July 2020 Issue 9 The Cheryl Spencer Department of Nursing Newsletter
University of Haifa, 199 Aba Khoushy Ave. Mount Carmel, Haifa, Israel 3498838 Web site: http://hw.haifa.ac.il/nursing-home
Message from the Editor
It is a great pleasure for me to bring forward this exciting Inside This Issue volume of the Cheryl Spencer Department of Nursing Message from the Editor 1 newsletter. As we can forcefully tell these days, nurses are Message from the Head of the Department 2 important engines in society and Articles 3 constitute a significant element of its values and norms. They are The COVID-19 Outbreak: Helping the Community, shaped by them but also influence their expansion and application Doing Research, and Contributing to the Public Debate 13 in daily therapeutic and non‐therapeutic actions. For nurses to flourish but also be accountable to patients and to the society COVID-19 Articles 15 which they serve, they have to live life well, to reason and judge morally, and to regard others as human beings. Ethics is the key Graduate Students Pushing the Frontier of Knowledge Debate 21 component of their professional and social competence. Without ethics, their mission cannot be accomplished. Expanding the International Scope 24
But ethics involves dilemmas, challenges and hardship. Exploring Faculty Achievements and Recent Publications 26 these elements and finding ways to manage them decently and with substantive justifications is one of the most important goals of News and Updates 31 nursing training programs and nursing educators. This volume is one way of pursuing such a goal. It addresses many aspect of ethical life in the context of the nursing occupation: from utilitarian concerns in end‐of‐life and COVID‐19 care, to causing possible harm in mental health care or through missed nursing care, to performing defensive nursing or taking precautions during research. The issues of training nurses and practicing ethics are usually addressed routinely but are of high importance in disasters or pandemics. Ironically, the COVID‐19 outbreak has made it possible for this newsletter to refer to these concepts from all of these aspects. The rich and diverse articles included in this volume are complemented by some updates on faculty research and voluntary actions to help the professional and civil society during the corona outbreak and regardless of it, as well as on other achievements of our strong and promising graduate students who push the frontier of knowledge. I welcome you all to enjoy this volume and encourage you to further your ties with our faculty and department for a better‐off and thriving community.
Prof. Daniel Sperling, S.J.D., B.A. (Philosophy)
Message from the Head of the Cheryl Spencer Department of Nursing
Dear Colleagues and Friends of the Cheryl Spencer Department of Nursing, In the shadow of the Coronavirus pandemic, I am proud to introduce our new 2020 newsletter from the Cheryl Spencer Department of Nursing. We initially planned to dedicate this volume to the everyday ethical issues that nurses, nurse managers and educators face, but as we all have heard, man makes plans and God laughs . . . These are indeed challenging times. There is no coronavirus playbook, and we find ourselves living through educational, clinical, emotional, and civilian challenges. When you flip through this newsletter, you may appreciate how our department practiced resilience to maintain students, staff, and community growth in these difficult times. On the faculty‐students frontier, the pandemic changed the way we teach and educate the next nursing generation. Universities decided to replace face‐to‐face teaching and provide learning via online channels instead. Moreover, with many nursing students preparing to join forces to combat the COVID‐19 emergency, the issue of students’ resilience and preparedness has become even more salient. We have made efforts to continually support our students, and to enable them to express their thoughts and concerns, safe in the knowledge that they are being heard. Thanks to teamwork, continuous participation with success and failures, and mutual support among all faculty members, we have rapidly succeeded in coping with the technological barriers, and in finding creative solutions to large‐scale theoretical courses as well as to more intimate seminar courses. Yet, we quickly recognize that the most burning issue is to be attentive to our students, and to their distresses, anxieties, and difficulties. For example, many of our students, who come from low socio‐economic situations, are unable to engage in the online courses that we offer because they lack either a quiet corner in their homes where they can concentrate on the lectures or the equipment needed to connect to the online courses. Their attention is compromised by financial concerns, such as how to provide for their families as one or more of them have become unemployed, or by the emotional distress of not infecting their older parents / young children while ensuring that they receive needed care. We have learned how to flex our teaching to better fit the students’ needs, without compromising the quality of teaching. We focus on how to provide information that they need and are able to process; and how to open new channels of communication to help students cope emotionally. At the same time, we have tried to be attentive to our community. Experts have initiated projects to help the community, each via their own expertise. Just to name several examples: our faculty members who are experts in geriatrics initiated projects to improve the well‐being of the elderly, among the greatest victims of the pandemic. Some faculty who are experts in post‐trauma, initiated workshops and delivered tips to students and nursing staff that are experiencing high level of stress; other faculty members helped in searching the data for evidence‐based‐practices on burning issues. Finally, because one of our department’s trademarks is interdisciplinary research, our department has organized into several research teams focusing on such issues as coronavirus patients’ symptoms; nurses’ resilience; ethical dilemmas in fighting the pandemic; and coping of various subgroups with the pandemic. We hope to introduce our findings in the 2021 Newsletter. To conclude, as nurses we possess irreplaceable information on how to cope successfully with public health issues. We should not be afraid to speak out on those issues. The voice of the nursing profession needs to be heard by the world. Not only in the battle against the coronavirus but also in preparation for the next major health challenge. Stay safe, and thank you for being part of our community,
Prof. Anat Drach‐Zahavy, Ph.D. Articles 3
Is There an Ethical Problem in Giving Non- Evidence-Based Mental Health Care?
By Daniel Sperling and Yori Gidron
The field of mental health has undergone tremendous changes in the past decades, with important discoveries in neuroscience and with the development of information technologies for educational and therapeutic purposes. Furthermore, mental health has advanced thanks to the adoption of rigorous research methods to develop better assessment tools and to provide patients scientifically tested or evidence‐based practice (EBP) treatments. Multiple studies have shown the effectiveness of certain psychological treatments such as cognitive‐behavioral therapy (CBT) or behavioral activation in addressing multiple mental health problems, as demonstrated by meta‐analyses (e.g., Carpenter et al., 2018; Ekers et al., 2014). Numerous brief quantitative assessment tools have been developed to reliably assess mental health outcomes such as the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1983) and the Post‐traumatic Checklist for DSM‐5 (Belvins et al., 2015). Such tools precisely permit excluding biases that clinicians may have when estimating patients’ condition over treatment. The Oxford pyramid of evidence guides clinicians from all domains to adopt and advocate the use of a given treatment only based on the highest level of evidence, namely on randomized controlled trials (RCT) and preferably on meta‐analyses of RCTs. The lowest level of evidence for advocating any treatment is “expert opinion.” However, still in many societies, this pyramid stands on its head. One can argue that from an ethical (and possibly also legal) perspective that not using standardized assessment tools results in harming the patient twice (Christiansen & Lou, 2014). The first occurs when performing diagnoses based only on clinical impressions and not evaluating patients’ progress over time with standardized tools.
“To from an ethical (and possibly also legal) perspective, not using standardized assessment tools results in harming the patient.”
The second possible harm concerns the use of therapeutic approaches which are often not based on scientific studies and RCTs. Take, for example the attempts to prevent post‐traumatic stress disorder (PTSD) with psychological debriefing. In this common method, people recall their traumatic event while receiving empathy and support from the therapist, who also normalizes their reactions and encourages them to express their feelings. However, four meta‐analyses have shown that debriefing does not prevent and may even increase the risk of PTSD (e.g., Rose et al., 2002; Qi et al., 2016). Furthermore, the WHO and the UN prohibit the use of debriefing in disaster zones, although it is still used a lot to some extent. However, non‐EBP has ethical considerations as well. In mental health practice, there is little to no monitoring of how therapists diagnose and treat patients. Patients are put in the hands and minds of highly educated and well‐intended therapists, who choose (a) certain treatment(s), often because they “believe” it works based on their clinical experience, without using standardized assessments or with little basis in RCT.
