artery bypass grafting (CABG).
Percutaneous Coronary Intervention (PCI)
Revascularization or PCI is recommended for patients diagnosed with low atherosclerotic burden (Virani et al., 2023). PCI is a nonsurgical invasive procedure estimated to be utilized in 1 million U.S. CAD patients. It was
first performed in 1977 in Germany; today, PCI has advanced tremendously (Tsoulou et al., 2023). PCI has been shown to reduce mortality and reinfarction rates among patients with CAD and improve their QoL (Damman et al., 2016). The benefit of PCI depends on its effect on patients' QoL, including angina, physical activity, and emotional well-being (Blankenship et al., 2013). A poorer HRQoL has been shown to predict a higher risk of hospital readmission and increased mortality in patients with CAD (Phyo et al., 2021).
Quality of Life
QoL is a broad concept that covers all aspects of human life. While HRQoL focuses on illness and the impact of treatment on QoL, it also provides a comprehensive evaluation of all the aspects of QoL related to health (Guyatt et al., 2007). HRQoL is a subjective concept for providers regarding patient viewpoint, measured as patient-reported outcomes (PRO), which significantly affects healthcare outcomes and reimbursement (Agarwal & Mathur, 2022). This multifaceted concept seeks to understand disease conditions, side effects of treatment, and functional status. It includes physiological, sociological, and psychological domains. HRQoL instruments measure patients’ experience from gained or lost HRQoL and provide a non-disease-specific outcome measure (Németh, 2006). A combination of subjective and objective clinical indicators of HRQoL helps improve the effectiveness of medical treatment by evaluating methods of symptom management and treatment effects (Lin et al., 2017).
There is a growing awareness among healthcare providers about the inclusion of patients in health-related decision-making, indicating the need for patient-reported outcome research to be integrated into clinical practice. Patient-centered treatment outcomes, such as HRQoL, can significantly reflect patients’ needs (Sullivan, 2003). HRQoL is vital to patient-centered care, as it contributes to increasing patients’ realistic expectations of the benefits of an intervention and helps them engage in better decision-making about their health. It also improves patients’ well-being through better treatment adherence, higher satisfaction with better health outcomes, and decreased DALYs (Lawton et al., 2022).
Understanding HRQoL after PCI could help understand patient outcomes and recognize early signs of disability. Relevant measures must be implemented to improve QoL and prevent premature death and disability. A deeper understanding of the literature is needed to understand how HRQoL is affected after PCI.
There is a growing awareness among healthcare providers about the inclusion of patients in health-related decision-making, indicating the need for patient-reported outcome research to be integrated into clinical practice.
Methods
Literature Search
An integrative review of the literature was conducted to summarize what is known about the effects of percutaneous coronary intervention on HRQoL in patients living with coronary artery disease. The methodology described by Whittemore and Knafl (2005) was utilized as a guide for this review. This approach ensured the inclusion of diverse methodologies and enabled the summarization of all empirical and theoretical literature by informing research and practice.
A search strategy was designed with the help of an experienced research librarian at Pace University to determine what is known about the effects of PCI on HRQoL among patients with CAD. The following databases were searched for all original research studies and theoretical papers from different disciplines: MEDLINE/PubMed, CINAHL, APA PsycInfo, ProQuest Central, Cochrane, and Google Scholar. An initial search was conducted using the following key terms: “percutaneous coronary intervention,” “coronary artery disease,” and “health-related quality of life.” Filters were applied in each database. Only articles published from 2018 to 2023 in the English language and in peer-reviewed academic journals were included. Boolean operators “and,” “or,” and “not” were used to extract more focused results. Medical subject headings (MeSH) terms were not used, as for the term “PCI mapping,” results included vascular and endovascular procedures, while for the term “HRQoL mapping,” the results included QoL. The titles and abstracts of the retrieved articles were screened to identify other key terms and concepts to ensure a comprehensive search. Hand-searching and citation mining were also performed.
Inclusion and Exclusion Criteria
The search criteria yielded 2,379 studies, and after applying the inclusion criteria: a) the studies that address the HRQoL among patients with CAD after PCI were included; b) the population included were adults older than 18 years old (pediatric population also undergo PCI). A total of 136 studies remained for evaluation. The next step of applying the exclusion criteria to the remaining studies was utilized. The exclusion criteria were a) studies that focused on QoL, which differs from HRQoL; b) studies involving cardiac rehabilitation as an intervention; c) tool development studies that measured QoL; and d) studies that compared treatment modalities for patients living with CAD were excluded.
Search Results
Twelve studies were included in the review. All studies were quantitative, and 11 were conducted outside the United States. Via hand-searching, an additional editorial article from the American Heart Association was identified as gray literature, but it was not included in the review as it was an opinion article on improving symptoms and QoL among stable patients with CAD. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart in Figure 1 shows the search process.
Critical Appraisal
The 12 peer-reviewed studies were critically appraised using Bowling’s (2009) critical appraisal tool. The articles that met at least 11 of the 20
criteria were eligible for inclusion in the review. Each study’s total number of criteria ranged from nine to 12. Most studies had either a longitudinal, descriptive, or prospective cross-sectional cohort design; one study had a pretest-posttest design. The critical appraisal process is further detailed in Table 1 and the summary is shown in Table 2. The complete data extracted are displayed in Table 3.
HRQoL Instrumentation
To estimate the impact of PCI on HRQoL, data were extracted from the 12 quantitative studies that measured HRQoL among adult patients with CAD using six different instruments. The HRQoL instruments used most frequently in these studies were generic HRQoL instruments, such as the Short Form-36 (SF-36), SF-12, and European Quality of Life-5 Dimensions (EQ-5D). Cardiac-specific, validated HRQoL instruments were also utilized, such as the Seattle Angina Questionnaire (Thomas et al., 2021) and the MacNew quality of life questionnaire (Hofer et al., 2012). In addition to the generic HRQoL tools, depression and anxiety were also measured using the Hospital Anxiety and Depression Scale (HADS) (Snaith, 2003). Table 4 shows the domains, scoring, and interpretation of the HRQoL instruments used in this review.
Results
To understand the effects of PCI on HRQoL among patients with CAD, findings from this integrative literature suggest that HRQoL scores are poor to moderate among patients after the PCI procedure. HRQoL scores were evaluated at various time intervals, such as within 1 month, 3 months, 6 months, or a year after PCI. Various factors that influence HRQoL scores after PCI were also identified. These can be grouped into five main categories, originating from data extracted from the samples. These categories were chosen because they are closely related to the domains (physiological, sociological, and psychological) from the HRQoL definition (Németh, 2006). The first category was patient characteristics, with subcategories of sex, age, and comorbidities. The second category was social determinants, with subcategories of social and community contexts, marital status, economic stability, and educational status. The third category was physical factors, with the subcategories of mobility, pain and discomfort, and number of stents placed. The fourth category was emotional factors, with subcategories of anxiety and depression. The fifth category was the effect on mortality after PCI.
Patient Characteristics
Patient characteristics, including sex, age, and comorbidities, were found to influence the HRQoL scores of patients living with CAD.
Sex
Four reviewed studies in this review consistently found that women had a poorer HRQoL after PCI than men (Al Abdi et al., 2019; Conradie et al., 2022; Huriani & Mailani, 2023; Oreel et al., 2020). In their prospective cohort study, Al Abdi et al. (2019) examined the influence of three domains of HRQoL (physical, emotional, and social). Among 871 patients who underwent elective PCI, about 65 (27%) were women. Participants completed the MacNew quality of life (QLMI-2) questionnaire around
6 months after PCI. Pertinent results showed that of the three domains (physical, emotional, and social) of HRQoL, women (physical domain: 3.97 ± 1.22, emotional domain: 4.07 ± 1.13, social domains: 4.00 ± 1.36, p < 0.05) had significantly lower HRQoL scores in all three domains than men (physical domain: 4.52 ± 1.28, emotional domain: 4.50 ± 1.16, social domain: 4.47 ± 1.40, p < 0.05). Similarly, Conradie et al. (2022) conducted a longitudinal cohort study to evaluate HRQoL and the effects on outcomes based on age and sex among 6,591 patients, of whom 2,588 were women. Participants completed the EuroQol 5 Dimension 5 Level (EQ-5D-5L) at three different time intervals: at discharge, 30 days later, and after 1 year. Younger women had lower QoL scores than men (68.0 ± 10.9 years with a poor QoL, p < 0.001). The QoL scores, assessed using the visual analog scale (VAS), scores were lower in women than in men (67.7 in women vs. 71.7 in men, p < 0.001). In their descriptive, cross-sectional, correlational study, Huriani and Mailani (2023) examined the relationship between the emotional and physical domains of HRQoL among 154 patients, including 139 men (90.3%) and 15 women (9.7%). Four trained research assistants collected participant data; men scored higher in HRQoL scores (M = 5.13, SD = 0.90) than women (M = 4.95, SD = 0.85) in the new MacNew Heart Disease HRQoL questionnaire. These findings are consistent with a longitudinal study by Oreel et al. (2020). The authors evaluated the sex differences in QoL among 230 patients with CAD and comorbidities undergoing coronary revascularization among 74% males and 26% females. Participants completed the generic Short Form Health Survey 36 and the SAQ-7 tools at 2-week intervals, 3-month intervals, and 6 months after PCI. Physical and disease specific HRQoL was poorer in females (36%, p < 0.001) than in males (44%, p < 0.001). Female samples were much smaller than male samples included in these studies.
Age
Multiple studies indicated that older patients had a better HRQoL than patients younger than 55 years (Conradie et al., 2022; Kim, 2022). In the study by Conradie et al. (2022), based on the results from the EQ-5D-5L, younger patients (< 55 years) perceived their QoL as significantly worse (M = 68.0, SD = 10.9) when compared to older patients who were greater than 60 years (M = 69.2, SD = 9.7, p < 0.001), with no statistical significance (p = 0.54). Similarly, Kim (2022) conducted a cross-sectional study to identify the factors influencing HRQoL among 179 patients with CAD who underwent PCI. HRQoL scores using the tool SAQ-7 version varied significantly with age; participants less than 54 years had lower HRQoL scores (M = 63.11, SD = 22.52) than older participants between the ages of 65 to 74, they had higher HRQoL scores (M = 80.15, SD = 14.89 F = 4.62, p = 0.004).
Comorbidities
Two studies indicated that the presence of diabetes mellitus (DM), hypertension (HTN), and hyperlipidemia (HLD) influenced HRQoL after PCI (Al Abdi et al., 2019; Sajobi et al., 2018). In the study by Al Abdi et al. (2019), researchers used echocardiography and clinical data on admission to evaluate HRQoL. They designed a model to predict elective PCI outcomes on HRQoL in a sample of 239 patients who completed the MacNew quality of life after 6 months of undergoing the procedure. Patients with comorbidities of DM and HTN had lower physical and social HRQoL scores than emotional scores
(4.5, CI: 95%, p < 0.05) than patients without comorbidities of DM and HTN (5.0, CI: 95%, p < 0.05). Similarly, a prospective longitudinal cohort study was conducted in Canada by Sajobi et al. (2018) to identify the trajectories of HRQoL in 6,226 patients with CAD and determine patient characteristics that discriminate among these trajectories. Participants completed the SAQ-7 via mail one week after PCI. Results from a multi-trajectory analysis identified four HRQoL trajectory subgroups, including high (25.1%), vastly increased (32.3%), primarily decreased (25.0%), and low (17.6%) trajectories. The proportion of patients who experienced a decrease in their HRQoL was 25%, whereas the remaining patients experienced different levels of improvement over the next 5 years. The highest comorbidity among participants was among patients with a history of HLD (77.3%), then HTN (71.6%), and DM (24%); smokers had lower HRQoL than smokers who quit after PCI. Patients with a low ejection fraction (EF) of less than 50% showed a moderate QoL score of 66.4 (24.6%).
Social Determinants
Social determinants are non-health-related factors that influence HRQoL after PCI. They include social and community contexts, which can be categorized into marital status, economic stability, and educational status.
Social and Community Context: Marital Status
Marital status can influence HRQoL scores in cardiac patients. A crosssectional study by Kim (2022) showed that married samples had higher HRQoL scores (M = 78.26, SD = 16.51, F = 4.81, p = .009) than unmarried samples (M = 77.78, SD = 12.41). This was similar to a finding by Huriani and Mailani (2023) in a study that examined the relationship between emotional and physical symptoms in HRQoL. Participants who were married had higher HRQoL (M = 5.12, SD = 0.91) than unmarried participants (M = 4.94, SD = 0.43).
Economic Stability
Economic stability is a critical factor that influences HRQoL among cardiac patients. A descriptive cross-sectional study by Kim et al. (2019) evaluated HRQoL and its determinants among outpatients with CAD after PCI. Participants with a lower socioeconomic status were associated with lower HRQoL scores (M = 63.74, SD = 17.16, F = 3.716, p = 0.027) than samples with higher socioeconomic status (M = 73.10, SD = 15.25). Similarly, in a cross-sectional study by Kim (2022), pertinent results show that samples with moderate economic status had higher HRQoL scores (M = 73.1, SD = 15.13) than those with low socioeconomic status (M = 63.74, SD = 17.16, F = 3.53, p = .031). In the cross-sectional descriptive correlational study conducted by Huriani and Mailani (2023), participants with higher income had more excellent HRQoL scores (M = 5.33, SD = 0.36) than low-income participants (M = 4.57, SD = 1.15).
Educational Status
Understanding the relationship between educational status and HRQoL is essential as it influences patients’ healthcare decision-making skills. In a cross-sectional descriptive correlational study conducted by Huriani and Mailani (2023), participants with an educational level higher than the master’s level had higher HRQoL scores (M = 5.96, SD = 0.53) than those with an elementary level of education. The HRQoL scores of those with an
elementary level of education were (M = 4.80, SD = 0.86). Similarly, Kim et al. (2019) findings from the Seattle Angina Questionnaire indicated that participants with a lower education level had significantly lower HRQoL scores (M = 61.89, SD = 15.95, t = -4.048, p < 0.001) than those who completed high school.
Physical Factors
Physical factors influencing HRQoL can be categorized as mobility, pain, and discomfort. Impaired mobility, secondary to pain from the procedure site or complications such as hematomas at the procedure site, is a significant factor that physically limits patients after PCI. The total number of stents placed and the timeframe since PCI also influence HRQoL among patients after PCI.
