A core principle in multiple national quality improvement strategies is the engagement of chronically ill patients in the creation and execution of their treatment plans. Numerous initiatives are underway to use health information technology (HIT) to support patient engagement however the use of HIT and other factors such as health literacy may be significant barriers to engagement for older adults. This qualitative descriptive study sought to explore the ways that older adults with multi-morbidities engaged with their plan of care. Forty participants were recruited through multiple case sampling from two ambulatory cardiology practices. Participants were English-speaking, without a dementia-related diagnosis, and between the ages of 65 and 86. The older adults in this study performed many behaviors to engage in the plan of care, including acting in ways to support health, managing health-related information, attending routine visits with their doctors, and participating in treatment planning. A subset of patients engaged in active decision-making because of the point they were at in their chronic disease. At that cross roads, they expressed uncertainly over which road to travel. Two factors influenced the engagement of older adults: a relationship with the provider that met the patient's needs, and the distribution of a Meaningful Use clinical summary at the conclusion of the provider visit. Participants described the ways in which the clinical summary helped and hindered their understanding of the care plan.

Insights gained as a result of this study include an understanding of the discrepancies between what the healthcare system expects of patients and their actual behavior when it comes to the creation of a care plan and the ways in which they take care of their health. Further research should examine the ability of various factors to enhance patient engagement. For example, it may be useful to focus on ways to improve the clinical summary to enhance engagement with the care plan and meet standards for a health literate document. Recommendations for the improvement of the clinical summary are provided. Finally, this study explored potential reasons for the infrequent use of online health information by older adults including the trusting relationship they enjoyed with their cardiologist.

Health and healing in the United States is in a moment of deep and broad transformation. Underpinning this transformation is a shift in focus from practitioner- and system-centric perspectives to patient and family expectations and their accompanying localized narratives. Situated within this transformation are patients and families of all kinds. This shift's interpretation lies in the converging and diverging trails of biomedicine, a patient-centric perspective of consensus between practitioner and patient, and postmodern philosophy, a break from prevailing norms and systems. Lending context is the dynamic interplay between increasing ethnic/cultural diversity, acculturation/biculturalism, and medical pluralism. Diverse populations continue to navigate multiple health and healing paradigms, engage in the process of their integration, and use health and healing practices that run corollary to them. The way this experience is viewed, whether biomedically or philosophically, has implications for the future of healthcare. Over this fluid interpenetration, with its vivid nuance, loom widespread health disparities. The adverse effects of static, fragmented healthcare systems unable to identify and answer diverse populations' emergent needs are acutely felt by these individuals. Eradication of health disparities is born from insight into how these populations experience health and healing. The resulting strategy must be one that simultaneously addresses the complex intricacies of patient-centered care, permits emergence of more localized narratives, and eschews systems that are no longer effective. It is the movement of caregivers across multiple health and healing sources, managing care for loved ones, that provides this insight and in which this project is keenly interested. Uncovering the emergent patterns of caregivers' management of these sources reveals a rich and nuanced spectrum of realities. These realities are replete with opportunities to re-frame health and healing in ways that better reflect what these diverse populations of caregivers and care recipients need. Engaging female Mexican American caregivers, a population whose experience is well-suited to aid in this re-frame, this project begins to provide that insight. Informed by a parent framework of Complexity Science, and balanced between biomedical and postmodern perspectives, this constructivist grounded theory secondary analysis charts these caregivers' processes and offers provocative findings and recommendations for understanding their experiences.

A growing body of research shows that characteristics of the built environment in healthcare facilities impact patients' well-being. Research findings suggest that patients form judgments of perceived quality care based on environmental characteristics. Patient outcomes and ratings of quality of care are linked to the environments' ability to reduce patient stress as well as influence perceptions of quality of care. Historically, this research has been focused in the hospital environment. The United States healthcare system heavily relies on hospitals to treat (rather than prevent) illness, leading to a high per capita healthcare expenditure. Currently, this healthcare system is shifting to rely heavily on ambulatory care settings and primary care providers to detect, prevent, and manage expensive medical conditions. The highest rates of preventable disease and the lowest rates of primary care usage are found in the young adult population (ages 18 to 24). More than any other patient population, this segment rates their satisfaction with healthcare significantly low. For this population education, early detection, and monitoring will be key for a primary care focused model to have the greatest impact on care and long-term savings. Strong patient-physician connections ensure the success of a primary care focused model. The physical environment has the opportunity to provide a message consistent with a physician's practice values and goals. Environmental cues in the waiting area have the potential to relay these messages to the patient prior to physician contact. Through an understanding and optimization of these cues patient perception of quality of care may be increased, thus improving the patient-physician relationship. This study provides insight on how to optimize environmental impact on the healthcare experience. This descriptive exploratory study utilized a non-verbal self-report instrument to collect demographic information and measure participant's responses to two panoramic photos of primary care provider waiting areas. Respondents were asked to identify physical elements in the photos that contributed to their perceptions of the quality of care to be expected. The sample population consisted of 33, 18 to 24 year-olds leaving a total of 234 emotional markers and comments. Qualitative and quantitative revealed three key themes of appeal, comfort, and regard. Physical elements, in the photos, related to the themes include: General areas that were important to the respondents were the seating and reception areas, as well as the overall appearance of the waiting area. Key elements identified to be significant characteristics influencing perceptions of quality of care are presented in this study.