Articles 4
The quantitative EBP approach has its own limitations. First, assessment of complex mental states by a brief questionnaire does not include the full richness and individual heterogeneity of such experiences. Second, an RCT often lacks some generalizability and relevance to clinical reality (Kennedy‐Martin et al., 2015), where patients have mental co‐morbidities and where not all protocols are suitable to all patients’ personality differences. Clinical researchers must examine effects of any treatment in light of co‐morbidity and personality. Nevertheless, we argue that not using the most effective diagnostic or therapeutic tools for one’s patient demands that the qualified therapist be accountable. The therapist should be accountable first and foremost ethically to their patient and second to their professional community, and must to be able to justify their clinical choices. Rules of informed consent aimed at increasing patient trust and transparency may apply in such scenarios so that a candid conversation and primary expectations must be offered the patient. This also provides patients greater awareness of and control over their own therapeutic process. A stronger argument, which should be examined, is whether mental health practice needs to shift to an EBP approach and require all therapists to use standardized tools to assess patients’ mental health and provide care only with “proven” EBP techniques. While this argument may violate therapists’ professional autonomy, it nonetheless calls for the ethical examination of mental health practice in light of the increasing importance of evidence‐based psychological diagnostic tools and treatments.
References
Blevins, CA, Weathers, FW, Davis, MT, Witte, TK, and Domino, JL. The Posttraumatic Stress Disorder Checklist for DSM‐5 (PCL‐5): Development and initial psychometric evaluation, Journal of Traumatic Stress, 2015, 28(6):489‐98.
Christiansen, C and Lou, JQ. Ethical considerations related to evidence‐based practice. American Journal of Occupational Therapy, 2001, 55, 345‐349.
Carpenter, JK, Andrews, LA, Witcraft, SM, Powers, MB, Smits, JAJ, and Hofmann, SG. Cognitive Behavioral Therapy for Anxiety and Related Disorders: A Meta‐analysis of randomized placebo‐controlled trials. 2018, Depression and A35(6):502‐514.
Ekers, D, Webster, L, Van Straten, A, Cuijpers, P, Richards, D, and Gilbody, S. Behavioural activation for depression; An update of meta‐analysis of effectiveness and sub group analysis., PLoS One, 2014, 17;9(6):e100100.
Kennedy‐Martin, T, Curtis, S, Faries, D, Robinson, S and Johnston, J. A literature review on the representativeness of randomized controlled trial samples and implications for the external validity of trial results, Trials, 2015, 16, (open access) Article number: 495.
Qi W, Gevonden M, Shalev A. Prevention of post‐traumatic stress disorder after trauma: Current evidence and future directions. Current Psychiatry Reports, 2016, 18(2), 20.
Rose, S, Bisson, J, Churchill, R, and Wessely, S. Psychological Debriefing for Preventing Post Traumatic Stress Disorder (PTSD). Cochrane Database Systematic Reviews, 2002, (2):CD000560.
Zigmond, AS; Snaith, RP. “The hospital anxiety and depression scale”. Acta Psychiatrica Scandinavica, 1983, 67 (6): 361–370. Articles 5
Student Participation in Faculty-Based Research: The Real Meaning of Informed Consent
By Nadya Golfenshtein
As a new faculty member, I have recently been encouraged to integrate my undergraduate students into active research projects. The request comes from our faculty, who aim to increase their student‐participant research pool, for studies performed by faculty members. Our student‐participant research pool, historically inherited from another faculty, currently serves about 60 researchers of our own. Undergraduate students across all faculty departments are now being asked to join the pool and serve as research participants. The students must complete 4 hours of active research (by joining the pool), or an alternative theoretical research assignment, for credit in one of their introductory nursing courses. The assignment is described in the syllabus as follows: “University of Haifa is a research university; therefore, a research assignment is integrated into the curriculum, so students could actively learn and firsthand witness the conduct of research. The research assignment in this course will not be graded, completion is required for successfully passing the course.” The benefits of active student participation in such research pools are clear. For faculty members, the pool enables low‐ to no‐cost participant recruitment for our research projects. For students, according to the university, thanks to the pool, they are now being exposed to research methodologies and measurements otherwise unavailable during their studies. Indeed, I have heard researchers indicate that it was their own undergraduate research experience that resulted in their academic career. These are the ethical aspects of student involvement as research subjects, and of their informed consent to participate in such pools, that I wish to further highlight. Our faculty certainly does not ignore matters of ethical conduct of research. Each research project to be included in the pool must first obtain institutional review board approval. Moreover, it has been clearly stated to students that they should not feel obligated to actively participate in the pool; instead, they can alternatively complete an equivalent, 4‐hour theoretical research assignment (no grade provided). Nevertheless, debate remains regarding the assignment description, and specifically, the presented research benefit. First, the syllabus description lacks the full/true rationale for the assignment requirement. The assignment is described as purely educational, with sole student benefits. The benefits to the research community are nowhere mentioned. Second, the alternative theoretical assignment is expected to bring little value to the students, who are expected to invest 4 hours of their time but should not expect any teacher feedback for their efforts (grading 120 written assignments is, indeed, unrealistic). As a community member in a research university, I truly value resource utilization and welcome the idea of student involvement in research. I do, however, fear the day that our scholarly enthusiasm leads to ethical misconduct in teaching and in research. As a teacher I experience a certain moral dissonance by providing my students the assignment as currently described. It is crucial that we carefully examine all ethical aspects, especially concerning student involvement in research, whenever institutional authority is applied.
Articles 6
Falls vs. Mobility: The Case of Defensive Nursing
By Efrat Shadmi and Anna Zisberg
If you’ve visited in an internal medicine ward in a hospital in recent years, you may have noticed the absence of patients strolling in the corridors. A quick peek into patients’ rooms will reveal many patients recumbent in bed with the side rails up. Hospitalized patients are increasingly older, with more complicated health conditions and lower functioning levels. Yet, medical complexity should not necessarily directly translate to immobility. Recent evidence shows that even for the most complex patients, even minimal mobility can make a huge difference in post‐hospitalization outcomes (Brown et al., 2016; Cohen et al., 2019). One explanation for the “immobilization” phenomenon comes from a defensive treatment approach in hospitals, specifically defensive nursing. In health care we are more familiar with the term defensive medicine than defensive nursing — both are defined similarly: Defensive practice occurs whenever a practitioner gives a higher priority to self‐protection from blame than to the best interests of the patient. Practices associated with in‐hospital fall prevention are increasingly considered one of the most common examples of defensive nursing. Falls have been defined as a nursing‐sensitive quality indicator for the past two decades (ANA, 1999). It is interesting that recent studies have not managed to show a significant decrease in the number of falls due to hospitals’ fall‐defensive policy (Waters el al., 2015); what this policy has mainly brought is an introduction of protocols meant to identify patients that are at the highest risk of falls, and the increasing use of pharmaceutical or physical restraints to prevent patient falls (Fehlberg et al., 2017). Studies are beginning to reveal that we may, in fact, be treating the wrong problem. The trade‐off between fall prevention and patient mobility is hazardous. The path to decreasing falls does not lie in a policy of “zero falls” (Challener et al., 2019); in fact, these policies usually cause a “fear of falls” in the nursing staff, who may then hesitate to open the side rails or to take the patient out for short walks such as to the restroom, leading to loss of functioning and even hospital‐acquired incontinence (King, 2016; Zisberg et al., 2011). Additionally, evidence is building that interventions that increase mobility bring to a decrease in functional decline, a decrease in incidence of delirium, and shortened hospitalizations, while not increasing the number of falls (Barker et al., 2016). “Fear of falls” from the nursing staff and a desire to prevent any risk of a patient fall means not allowing or not encouraging hospitalized patients to walk around. While falls occur in 2% of hospitalized patients, immobility can result in functional decline in as many as 30% to 40% of hospitalized older adults even up to several months post‐discharge. Based on this growing robust body of evidence, Israeli nursing should implement a comprehensive approach to functional preservation/improvement and move away from non‐evidence‐based approaches to in‐hospital fall prevention. The time has come to effectively practice patient‐centered care, to use more professional judgment and less defensive nursing, and to allow and even encourage hospitalized older patients to get out of bed.