Mobility
Understanding patients’ physical limitations pre- and post-PCI is essential to ensuring better HRQoL. In the cross-sectional cohort study conducted in India by Agarwal and Mathur (2022), researchers assessed the association of HRQoL with mobility, self-care, usual activities, pain, and anxiety/depression among patients undergoing PCI. They found that mobility moderately altered HRQoL among cardiac patients who underwent PCI. The null hypothesis was accepted. There was a significant difference between the coronary angioplasty group, the angioplasty group, and the control group (CG). The dimension of mobility was assessed using the EQ-5D-3L tool (Kruskal-Wallis H-test H(2) = 7.599, p = .022). Conversely, Conradie et al. (2022) evaluated HRQoL and its effects on outcomes. Participants were assessed at discharge and after 1 year using the EQ-5D-5L tool. Mobility moderately influenced HRQoL, and women (26.1%) had more outstanding mobility issues than men (18.7%, p < 0.001). Findings suggest that mobility issues are a significant factor that influences HRQoL after PCI.
Pain and Discomfort
The duration and intensity of pain and discomfort can influence HRQoL among patients undergoing PCI. The longitudinal observational study conducted by Arantes et al. (2018) evaluated the long-term effects of an educational program on HRQoL after PCI. Initially, the physical domain of HRQoL was poor both before PCI (T0, CG = 32.4; IG = 29.3) and 12 months after PCI (T1, CG = 51.8; IG = 55.2). After the educational intervention, the physical role scores in HRQoL improved in the intervention group (IG) after 12 months. After 12 months of PCI, pain domains were better in the CG (T0 = 39.2, SD = 34.3) than the IG (T1 = 59, SD = 27.1). Bodily pain scores after 12 months of PCI were (T0 = 56.5, SD = 28.4), but physical pain scores improved with intervention (T1 = 56.5, SD = 28.4). Results showed a significant increase in HRQoL and a statistically significant difference between the control group and intervention group. Conversely, in a longitudinal cohort study conducted by Conradie et al. (2022) to access HRQoL and its effects on patient outcomes based on age and sex in 6,591 patients, pain and discomfort were an extreme problem among more women (8.2%) than men [(5.3%) (p < 0.001)]. Also, it was a severe problem among samples of both genders in the younger age group less than 55 years (9.1%, p < 0.001). So, women and younger patients reported more pain and discomfort than men and older patients.
Number of Stents and Time Frame Since PCI
The time frame since PCI and the number of stents inserted were found to influence HRQoL. In the descriptive, cross-sectional, correlational study conducted by Huriani and Mailani (2023), 67.5% of the samples underwent PCI for the first time. Findings suggest that samples with a more significant number of stents had higher HRQoL scores (M = 5.70, F = 2.914, p = 0.015) compared to samples with only one stent (M = 5.23, SD = 0.89, F = 2.914, p = 0.015). Kim (2022) also found that participants with a more significant time duration since their first PCI (greater than 7 years) showed higher HRQoL scores (M = 81.52, SD = 14.91, F = 3.74, p = .012) than patients who underwent PCI less than a year ago (M = 72.81, SD = 19.07, F = 3.74, p = 0.012). This indicates that patients with more stents placed and years after the procedure have higher HRQoL scores.
Emotional Factors
Emotional factors, including anxiety and depression, influence HRQoL after PCI. Symptoms of anxiety and depression are highly prevalent among cardiac patients and are the driving factor behind higher healthcare costs (Palacios et al., 2018).
Anxiety and Depression
In the descriptive cross-sectional study conducted by Kim (2022), using the Hospital Anxiety and Depression Scale (HADS), pertinent results, the mean score for depression was 7.69 (SD = 4.06), and the mean score for anxiety was 4.61 (SD = 3.84). The anxiety and depression scores moderately influenced the HRQoL scores (anxiety score: t = 4.47, p < .001; depression score = 3.64, p < 0.001). Conversely, the cross-sectional study by Kim et al. (2019) identified the factors influencing HRQoL among patients with CAD. The level of anxiety was found to be moderate (13.10 + 5.03); approximately 62.1% of participants were categorized as having an anxiety disorder (score: greater than 11). The level of depression score was also moderate (13.90 + 4.43); approximately 74% of participants were categorized as having a depressive disorder (score: greater than 11).
In their cross-sectional study, Lofti-Tokaldany et al. (2019) examined the association between illness perception and HRQoL among 782 patients with preexisting premature CAD. Results indicated that physical health factors (62.77) and mental health factors (63.51) equally contributed to the overall HRQoL. Similarly, Da Silveira et al. (2021) performed a longitudinal study in Brazil to compare the QoL in patients with stable CAD treated with medical therapy, PCI, and CABG. The physical component score (PCS) was slightly higher (M = 46.4, SD = 46) than the mental component score (MCS) (M = 53.7, SD = 53). In contrast, Mori et al. (2021) conducted a multicenter longitudinal cohort study in the United States. They found that the incidence of MCS improvement was higher among the PCI group (40%), but the incidence of PCS improvement was the lowest in the PCI group (34%).
Mortality
A poor HRQoL influenced mortality and readmission rates among patients after PCI. Two studies found that a lower HRQoL score increased the risk of mortality (Conradie et al., 2022; Sajobi et al., 2018). Conradie et al. (2022) conducted a longitudinal cohort study to evaluate using the
EuroQol visual analog scales, and the participants with lower scores in all five domains of the EQ-5D-5L had a higher death rate (2.6%, p = 0.03). However, lower scores had no statistically significant effect on the rates of unplanned cardiac readmission (11.4%, p = 0.11) and major adverse cardiovascular events (MACE) (8.1%, p = 0.10). Lower HRQoL scores were associated with increased rates of mortality (2.4%, p < 0.01) and MACE at 1 year (7.9%, p = 0.04) in both men and women.
Discussion
The purpose of this integrative review was to obtain a comprehensive understanding of what is known about the impact of PCI on HRQoL among patients living with CAD. HRQoL is substantially affected by CAD but is modulated by effective prevention, intervention, and rehabilitation post-PCI. There are different viewpoints on the impact of PCI on HRQoL. Research indicates that PCI improves patients’ HRQoL (Sipötz et al., 2013; Siriyotha et al., 2023) and decreases patient HRQoL within 12 months of the procedure (Dimagli et al., 2023). However, the key findings from this review suggest that HRQoL ranges from poor to moderate within 1 month, 3 months, 6 months, and a year after PCI. The factors that influence HRQoL are patient characteristics such as gender, sex, and comorbidities, physical factors like pain and mobility, emotional factors such as anxiety and depression, and mortality.
This integrative review evaluated 12 studies to summarize the impact of PCI on HRQoL among patients with CAD. Two studies indicated a poor HRQoL among patients with CAD within 6 months to 1 year of a follow-up (Agarwal & Mathur, 2022; Conradie et al., 2022). A poor HRQoL is a powerful predictor of rehospitalization within the next 3 years (Benzer et al., 2016). Two other studies showed a moderate HRQoL among patients within 1 month to 3 months of follow-up (Huriani & Mailani, 2023; Kim et al., 2019). A decreased HRQoL might increase acute coronary syndrome (ACS) recurrence and reduce patients’ survival rate (De Smedt et al., 2013; Pedersen et al., 2007). For these reasons, accurate identification and improvement of HRQoL among outpatients with ACS during follow-up treatment are essential.
Other reviewed studies indicated that HRQoL improves over time when measured within 1 year of PCI (Arantes et al., 2018; Oreel et al., 2020; Sajobi et al., 2018). In their study, Sipötz et al. (2013) found that physical and social HRQoL improved within 6 months after PCI among 63 patients from six cardiac units. Arantes et al. (2018) also indicated that educational intervention increased the HRQoL compared with control groups. Similarly, in another study conducted among 148 samples with ACS after PCI used Orem’s Self-care Theory to guide the process. Results indicated that nursing intervention reduces postoperative complications and improves patients’ negative emotions, disease cognition, self-care abilities, QoL, and rehabilitation efficacy (Zhu et al., 2021).
One study conducted among patients with CAD indicated a higher HRQoL after PCI within 6 months of follow-up (Kim, 2022). A study by Zhang and Wei (2021) studied the efficacy and safety of coronary stents in treating CAD and found that the QoL score at 3 months was (81.19 ± 6.05), which was higher than that of controls (77.49 ± 5.64; p = 0.002). Similarly, randomized controlled trial (RCT) (RITA-2 trial) has found that PCI improves a patient’s QoL, measured at 3 months, 1 year, and after 3 years of PCI (Pocock et al., 2000).
The determinants influencing HRQoL after PCI among patients with CAD could be divided into five categories. Firstly, for patient characteristics related to gender, women had poorer HRQoL than men (Al Abdi et al., 2019; Conradie et al., 2022; Huriani & Mailani, 2023; Oreel et al., 2020). Most reviewed studies included substantially fewer women samples than men. Similarly, a study conducted to measure HRQoL five years after intervention of PCI indicated that women have lower HRQoL (3.5/5) than men (3.8/5) in reference to self-rated health and QoL (Tchicaya & Lorentz, 2016). These findings could be explained by the fact that women with acute myocardial infarction are much older and exhibit more risk factors for DM than men. Further, women are cardio-protected by the hormone estrogen until menopause (Yasmin et al., 2022).
Another interesting finding is that patients younger than 55 years had a poorer HRQoL than older patients (Conradie et al., 2022; Kim, 2022). Elderly patients with symptomatic CAD have been shown to have improved QoL with PCI compared with younger patients (Seto et al., 2000). Today, PCI is initiated even at ages below 30 years. Therefore, closer identification and monitoring could help reduce early disability. It is also essential to understand the role of comorbidities on HRQoL. Two reviewed studies indicated that comorbidities such as diabetes mellitus (DM), hypertension (HTN), and hyperlipidemia (HLD) significantly influenced HRQoL (Al Abdi et al., 2019; Sajobi et al., 2018) more than other comorbidities. In their study, Lin et al. (2017) found that patients with a history of DM had a higher mortality rate than patients without DM and HTN after PCI.
The second category influencing HRQoL after PCI was social determinants. Patients who were married and patients who received master’s education had higher HRQoL scores, while patients who had a low socioeconomic status had lower HRQoL scores (Huriani & Mailani, 2023). Similarly, a prospective observational study conducted over 12 months indicated that patients with low socioeconomic status had higher hospital readmission rates and lower QoL scores (Denvir et al., 2006). The third category was physical factors. Pain, discomfort (Conradie et al., 2022), and mobility (Agarwal & Mathur, 2022) significantly decreased HRQoL. The fourth category was emotional factors. Anxiety and depression had a moderate influence on the HRQoL scores. Further, physical and mental health equally contributed to the overall HRQoL.
The last category was mortality. Understanding the influence of HRQoL on mortality after PCI could help early recognition and prevent complications (Conradie et al., 2022; Kim, 2022). A systematic review of approximately 1,200,000 patients indicates that a poor HRQoL was associated with a higher mortality risk (Phyo et al., 2020). The fundamental goal of treating CAD is to improve patient symptoms, function, and QoL (Patel, 2022). Understanding cardiac intervention, such as PCI, and its influences on HRQoL could help providers reflect on an individual’s perception of and response to physical, emotional, and overall well-being, and mortality.
Knowledge regarding currently available treatment modalities for CAD could help providers make the right treatment choices. Dimagli et al. (2023) conducted a systematic review and meta-analysis of randomized controlled trials that compared QoL after CABG versus PCI at one, 6, 12, and 60 months after the procedure. There was an improvement of 22 points (95% CI, 21.0–25.6) after PCI and CABG using the Seattle Angina Questionnaire (SAQ). SAQ-QoL showed improved PCI scores at 1 month (-2.92 [95% CI, -4.66 to -1.18]) and CABG scores at 6 months (2.50 [95% CI, 1.02–3.97]), 12 months (3.30 [95% CI, 1.78–4.82]), and 36 to
60 months (3.17 [95% CI, 0.54–5.80]). The author concluded that QoL improves with PCI by the first month after the procedure and with CABG within 6 to 12 months. Similarly, among 14 systematically reviewed RCT involving 12,238 patients, PCI with optimal medical therapy improved HRQoL (SD = 0.16; 95% [CI] 0.1–0.23; p < 0.0001) at 6 months after the procedure (Hirao et al., 2023). Various socioeconomic factors, comorbidities, and treatment modalities must be evaluated to understand the influence on HRQoL after PCI and the overall benefits among patients with CAD.
Strengths
An adequate sample size is essential to conclude on the generalizability of study findings (Burns & Grove, 2009). Eleven of the 12 studies included in this review used nonprobability sampling of varying sizes, from 56 to 6,591. Nine used purposive sampling, two used convenience sampling, and one used probability sampling. Only one study conducted a power analysis to determine the adequate sample size (Kim, 2022). Using a theoretical framework is essential in health research to standardize and guide the development and testing of concepts (Burns & Grove, 2009). One reviewed study conducted in Korea used a theoretical framework, TOUS: the Theory of Unpleasant Symptoms, to guide the study design (Kim, 2019).
Limitations
Most studies included in this review had cross-sectional and descriptive designs, and only a few adopted a longitudinal design. This weakens the findings’ applicability in evidence-based practice, recommendations, or changes. Most studies were conducted in countries outside the United States (11 of 12) and in single academic or hospital settings, limiting the generalizability of the findings to other institutions of varying sizes and other different geographic areas. Selection biases were present because the samples selected did not represent diverse ethnicities, so generalizations could not be made. Measurement errors or data entry errors might have also occurred. Patients completed the surveys independently in some studies, while others were guided by a trained research assistant.
The authors of the selected articles used several different instruments (tools) to measure HRQoL among patients after PCI, limiting the current author’s ability to compare the findings. Many tools were not validated for patients with CAD, reducing their internal validity. The initial literature search found that HRQoL and QoL are used interchangeably even though they are conceptually different defined concepts (Karimi & Brazier, 2016). QoL refers to an individual’s subjective well-being, while HRQoL is defined as an individual’s perceived physical, mental, and social well-being and how it improves life functioning (Killewo et al., 2010).
The proportion of female participants was smaller than that of male participants, limiting the generalizability of the findings. According to Burgess and Mamas (2022), women with CVD are underrecognized by physicians and allied health professionals, leading to delays in the recognition and treatment of heart disease with PCI. Women are noted to have higher in-hospital mortality rates than men (2.0% vs 1.4%). They are also underrepresented as samples in RCTs.
Implication for Nursing Practice Patient Care
Nurses should pay close attention to the assessment of sociodemographic data and develop comprehensive and systematic interventions to address factors that influence HRQoL among patients with CAD. Patients, particularly women, must be screened before PCI for a history of polycystic ovarian syndrome, gestational diabetes, history of hysterectomy, preeclampsia, and preterm childbirth. Patients’ HRQoL must be evaluated before and during intervals of 1 month, 3 months, and 6 months to a year after PCI to identify any challenges patients face. Patients' physical or mental limitations must be assessed before and after PCI. These measures could help healthcare team members ensure early detection and provide access to care and supportive services through patient education immediately and up to a year after PCI, thereby ensuring physical and mental rehabilitative services when appropriate.