"Too often, people in pain are stuck in limbo. With no diagnosis there is no prognosis. They feel that without knowing what is wrong, there is no way to make it right" (Lewandowski, 2006, p. ix). Research has shown that environmental factors, such as views of nature, positive distractions and natural light can reduce anxiety and pain (Ulrich, 1984). Patients with chronic, painful diseases are often worried, anxious and tired. Doctor's appointments for those with a chronic pain diagnosis can be devastating (Gilron, Peter, Watson, Cahill, & Moulin, 2006). The research question explored in this study is: Does the layout, seating and elements of positive distraction in the pain center waiting room relate to the patients experience of pain and distress? This study utilized a mixed-method approach. A purposive sample of 39 individuals participated in the study. The study employed the Positive and Negative Affect Schedule (PANAS), the Lewandowski Pain Scale (LPS) and a researcher developed Spatial Perception Instrument (SPI) rating the appearance and comfort of a pain center waiting room in a large metropolitan area. Results indicated that there were no significant correlations between pain, distress and the waiting room environment. It is intended that this study will provide a framework for future research in the area of chronic pain and distress in order to advance the understanding of research in the waiting area environment and the effect it may have on the patient.

ABSTRACT Nursing physical fatigue is a critical issue that may lead to degradation of care delivery and ultimately result in medical errors. This issue is equally relevant due to the looming shortage of nurses, which has been linked to the physical demands and potential occupational hazards intrinsic to the profession; as well as to the graying of the nursing workforce who experiences gradual loss of strength and agility that accompanies aging as time in the career advances. In a hospital Emergency Department, the level of nursing physical fatigue can potentially reach its threshold in light of challenging workloads, scope of job assignments and demanding schedules. While in other safety-sensitive industries such as aviation and nuclear plants, similar concerns have been the object of systematic research and addressed with consequent regulations, just recently, the healthcare sector has been engaged in further investigations. This study proposed to explore the linkage between Emergency Department design-layout and nursing physical fatigue. It was expected that further understanding on this relationship would support evidence-based design propositions linking nursing wellness, job satisfaction, and performance to a higher quality of care and improved patient safety levels. To this end, data collection was performed during four weeks in a community-based hospital. A convenience sample of twenty-four eligible nurses was invited to participate in this two-part study. The first section consisted of the completion of a self-administered questionnaire, which assessed nurses' perception of the impact of working conditions on nursing physical fatigue. The second section included the monitoring, through the use of accelerometers, of nurses' actual activity intensity levels during three consecutive shifts. Among other findings, data demonstrated that nurses perceive several attributes or components of the built environment as potential contributors to physical fatigue. In addition, various operational practices and organizational protocols were linked to physical fatigue. Contrary to nurses' perception of physical fatigue, their actual physical activity levels fell mostly between sedentary or light intensity ranges. This paradox offers the opportunity for design interventions that, in alignment with operational practices and organizational protocols will enhance nurses' performance and improve nurses' retention.

The goal of this research was to contribute to the understanding of how the physical design of Intensive Care Unit (ICU) environments may be improved to enhance nursing communication, and in turn, the quality and safety of patient outcomes. This study was guided by two research questions: (1) What are the major characteristics of nurse communication in a hybrid ICU nurse station design? (2) What are the factors in the built environment that enhance or hinder nurse communication in a hybrid ICU nurse station design? The research design was exploratory and qualitative. Observations were conducted in two ICUs with hybrid nurse station layouts. Participant observation was used to systematically observe and document nurse communication and the physical attributes of the ICU nurse work environment that affect communication. Literature, observations, and information regarding staffing and design about the selected ICUs were analyzed for the generation of concepts and the exploration of significant themes. Results show that nurse interactions with other staff members varied within the different zones of the ICU pod. A biaxial map illustrates four key types of core nurse communication interactions: At ease, On guard, In motion, and On the edge. The quadrants representing barriers to nurse communication are On guard and On the edge, and included interactions with other staff members in the pod. The quadrants representing facilitators to nurse communication are At ease and In motion. The hybrid nurse station layout supported nurse-nurse communication, but not communication interactions with other staff members present on the pod. The results provide a broad understanding of how nurse communication is affected by the environment in which nurses work, and allows for the emergence of design opportunities to enhance nurse communication.