References
American Nurses Association. (1999). Nursing‐sensitive quality indicators for acute care settings and ANA’s safety and quality initiative. Washington, DC: American Nurses Publishing. Barker, A. L., Morello, R. T., Wolfe, R., Brand, C. A., Haines, T. P., Hill, K. D., . . . & Sherrington, C. (2016). 6‐PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. BMJ, 352, h6781. Brown, C. J., Foley, K. T., Lowman, J. D., MacLennan, P. A., Razjouyan, J., Najafi, B., . . . & Allman, R. M. (2016). Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Internal Medicine, 176(7), 921–927. Challener, D. W., Prokop, L. J., & Abu‐Saleh, O. (2019). The proliferation of reports on clinical scoring systems: issues about uptake and clinical utility. JAMA, 321(24), 2405–2406. Articles 7
Cohen, Y., Zisberg, A., Chayat, Y., Gur‐Yaish, N., Gil, E., Levin, C., . . . & Agmon, M. (2019). Walking for Better Outcomes and Recovery: The Effect of WALK‐FOR in Preventing Hospital‐Associated Functional Decline Among Older Adults. The Journals of Gerontology: Series A, 74(10), 1664–1670. Fehlberg, E. A., Lucero, R. J., Weaver, M. T., McDaniel, A. M., Chandler, M., Richey, P. A., . . . & Shorr, R. I. (2017). Impact of the CMS no‐pay policy on hospital‐acquired fall prevention related practice patterns. Innovation in Aging, 1(3), igx036. King, B., Pecanac, K., Krupp, A., Liebzeit, D., & Mahoney, J. (2018). Impact of fall prevention on nurses and care of fall risk patients. The Gerontologist, 58(2), 331–340. Waters, T. M., Daniels, M. J., Bazzoli, G. J., Perencevich, E., Dunton, N., Staggs, V., . . . Shorr, R. (2015). Effect of Medicare’s nonpayment for hospital‐acquired conditions: Lessons for future policy. JAMA, 175, 347–354. doi:10.1001/jamainternmed.2014.5486 Zisberg, A., Shadmi, E., Sinoff, G., Gur‐Yaish, N., Srulovici, E., & Admi, H. (2011). Low mobility during hospitalization and functional decline in older adults. Journal of the American Geriatrics Society, 59(2), 266–273.
Articles 8
Hidden Ethical Dilemmas of Missed Nursing Care
By Mirit Cohen, Anat Drach-Zahavy, and Einav Srulovici
In the midst of multiple demands and inadequate resources, nurses sometimes ration care while striving to provide what they perceive to be adequate (“good enough”) care under the circumstances, leading to missed nursing care (MNC). MNC, defined as necessary nursing care that is omitted or delayed, has been related to detrimental consequences for patients, nurses, and organizations.1,2 Specifically, when nurses miss care, they might be simultaneously denying the patient’s rights to optimal, holistic, and high‐quality care and compromising their professional and ethical role. Thus, MNC hides ethical dilemmas with respect to patients3,4 and nurses alike.4 For patients, particular groups (e.g., difficult patients, less complex patients, or patients from different age groups) have greater exposure to MNC, thus raising issues of inequality of care. For nurses, the inability to provide the optimal and holistic care that they want to give may cause them moral distress, defined by Carse5 as “anxiety or concern about one’s capacity to meet the challenges to one’s integrity” (p. 147). It occurs when one knows the ethically correct action to take but feels powerless to take that action. In the current diary‐study design, these hidden ethical dilemmas embedded in MNC were tackled using multisource data gathered from nurses on five different occasions and from their patients in several medical‐ surgical wards. We examined whether nurses’ accountability can serve as a moral compass guiding behavior, thus limiting nurses’ tendency to compromise the care provided to patients, especially in times of inappropriate work demands (i.e., workload), thereby limiting nurses’ moral distress. Results supported a moderated‐mediation model (Figure 1). Specifically, nurses’ MNC fully mediated the relationship between personal accountability and moral distress under high and medium workload levels, but not under low workload levels.
Figure 1. Study model.
The findings indicate that accountability has an important role in guiding nurses toward appropriate ethical behavior and encouraging high‐quality care, especially under high and medium workload levels, which in turn helps in designing a healthier workplace for both patients and nurses. Given that nurses usually experience high workloads, the significant role of accountability as a buffer for MNC and a shield for moral distress is encouraging because the promoting of accountability is feasible: (1) Developing ability as a moral compass guiding nurses’ behavior. Education programs for nursing students and nurses should highlight personal accountability as professional; (2) Organizational accountability or ward accountability are also important. Thus, creating a climate of accounted staff might limit nurses’ MNC and could shape ethical and more safety‐oriented behavior; (3) Examining accountability as part of the manager’s role. Managers (e.g., head nurses) are influential factors in determining the culture in their unit. Founding ethical values, such as accountability, will enable the design of workplaces that foster nurse’s well‐being and a system that promotes high‐quality care.
Articles 9
References
1. Kalisch, B. J., Landstrom, G. L., & Hinshaw, A. S. (2009a). Missed nursing care: A concept analysis. Journal of Advanced Nursing, 65(7), 1509–1517.
2. Jones, T. L., Hamilton, P., & Murry, N. (2015). Unfinished nursing care, missed care, and implicitly rationed care: State of the science review. International Journal of Nursing Studies, 52(6), 1121–1137. https://doi.org/10.1016/j.ijnurstu.2015.02.012
3. Papastavrou, E., Andreou, P., & Vryonides, S. (2014c). The hidden ethical element of nursing care rationing. Nursing Ethics, 21(5), 583–593. https://doi.org/10.1177/0969733013513210
4. Suhonen, R., Stolt, M., Habermann, M., Hjaltadottir, I., Vryonides, S., Tonnessen, S., . . . Scott, P. A. (2018). Ethical elements in priority setting in nursing care: A scoping review. International Journal of Nursing Studies, 88, 25–42. https://doi.org/10.1016/j.ijnurstu.2018.08.006