Education and Research
Patient literacy must be improved to recognize the risk factors of CAD, manage the disease effectively, and ensure better use of referral information from appropriate community resources. More campaigns targeting heart disease prevention and awareness for women and younger adults are needed. Further, there is an increasing need to ensure the proactive recruitment of women to RCTs as samples to address the research data gap among this population.
Administration
Cardiac clinics led by nurse practitioners could help improve awareness regarding the risk factors and treatment of CAD. Early referral to cardiac rehabilitation centers for evaluation and management of symptoms after PCI must be ensured to achieve independent functional status among patients.
Implication for Future Research
HRQoL is a subjective patient outcome indicator that is measured objectively using various tools. Further qualitative research is needed to understand patients’ viewpoints and this phenomenon more comprehensively. Another aspect that requires more attention is the inclusion of diverse populations in the United States, as CAD is more common among Blacks, Hispanics, and South Asians. There is also an increasing need to recruit women to cardiac RCTs as samples to address the research gap among this population. Further, more studies are needed to validate more disease-specific tools for measuring HRQoL in patients with CAD, especially in relation to pain-related limitations before and after the procedure, as this aspect is one of the significant factors affecting HRQoL. Providers must create individualized, tailored care plans for different age groups based on their needs, such as mobility needs. Patients with depression and anxiety disorders need to be identified and referred to relevant services, and policy changes need to be implemented to enhance early recognition of decreased HRQoL. Further longitudinal research is
n Effects of Percutaneous Coronary Intervention on Health-Related Quality of Life Among Patients Living With Coronary Artery Disease
needed to assess the importance or influence of physical and mental rehabilitation after PCI.
Conclusion
While an examination of 12 studies cannot support generalizations, this integrative review identified the need to assess HRQoL among U.S. patients before and one year after PCI to understand the limitations
and challenges patients face. Knowledge and awareness about these challenges must be increased, and appropriate referral services must be implemented to reduce premature mortality and morbidity. Nurses could enhance communication, awareness, and attitudes toward care among patients through education about the risk factors after PCI. Improving policies by creating awareness of the need for early physical and mental rehabilitation services after PCI could also work to reduce premature mortality.
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Zhu, T., Liu, H., Han, A., Gu, H., & Li, X. (2021). Orem’s self-care to treat acute coronary syndrome after PCI helps improve rehabilitation efficacy and quality of life. American Journal of Translational Research, 13(4), 2752–2762.
Screening
Identification of studies via databases and registers
Records identified from:*
Databases (n = 6)
Google Scholar (n = 298)
PubMed (n = 61)
CINAHAL (n = 86
PsycInfo (n =13)
ProQuest (n=108)
Cochrane (n = 1)
Records screened by title and abstract (n = 140)
Records sought for retrieval (n = 125)
Records assessed for eligibility (n = 41)
Records removed before screening:
Duplicate records removed (n = 4)
Records removed for other reasons:
Not published in last 5 years (n = 413)
Key words screen (n = 8)
Not English (n = 2)
Records excluded (n = 15)
Reports not retrieved (n = 84)
Perceived health (n = 40)
QoL not HRQoL (n = 44)
Reports excluded (n = 29)
Reason 1:
Cardiatric rehabilituation (n = 11)
Reason 2:
Tool development (n = 8)
Reason 3:
Comparing treatment modalities (n = 10)
Identification of studies via other methods
Records indentified from:
Citation searching (n = 4)
Hand-searching (n =1)
Reports sought for retrieval (n = 5)
Reports not retrieved (n = 2)
Reports assesssed for eligibility (n = 3)
Reports excluded in (n = 3)
Reason 1
(n = No PCI*** intervention)
Reason 2
(n = measuring fatigue)
Reason 3 (n = opinion paper)
Studies included review (n = 12)
Hand-searching (n = 0)
Citation mining (n = 0)
Note. From “The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews,” by M. J. Page, J. E. McKenzie, P. M. Bossuyt, I. Boutron, T. C. Hoffmann, C. D. Mulrow et al., 2021, British Medical Journal, 372(71) (https://doi.org/10.1136/bmj.n71). For more information, visit: https://www.prisma-statement.org/.
Rethinking improvement in health-related quality of life post percutaneous coronary intervention: A comparative analysis
(Agarwal & Mathur, 2022)
Research question
Assess and compare the difference between HRQoL (mobility, self-care, usual activities, pain, anxiety/ depression) among patients undergoing PCI, angioplasty, angiography and control group without cardiac disease.
Design/ method
Cohort crosssectional study
Purposive sampling
Hospital of Ahmedabad, India
N = 65 (PCI = 23)
Age: 40–72 yrs
Male and female
Three groups: Before PCI
Follow up: one month post-PCI Medically managed CAD patients
Instrument: EuroQol five dimensions with 3 levels (no problem, some problem, and extreme problem)
EQ-5D: descriptive system includes mobility, self-care, usual activities, pain, anxiety/ depression.
EQ-VAS: visual analog scale
Descriptive statistics
Kruskal-Wallis H-test
Post-hoc test (unequal groups)
Mobility significantly altered HRQoL in cardiac patients who underwent PCI compared to the other two groups.
Descriptive statistics
Angioplasty: (N = 23), Mean: 26.96
Angiography: (N = 17), Mean: 29.41
Healthy group: (N = 25), Mean: 41
Kruskal-Wallis H-test
H(2) = 7.599, p = .022, showing a statistical difference between the three groups (angioplasty, angiography, and healthy control) regarding HRQoL.
The angioplasty group had the worst decrease in HRQoL at 1 month follow-up compared to the angiography and healthy groups.
Limitations: Size sample size (N = 65)
Unable to generalize as it was conducted at one site in Ahmedabad.
Age and sex were not recorded.
Strengths: Able to look at different groups of cardiac intervention.
The use of echocardiography and clinical data recorded on admission to simple decisionmaking for elective percutaneous coronary intervention.
(Al Abdi et al., 2019)
Evaluate the three domains of HRQoL (physical, emotional, social).
Design models using admission data (sociodemographic and clinical) of CAD patients to predict ePCI outcomes on HRQoL.
Prospective cohort study
Purposive sampling King Abdullah University Hospital, Jordan Identified from discharge summary.
Over 18 months (January 2014 to May 2015)
Total sample who completed the questionnaire: N = 239
Age: 30-81 years
Males: n = 174 (73%)
Females: n = 65 (27%)
Data collected: clinical: echocardiographic, electrocardiographic, demographic, and labs.
Length of stay: The average length of hospital stay: 2.9 days
The participants completed the MacNew quality of life (QLMI-2) questionnaire 6 months after ePCI.
It is a 26-item questionnaire including 9 socio demographic questions.
Translated from English to Arabic by three psychologists.
Response rate: 69.3%
SPSS t-test
Normality checks with histogram
Significant predictors of the three domains of HRQoL: multivariate linear regression
All three domains data was normally distributed.
Mean HRQoL scores:
Range: 1 to 7
Physical: 4.38 + 1.27
Emotional: 4.4 + 1.11
Social: 4.37 + 1.32
R2:
Physical: 0.630
Emotional: 0.604
Social: 0.534
Model partially predicts the outcome of HRQoL.
Basophil level on admission: positive correlation with three domains of HRQoL
Women had lower HRQoL scores than men (p < 0.05).
Patients with diabetes and hypertension had lower HRQoL scores (p < 0.05).
Limitations: HRQoL was only measured once after PCI, so we are unable to compare before intervention.
Women’s sample size was smaller.
No psychometric on translated MacNew
Strengths:
The effect of comorbidities on HRQoL was measured.
Tools were translated into Arabic.
Table 3
Data Extraction (con’t)
Study (APA format)
Health-related quality of life and the effects on outcome in patients presenting with coronary artery disease and treated with percutaneous coronary intervention: Differences were noted by sex and age
(Conradie et al., 2022)
Research question
Access HRQoL at baseline and its association with patients undergoing PCI with CAD.
To determine if there is a correlation between subsequent myocardial infarction (MI), target vessel revascularization, unplanned cardiac readmission, and adherence to evidence-based drugs (statins, ACE, ARB, beta blocker, and antiplatelet)
To evaluate the difference between sexes and age
Cohort study
Purposive sampling
N = 6,591 (43.4%)
Males: n = 4,003 (76.6%)
Females: n = 2,588
Average age: 69 yrs
Data obtained from the GenesisCare Cardiovascular Outcomes Registry (GCOR)
Conducted in Switzerland
Time frame: 11 years (January 2009 to December 2019)
Follow-up assessments were conducted by research coordinators at discharge, 30 days, and 1 year postprocedure.
Tool EQ-5D-5L: Patient survey was completed to discharge.
Descriptive statistics: baseline characteristics and risk factors
Student t-test, ANOVA, or chi-square test was used to compare baseline characteristics with risk factors.
Association of clinical outcome pre- and post-procedure was done using univariate and multivariate Cox proportional hazard regression models.
A multivariate regression model was used to adjust confounding variables (excellent and poor QoL, age, sex, BMI, EF).
Poor QoL age less than 60 yrs was reported among higher among younger women.
Differences between males and females: Mobility: Moderate problem: women greater than men: 26.1% and 18.7% (p < 0.001)
Extreme problem: noted among younger age group: <55 yrs: 3.5% (p < 0.001)
Personal care: Moderate problem: women greater than men: 7.8% and 6% (p = 0 .002)
Usual care: Moderate problem: women greater than men: 31.2% and 27.1% (p < 0.001)
Extreme problem: noted among younger age group: < 55 yrs: 10.3% (p < 0.001)
Pain and discomfort: Extreme problem: women 8.2% was more significant than men: 5.3% (p < 0.001)
Extreme problem: noted among younger age group: <55 yrs: 9.1% (p < 0.001)
Anxiety and depression: Extreme problem: 6.1% greater than men: 3.3% (p < 0.001)
Extreme problem: noted among younger age group: < 55 yrs: 8.7% (p < 0.001)
Samples with problems in all five domains have higher rates of deaths 2.6% (p = 0.03), no effects on unplanned cardiac readmission: 11.4% (p = 0.11); and major adverse cardiovascular events (MACE): 8.1% (p = 0.10).
Poor HRQoL increased mortality (2.4%, p < 0.01) and MACE at 1 yr. (7.9%, p = 0.04) in both men and women.
Limitation:
Use of generic instruments, not disease-specific for PCI
Strengths: Differences between genders were identified.
Large sample size
Determinants of HRQoL among outpatients with CAD after PCI
(Kim et al., 2019) To identify HRQoL (physical limitation, treatment satisfaction, degree to which patient perceived their disease to affect their QoL) and its determinants in outpatients with CAD after PCI
Descriptive, cross-sectional design
Convenience sampling
N = 124
Mean age: 61.7 yrs
Gender:
Male: 98 (79%)
Female: 26 (21%)
Conducted at National University Hospital, South Korea, from the cardiology outpatient clinic
Theoretical framework: The Theory of Unpleasant Symptoms (TOUS)
Time frame: September 2015 to February 2016
The tool used: Seattle Angina QuestionnaireKorean
Average time to administer questionnaire: 20–30 min.
Experience of symptoms was measured using the ACS symptom checklist (14 items).
Depression and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS: 7 items).
Descriptive statistics are used to analyze sociodemographic and clinical characteristics.
Determinants of HRQoL attained using multiple linear regression analyses
Cronbach’s alpha for HRQoL: Physical limitation: 0.88
Treatment satisfaction: 0.71
Disease perception: 0.68
Living with family: 105 (84.7%)
Education less than high school: 67 (54.2%)
Former smoker: 63 (50.8%)
Number of obstructive vessels 1: 60 (48.4%) and obstructive vessels 2–3: 64 (51.6%))
Poorer level of HRQoL with severe symptom experience, higher depression, higher low-density lipoprotein cholesterol, low social support, and education level.
The mean score of HRQoL was moderate: 67.85 ± 16.05.
Three domains score: Physical limitation (highest): 84.21 ± 18.77
Treatment satisfaction: 77.27 ± 19.83
Disease perception (lowest score): 42.07 ± 22.34
The mean score for depression was moderate: 13.90 ± 4.43
The mean score for anxiety was moderate: 13.10 ± 5.03
The mean score for social support was moderate: 3.44 ± 0.95, higher among patients with social support
Social determinants: Living alone (t = -2.021, P = 0.045), lesser education (t = -4.048, p < 0.001), and lower socioeconomic status (F = 3.716, p = 0.027) were significantly associated with lower HRQoL.
Limitations: Convenience sampling: Introduces biases and chances of high sampling error.
The female sample size is smaller.
Strengths: Looked at outpatients with acute coronary syndrome.
Seattle Angina Questionnaire was translated into Korean.
Table 3
Data Extraction (con’t)
Study (APA format)
HRQoL in patients with CAD undergoing PCI.
(Kim, 2022)
Research question Design/ method Sample
To identify the factors influencing HRQoL in patients with CAD who underwent PCI
Develop patient education and intervention programs.
Crosssectional study
Convenience sample N = 179
G power: 3.1
Final sample: N = 210
Conducted in a tertiary hospital in South Korea
Time frame: February 7 to 27, 2014
Undergone PCI:
163 (77.6%)
The time frame for PCI: 7 yrs ago (37.6%) Male: 156 (74.3%)
Female: 54 (25.7%)
Mean age: 69 yrs
Married: 81 (38.5%)
Unemployed: 176 (83.8%)
Moderate economic status: 107 (51%)
High school educated: 81 (38.5%)
Two trained research assistants administer the survey.
Total time for questionnaire: 15 min
Tools: Anxiety and depression were measured using the HADS: Korean version (14 items, self-administered questionnaire, seven odd numbers measure anxiety, and seven even numbers measure depression, 4-point rating scale).
Social support is measured using a multidimensional scale of perceived social support (12 items, each item rated with a 5-point scale).
HRQoL measured using Seattle Angina Questionnaire: Korean version
Descriptive statistics
Independent t-test (general characteristics)
The relation between HRQoL and participant characteristics was measured: one-way analysis of variance, Scheffé test, Pearson correlation test.
Multiple linear regression (variables influencing HRQoL)
The overall mean HRQoL score was 71.71.
HRQoL varies significantly with = age: Higher in participants > 55 (F = 4.62, P = .004).
Marital status: Married people had higher scores (F = 4.81, p = .009).
Economic status: Moderate economic status samples had higher scores (F = 3.53, P = .031).
Primary caregiver: Higher score on HRQoL was seen among samples who relied on themselves than others (F = 6.64, P < .001).
Duration since first PCI: Patients whose first PCI was > 7 yrs had higher HRQoL than patients with recent PCI, F = 3.74, p = .012).
Anxiety (4.61, SD = 3.84), depression (7.69, SD = 4.06), and social support (3.62, SD = 0.62).
Limitations: Convenience sample: selection biases
A small gift was given as an incentive.
Strengths: G power was calculated for sample size.