5. Carse, A. (2013). Moral distress and moral disempowerment. Narrative Inquiry in Bioethics, 3(2), 147–151.
Articles 10
Ethical Aspects in Experimental Pain Research
By Hadas Grouper
Chronic pain affects an estimated 20% of the worldwide population and accounts for nearly one‐fifth of physician visits. Enhanced research can promote greater awareness of pain and ensure that it becomes a global health priority with the primary goal of acquiring new knowledge on the pathogenesis, diagnosis, and treatment of pain. This requires research on humans, either healthy persons or patients, in a laboratory or a clinical setting. My field of interest engages with exploring factors that could explain differences in pain perception, in healthy people. The foreground of my research is understanding the underlying mechanisms of pain processing and pain modulation by examining psychological, personality, and sensory factors alongside identifying neuroimaging biomarkers for pain. Evoking pain in non‐clinical healthy individuals has the advantage of exploring the potential of pre‐existing factors that may affect pain perception. This advanced and important understanding could establish the management and treatment of patients suffering from pain. The healthy volunteers recruited into our studies undergo a psychophysical pain assessment that uses quantitative sensory testing (QST). This approach is derived from experimental psychophysics and consists of measuring the responses evoked by various modalities of noxious stimulation (i.e., heat, cold, mechanical). Accordingly, several ethical aspects should be taken into account by the pain researcher when performing the QST. Attention to ethical aspects in the pain research must occur early on, at the study design phase, to ensure that it offers participants a reasonable balance between risks and benefits. To protect human participants involved in the pain research, we must ensure that the study design is as consistent as possible with their preferences and goals. To verify that a participant agrees to participate voluntarily and understands the nature and purpose of the proposed study, we obtain written consent, provide thorough instructions, and give them an opportunity to ask questions. Potential participants are fully informed of the goals, procedures, and risks of the study prior to giving their consent. Healthy participants must be informed that they can decline or terminate their participation at any stage without a risk or penalty whatsoever. As a pain investigator I take full responsibility for the conducted research and its effects on the experimental participants, regardless of their consent to take part in a study. I evaluate the potential of any undesirable physical or psychological effects occurring during the research, while adhering to strict ethical principles, as my research may involve painful stimuli or the delaying of pain relief in participants. As such, during any pain study session, I must guarantee that stimuli never exceed a participant’s tolerance limit and that participants be able to escape or terminate a painful stimulus at will. Furthermore, I must be certain that I am using the minimal intensity of noxious stimulus necessary to achieve the goals of the study and not exceeding it. Our highest priority as pain researchers is to always pursue advanced the health, safety, and dignity of human participants.
Articles 11
Choosing Antibiotic Treatment Wisely to Reduce Futile Therapy at End of Life: Cost- Benefit Model Development and Testing
By Yael Dishon Benattar
Antibiotic resistance has become a global threat, with increasing selection and spread of resistant strains of bacteria at a pace that exceeds the development of new antimicrobial agents. Antibiotic treatment is frequent at end of life (EOL), promoting the exhaustion of this precious resource while gaining a very small benefit to the patient, if any. The topic of antibiotic treatment at EOL is frequently avoided because of ethical difficulties and the lack of a framework for defining good clinical practice, as well as the lack of consensus regarding definitions for futile antibiotic treatment. A possible method to facilitate this complex decision‐making process is a computerized decision support system (cDSS), adopting a defined ethical framework. TREAT is a cDSS, in clinical use, based on a causal probabilistic network, balancing between treatments’ costs and benefits and advising empirical antibiotic treatment. However, TREAT uses a simple model for antibiotic costs related to resistance development (ecological costs) that neither is individualized nor takes into account EOL conditions. The current study is based on fundamental theories of distributive justice. Unlike other health resources, which are mainly budget‐dependent and theoretically infinite, antibiotics can be regarded as a nonrenewable resource, and therefore as a “societal” resource, or “common goods.” This occurs because antibiotic treatment given to certain patients affects other and future patients. In our study, we developed a novel approach to individualize the cost‐ benefit model according to patients’ characteristics, to account for EOL conditions and to reflect the higher potential of these patients to harbor and transmit resistant bacteria. Prior to the model development, we assessed the local perceptions of treatment futility through a survey of health care professionals (physicians, nurses, and social workers), in all internal medicine wards of two hospitals in Israel (52.4% response rate, 274/523). We observed that only 33.8% (541/1601 valid answers) favored antibiotic treatment at EOL. Development and testing of the new TREAT model on a cohort of inpatients with suspected or proven infections resulted in change of advice for 44.7% (551/1232) patients. The antibiotics recommended to patients at EOL had significantly lower ecological costs than those recommended to survivors. The newly developed model is yet to be clinically assessed. In my Ph.D. thesis under the supervision of Prof. Efrat Dagan and Prof. Mical Paul, we assessed our newly developed model according to three theories of distributive justice: utilitarianism, egalitarianism, and maximin (or a Rawlsian approach). By advising ecologically cheaper treatments, the model aims to maintain the maximum effectiveness of antibiotics, for use by other and future patients, and hence complies with the utilitarian approach. The model also complies with the assertion that goods should be allocated “to each according to her utility.” Patients at EOL may not gain better health through antibiotic treatment; therefore, they have a smaller utility gain than other patients. Considering the egalitarian theory in the context of patients very near EOL, we can assume a survival gain nearing null from antibiotics. Equity may be irrelevant from their perspective. However, TREAT ensures equity among all other patients by assuming a uniform life expectancy for all 30‐day survivors, regardless of age, and thus an equal benefit from antibiotic treatment. We also evaluated our newly developed model in the context of maximin, a term often associated with John Rawls’s A Theory of Justice, focusing on the interest of the least advantaged in a social group, and suggesting that distribution of goods should be made “to each according to her need.” The TREAT system is modeled to treat patients according to sepsis severity, increasing the spectrum of coverage (and treatment aggressiveness) for patients with more severe infections. Articles 12
However, the dying patient suffers from other severe conditions, and antibiotic treatment would not fulfill their need. Patients suffering from infections and not approaching EOL are those in need. Cost‐effectiveness analyses are criticized for violating ethical principles of equity and distributive justice, and economic models for being mainly resource‐oriented and often neglecting the patient’s point of view. However, this study was a first attempt to reconcile these gaps and to construct a model that takes into consideration economic and, more importantly, moral, ethical, and social considerations.
13
The COVID-19 Outbreak: Helping the Community, Doing Research, and Contributing to the Public Debate
The Door‐to‐Door Initiative: Driving Paid Caregivers to Help Frail Older Adults
In the State of Israel, 220,000 older people with functional disabilities rely daily on paid caregivers’ assistance within the coverage of the “Nursing Law.” In most cases, these are caregivers who come to help elderly people perform the most basic tasks: getting out of bed and getting dressed, taking a shower, organizing food, arranging and taking medications, and so forth. Many older people have no alternative should this type of care be made unavailable to them. During the COVID‐19 pandemic, public transportation was reduced to 25%, and for many caregivers it becomes impossible to continue to provide care. To prevent this potential harm to older adults due to a lack of care, Prof. Anna Zisberg along with the association Matav began a campaign to recruit volunteers to drive caregivers to elderly people’s homes. Of the 20 volunteers, 10 are UOH students. Faculty organized a WhatsApp group together with Matav and provided daily driving services to caregivers across the city of Haifa. Similar initiatives followed across the country. Prof. Yori Gidron developed and administered a brief 15‐minute workshop on stress management, whose components are fully evidence‐based, for medical staff in emergency rooms and infectious disease units of the Rambam and Ziv hospitals. He has already delivered more than 10 such workshops. Prof. Anna Zisberg and Prof. Efrat Shadmi have partnered with several hospitals in northern Israel to develop tools for gathering information on nursing knowledge and needs during the COVID‐19 outbreak. The aim is to allow nursing managers to evaluate their staff’s personal needs (such as caring for young children or experiencing financial hardship) and levels of knowledge (e.g., regarding use of protective gear) in order to allow them to adequately respond to their staff’s needs on an ongoing (weekly) basis. Congratulations to Prof. Anat Drach‐Zahavy and to Prof. Yori Gidron for receiving research grants from the Ministry of Science and Technology related to COVID‐19. Prof. Drach‐Zahavy’s research project is entitled “Towards a Comprehensive Meso‐Level Model of Resilience in the Face of the 2020 Corona Crisis.” Prof. Gidron’s research proposal is entitled “Effects of an App Based on ‘Psychological Inoculation’ on Anxiety and Adherence to Requirements of the Ministry of Health.”
14
COVID-19 Ongoing Research Projects
The research team of Prof. Efrat Dagan, Prof. Mical Paul (Head, Institute for Infectious Diseases, Rambam Health Care Campus), Prof. Anat Drach‐Zahavy, and Yael Dishon‐Benattar is about to conduct a study assessing the association between resilience, vocational values, and nurses’ well‐being and professional performance during the COVID‐19 outbreak. The anonymous online survey will be conducted among nurses of all ranks and positions in Israel and will be circulated through social media. We believe that understanding the association between personal resilience and professional values, and the well‐being and professional performance of nurses, in the presence of a newly emerging, stressful situation, may contribute to development of supportive interventions to promote nurses’ ability to cope with the current and similar, dynamic situations in the future. Prof. Dorit Pud, Prof. Efrat Dagan, Prof. Efrat Shadmi, and Prof. Anna Zisberg submitted a research proposal to the Ministry of Science and Technology and to the Israel National Institute for Health Research and Policy whose aim is to explore the trajectories of physical and psychological symptoms experienced by isolated adults with and without a diagnosis of COVID‐ 19. The research will be a web technology‐based longitudinal study. Prof. Daniel Sperling is completing a survey of 4th‐year nursing students who are in their internships and of hospital nurses throughout the country to examine the ethical dilemmas, challenges, and opportunities related to the provision of care during the COVID‐19 outbreak. He is also involved in a research project that explores the attitudes of care teams, hospital administrators, and ethics committee members regarding ethics guidelines “for the Prioritization of Severely Ill Patients During the Corona Epidemic” and their implications for the quality of health services. In addition, he plans to investigate the concept of patient dignity and its application to the care of institutionalized dementia patients during the COVID‐19 crisis. Prof. Yori Gidron has been involved in three research projects. The first studies the effects of “psychological inoculation” (a cognitive method) on anxiety and adherence to Ministry of Health recommendations during the coronavirus epidemic. Two other planned projects examine the effects of emotional regulation on mental health outcomes in quarantined people during the epidemic and the effects of vagal nerve activation on prognosis of patients with mild coronavirus infections. Staying at home to avoid exposure to the coronavirus changes our daily routines but also affects nighttime sleep schedules. While some enjoy longer and better sleep, others sleep poorly because of fears and anxieties related to the crisis. Researchers from the University of Haifa and the Technion are assessing sleep patterns of stay‐at‐home children and adults by collecting data from electronic sleep diaries. This project, directed by Prof. Tamar Shochat, is an initiative of the Research Excellence Center: Taking Citizen Science to School (TCSS), supported by the Israel Science Foundation and the Ministry of Education. Prof. Anat Drach‐Zahavy, Prof. Hadass Goldblatt, and the Heads of Departments of Nursing in four other universities and academic colleges throughout the country are collaborating in the study “Implementing Resilience and Preparedness to Cope with a Crisis: Optimal Training of a New Generation of Nurses.” Participants are undergraduate students from all years, academic, clinical, and administrative staff, and the Ministry of Health Nursing Division representatives. Prof. Hadass Goldblatt, Prof. Anat Drach‐Zahavy, Dr. Orit Cohen Castel, and a researcher from the College of Management are conducting the study “Remote Family Medicine Sessions: Lessons Learned from Caregiver–Patient Relationships and the Implementation of Hybrid Practice During the COVID‐19 Crisis.” The study is conducted among primary care physicians and patients, to understand how the pandemic has changed physicians’ and patients’ preferences regarding participation in remote family medicine, and exploring how such sessions reshape patient–provider encounters. COVID-19 Articles 15
Training Nurses to Better Deal with Ethical Dilemmas in Pandemics
By Daniel Sperling
As the Israeli community, professionals, and policymakers work together to confront the coronavirus pandemic, difficult ethical and social decisions and implications arise. Among these are issues related to rationing limited health resources, including protective equipment for medical staff and respiratory machines for sick patients, especially in the critically care units; imposing limits on individual freedoms and movement with a possible distinction between groups of people, such as elderly people as opposed to the younger generation; expanding access to palliative care to dying COVID‐19 patients; upholding professional and ethical duty to treat and care in the face of serious health risk and personal danger; and so forth. While these “big questions” are serious and acute, one must not pay less attention to other questions that are hidden and, at times, even pushed away from the public discourse. Media converge in Israel, as in many other Western countries focuses on the health‐related and economical aspects of the pandemic. The voice of medical teams, especially nurses, is rarely raised even by their own professional organizations.
“As nurses are expected and feel obligated to provide care despite the health risk and threat for them and for their beloved ones who are at their personal surroundings and under their responsibility, they feel more ethical pressure.”
Caring in times of the COVID‐19 outbreak is extremely stressful. A recent study in China questioning more than 800 nurses and nursing college students during the pandemic outbreak unsurprisingly reveals that the closer COVID‐19 is to participants, the more it causes anxiety and anger (Huang, ming xu, & Liu, 2020). We know from previous pandemics that the conflict between the duty of care, especially at times of crisis, and the high perceived risk of infection along with low agreement with infection control measures creates more ethical problems and dilemmas for nurses. Nurses can refuse to care for patients with contagious diseases because of a fear of stigmatization (Kollie, Winslow, Pothier, & Gaede, 2017). The most complex dilemma concerns having a mind‐set of patient avoidance and preference for caring for non‐infected patients (Choi & Kim, 2018). Because nurses are expected and feel obligated to provide care despite the health risks and threat to them and to the people they live with and care for, they experience greater ethical pressure. This ethical tension is exacerbated the more that nurses are aware of the lack of professional resources and feel strong responsibility not only to patients but also to COVID-19 Articles 16
society at large (Kim, 2018). In Israel, as in many other Western countries, the shortage of nurses, which is even more severe when some of them are sick or under quarantine, serves as another considerable factor to weigh against nurses’ unwillingness to report for work. Schools of nursing as well as professional organizations should be aware of these ethical conflicts and discuss them in advance with nursing students and nurses. Given the influence of peers on one’s decision to work under threatening conditions (Ganz et al., 2019) and more generally on deliberating ethical dilemmas, peer learning and discussions of such dilemmas may be more fruitful for the nursing community and for society at large. These important revisions to the nursing education follow previous calls to re‐examine the teaching approaches and methods of nursing ethics education (Woods, 2005) so that nurses will indeed be able to “deliver the good(s).”
References
Choi, J‐S., & Kim, J‐S. (2018). Factors influencing nurses’ ethical problems during the outbreak of MERS‐Cov. Nursing Ethics, 25(3), 335–345.
Ganz, F.D., Margalith, I., Benbenishty, J., Hirschfeld, M., Wagner, N., & Toren, O. (2019). A conflict of values: Nurses’ willingness to work under threatening conditions. Journal of Nursing Scholarship, 51(3), 281–288.