Instrument reliability was checked for the Seattle Angina Questionnaire.
Trained research assistance was used to administer questionnaires, decreasing biases.
The relationship between physical and emotional symptoms and HRQoL of patients after PCI
(Huriani, E. & Mailani F., 2023)
To identify physical (fatigue, angina, and dyspnea) and emotional (stress, anxiety, and depression) symptoms related to HRQoL of myocardial infarction patients after PCI
Cross-sectional descriptive correlational study
Nonprobability purposive sampling method.
N = 162 agreed, excluding 8 due to incomplete data
Final N = 154
Conducted in Indonesia outpatient cardiac clinic.
Time frame: May to June 2022 (1 month)
Four trained nurse research assistants were used to collect data.
Tools: The Indonesian version of: Fatigue Assessment Scale (FAS)
Seattle Angina Questionaire-7 (SAQ-7)
Dyspnea scale
Depression, anxiety, stress scale 21 (DASS-21)
MacNew quality of life questionnaire
Time to complete questionnaire: 30 mins.
Descriptive statistics of demographic Independent t-test
One-way analysis of variance
Pearson correlational test
Linear regression
Average age: 59.5 yrs
Gender:
Males: 139 (90.3%)
Female: 15 (9.7%)
Males had higher HRQoL than females: 5.13 (SD = 0.90)
Education: High school educated: 47.7%
Doctoral-level education had higher HRQoL than elementary education: 6.59.
Income: moderate social income: 84.4%
Higher-income level had greater HRQoL than low income: 5.33 (SD = 0.36)
Marital status: Married sample: 96.1% had higher HRQoL than the single sample (5.12, SD = 0.91)
Underwent PCI once: 67.5%
Patients with six stents placement had higher HRQoL compared to one stent placement (5.70).
Functional classification:
New York Heart Association functional class 1:61.7%, HRQoL is greater than Class 111: 5.18 (SD = 1.03).
Global HRQoL is average: 5.11 (SD = 0.90)
The highest was in the emotional domain compared to physical limitation and social function (5.32, SD = 0.97).
There is a significant relationship between, angina (b = 0.32) and stress (b = 0.30), on HRQoL (p < 0.05).
Limitations:
The time frame of the study was 1 month.
Unable to generalize results as was performed in a regional cardiovascular center in Indonesia.
Strengths: The sample size was calculated with an alpha level of 0.05.
Instruments’ psychometric properties were accessed. Translated tools to local language.
Trained nurse research assistance was utilized for data collection.
Table 3
Data Extraction (con’t)
Study (APA format) Research
Association between illness perception and HRQoL in patients with preexisting premature CAD
(Lofti-Tokaldany et al., 2019)
To examine the association between illness perception on physical and mental domains of HRQoL in patients with premature CAD
Crosssectional study
Purposive sampling
N = 782: invited N = 779: included
Mode of contact: outpatient cardiology clinic and telephone
Conducted in Tehran, Iran
Time frame: November 2016 to September 2017 (10 months)
During outpatient cardiac visit, patients completed the tools: 36-Item Short Form Health Survey (SF-36), eight scales and two domains: Persian version.
Pearson correlation coefficient to understand linear relation between illness perception and HRQoL.
Age: 45–54 yrs
Men: 370 (47.5%)
Female: 409 (52.5%)
High school educated: 76.2%
Highest comorbidity: hyperlipedemia: 78.7%
PCI intervention: 39.5%
Severe or moderate depressive symptoms: 23.1%
Severe or moderate anxiety: 25.5%
Physical (62.77) and mental health (63.51) equally contributed to overall HRQoL.
Limitations: Single center study
Seen after a year of diagnoses of CAD
Strengths:
Tool assessed for reliability and validity
Translated tool was utilized.
Data Extraction (con’t)
Limitations and strengths Table 3
Study (APA format)
Changes in Functional status and HRQoL in older adults after surgical, interventional, or medical management of Acute myocardial infarction
(Mori et al., 2021)
Research question Design/ method Sample Interventions
To characterize the incidence of decline in functional status and HRQoL after CABG, PCI or medical management after AMI
Evaluate if various treatment modality (PCI, CABG) has difference in rate of decline in functional status and HRQoL.
Multicenter longitudinal cohort study
Total Included sample: N = 3,041
Data collected from 94 different sites in United States
Participants were enrolled in SILVER-AMI (comprehensive evaluation of risk in older adults with AMI)
Age: 75 yrs and older
Median age: 81 yrs
Male: N = 1,695
Female: N = 1,346 (44.3%)
Site coordinators conducted baseline characteristic interview (age, gender, race, marital status) and medical record review (presenting symptoms, length of hospitalization, treatment, fall history).
Telephone interview was conducted 6 months after hospitalization.
Tools:
Functional status was accessed 1 month prior to hospitalization by accessing ADL (bathing, dressing, raising from chair, and ambulating).
HRQoL was measured 1 month prior to hospitalization using SF-12 (mental and physical health component, score of 100 is the best, mean: 50 with SD: 10).
Statistical analysis Findings
Descriptive statistics for pre- and post-op characteristics
Multivariate logistic regression model analyzed predictors of functional and HRQoL decline.
Underwent PCI intervention: N = 1,708
Death after PCI: N = 109 (6.4%)
No change in ADL: 1,369 (60.8%)
Decline in one domain of HRQoL after PCI: N = 796 (47%)
Patients with higher baseline HRQoL had a larger decline at 6 months in both MCS and PCS scores after PCI.
Multivariate model identified predictors of MCS and PCS decline as older age, non-white race, baseline ADL impairment, prior fall, low activity level, and comorbidities.
Higher MCS score at baseline, was associated with higher decline in MCS, but protective against PCS decline while living with someone and higher PCS score at baseline increased the MCS score.
Incidence of MCS improvement were higher among PCI group (40%), but PCS improvement was lowest in PCI group (34%).
Limitation:
Older adults greater than 75 years were included.
Strengths:
Multicenter large study
Generalizable data
Data Extraction (con’t)
Trajectories of HRQoL in CAD
(Sajobi et al., 2018)
Identify subgroups of longitudinal HRQoL trajectories in patients with CAD over 5 years.
Determine patient characteristics that discriminate among these trajectory.
Prospective longitudinal cohort study
Purposive sampling N = 6,226
From Canada’s Alberta Provincial Project for Outcome Assessment in Coronary Heart (APPROCH) disease registry
Time frame: January 1, 2006, to December 31, 2009
During catheterization demographic collected: sex, age, address, clinical comorbidities, measures of disease severity, HRQoL measures
Tools:
Self-reported HRQoL measure
Seattle Angina Questionnaire (19 item, five domains, total score: 100) to measure was collected before procedure of PCI, post: at 1st, 3rd, and 5th years after PCI.
Descriptive statistical analysis for demographics, clinical and psychological characteristics
Multinominal logistic regression analysis to identify missing data
Multidirectory analysis to characterize differing patterns of HRQoL
Male: 80.6%
Age range: 24–94 yrs
Obese: 78%
Underwent PCI: 3,580 (58.5%)
HADS-depression, mean 4.1 (SD = 3.3)
HADS-anxiety: 5.6 (SD = 3.9)
Highest comorbidity: HLD:
4,812 (77.3)
HTN: 71.6%
DM: 24.0%
Smokers had lower HRQoL than smokers who quit after PCI.
Patients died in first 5 yrs: 12.6% after cath.
EF < 50%: 62.2%
SAQ quality of life domain: 66.4% (24.6%)
HRQoL increased from 65% from 1 yr to 85% by 5th yr in 32.3%, decrease in HRQoL was noted in 25%.
Limitations:
Large missing data: 14,345 were eligible, only 6,226 completed HRQoL report
Follow-up cardiac procedures during study were not documented.
Strengths:
Identified subgroups of individuals across multiple dimensions of SAQ
Large sample size
Data Extraction (con’t)
Study
Quality of life in a patient with stable CAD submitted to PCI, surgical and medical therapies: a cohort study
(da Silverira et al., 2021)
Compare QoL in a cohort of patients with stable CAD treated with medical therapy, PCI, and CABG.
Longitudinal study
Purposive sampling
PCI: N = 251 HRQoL questionnaire was completed: N = 124
Conducted in Brazil
Time frame: 6 yrs
Tool: Validated Brazilian version of the 12-item Short Form Survey (SF-12) questionnaire
Physical health domain: general health, physical function, physical role, and body pain
Mental health domain: vitality, social function, emotional role, and mental health
PCS and MCS were calculated.
Descriptive statistics
One-way analysis of variance (ANOVA)
Elective PCI patients:
Age: 60–69 yrs
Male: 154 (68.8%)
Education: high school: 6.9
Current smoker: 13.4%
HTN: 213 (95.1%)
Triglycerides: 148.8
PCS: 46.4 (SD = 46)
MCS: 53.7 (SD = 53)
In patients with stable CAD there was not much difference in HRQoL in the PCS and MCS domain scores; PCS was slightly higher than MCS.
Limitations: Did not access HRQoL at baseline; introduces biases in follow up.
Study was carried out at one center.
Strengths: Two authors evaluated data.
Long term follow-ups
Table 3
Data Extraction (con’t)
Study (APA format)
Educational program for coronary artery disease patients: results after one year
(Arantes et al., 2018)
Research question Design/ method
To evaluate the long-term results of an educational program compared to usual care
Longitudinal observational study
Probability sampling
Public hospital located at State of São Paulo, Brazil
Time frame: September 2012 to June 2013
N = 56
Interventional group (IG): 29 Control group (CG): 27
Selected from a previous randomized control trial (N = 60, followed for 6 months after PCI)
This study same sample, recruited by phone, 1 yr after PCI, n = 4 dropped out
Intervention group: received telephone follow up: educational program
Control group: received usual care
Face-to-face interviews: total time: 6 min
Both group results were compared at admission and one year after PCI.
Tools used in evaluation HRQoL:
Medical outcome study: SF-36 Hospital Anxiety and Depression Scale (HADS): measured anxiety and depression symptoms.
SPSS
Socio demographic characteristics (sex, marital status, occupation, readmission, type of PCI, age): mean and standard deviation
Chi-squared test (sex, marital status, and employment)
Repeated measure analysis of variance (ANOVA), to access changes in HRQoL (p = 0.05)
Mean ages: IG: 64.6 yrs; CG: 61.3 yrs
Sex:
Male: IG: 58.6%; CG: 51.9%
Female: IG: 41.4%; CG: 48.1%
Married:
Baseline: IG: 75.8%; CG: 74.1%
After 12 months of PCI
IG: 72.4%; CG: 70.4%
No significant, statistical association among variables (p = 0.87)
Unemployed:
Baseline
IG: 65.5%; CG: 59.3%; p = 0.63
After 12 months of PCI: IG: 82.8%; CG: 66.7%; p = 0.17
No significant, statistical association among variables
In SF-36: Role emotional domain after 12 months of PCI, showed a statistically significant difference among CG (60.5, SD = 43.4) and IG (75.9, SD = 35.5).
Role physical and bodily pain domains showed an increase in HRQoL, which was a statistically significant difference among CG:
Bodily pain (59, SD = 27.1)
Role-physical (51.8, SD = 43.3) and IG:
Bodily pain (56.5, SD = 28.4)
Role-physical (55.2, SD = 44)
In the assessment of anxiety and depression with ANOVA: No statistical significance was noted in either group.
Anxiety: T1 (after 12 months of PCI);
CG: 6.6, SD = 3.5
IG : 6.3, SD = 3.9
Depression
CG: 5.9, SD = 4.3
IG: 5.3, SD = 3.4
Limitations and strengths
Limitations:
Small sample size
Sample was from one institution.
Strength: Tools were translated to Portuguese and validated.
Gender differences in quality of life in CAD patients with comorbidities undergoing coronary revascularization
(Oreel et al., 2020)
Understand the impact of comorbidity burden on HRQoL among males and females with CAD following coronary intervention (PCI and CABG).
Longitudinal study Purposive sampling Met the inclusion and exclusion criteria
N = 230 Completed questionnaire (paper or online): one week before intervention
After interventions: at 2 weeks, 3 and 6 months
Conducted in Amsterdam University Medical Center, Cardiology Department
Time frame: September 2015 to March 2018
Age (self-reported) and intervention type (from hospital records) were identified as confounding variables.
Tools used: Generic HRQoL: SF-36 (PCS and MCS)
Disease specific HRQoL: Short Form Seattle Angina Questionnaire (SAQ: 3 domains, scores range from 0 to 100)
R package lme4 version
Linear mixed model to access change of HRQoL over time
PCI:
Males: 129 (75%)
Female: 53 (90%)
Mean age: 68 yrs
Diabetes: significant comorbidity:
Male: 86 (50%)
Female: 20 (34%)
Physical health and recovery from procedure over time was worse in females than males.
Disease specific HRQoL was poorer in females than males.
Mental health improved over time on both males and females after procedure.
Limitations:
Sample size small in females (26%)
Patients without comorbidities were not included in the sample.
Socioeconomic status was not identified.
Strengths:
Longitudinal design using two cardiac centers
Usage of generic and disease specific HRQoL
Note. HRQoL: health-related quality of life, PCI: percutaneous coronary intervention, e PCI: elective percutaneous coronary intervention, EQ-5D-5L: EuroQol 5 Dimension 5 Level, EQ VAS: EuroQol visual analog scales, QLMI-2: MacNew quality of life scale, SPSS: statistical package for the social sciences, CAD: coronary artery disease, QoL: quality of life, ACS: acute coronary syndrome, HADS: Hospital Anxiety and Depression Scale, FAS: Fatigue Assessment Scale, SAQ: Seattle Angina Questionnaire, DASS-21: Depression, Anxiety and Stress Scale 21, SF-36: 36-Item Short Form Health Survey, MCS: mental component scale, PCS: physical component scales, SILVER-AMI: The Comprehensive Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarctions, ANOVA: Analysis of variance, MI: myocardial infarction, ACE: angiotensin-converting enzyme, ARB: angiotensin II receptor blockers, BMI: body mass index, EF: ejection fraction, MACE: major adverse cardiovascular events, TOUS: Theoretical framework: The Theory of Unpleasant Symptoms, IG: interventional group, and CG: control group.
Table 4
HRQoL Instruments Used
SF-36 (Short Form-36)
Generic HRQoL instrument 36 questions under eight domains
EQ-5D (Euro-Qual 5D) Generic HRQoL Instrument
SF-12 (Short Form-12)
QLMI (MacNew quality of life)
HADS (Hospital Anxiety and Depression Scale)
Generic HRQoL instrument shorter version of SF-36
Disease-specific HRQoL instrument
Five questions under five dimensions.
0 = worst HRQoL
100 = best HRQoL
(The higher the score, the better the HRQoL)
100 = worst health
(The higher the score, the worse the HRQoL)
Total number of items: Twelve under eight domains 0–100 0 = worst HRQoL
100 = best HRQoL
(The higher the score the better the HRQoL)
Twenty seven items with subscales of physical, emotional, and social function 1–7 1= low score 7= high score
Generic HRQoL instrument Two subscales with seven items 0–3 0–21
SAQ (Seattle Angina Questionnaire)
Disease-specific HRQoL instrument
19-item with 5 domains 0–100
(The higher the score, the better the HRQoL)
Each item: 0 = no, not at all 3 = yes, definitely
Subscales: 0–7 = normal
8–10 = borderline abnormal 11–21 = abnormal
0–24 = poor health status
25–49 = poor to fair
50–74 = fair to good
75–100 = good to excellent (The higher the score, the better the HRQoL)
SF-36 form generates eight subscales and two summary scores on physical and mental health.
Three degrees of disability under each dimension: Level-1 no disability, Level 2 moderate disability, and Level 3 severe disability
Measures physical and mental health scores
Change in health is not measured.
Specifically for patients with myocardial infarction
Translated into 28 languages
Measures anxiety and depression
Measure HRQoL in patients with CAD Self-administered Translated into 55 languages
Nurses Advancing Equity and Inclusion Through Communication and Language
Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD
Lucille Contreras Sollazzo, MSN, RN-BC, NPD
n Abstract
In and out of healthcare settings, part of a nurse’s role is to communicate with patients, other healthcare professionals, family members, and people in the community. This communication takes place through documentation in patient charts, verbally, through facility and government policy writing, and publishing journal articles, to name a few. Nurses communicate as advocates not only for specific patients but for a community of people. Without consciousness of the impact of language, or awareness of words and phrases that perpetuate disparities and othering, disparities rather than true advocacy and inclusion can be perpetuated. This article and literature review outlines practical tips for inclusive healthcare practice and delivery of nursing care, covering diversity aspects and intersectionality. In addition, in the context of this article, inclusive language is defined as language that includes everyone, regardless of a person’s gender and/or sexual diversity, migrant or refugee status, rural health status, socioeconomic disadvantages, disability, chronic health conditions, age, or ethnicity.
Keywords: inclusive language, health equity, nursing, person-first language
Introduction
Disparities in health care and our society persist today, but nursing can be part of the solution in addressing institutionalized racism, heterosexism, ageism, ableism, classism, and other bigotries. One way to do this is through communication and language. Language and communication can be considered part of the realm of healing. The use of terms, phrases, and words, can be the difference between marginalization and inclusion, being seen as an individual or a stereotype, and embarrassing someone or making them feel whole. Changing the use of words and language can help to move toward less disparities, othering, and marginalization. Of course, the use of language, phrases, and words is not the only change needed to raise the consciousness of institutions and change individual biases, othering, and marginalization of a person or groups of people. Nevertheless, inappropriate language communicates a lack of respect to both colleagues and patients. Nurses can support family members, other healthcare professionals, friends of patients, and patients themselves in language changes to foster equity and inclusivity through education and practice.
The Code of Ethics in Nursing, Nursing’s Social and Policy Statement, and the International Council of Nurses opine that the highest attainable state of health is a fundamental right of every human being (ANA Code of Ethics With Interpretive Statements, 2015; ANA Nursing’s Social and Policy Statement, 2010; ICN Position Statement on Health Inequities, Discrimination and the Nurse’s Role, 2023). These foundational nursing documents also encourage patient-centered care. For the purposes of this article, patient-centered care is defined as care that is respectful of and responsive to individual patient preferences, needs, and values, and ensures that a patient’s values guide all clinical decisions (Newell, 2015). All too often, the lack of healthcare equity stems from biases deeply embedded in the very language of health care and a lack of applying patient-centered care principles in the delivery of care.
The language of health care consists of anything that is written, visual, spoken, or in any way communicated between nurses and patients, guiding the decisions they make, consciously and unconsciously. Language can impact patient perceptions and quality of care by perpetuating
Carol Lynn Esposito, EdD, JD, MS, RN-BC, NPD, New York State Nurses Association, New York, New York
Lucille Contreras
Sollazzo, MSN,
RN-BC, NPD, New York State Nurses Association, New York, New York
misconceptions and supporting stereotypes, and can influence inappropriate nurse decision-making related to nursing diagnosis, patient teaching, and plans of care.
The geographical location of a healthcare facility, the services it provides, and the type of insurance the facility accepts, as well as other factors, all impact the population of patients that receive care at that facility. Compounding the issue, nurses, much like other healthcare providers, do not always reflect the population receiving care at a facility and may not have routine connections with the various populations of people in
Table 1
Themes and Essential Components of Culturally Responsive Communication
Sub-theme
Required characteristics of the healthcare practitioner communicator
Required foundational communication skills
Required contextual factors
Reflexivity
Flexibility
Self-/other-awareness
Respectful
Trustworthy
Honest and transparent
Nonjudgmental
Willing to learn
Ability to listen
Checking understanding
Inclusion and/or acknowledgement of family
Use of simplified, inclusive language
Diversity in staff
Access to culturally appropriate resources and literature
Availability, quality and use of interpreter services
Note. From “Exploring the Incidence of Culturally Responsive Communication in Australian Health Care: The First Rapid Review on This Concept,” by C. Minnican and G. O’Toole, 2020, BMC Health Services Research, 20(1), p. 20 (https://doi.org/10.1186/ s12913-019-4859-6).
their day-to-day lives. Nurses who have graduated from a nursing program prior to 2020, or who have not written an article utilizing the American Psychological Association (APA) 7th Edition (2020), may not be familiar with the changes in APA that, for the first time, provides inclusive language guidelines related to reducing bias. Currently, healthcare facilities may not have policies and practices that utilize inclusive language, and electronic medical records may also not be structured in such a way to support inclusive language. Other contextual considerations for culturally responsive communication are identified and categorized in accordance with Table 1 (Minnican & O’Toole, 2020).
A general literature search as recent as 2021 and 2022 fails to identify inclusivity guides covering multiple diversity aspects and their intersections. Equally lacking is guidance for nurses on practical tips and steps for inclusive practice (Marjadi et al., 2023). We must change the paradigm by changing our behavior and practice to one of lifelong cultural humility and provide culturally and socially responsive care in an ever-changing social landscape (Van Liew et al., 2024).
The Scope of the Problem
How conscious are we of the words and phrases that we use while we are with our patients, writing our notes in the medical record, writing an article, or interacting with the interdisciplinary healthcare team?
The words that we use can be perceived as biased language, can have a negative impact on the patient, on the reader, and on the healthcare team. The way we speak can both directly and indirectly impact the patient. If we communicate utilizing biased language during a team meeting, we can impact the way in which the healthcare team perceives the patient, which can correlate to the team treating the patient disparately. The term “biased language” refers to words and phrases that are considered prejudiced, offensive, and hurtful. Biased language includes expressions that demean or exclude people because of age, sex, race, ethnicity, social class, or physical or mental traits. Using biased language is generally perceived to contain “hidden messages” about the superiority or inferiority of various groups or types of people (Nordquist, 2019).
Language can impact patient perceptions and quality of care by perpetuating misconceptions and supporting stereotypes, and can influence inappropriate nurse decisionmaking related to nursing diagnosis, patient teaching, and plans of care.
Take a moment to reflect: What connotations does a Southern or Boston accent have for you? Are there words or phrases that you hear and immediately think something about the person uttering them? We all carry linguistic bias, most of which is implicit or unconscious. That’s because we naturally gravitate toward our own experiences and don’t even realize we have a bias until someone points it out. Not only do we all carry linguistic bias, we all carry some form of cognitive biases. Cognitive biases are predispositions to respond in predictable ways. The literature reveals medical errors account for up to 440,000 deaths annually. Cognitive biases frequently lead to disparate patient outcomes and have been associated with 28% of diagnostic errors (Greenberg et al., 2022) and diagnostic errors contribute to as many as 70–74% of medical errors (DiMaria et al., 2020; Royce et al., 2019). Moreover, cognitive errors outpace knowledge deficits as causes of error in diagnosis (Loncharich et al., 2023).
Everyone exhibits cognitive bias. It might be easier to spot in others, but it is important to know that it is something that also affects your thinking. Some signs that you might be influenced by some type of cognitive bias include (Cherry, 2024):
• Only paying attention to news stories that confirm your opinions
• Blaming outside factors when things don’t go your way
• Attributing other people’s success to luck, but taking personal credit for your own accomplishments
• Assuming that everyone else shares your opinions or beliefs
• Learning a little about a topic and then assuming you know all there is to know about it
When you are making judgments and decisions about your practice, you like to think that you are objective, logical, and capable of taking in and evaluating all the information that is available to you. Unfortunately, these biases sometimes trip us up, leading to poor decisions and bad judgment.
How often do members of a healthcare team say that the patient “claims” or “insists” when speaking about the care of the patient or writing a note in the medical record? This conveys a sense of doubt or negative judgment (Greenberg et al., 2022). These kinds of statements or words have been seen more often when dealing with female and Black patients which can imply that the credibility of the patient is in question. This can lead to negative attitudes, delayed diagnosis, inappropriate treatments, unnecessary pain and suffering and even death (Greenberg et al., 2022).
Many people in society and in health care have made statements like, “Oh we are just being too sensitive when it comes to language these days.” or “Why do I have to change the way that I speak?” or “People should just know what I mean as I do not mean anything mean or disparaging by the words that I am using.” Research does reveal, however, that changing the paradigm and engaging in instruction in metacognition, reflective practice, and cognitive bias awareness may help providers move toward adaptive expertise and help clinicians improve diagnostic accuracy (Royce et al., 2019).
Stigmatizing language used in medical records to describe patients can influence subsequent practitioners in terms of their attitudes toward the patient and their plans of care. A randomized study showed that physicians who read a vignette with the term, “substance abuser” instead of language that referred to the person as someone with a substance use disorder, expressed that they were more likely to perceive that person as personally responsible and more deserving of punitive measures than as someone with a substance use disorder in need of treatment (Goddu et al., 2018). This is an important and overlooked pathway by which bias can be propagated from one clinician to another. Recognizing and creating strategies to minimize these biases is crucial to optimizing medical care for our patients.
Definitions
The following concepts and definitions were agreed upon by Vital Strategies and the Data for Health Gender Equity Working Group in 2021, and are used here to inform the reader (Gender Equity Unit, 2024).
• Gender – A social and cultural construct, which distinguishes differences in the attributes of men and boys, women and girls, and people of diverse genders, and accordingly refers to the gendered roles and responsibilities of people. Gender-based roles and other attributes, therefore, change over time and vary with different cultural contexts. The concept of gender includes the expectations held about the characteristics, attitudes, and likely behaviors of people
(femininity and masculinity). This concept is useful in analyzing how commonly shared practices legitimize discrepancies between sexes.
• Gender identity – One’s innermost concept of self as male, female, a blend of both, or neither—how individuals perceive themselves and what they call themselves. One’s gender identity can be the same or different from their sex assigned at birth.
• Transgender – A term used by some people whose gender identity differs from what is typically associated with the sex they were assigned at birth. Transwomen; identify as women but were classified as males when they were born; transmen identify as men but were classified female when they were born; while other transgender people don’t identify with the gender binary at all. Some transgender people seek surgery or take hormones to bring their body into alignment with their gender identity; others do not. Being transgender does not imply any specific sexual orientation. Therefore, transgender people may identify as heterosexual, gay, lesbian, bisexual, etc.
• Sex – Refers to the biological and physiological reality of being male or female.
• Gender equality – The concept that people of all genders—women and girls, men and boys, and people of diverse genders—have equal conditions, treatment, and opportunities for realizing their full potential, human rights, dignity, and for contributing to (and benefiting from) economic, social, cultural, and political development. It is based on women and men (and people who are gender diverse, where legal) being full partners in the home, community, and society. Equality does not mean that all people will become the same, but rather that each person’s rights, responsibilities, and opportunities will not be dependent on whether they are labeled as male, female, or intersex at birth.[4] Gender diversity is unfortunately often not considered in discussions of gender equality.
• Gender equity – The process of being fair to men and women, boys and girls, and people who are gender diverse, and the equality of outcomes and results. Gender equity may involve the use of temporary special measures to compensate for historical or systemic bias or discrimination. Equity ensures that people of all genders have an equal chance, not only at the starting point, but also when reaching the finish line. It is about the fair and just treatment of people of all genders and considerations of the different needs, cultural barriers, and impacts of present and historical discrimination against a given person or group. True gender equity also includes equity for gender diverse individuals, who often face the greatest amount of disadvantage or bias because they do not fit the male/ female gender binary.
• Gender equity in health – Fairness in addressing the different health needs of people according to their gender. Inequitable health outcomes based on gender are both avoidable and unacceptable. A concept of fairness recognizes that there are differences between the way people of different genders are treated and that resources must be allocated differently to address unfair disparities.
• LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual) – LGBTQIA+ raises evolving issues which need to be debated and resolved in the legislatures and political space in general to deconstruct and redefine the narratives which have
been influenced by the dominant sociocultural stereotypes. Conflict between the mainstream society and these minorities is contextualized in the larger framework of patriarchal male-dominated society. Democratization is a critical ongoing process, which helps in deepening and facilitating democratic values, principles, and goals to achieve a truly egalitarian society with equitable rights and entitlements for all people. Practitioners who use gender-affirming language and appropriate sexual and gender history-taking empower people and support true democratization in society (Dahl, 2022).
• Implicit (unconscious) bias – Implicit bias, also known as implicit prejudice or implicit attitude, is a negative attitude, of which one is not consciously aware, against a specific social group.
• Cognitive bias – The way a particular person understands events, facts, and other people, which is based on their own particular set of beliefs and experiences and may not be reasonable or accurate (Cambridge, 2023).
Some additional terms that will inform the reader include:
• Nonbinary – Indicates a gender identity or expression that is neither entirely male nor entirely female (Bigeye National Study, 2021).
• Genderqueer – Gender nonconformity reflecting deviation from conventional norms for masculinity and femininity. Some individuals prefer to use the term “gender non-conforming” (Bigeye National Study, 2021).
• Genderfluid – People experiencing a gender identity that is not fixed, who may feel a mix of both genders, and/or more male on some days and more female on others (Bigeye National Study, 2021).
Language Intended to Create and Facilitate Non-Meaningful Hierarchies
Race
Race is a political and social construct used to group people, but these constructs are fluid. Race was constructed as a hierarchal humangrouping system, generating racial classifications to identify, distinguish, and marginalize some groups across nations, regions, and the world. Race divides human populations into groups often based on physical appearance, social factors, and cultural backgrounds (Bonham, 2024).