Huang, L., ming xu, F., & Liu, H.R. (2020). Emotional responses and coping strategies of nurses and nursing college students during COVID‐19 outbreak. MedRxiv. doi: https://doi.org/10.1101/2020.03.05.20031898
Kim, Y. (2018). Nurses’ experiences of care for patients with Middle East respiratory syndrome‐coronavirus in South Korea. American Journal of Infection Control, 46(7), 781–787.
Kollie, E.S., Winslow, B.J., Pothier, P., & Gaede, D. (2017). Deciding to work during the Ebola outbreak: The voices and experiences of nurses and midwives in Liberia. International Journal of Africa Nursing Sciences, 7, 75–81.
Woods, M. (2005). Nursing ethics education: Are we really delivering the good(s)? Nursing Ethics, 12(1), 5–18.
COVID-19 Articles 17
The Access Block Health Care Utilization Dangers Caused by Social Distancing Related to the COVID-19 Pandemic
By Mor Saban and Tal Shachar
Currently, the absence of a COVID‐19 vaccine or any definitive medication has led to increased use of non‐pharmaceutical interventions (NPIs), particularly social distancing.1 However, these NPIs indirectly lead to a significant decrease in health care utilization (e.g., emergency department [ED] referrals), especially in two populations: older adults and the chronically ill, and voluntarily isolated persons who had contact with a verified patient or person returning from abroad (Fig. 1).
COVID-19 Articles 18
Figure 1. COVID‐19’s effect on medical care access.
For older adults (above 60 years old) and those with severe or chronic illness at higher risk of being affected and severely impacted,2 access to medical facilities essentially became unachievable. These populations are avoiding both routine and emergency medical care related to their baseline illness, even if they experience mild symptoms, for several reasons: (1) significant fear of infection by the virus in light of global media coverage, (2) health care professionals’ campaigns encouraging people to stay in their households that include frequent displays of health care teams’ collapse, (3) the body’s natural stress responses helping them overcome the worsening in symptoms of their underlying illness,3 (4) and closed clinics and primary medical centers offering telemedicine and remote medical services as an alternative. These platforms are known to have a certain amount of success; however, older people and those with chronic illnesses do not always possess these qualities.2,4 Evidence of the current problematic situation in these populations can be seen in decrease of ~80% in ED referrals, including a decrease of ~40% in urgent referrals such as for stroke or myocardial infarction, since the onset of the pandemic. Late‐arrival cases have also emerged, and in some cases the situation is irreversible, leading to a possible increase in mortality. Possible scenarios for those with severe chronic illness are illustrated in Fig.2.
Figure 2. Possible scenarios for patients with severe chronic illness per hospital*
Permanent damage/death (n) <2 weeks damage (n) Optimistic 1 3 Intermediate 1 4 Pessimistic 1–2 4–5 *P‐Urgent priority, range from P1‐P5 according to the Canadian triage and acuity scale * The numbers should be multiplied by 29 (ED’s numbers in Israel)
Voluntary home quarantine COVID-19 Articles 19
Another population of interest are those in voluntary home quarantine as a result of contact with a verified patient, or who have recently returned from abroad. Included are all age groups, who face the same difficulties accessing health services for the above and other reasons. The ongoing flow of information regarding new non‐specific signs and symptoms indicating COVID‐19 infection (such as gastrointestinal symptoms, impaired sense of taste and smell [anosmia], and general weakness)5 has resulted in a state of uncertainty about whether symptoms indicate a psychogenic effect or the viral infection. When seeking to ascertain the nature of the symptoms, this population mostly contacts the telemedicine platform because of home quarantine, in lieu of clinical diagnosis by a physician. Some also refrain from using technology alternatives in light of a hampered health orientation. In addition, nowadays emergency medical services teams respond to suspected symptomatic cases for the sole purpose of COVID‐19 testing with no further clinical examination. As the number of people under quarantine has a dynamic growth pattern and the COVID‐19 prevalence is continuously changing, we offer an estimate for the risk associated with the quarantined people condition (Fig. 3).
Figure 3. Estimation for risk associated with quarantine population
Summary
The current status raises an urgent need to formulate an appropriate response to the risky delay in addressing diverse population groups. Such actions could save lives and prevent deterioration in health and wellness, which would assist the population and improve the health system long after the crisis is resolved.
COVID-19 Articles 20
References
1. Ferguson NM, Laydon D, Nedjati‐Gilani G, et al. Impact of non‐pharmaceutical interventions (NPIs) to reduce COVID‐ 19 mortality and healthcare demand. 2020. doi:10.25561/77482 2. Smith AC, Thomas E, Snoswell CL, et al. Telehealth for global emergencies: Implications for coronavirus disease 2019 (COVID‐19). J Telemed Telecare. March 2020:1357633X2091656. doi:10.1177/1357633X20916567
3. Rosenbluth J. Pandemic response: developing a mission‐critical inventory and cross‐training programme . J Bus Contin Emerg Plan 126‐131:(2)4;2010 . . https://www.ingentaconnect.com/content/hsp/jbcep/2010/00000004/00000002/art00004. Accessed March 20, 2020. 4. Mohr NM, Campbell KD, Swanson MB, Ullrich F, Merchant KA, Ward MM. Provider‐to‐provider telemedicine improves adherence to sepsis bundle care in community emergency departments. J Telemed Telecare. January 2020:1357633X1989666. doi:10.1177/1357633X19896667 5. An P, Chen H, Jiang X, et al. Clinical Features of 2019 Novel Coronavirus Pneumonia Presented Gastrointestinal Symptoms But Without Fever Onset. SSRN Electron J. February 2020. doi:10.2139/ssrn.3532530 Graduate Students Pushing the Frontier of Knowledge Debate 21
Juliana Smichenko, currently a PhD student (advisors: Prof. Anna Zisberg and Prof. Tamar Shochat), presented her dissertation findings at the 2018 Gerontological Society of America (GSA) Annual Scientific Meeting and recently published her paper “Relationship between Changes in Sedative Hypnotic Medications Burden and Cognitive Outcomes in Hospitalized Older Adults” in the journal Gerontology Series A: Biological sciences and Medical Sciences. This work showed that the odds of cognitive decline were two times higher in patients whose sedative burden increased during days of hospitalization compared with patients with decreased sedative burden. These findings carefully suggest that modifications in medications should be made in older hospitalized patients to help prevent decline in cognitive status. Dr. Nossaiba Rayan‐Gharra, who has recently graduated from our PhD program (2019; advisor: Prof. Efrat Shadmi), has published her paper: “Association between Cultural Factors and Readmissions: The Mediating Effect of Hospital Discharge Practices and Care‐Transition Preparedness” in the high‐ranking journal BMJ Quality and Safety. In an editorial commissioned to comment on this paper, the relevancy to health care systems worldwide was pointed out: “What are the implications of this work for clinicians and researchers? . . . This study underscores the need to explore in greater detail cultural and other differences that may drive disparities in health outcomes. Similarly, this study reinforces the need to investigate clinician behaviour to delineate what clinician actions most impact patient outcomes” (Khoong EC, Fernandez A Language, culture and preventable readmissions: pragmatic, intervention studies needed, BMJ Quality & Safety 2019;28:859‐861.) Orly Tonkikh is currently performing her PhD program under the supervision of Prof. Efrat Shadmi and Prof. Anna Zisberg and supported by a joint scholarship of the Cheryl Spencer Institute of Nursing Research and the Advanced Studies Authority at the University of Haifa. Her dissertation focuses on the association between nursing staffing and processes and functional outcomes of hospitalized older patients. Orly’s PhD paper (under review in the Journal of Nursing Management) examines the relationship between nursing interpersonal continuity (the extent of different nurses assigned to take care of each patient during the hospital stay) and functional outcomes, showing that when patients were cared for by a larger number of different nurses on each shift (lower relational continuity: lower weighted sum of squared frequencies of shifts that each nurse was assigned to care for the patient), this was associated with a higher risk of decline in cognitive functioning and lower satisfaction with the hospital care experience. These findings suggest relational continuity as a potential modifiable factor that could play a role in preserving the cognitive functioning of hospitalized older adults. These results were presented at the 2019 Gerontological Society of America (GSA) Annual Scientific Meeting and awarded the Health Sciences Person‐in‐Training Award. MA graduate (2019) Hava Bar Niv (advisors: Dr. Einav Srulovici and Prof. Efrat Shadmi) has one the Best Poster award at the Annual Meeting of the Israeli Association of Nursing Research on her MA thesis work “Continuity of Care from the Community to the Emergency Department: The Relationship between Characteristics of Patients, the Perception of Continuity of Care and Access to Community Health Care and Referral Type (self versus community care referral).”