Race has been used historically to establish a social hierarchy, whereby individuals are treated differently resulting in racism. Genomic scientists are currently investigating the relationship between self-identified race and genetic ancestry. Notably, there is more genetic variation within self-identified racial groups than between them. Practitioners must be careful to not fall victim to genetic discriminatory practices, which occur when a person is treated in an unjust manner because of their genetic makeup. Furthering the problem, scientific racism is an organized system of misusing science to promote false scientific beliefs in which dominant racial and ethnic groups are perceived as being superior. Scientific racism unfortunately continues to exist and we must continually monitor science to avoid scientific racism (Bonham, 2024).
Microaggressions
The term “microaggression” was first coined in 1978 by Chester M. Pierce to describe a phenomenon of subtle negative exchanges directed toward African Americans (Harrison & Tanner, 2018). Subtle discrimination and how it may affect individuals in society, especially those from groups that have been historically marginalized, have received greater attention in recent years. Microaggressions can be related to race, gender, sexual orientation, socioeconomic status, religion, or other features that reflect some aspect of personal identity. And while microaggressions most often present as verbal slights in spoken language, they may also take on nonverbal or environmental forms.
Scholars have proposed three categories of microaggressions that can occur in everyday interactions: microassaults, microinsults, and microinvalidations. A microassault is a conscious, deliberate and either subtle or explicit, biased attitude, belief, or behavior that is communicated to marginalized groups through environmental cues, verbalizations, or behaviors. A microinsult is characterized by interpersonal or environmental communications that convey stereotypes, rudeness, and insensitivity and that demean a person’s identity. A microinvalidation is characterized by communications or environmental cues that exclude, negate, or nullify the thoughts, feelings, or experiential realities of certain groups (Harrison & Tanner, 2018). All three are contextualized in Table 2.
Microaggressions are not simply cultural missteps or racial faux pas, but function as a form of oppression designed to reinforce the traditional power differential between groups whether or not this was the conscious intention of the offender. Microaggressions committed by a practitioner against a patient facilitate barriers to not only communication, but to treatment as well (Williams, 2020).
Experiencing a microaggression signals a dangerous environment, resulting in corresponding psychological and physiological stress responses including confusion, anger, anxiety, helplessness, hopelessness, frustration, paranoia, and fear. Additionally, because microaggressions are so common, they can be conceptualized as a form of chronic stress that may also result in physical problems, such as hypertension and impaired immune response. Further, microaggressions that interrogate targets about where they are from constitute a means of “othering” communicating a lack of belonging and exclusion, which can lead to feeling alienated, which is particularly psychologically damaging (Williams, 2020).
Cognitive Bias
Cognitive bias is defined as the way a particular person understands events, facts, and other people, which is based on their own particular set of beliefs and experiences and may not be reasonable or accurate (Cambridge, 2023). Cognitive bias in health care are flaws or distortions in judgment and/or decision-making (Joint Commission, 2024).
Two processes in thinking and decision-making help describe how cognitive biases manifest. The intuitive process, known as System I, is associated with unconscious, automatic, “fast” thinking, whereas the
analytical process, known as System II, is deliberate, resource intensive, “slow” thinking. Fast thinking responds to stimuli, recognizes patterns, creates first impressions, and is associated with intuitions. It is where heuristics (shortcuts or rules of thumb drawn from repeated experiences and learned associations) are deployed to expedite thinking without expending much, if any, attentional resources (Table 3). It is important for healthcare organizations to gain knowledge around cognitive biases and provide sociotechnical work systems that recognize and compensate for limitations in cognition, as well as promote conditions that facilitate decision-making.
While mitigating the occurrence of cognitive bias can be challenging, healthcare organizations and nurses should consider the following strategies to help increase the awareness of cognitive biases and promote work system conditions that can detect, protect against, and recover from cognitive biases and associated risks (Joint Commission, 2024).
Table 2
Enhance knowledge and awareness of cognitive biases:
• Support discussion of clinical cases to expose biases and raise awareness as to how they occur (morbidity and mortality meetings, reflective case reviews).
• Provide simulation and training illustrating biased thinking. Enhance professional reasoning, critical thinking and decision-making skills:
• Train for and incorporate strategies for metacognition (“thinking about one’s thinking”).
• Practice reflection or “diagnostic time-out,” which facilitates being open to and actively considering alternative explanations/diagnoses asking the question, “How else can this be explained?”
• Train for and incorporate systematic methods for reasoning and critical thinking (Bayesian model or probabilistic reasoning, mnemonics such as “SAFER”).
Microassaults vs Microinsults vs Microinvalidations
Type Microagression
Microassault
“It’s so gay that we can’t get this assay to work correctly.”
“Really, it’s ridiculous that anyone believes in God, you can’t be a real scientist if you believe in God.”
“You should do med school back in Mexico, because I don’t think people like you can succeed here.”
“It’s a shame you are having kids in graduate school, you have really been something special.”
Message
Being gay is bad/abnormal.
Religious people cannot be scientists.
Latino people cannot be successful in the United States.
Women cannot have children and succeed in science.
Microinsult
“I didn’t do well, but, oh well, girls aren’t supposed to be good at science anyway, ha-ha.”
“Is there any way you can dial back the accent a bit? It really makes you sound unscientific.”
“You’re the first Black person I have had in my bio classes, it must be hard being an athlete and a biology major.”
“A plain white lab coat? But you’re gay, so you lab coat should be fabulous.”
Microinvalidation “Race isn’t an issue in our department, students just need to take better advantage of the resources on campus.”
“The book is expensive, but it shouldn’t be an issue. Just have your parents pay for it.”
“We only focus on males mating with females in this class because in this class that is all we care about in genetics.”
“I don’t believe Dr. Doe was being sexist with his comments, you’re blowing this out of proportion.”
Women cannot be good at science.
You cannot have an accent and be a good scientist.
African Americans are only in school for athletics.
All gay people dress a certain way.
Students’ racial experiences do not matter.
Students’ financial situations are not an issue in my class.
We do not care about nonheterosexual experiences.
You are being too sensitive, and I understand your experience better than you.
Note. From “Quick Safety 28: Cognitive Bias in Health Care,” by Joint Commission, 2024 (https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/ quick-safety/quick-safety-28/cognitive-biases-in-health-care/).
• Promote systematic method for presenting information to reduce framing effect.
• Provide simulation opportunities to increase experience and exposure.
• Provide focused and immediate feedback regarding diagnostic decision-making (why it was right or wrong) to allow insight into one’s own reasoning and recalibrate where needed.
Enhance work system conditions and workflow design that affect cognition:
• Promote conditions that facilitate perception/recognition/decisionmaking (e.g., useful information displays, adequate lighting, supportive layout, limited distractions, interruptions and noise).
• Limit cognitive loading, task saturation, and fatigue.
• Allocate time to review information, gather data, and discuss cases.
• Provide access to/clarity of information (e.g., test results, referrals, history and physical).
• Facilitate care transitions.
• Ensure health information technology (IT) is usable, accessible, and integrated within the workflow.
• Facilitate real-time decision-making and reduce reliance on memory (e.g., technology, clinical decision support systems, cognitive aids, algorithms).
• Promote inter- and intra-professional collaboration/teamwork to verify assumptions, interpretations, and conclusions (e.g., communication/ teamwork training).
• Design for error and build resilient systems that help detect and recover from error (redundancies, flagging critical lab values, triangulating data).
Promote an organizational culture that supports decision-making processes:
• Provide an organizational culture that supports the items listed previously.
• Support a safe, nonpunitive reporting culture to learn from near misses and incidents (how cognitive biases arise, what strategies can be deployed to mitigate risk).
• Actively include consideration of cognitive biases in patient safety incident analyses to enhance understanding of how they contribute and can be mitigated.
• Empower and encourage professionals to speak up.
• Engage and empower patients and families to partner in their care, understand their diagnoses, ask questions, and speak up.
Literature Review
The Diversity, Equity, and Inclusion Special Interest Group of a national public health association developed five common concepts that underpin 12 tips in multiple and intersecting areas of diversity, including—but not limited to—social determinants of health, gender, and/or sexual diversity, migrants and refugees, rural health, socioeconomic disadvantages, disability, chronic health conditions, children and young people, elderly people, and ethnic minorities (Marjadi et al., 2023, p. 21) (Figure 1).
These tips underpin the concepts practitioners need to be cognizant of in order to change the paradigm to genuine inclusivity (Marjadi et al., 2023).
Tip 1: Beware of assumptions and stereotypes: Patients may have complex and multiple diverse characteristics. Without taking a full history, practitioners may wrongly assume some things by default. For example, a patient who exhibits tremors and has difficulty speaking may conjure up the assumption about the patient’s ability to make healthcare decisions.
Tip 2: Replace labels with appropriate terminology: Practitioners should try to keep up with best-practice terminology (sources are reviewed in this article).
Tip 3: Use inclusive language: Practitioners should be cognizant of words that can exclude classes of people or designate someone as an “other” when deemed to be different to oneself.
Tip 4: Ensure inclusive physical spaces: Physical, sensory, and cognitive needs need to be accommodated for to improve the patient experience.
Tip 5: Inclusive signage and symbols: The design and format of signs and symbols need to consider accessibility and recognition by people with diverse needs, such as font size, colors used, tactile elements, and depiction of people.
Tip 6: Appropriate communication methods: Practitioners need to incorporate appropriate and preferred methods of communication into their practice, including written materials, visual aids, body language, and the use of interpreters.
Tip 7: Adopt a strengths-based approach: Practitioners should avoid stereotyping certain features with generalizing patient behavior or needs. Not all patients fit the stereotype of their group. Do not assume that patient characteristics should be viewed through a deficit lens.
Tip 8: Ensure inclusivity in healthcare service research: Many classes of people have been under-represented in clinical trials despite well-recognized health inequalities in these groups. Non-inclusive research practices may generate a skewed picture of the plan of care needed.
Tip 9: Expand the scope of inclusive healthcare delivery: Marginalized populations may benefit from services with after-hours and walk-in facilities and holistic and integrated health care that considers all aspects of an individual’s physical and psychological well-being, including their social needs.
Tip 10: Advocate for a more inclusive healthcare system: Nurses are mandated under the Code of Ethics to integrate the principles of social justice into nursing and health policy (ANA Code of Ethics, Provision 9.3). Nurses must take action to influence legislators, governmental agencies, nongovernmental organizations, and international bodies to address the social determinants of health and advocate for inclusive care.
Tip 11: Self-educate on diversity in all its forms: Practitioners need to commit to an ongoing process of becoming more inclusive to more diversity. Continuous, self-directed continuing education regarding the diverse needs of patients and how to address them is a mandate under the Nurses Code of Ethics (ANA Code of Ethics, Provisions 3.3, 5.5).
Tip 12: Build individual and institutional commitments: These tips should be incorporated into the policies and protocols in all practice arenas. Inclusivity needs to be clearly visible and authentic.
The Language of Inclusion
Language plays a crucial role in shaping discourses and responses between patient and practitioner. Terminology used can be empowering, or stigmatizing, discriminatory, marginalizing, and even criminalizing, reinforcing the “othering” of those affected. To combat this, an inclusive language approach can remove conscious and unconscious hurdles and align with the U.S. Department of Health and Human Services Healthy People 2030 goals.
In 2021, the American Psychological Association (APA) (2023) published an Inclusive Language Guideline, “because words matter” and “have an important role in creating psychologically safe, inclusive, respectful and welcoming environments.” The guide also provides the reason for terms that can create issues with alternatives. The APA emphasizes the need to use language that is free of bias and avoid perpetuating prejudicial beliefs or demeaning attitudes in writings. The guidelines for bias-free language contain both general guidelines for writing about people without bias across a range of topics and specific guidelines that address the individual characteristics of age, disability, gender, participation in research, racial and ethnic identity, sexual orientation, socioeconomic status, and intersectionality (APA, 2023).
Table 3
Examples of Cognitive Biases
Anchoring bias
The words that you use take consciousness, effort, and practice. It is not about perfection; it is about consciousness and a willingness and acceptance to be wrong and making an effort to use different language.
With permission provided by the American Psychological Association, we have reproduced their guidelines in Tables 4–11. (See also CDC, 2022.)
The acronym LGBTQIA+ combines sexual orientation with gender identity. Sexual orientation is the enduring emotional, romantic, sexual, or affectional attraction to another person. Using language that assumes another person’s gender or pronouns can cause harm. We need to shift our language to avoid assumptions. Small changes in language can make a big difference in people’s lives. Some simple changes that can be made instead of “Yes, sir” or “Can I help you miss?” are noted in Table 13.
A dditionally, the literature reveals lesbian, gay, bisexual, and transgender people experience profound mental health challenges, including emotional distress, stigmatization, victimization, discrimination, and barriers to accessing healthcare services. Healthcare providers are in a singular position to address challenges related to social and healthcare structures and act as advocates in order to promote the physical and mental health of LGBTQIA+ individuals (Moagi et al., 2021).
Giving weight and reliance on initial informative/impressions, and not adjusting from this (anchor) despite availability of new information. “Jumping to conclusions” can lead to missed/delayed diagnoses.
Ascertain bias
Shaping decision-making based on prior expectations (e.g. stereotyping, gender bias). “Frequent flyers” with recurrent complaints can affect decision-making or, in the case of falls, a patient who “always uses the call bell” may predisposed staff to expect that behavior.
Availability bias
Judging likelihood of a diagnosis based on the ease with which examples can be retrieved (more familiar, common, recent, memorable) (e.g., diagnosing a patient based on frequently seen conditions such as the flu, or not considering less common diagnosis).
Confirmation bias
Selectively noticing/seeking information that confirms opinion/impressive versus seeing information that disconfirms. Evidence in support of beliefs is given more weight; evidence that refutes may not be noticed (e.g., not noticing a warning label on medication or performing procedure on incorrect site).
Diagnostic momentum (bandwagon effect)
Once a label (diagnosis) has been assigned, momentum takes hold and reduces ability to consider other alternatives. Can affect future work-up or patient and handoffs are “framed.”
Framing effect
How information is presented, and how a question is framed can impact future decisions (e.g., framing in probabilities as to whether patient might “die” or “live”). Source information (e.g., superior, trusted source) and context can influence framing.
Search satisfying/premature closure
Cease looking for findings/signals (e.g., disease processes, fracture, retained object) once something has been identified. Accepting a diagnosis before considering all information and verifying diagnosis.
Note. From “Quick Safety 28: Cognitive Bias in Health Care,” by Joint Commission, 2024 (https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/ quick-safety/quick-safety-28/cognitive-biases-in-health-care/).
Figure 1
Tips for Inclusive Practice and Their Five Underpinning Concepts
Twelve Tips
1. Beware of assumptions and stereotypes
2. Replace labels with appropriate terminology
3. Use inclusive language
4. Ensure inclusivity in the physical space
5. Use inclusion and appropriate signs and symbols
6. Ensure appropriate communications methods
7. Adopt strength-based approach
8. Ensure inclusivity in healthcare research
9. Expand the scope of inclusive healthcare delivery
10. Advocate for a more inclusive healthcare system
11. Self-educate on diversity in all its forms
12. Build individual and institutional commitments
Five Underpinning Concepts
Note. From “Twelve Tips for Inclusive Practice in Healthcare Settings,” by B. Marjadi, J. Flavel, K. Baker, K. Glenister, M. Morns, M. Triantafyllou, P. Strauss, B. Wolff, A. M. Procter, Z. Mengesha, S. Walsberger, X. Qiao , and P. A. Gardiner, 2023, International Journal of Environmental Research and Public Health, 20(5), p. 4657 (https://doi.org/10.3390/ijerph20054657).
Table 4
Identity Related Language
and
dependents
Geriatric pregnancy
Silver tsunami
Advanced maternal age Pregnancy at age 35 or older
Age-related population changes
Age-related demographic changes
Avoid language that promotes stereotypes that “other” older adults. However, please note that in certain cultures, the term “Elder” is considered honorific.
Use person-first language to describe the age of a pregnant person. Older pregnant people may benefit from additional screening.
Use affirmative language specific to the demographic information.
Note. From the Inclusive Language Guide (2nd ed.), by American Psychological Association, 2023, p. 11 (https://www.apa.org/about/apa/equity-diversity-inclusion/language-guide. pdf). Copyright 2023 American Psychological Association.
Table 5
Person-First Language
Terms to avoid
Wheelchair-bound
Confined to a wheelchair
Mentally ill
Crazy Insane Mental defect
Suffers from or is afflicted with [condition]
Person who uses a wheelchair
Wheelchair user
Person living with mental illness
Suggested alternatives
Person with a preexisting mental health disorder
Person with a preexisting behavioral health disorder
Person with a diagnosis of a mental illness/mental health disorder/behavioral health disorder
Asylum Psychiatric hospital/facility
Drug user/abuser
Addict
Alcoholic Alcohol abuser
Person taking/prescribed medication-assisted treatment (MAT)
Person who relapsed
Smoker
Homeless people
The homeless
Transient populations
Prostitute
Prisoner Convict
Person who uses drugs
Person who injects drugs
Person with a substance use disorder
Person with alcohol use disorder
Person in recovery from substance use/alcohol disorder
Person taking/prescribed medications for opioid use (MOUD)
Person who returned to use
Person who smokes
People without housing
People experiencing homelessness
People experiencing unstable housing/housing insecurity/people who are not securely housed
People experiencing unsheltered homelessness
Clients/guests who are accessing homeless services
People experiencing houselessness
People experiencing housing or food insecurity
Person who engages in sex work
Sex worker (abbreviated as SWer)
Person who is/has been incarcerated
Slave Person who is/was enslaved
Note. From the Inclusive Language Guide (2nd ed.), by American Psychological Association, 2023, pp. 9–10 (https://www.apa.org/about/apa/equity-diversity-inclusion/ language-guide.pdf). Copyright 2023 American Psychological Association.
Table 6
Body Size and Weight Language
Terms to avoid
Suggested alternatives
Lower weight Higher weight
Unsolicited comments on body size of body changes, either observed or measured:
“Wow, you’re looking great!”
“Look at how much weight you’ve lost! I’m so proud of you!”
“Your getting so big!”
“What happened, you’ve lost/gained so much weight?”
To avoid perpetrating weight stigma, use neutral terms that affirm and respect the dignity of all individuals regardless of their body size (Meadows & Danielsdotir, 2016). Please note that the term “fat” is being reclaimed by individuals who identify as part of the fat-acceptance community as a neutral descritptor to normalize the existence of fat bodies (Saguy & Ward, 2010).
Language to be inclusive of body diversity to avoid microagressions
Comments on body size or body changes warranted by the context (e.g., a medical discussion with a health care professional), after asking consent:
“Is it alright if we talk about your weight?”
“Would you feel okay or comfortable if we discussed your weight?”
Or, if in survey form, “the next questions concern your weight. You may answer them or skip to the next section.”
“What, if any concerns might you have about your weight?”
“How do you view or feel about your body?”
“Have you experienced any significant weight changes?”
If yes:
“How do you feel about that?”
“What do you think might be going on?”
“How may I help?”
Discussion of body weight in writing
“Your weight is....”
“The health indicator(s) for you to be aware of is/are”
Avoid unsolicited commentary or body size or body changes or do not comment at all unless you are the individual’s healthcare provider. This prevents unintended consequences or mixed messages about people’s health or appearance (American Diabetes Association, n.d).
“Use neutral, nonjudgmental language based on facts, actions, or physiology/biology” (American Diabetes Association, n.d., p. 1).
BMI is population-based measure that is less helpful in individual clinical practice. Rather than focus on weight focus exclusively on the health issue at hand, for example, cholesterol, blood pressure, or A1C levels.
“Avoid referring to individuals by a label that implies that the person is defined by the diagnosis of symptoms that they experience” (Weissman et al., 2016, p. 350). Examples include “anorexic,” “bulimic,” “binge eater,” and “obese person.”
Note. From the Inclusive Language Guide (2nd ed.), by American Psychological Association, 2023, pp. 13–14 (https://www.apa.org/about/apa/equity-diversity-inclusion/languageguide.pdf). Copyright 2023 American Psychological Association.
Table 7
Disability Language
Terms to avoid
Special needs
Differently abled
Multiabled
Physically challenged
Mentally retarded
Handi-capable
Handicapped
Suffering with... [disability or conditions]
Mentally ill
Person with deafness
Hearing-impaired person
Person who is hearing impaired
Person with deafness and blindness
Suggested alternatives
Use of person-first language rather then condescending terms
Person with a disability
Person who has a disability
Disabled person
People with intellectual disabilities
Child with a congenital disability
Child with a birth impairment
Physically disabled person
Person with a physical disability
Person with a mental disorder
Person with a mentall illness
Person living with a mental health condition
Comments
Use person-first or identity-first language as is appropriate for the community or person being discussed. The language used should be selected with the understanding that disabled people’s expressed preferences supersede mater of style. There are some patterns–people with physical and intellectual disabilities often prefer person-first language, whereas the autistic community and people with sensory disabilities (e.g., blind people) often prefer indentity-first language. Avoid terms that are condescending or patronizing.
Description of Deaf or hard-of-hearing people
Deaf person
Person who is deaf
Person with blindness
Visually challenged person
Visually impaired person
Vision-impaired person
Person who is visually impaired
Person who is vision impaired
Sight-challenged person
Wheelchair-bound person
Confined to a wheelchair
Cripple
Invalid
Gimp
hard-of-hearing person
Person who is hard-of-hearing
Person with hearing loss
Deaf-Blind person
A Deaf person with low vision
A person who is deaf with low vision
Most individuals who belong to the Deaf or Deaf-Blind cultures prefer to be called Deaf or Deaf-blind (capitalized) rather than “hearing-impaired.”
The word “deaf” with a lower case “d” is used to refer to audiological status, whereas “Deaf” with and uppercase “D” “refers to a particular group of deaf people who share a language—for example, American Sign Language and a culture” (National Association of the Deaf, n.d., “Deaf” and “deaf” section).
Some individuals prefer to use Deaf+ (to include other intersectional identites) when referring to themselves.
Description of blind people and people who are visually impaired
Blind person
Person who is blind
Person with low vision
People who have complete or almost complete loss of sight may be referred to as “blind.” Other terms are acceptable for those with a visionbased disability.
Some people may object to the term “visually impaired” because of the negative connotation of the word “impaired.” The use of such terms is complex, often culturally bound, and deeply personal. If you are uncertain about how someone identifies, it is recommended that you ask what identity-first or person-first terms they prefer (e.g., “blind or blind person”). (For further guidance on this topic please consult the National Center on Disability and Journalism, 2021.)
Use of pictorial metaphors, negativistic terms, and slurs
Wheelchair user
Person who usees a wheelchair
Person with a physical disability
Avoid language that uses pictorial metahpors, negativistic terms that imply restriction, and slurs that insult or disparage a particular group. As with other diverse groups, insiders in disability culture may use these terms with one another; it is not appropriate for an outsider (i.e., a nondisabled person) to use these terms.
Health Equality and Health Equity
One of the overarching goals of Healthy People 2030 is to eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and social determinants of health—and to eliminate disparities in health and health care.
Health equality (treating everyone the same and giving everyone access to the same opportunities) means giving everyone the same opportunities, care, and services. A doctor might offer the same test to everyone at the
Table 7
Disability Language (con’t)
Terms to avoid
Brain damage
Defective
Nuts
Crazy
Alcoholic
Addict
Stand up for
Turn a blind eye
Be myopic or shortsighted
Have a blind spot for
Blind review
Blind coding
Color blind
same interval, without regard to risk factors, or provide the same information to everyone. The doctor might also believe that, as long as they treat everyone the same, they are not behaving in biased ways.
Health equity (proportional representation [by race, class, gender, etc.] in those same opportunities) means ending institutional and discriminatory barriers that lead to health inequities and inequality. This includes factors within the healthcare system, such as racism and sexism, as well as factors outside the healthcare system, such as poverty and unequal distribution of resources. To achieve equity, policies and procedures may result in an unequal distribution of resources.
Suggested alternatives Comments
Person with a traumatic brain injury (TBI)
Person with a mental disorder
Person with a mental illness
Person living with a mental illness
Person with alcohol disorder
Person with substance use disorder
Ableist terms and phrases in everyday language
Support
Champion
Ignore
Refuse to notice
Ignore
Miss
Show unconscious bias
Anonymous review
Masked review
Masked coding
Deuteranomaly, achromatopsia (or other type of color-vision deficiency)
Color-vision defciency
Note. From the Inclusive Language Guide (2nd ed.), by American Psychological Association, 2023, pp. 16–18 (https://www.apa.org/about/apa/equity-diversity-inclusion/ language-guide.pdf). Copyright 2023 American Psychological Association.
AIDS victim HIV patient
Person with AIDS Person with HIV Person living with HIV HIV-positive person
For additional guidance on avoiding stigma when using language to describe people living with HIV, visit Guide to Talking About HIV (CDC, 2022b).
On the policy level, health equality gives everyone the same support to access health care, while health equity prioritizes justice. In an equalitybased approach, everyone would get the same healthcare funding and services. In an equity-based approach, funding would depend on need, and the services a person could access would depend on their need. Thus, equity is a process and equality is an outcome of that process (Figure 2). Health equity is achieved when everyone can attain their full potential for health and well-being.
Table 8
Violent Language
Killing it
Understanding the difference between health equality and health equity is important to public health to ensure that resources are directed appropriately, as well as supporting the ongoing process of meeting people where they are. Inherent to this process is the promotion of diversity in teams and personnel, public health practice, research methods, and other related factors. For these reasons, providing the same type and number of resources to all is not enough. In order to reduce the health disparities gap, the underlying issues and individual needs of underserved and vulnerable populations must be effectively addressed.
Suggested alternatives
Nailing it Great job
Take a shot at
Take your best shot
Take a stab at
Target population
Off the reservation
Give it a go
Specific population
Group of focus
Disagree with the group
Defect from the group
Comments
Although these terms and idioms may seen innocuous ways to signal achievement, it is notable how pervasive violent or miltaristic language is seen as positive when it should be the opposite (Karlin, 2019). Even when used in medicine, violent metaphors have been described as “ironic, unfortunate, and unnecessary” (Nie et al., 2016, p. W9).
“Target population” may be offensive because many communities are targeted for violence.
This phrase has a harmful history in the United States because Native Americans “were forced into treaties that limited their mobility by placing them on reservations,” and the consequences for going “off the reservation” could often be lethal (RWJBarnabas Health, n.d., “Off the reservation” section).
Note. From the Inclusive Language Guide (2nd ed.), by American Psychological Association, 2023, p. 38 (https://www.apa.org/about/apa/equity-diversity-inclusion/language-guide. pdf). Copyright 2023 American Psychological Association.
Table 9
Language that Doesn’t Say What We Mean
Committed suicide/suicided
Failed/successful suicide
Completed suicide
Killed themselves
Child prostitute
Sex with an underage person
Nonconsensual sex
Date rape or acquaintance rape
Died by suicide
Death by suicide
Lost their life by suicide
Survived a suicide attempt
Child who has been trafficked
Child who has been raped
Rape
Rape or sexual assault
“Commit” implies crime or a sin. Do not describe suicide attempts as “successful,” or “unsuccessful,” or “failed.” Instead, say “survived a suicide attempt,” similar to describing someone who has survived a medical event such as a heart attack (Greenstein, 2018; National Institutes of Health, 2023).
The term “date rape” may lead to confusion that “date rape” is somehow different or less serious than rape... “[It is better to] name the crime, followed by information about the perpetrator” (RAINN, n.d., Date Rape or Rape? section).
Note. From the Inclusive Language Guide (2nd ed.), by American Psychological Association, 2023, p. 38 (https://www.apa.org/about/apa/equity-diversity-inclusion/language-guide. pdf). Copyright 2023 American Psychological Association.
Behind both equality and equity are underlying goals of fairness, justice, and respect for individual dignity. Historic injustices and ongoing patterns of poorly distributed economic and political power, along with conscious and unconscious biases toward group characteristics, permeate laws, policies, and healthcare practices in ways that impede those goals. Equity in current parlance offers ways to achieve equality by either meeting individual needs or producing alterations of entrenched patterns impairing equality. Recognizing the unique situation of each person calls for true patient centered providers of health care. Manifesting the dignity of each patient requires ensuring each receives the same respect and also finds opportunities that are realities (Minow, 2021).
Conclusion
The Code of Ethics for Nurses has always provided us with the pathway to social justice. Ensure the respect for the dignity of each individual and overcome historic and ongoing barriers due to stereotypes, “isms,” and compounded exclusions and degradations. Defend equal protection of the laws and advance systemic changes while attending to the unique situation of each person. It is a tall order, but it is what nursing’s foundational documents, laws, and justice demands, and all the concepts and legal tools available should be used. Both “equality” and “equity” can help illuminate deep problems in human societies, and both offer tools to make a different and better world—if those who share visions of change work together.
Table 10
Social Class Status Language
Terms to avoid
The poor Poor people
Low-class people
Lower-class people
Homeless people
Blue-collar worker
White-collar people
Ghetto/the ghetto
Suggested alternatives
Comments
People whose incomes are below the federal poverty threshold As always, there should be room for nuance and flexibility when using these terms. Many people find the terms “low-class” and ”poor” pejorative. Conversely, class solidarity exists in “poor people’s movements” and many individuals proudly identify as “working class.”
People who are of low SES/ Socioeconomic status
People without housing
People experiencing houselessness
People experiencing housing insecurity or food insecurity
Skilled tradesworker
Manual laborer
Salaried professional
Underresourced area
Low socioeconomic area
Define specific income brackets and levels if possible (e.g., “low income").