Improving pain assessment in northern Israel
Successful treatment of any condition depends on accurate diagnosis, assessment, and monitoring of the patient’s condition. This is especially challenging when the symptoms of interests are subjective – such as in the case of pain. Accurate assessment of pain is paramount because it guides clinical decisions. Nurses are those who are in charge of routinely assessing and monitoring patients’ pain. In recent years, accumulating evidence has shown that there is a gap between nurses’ and patients’ pain assessment. While documentation of this gap is established, attempts to minimize this gap have not yet been published. In a series of studies, graduate students from Dr. Roi Treister’s team are assessing the efficacy of various interventions aimed at minimizing this gap. The rationale is that the better that nurses’ pain assessment reflects the patient’s pain, the more appropriate and successful and ethical the treatment. These studies are currently conducted in hospitals in northern Israel, including Rambam Health Care Campus, Carmel Medical Center, Bnai Zion Medical Center, and Galilee Medical Center. The first study that was recently completed assessed the effects of educational intervention, aimed at training kids on how to report their pain accurately. The training is based on a series of cartoon films that were developed for this project. One‐ Graduate Students Pushing the Frontier of Knowledge Debate 22
hundred two kids admitted to undergo surgery were recruited and randomized into training and control arms. The results indicated that the pain reports of kids who underwent the training were more reliable and consistent, and that the gap between kids’, nurses’, and parents’ pain reports were smaller in the trained group. This project was done as part of the thesis project of Ms. Dafna Zontag, who was moved to pursue this line of research in the next few years as part of her PhD studies. The project’s success has led to the adoption of the educational tool in routine clinical care at Galilee Medical Center, and hopefully soon in other medical centers, both nationally and globally. Ms. Srihan Abo‐Rass, as part of her thesis project, is focused on improving nurses’ assessment, another way to minimize the above‐mentioned gap. In her study, the gap will be assessed before and after an intervention aimed at educating nurses on how to better assess pain. The study, which is planned to begin in May 2020, will be conducted in two departments: in one, the nursing staff will be trained, and the other will serve as control. Patients’ pain, consumption of analgesics after surgery, and satisfaction with pain management will be assessed. At Bnai Zion Medical Center, PhD student Meital Buzaglo developed and tested the effect of another technology‐based educational intervention aimed at improving nurses’ pain assessment. At Carmel Medical Center, the relationships between patients’ ability to report pain and pain‐related clinical outcomes, including pain, medication consumption, and satisfaction with treatment, are assessed, in a project led by Dr. Honigman Liat, Dr. Treister’s lab manager. We believe that this activity, alongside the promotion of science, will support improved pain assessment and treatments in northern Israel.
Graduate Students Pushing the Frontier of Knowledge Debate 23
Medical Cannabis
Cannabis is defined in the medical literature as a “hallucinogen” that may cause changes in a person’s opinions and consciousness. The use of cannabis for medical reasons has increased in recent years around the world, and we are seeing an increase in the rate of medical cannabis patients attending hospitalization. Despite its medical benefits, cannabis remains controversial in public discourse, and isn’t in regular use in hospitals, mainly because of the issue of drug maintenance and the multiplicity of existing types. Our work in the departments has exposed us to the complexities surrounding treatment with cannabis and to the suffering of these patients in the absence of a tailored treatment policy. As part of their Master’s Degree in Nursing programs, in a practicum course, under the guidance of Prof. Daphna Carmeli, Tzippi Domb and Naomi Fridman have chosen this topic with the aim of bringing about significant change and improvement in this field, a change that will allow us as treating teams to give these patients the proper care they are entitled to. The project examines the relationship between the attitudes of the caregiving (nursing & medical) team in the orthopedic division, in relation to the skilled and professional use of cannabis as part of hospital policy. At the center of this work we have placed the continued use of cannabis and balance of pain during hospitalization. Key needs identified: Patient’s right to quality and tailored care: 3 problematic situations were encountered during hospitalization: 1. The patient doesn’t take their cannabis, the therapeutic sequence is impaired, and the painkillers offered in the ward don’t meet their needs. 2. The patient is taking cannabis without reporting it, while negating pain. There is a conflict between the expected pain from the performed procedure and the patient’s report. 3. The patient is taking cannabis without reporting it and receiving analgesics according to a regular pain protocol, which includes other narcotic drugs, potentially causing unwanted mixing of substances. Difficulties in identifying cannabis patients upon their arrival at the ward because of different approaches to its use: i.e., as a prescribed medication, as a way of living, as a non‐drug, or because of the patient’s concern about being denied its use during hospitalization. Raising staff awareness of cannabis and exposure to existing practice. Adapting a dedicated pain protocol for cannabis patients to provide safe patient care. Step A: Fieldwork to identify needs, map potential problems, set goals, and segment the target population while examining the legalization of cannabis in Israel compared with other countries. The data were checked against the existing situation in the division and the existing procedure in the hospital and presented to management. Step B: Developing a dedicated anonymous questionnaire for teams that includes: 1. Demographic details 2. Review of staff attitudes and knowledge of cannabis 3. Closed questions examining attitudes toward inpatient medical cannabis use policies. The intervention program will be built in accordance with the study findings, with an emphasis on gaining professional knowledge, breaking stigmas, gaining familiarity with the existing procedures, and building a dedicated pain protocol for these patients. The intervention will take place at a divisional team seminar by hospital representatives: executive management, training and computing, and project representatives in collaboration with the division’s management. The project is currently in the implementation and lecture stages.
Expanding the International Scope 24
Sigma Theta Tau
Global Nursing Excellence is one of the biggest international nursing organizations in the world. Sigma Theta Tau [hereinafter: Sigma] has more than 135,000 active members, in more than 100 countries: 39% of active members hold master’s and/or doctoral degrees; 51% are in staff positions; 19% are administrators or supervisors; 18% are faculty/academics; and 12% are in advanced practice. There are roughly 530 chapters at more than 700 institutions of higher education throughout Armenia, Australia, Botswana, Brazil, Canada, Colombia, England, Ghana, Hong Kong, Japan, Jordan, Kenya, Lebanon, Malawi, Mexico, the Netherlands, Pakistan, Philippines, Portugal, Singapore, South Africa, South Korea, Swaziland, Sweden, Taiwan, Tanzania, Thailand, the United Kingdom, and the United States. The Cheryl Spencer Department of Nursing established the first Sigma chapter in Israel, the “Omega Lambda Chapter,” and the 561st chapter of the Sigma organization. September 25, 2019 was the Chapter Chartering Ceremony, attended by Prof. Beth Tigges, the 2017‐2019 President of Sigma Theta Tau International (Sigma), and Prof. Liz Madigan, the CEO.