These terms are considered somewhat outdated as they originated in the early 20th century (Harris, 2022; Wilkie, 2019).
A term that is often used to describe the intersectionailty of socioeconomic status and race/ethnicity. Merriam-Webster (n.d.-b) defines the word ghetto as “a quarter of a city in which members of a [marginalized] group live especially because of social, legal, or economic pressure” (Definition 2). It also has roots in antisemitism. The colloquial use of the term “ghetto” to describe others is rooted in classism and racsim.
Note. From the Inclusive Language Guide (2nd ed.), by American Psychological Association, 2023, pp. 35–36 (https://www.apa.org/about/apa/equity-diversity-inclusion/languageguide.pdf). Copyright 2023 American Psychological Association.
Table 11
Sexual Orientation, Gender Diversity, and Identity Language
Terms to avoid
Birth sex
Natal sex
Born a girl, born female
Born a boy, born male
Female to male
Male to female
Hermaphrodite
She-male, he female
Tranny
Transvestite
Transexual
Transgendered
Suggested alternatives
Assigned sex
Sex assigned at birth
Assigned female at birth (AFAB)
Assigned male at birth (AMAB)
Assigned female at birth (AFAB)
Assigned male at birth (AMAB)
Intersex
LGBTQ, LGBTQ+, LGBTQIA+, etc.
Transgender person
Transgender people
Trans and gender nonbinary folks or folx
Genderqueer
Queer
Transgender
Comments
Some people may use terms to describe themselves and others tthat may be perceived as pejorative but are empowering for those individuals and their communities. “Tranny” or “queer” are examples of such terms. Some members of the LGBTQIA+ community have reclaimed them, whereas others consider them offensive.
“Transgendered is a dated term that suggests a point in time when a person ‘became’ transgender, which diverges from the lived experiences of most transgendered people” (National Institutes of Health, 2023, Transgender, trans definition).
Note. From the Inclusive Language Guide (2nd ed.), by American Psychological Association, 2023, pp. 33–34 (https://www.apa.org/about/apa/equity-diversity-inclusion/languageguide.pdf). Copyright 2023 American Psychological Association.
See also “Contraception Across the Tansmasculine Spectrum,” by C. Krempasky, M. Harris, L. Abern, and F. Grimstad, 2020, Am J Obstet Gynecol, 222(2), pp. 134–143 (https://doi. org/10.1016/j.ajog.2019.07.043).
Birth people, bodies with vaginas, cervix havers, menstruators, non-males, non-men, people, people with a cervix, people with vaginas, uterus havers, vulva owners
Note. From “Effective Communication About Pregnancy, Birth, Lactation, Breastfeeding and Newborn Care: The Importance of Sexed Language,” by K. D. Gribble, S. Bewley, M. C. Bartick, R. Mathisen, S. Walker, J. Gamble, N. J. Bergman, A. Gupta, J. J. Hocking, and H. G. Dahlen, 2022, Global Women’s Health, 7(3), p. 818,856 (https://doi.org/10.3389/ fgwh.2022.818856).
Table 13
Gender-inclusive Language
Sexed terms
Yes Sir
Thank you Miss
Replacement terms
• Good morning!
• Thank you very much.
• It’s a pleasure.
• How can I be of assistance today?
• Could I help the next guest?
• Yes, please.
• Yes, absolutely. Coming right up.
Remarking about a particular “Man” “Woman”
Ladies and gentlemen Boys and girls Guys
He
She s/he (for Individuals who identify as non-binary, Genderqueer, and gender fluid)
Men
Women
Latino/a
• The person in the red shirt
• The person with their hand raised
• The person who just spoke
• The person over here (gesturing)
• Friends
• Colleagues
• Friends and colleagues
• Esteemed guests
• Children/youngsters
• Students
• Everyone
• They/them
• That person
• The patron
• The guest
• Everyone
• All people
• People of all genders
• Latinx/Latine
Note. From Pronouns.org. Inclusive Language, Retrieved from https://pronouns.org/ inclusive language.
Figure 2
Equality vs Equity
Note. From Design in Tech Report: Addressing Imbalance, by The George Washington University Milken Institute School of Public Health, 2019. Retrieved from https://onlinepublichealth.gwu.edu/resources/equity-vs-equality/.
Case Study
A year 3, Medical Student enters the emergency department to assess a 320 pound hypertensive cardiac patient who identifies as a person of color. The Medical Student asks the patient where they were born and compliments them on their articulation and English ability. The Medical Student proceeds to ask the patient “you know that being fat is bad” and that “it must be particularly hard for you to be thin because your people are all so obese.” The Medical Student begins talking to the patient about how being fat is a chronic and lifelong health condition that requires the patient to be motivated every day to do the right thing, to eat less, to exercise more, and not give into their food addictions or to shift meal planning towards convenience.
How to Change the Narrative
One of the most common settings where adults and children experience weight stigma and discrimination is in health care, a space that should be safe and free from judgment. Health care should be inclusive, allowing all people, no matter their reasons for attending, to receive advice support and relevant treatment.
Seek permission.
Unless introduced by the person living with obesity, prior to initiating the conversation, seek the person’s permission to discuss their weight.
Use language (including tone and nonverbal gestures) that is:
Free from judgment or negative connotations, particularly to avoid the threat of long-term consequences or scolding (‘telling off’)
Person-centered, (also known as ‘person-first’) to avoid labeling a person as their condition. An example is talking about ‘a person with obesity’ rather than an ‘obese person.’
Collaborative and engaging, rather than authoritarian or controlling
Free from generalizations, stereotypes, or prejudice
Free from words that attribute responsibility (or blame) to the person for either the development of their obesity or its consequences
Free from ridicule or humor
Accurate, evidence-based information when discussing weight
Be empathic, listen, and explore.
Use language that seeks to explore a patient’s point of view of their condition.
Use questions that seek out the patient’s own words or phrases about their weight and body image and explore the meanings behind them.
Acknowledge that there are many routes to achieving weight loss and what works for one may not work for all.
Be collaborative.
Build specific goals and activities together.
Agree when to meet again to review progress.
Acknowledge positive actions.
Congratulate existing positive actions. Remind the patient that it’s fantastic that they have made changes, and don’t worry that their weight hasn’t come down—the benefit to health goes way beyond weight loss with each change.
n References
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WHAT’S NEW
IN HEALTHCARE LITERATURE
Hospital-Onset Bacteremia in NICU Linked to Increased Mortality Risk
Rane, V. & BS Pharm. (2024, July 12) https://www.medscape.com/ viewarticle/hospital-onset-bacteremia-nicu-linked-increased-mortality2024a1000cv0?
Topline
Hospital-onset bacteremia (HOB) in the neonatal intensive care unit (NICU) is associated with increased mortality, according to a study that also identified birth weight and postnatal age as risk factors for HOB.
Methodology
• This multicenter retrospective cohort study was conducted from 2016 to 2021 and included 451,443 infants (55.6% men; 44.4% women) admitted to seven academically affiliated NICUs and 315 NICUs in the Pediatrix Medical Group for ≥ 4 days.
• The primary outcomes were HOB and HOB-attributable mortality.
• The association of birth weight and postnatal age with HOB risk was also assessed.
Takeaway
• A total of 9,015 HOB events were reported, and 54% events occurred without a central line in place.
• Overall, the HOB incidence rate was 1.1 per 1,000 patient-days (95% CI, 1.0–1.2). In the first 2 weeks after birth, the rate was 0.4 events per 1,000 patient-days among infants with a birth weight of 1,501–2,500 g (95% CI, 0.3–0.4) or > 2,500 g (95% CI, 0.4–0.5).
• After 42 days vs 4–14 days, the risk for HOB decreased by 90% (incidence rate ratio [IRR], 0.10; 95% CI, 0.1–0.1) in infants with a birth weight ≤ 750 g (IRR, 0.10; 95% CI, 0.1–0.1) but increased by 50% (IRR, 1.5, 95% CI, 1.2–1.9) in infants with a birth weight > 2,500 g.
• The pooled estimate of the absolute difference in the 7-day cumulative risk for mortality in the NICU between infants with HOB and those without HOB was 5.5% (95% CI, 4.7%–6.3%).
In Practice
“Together, HOB surveillance and targeted prevention strategies could decrease HOB rates and improve infant outcomes,” the authors wrote.
Source
The study was led by Erica C. Prochaska, MD, Johns Hopkins University School of Medicine in Baltimore, Maryland. It was published online on June 24, 2024, in JAMA Pediatrics
Limitations
The study sample did not represent all infants hospitalized in NICUs across the United States. The study did not include the data of infants who died after being transferred to a participating site or those who had a positive blood culture prior to the transfer. The set of infant and site-level acuity characteristics used to match infants might include unmeasured confounders.
Disclosures
This study was supported in part by the Centers for Disease Control and Prevention and grants from the National Institutes of Health. Several authors declared receiving personal fees, consultancy fees, grants, or funding from various sources.
This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.
Hyponatremia Linked to Severe Adverse Outcomes in Children
Mehta, Z. (2024, July 1). https://www.medscape.com/viewarticle/ hyponatremia-linked-severe-adverse-outcomes-children-2024a1000c5y?
Topline
Mild hyponatremia in children visiting pediatric emergency departments (PEDs) is associated with higher rates of vasopressor use, ward and pediatric intensive care unit (PICU) admissions, and mortality, with these adverse events increasing with increased hyponatremia severity.
Takeaway
Admission rates were higher in the mild hyponatremia group than in the normonatremia group (51.1% vs 35.6%; P < .001).
Vasopressor use and PICU admission rates were 1.1% and 2.4%, respectively, in the mild hyponatremia group, which were significantly higher than the corresponding rates of 0.6% and 0.9% in the normonatremia group (P = .014 and P < .001).
The mild hyponatremia group exhibited a significantly higher mortality rate of 1.5% than the normonatremia group, which had a corresponding rate of 0.3% (P < .001).
Rates of vasopressor use, PICU admissions, and mortality increased significantly from the normonatremia to severe hyponatremia groups.
In Practice
“Immediate intervention should be implemented in addition to identifying the cause [of mild hyponatremia]. These interventions are crucial for improving adverse outcomes and patient care in the emergency department setting,” the authors wrote.
Source
This study was led by Jisu Ryoo from the Department of Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea. It was published online on June 14, 2024, in Frontiers in Pediatrics.
Limitations
The study’s retrospective design and reliance on data from a single institution’s electronic medical records may limit its generalizability to all PED visits. Additionally, the use of anonymous data means that multiple entries for the same patient may have been included.
Disclosures
The study received financial support from the Catholic Medical Center Research Foundation. The authors reported no conflicts of interest.
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CE Activity: Nurses Advancing Equity and Inclusion Through Communication and Language
Thank you for your participation in “Nurses Advancing Equity and Inclusion Through Communication and Language,” a new continuing education (CE) activity offered by NYSNA. NYSNA members and nonmembers are invited to take part in this activity; 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 posttest, evaluation form, and earn 80% or better on the posttest.
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 the CH and CEU, participants must read the entire article, fill out the evaluation, and get 80% or higher on the posttest.
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
A significant part of a nurse’s role is to communicate with patients, other healthcare professionals, family members, and people in the community. This communication takes place in various ways, such as through
documentation in patient charts, verbally, through facility and government policy writing, and publishing journal articles. Nurses communicate as advocates not only for specific patients but for a community of people. Without an awareness of language’s impact and words and phrases that perpetuate disparities and othering, true advocacy and inclusion cannot be achieved. This is true for a nurse’s one-on-one interactions with a patient, as well as the communications that takes place between healthcare professionals about the patient. This article and literature review outlines practical tips for inclusive healthcare practice and delivery of nursing care that covers aspects of diversity and intersectionality. Inclusive language is defined as language that includes everyone, regardless of a person’s gender and/or sexual diversity, migrant or refugee status, rural health status, socioeconomic status, disability, chronic health conditions, age, or ethnicity.
LEARNING OUTCOME
Participants will recognize how prioritizing inclusive language in their nursing practice, strengthens patient-centered care and healthcare equity.
OBJECTIVES
At the completion of this learning activity, the learner will be able to:
1. Distinguish between a vocabulary of inclusive language choices to use and a vocabulary of marginalizing language to avoid.
2. Identify communication choices that can minimize diagnostic errors, stigmatization, and disparate impacts.
3. Distinguish between healthcare equity and healthcare equality. 4. Discuss the five common concepts underpinning guidance for inclusive 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, 2028.
1) Patient-centered care is respectful and responsive to individual patient preferences, needs, and values, and ensures that patients’ values guide all clinical decisions.
a. True
b. False
2) The APA has introduced changes that provide inclusive language guidelines related to reducing bias in nursing and other healthcare professions.
a. True
b. False
3) Healthcare equality can still limit someone’s opportunity to access and receiving and achieving healthcare success. An example of equal treatment might be a nurse who believes that as long as they are treating everyone the same or giving the same support to everyone, they are not behaving in a biased way. Healthcare equity, on the other hand, addresses the institutional barriers that prevent the equal distribution of resources and services to any given person or group, thus impeding their healthcare success.
a. True
b. False
4) Studies have found that cognitive biases are not associated with diagnostic errors.
a. True
b. False
5) Not everyone exhibits cognitive bias, especially not a nurse who assumes that everyone else shares their opinions or beliefs.
a. True
b. False
6) The use by healthcare professionals of terms like “claims” or “insists” when speaking about a patient’s communications is more common with female and Black patients. This can signify a perceived lack of patient credibility by a provider—or the belief that a patient isn’t necessarily to be believed.
a. True
b. False
7) Using stigmatizing language in medical records to describe patients cannot influence subsequent practitioners’ attitudes toward the patient or their plans of care.
a. True
b. False
8) The five concepts that underpin inclusive nursing practice are diversity, equality, inclusion, intersectionality, and deficit-based approach.
a. True
b. False
9) An example of gender-inclusive language would be to say, “the person with their hand raised” instead of “the man with his hand raised.”
a. True
b. False
10) Using the term “the elderly” is a suggested alternative phrase for older adults that helps to create a safe, inclusive, and welcoming environment.
a. True
b. False
Answer Sheet
Nurses Advancing Equity and Inclusion Through Communication and Language
Note: 1.0 CH and 0.1 CEU for this program will be offered until January 31, 2028.
Please print legibly and verify that all information is correct.
Daytime Phone Number (Include area code):
NYSNA Member # (if applicable):
ACTIVITY FEE: Free for NYSNA members/$10 nonmembers PAYMENT METHOD
Check—payable to New York State Nurses Association (please include “Journal CE”on your check).
Credit Card: Mastercard Visa Discover American Express Card Number: Expiration Date: / CVV#
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
Nurses Advancing Equity and Inclusion Through Communication and Language
Please use the following scale to rate statements 1–7 below:
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 authors’ 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 anonymous 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