As of today, we have 91 members and we are the largest chapter in our region: Europe. We are the 8th Sigma chapter in Europe. We are active in promoting the academia‐practice connection; our chapter has members from most of the general hospitals in northern Israel, public and private health care organizations in the community, and higher education institutions. We are also recruiting outstanding students from BA, MA, and PhD programs in the Cheryl Spencer Department of Nursing. This is a new tradition in Israel, and Israeli nurses are learning the benefits of having such an international nursing organization. We are in the process of building and creating a tradition of excellence and promoting nurses and nursing practice through the various activities at the chapter: an internal newsletter, meetings with nursing leaders from different Expanding the International Scope 25
countries around the globe, and extensive social networking activity. We encourage members to participate in Sigma International conferences, to tell their personal and professional stories, and to share knowledge and perspectives in person and in the social media. For the next Sigma International conference in Portugal we are sending 14 members to present posters, oral presentations, and symposia. Our vision is to be the leading chapter in inspiring and strengthening all nurses’ awareness of their professional and expert practice, in creating a supportive learning community for personal and professional development, and in sharing knowledge and promoting relevant nursing agendas in research and in practice. Dalit Wilhelm| Head of the Clinical Unit University of Haifa
Faculty Achievements and Recent Publications 26
Abdelhadi, N., Drach‐Zahavy, A., & Srulovici, E., (In Press). The nurse’s experience of decision‐making processes in missed nursing care: A qualitative study. Journal of Advanced Nursing.
Agostinho M, Canaipa R, Honigman L, Treister R. No Relationships Between the Within‐Subjects’ Variability of Pain Intensity Reports and Variability of Other Bodily Sensations Reports. Front Neurosci. 2019 Aug 13;13:774.
Amiri, C, Herzog, D, Lelorain, S., & Gidron, Y. (2019). Daliy hassles, coping and well‐being: The moderating role of hemispheric lateralization. Neuropsychiatry. 9(2) 2269‐2278
Aviram, J., Pud, D., Berkovitch, T., Schiff‐Keren, B., Ogintz, M., Vulfsons, S., Yashar, T., Adahan, H.M., Brill, S., Amital, H., Goor‐Aryeh, I., Robinson, D., Green, L., Segal, R., Fogelman, Y., Tsvieli, O., Yellin, B., Vysotski, Y., Morag, O., Tashlykov, V., Sheinfeld, R., Goor, R., Meiri, D., and Eisenberg, E. (2020) Estimation of Response to Long Term treatment with Herbal Cannabis for Chronic Pain and Related Symptoms European Journal of Pain (under revision)
Band‐Winterstein, T., Doron, I., Zisberg, L., Shulyaev, K., & Zisberg, A. (2019). The meanings of the unlicensed assistive personnel role in nursing homes: A triadic job analysis perspective. Journal of nursing management, 27(3), 575‐583.
Chudner, I., Drach‐Zahavy, A., & Karkabi, K. (2019). Choosing Video Instead of In‐Clinic Consultations in Primary Care in Israel: Discrete Choice Experiment Among Key Stakeholders—Patients, Primary Care Physicians, and Policy Makers. Value in Health, 22(10), 1187–1196.
Cohen Castel O, Shadmi E, Keinan‐Boker L, Granot T, Karkabi K, Dagan E. (2019). The association between patients’ perceived continuity of care and beliefs about oral anticancer treatment. Supportive Care Cancer. 27 (9), 3545‐3553. doi: 10.1007/s00520‐019‐04668‐6.
Cohen Castel, O., Shadmi, E., Keinan‐Boker, L., Granot, T., Karkabi, K., Dagan, E. (2019). The association between patients’ perceived continuity of care and beliefs about oral anticancer treatment. Support Care Cancer. 27(9):3545‐3553. doi: 10.1007/s00520‐019‐04668‐6.
Cohen, Y., Zisberg, A., Chayat, Y., Gur‐Yaish, N., Gil, E., Levin, C., Rand D., & Agmon, M. (2019). Walking for better outcomes and recovery: The effect of WALK‐FOR in preventing hospital‐associated functional decline among older. Journal of Gerontology: Aeries A‐biological sciences and Medical Sciences. doi:10.1093/gerona/glz025
Dagan E, Dubovi I, Levy M, Zuckerman Levin N, Levy S. T. (2019) Adherence to diabetes care: knowledge of biochemical processes has a high impact on glycemic control among adolescents with type‐1 diabetes. Journal of Advanced Nursing. 75 (11), 2701‐2709. https://doi.org/10.1111/jan.14098
De Couck, M, Caers, R, Musch, L, Fliegauf, J, Giangreco, A., & Gidron, Y. (2019). How breathing can help you make better decisions: Two studies on the effects of breathing patterns on heart rate variability and decision‐making in business cases. International Journal of Psychophysiology, 139, 1‐9.
Dryjanska L & Zlotnick C. (2019) Wannabe Israeli: Immigrants wrestling with their identity. Quality and Quantity, 53(5), 2557‐ 2574. DOI: 10.1007/s11135‐019‐00871‐z
Dubovi I, Levy ST, Levy M, Zuckerman Levin N., Dagan E. (2020) Glycemic control in adolescents with type 1 diabetes: Are computerized simulations effective learning tools? Pediatric Diabetes. 21 (2), 328‐338. https://doi.org/10.1111/pedi.12974
Enosh, G., Freund, A., Goldblatt, H., Drach‐Zahavy, A., Ofer‐Bialer, G., & Guindy, M. (2020). Whose fault is it? Attribution of causes of patient violence among exposed and unexposed family physicians. Health and Social Care in the Community. Advance online publication. https://doi.org/10.1111/HSC.13080 Faculty Achievements and Recent Publications 27
Flaks‐Manov, N., Shadmi, E., Hoshen, M., Balicer, R.D., & Topaz, M. (2019). Identifying patients at highest‐risk: the best timing to apply a readmission predictive model. BMC Medical Informatics and Decision Making. 19(1):118.
Gidron Y, De Couck M, Reynders T, Marechal R, Engelborghs S, D’hooghe AM (2019). Stronger Correlations between Neurophysiological and Peripheral Disease Biomarkers Predict Better Prognosis in Two Severe Diseases. Journal of Clinical Medicine, 20;9(1).
Goldblatt, H., Band‐Winterstein, T., Lev, S., & Harel, D. (2020). “Who would sexually assault an 80‐year‐old woman?” Barriers to detecting sexual assault in late life Journal of Interpersonal Violence. Advance online publication. https://doi.org/10.1177/0886260520934440
Goldblatt, H., Freund, A., Drach‐Zahavy, A., Enosh, G., Edlis, N., & Peterfreund, I. (2020). Providing healthcare in the shadow of violence: Does emotion regulation vary among hospital workers from different professions? Journal of Interpersonal Violence, 35(9‐10), 1908‐1933. https://doi.org/10.1177/0886260517700620
Goldblatt, H., Granot, M., & Zarbiv, E. (2019). “Death lay here on the sofa:” Reflections of young adults on their experience as caregivers of parents who died of cancer at home. Qualitative Health Research, 29, 533‐544.
Granot, M., Dagul, P., Aronson, D. (2019). Resting blood pressure modulate chest pain intensity in patients with acute myocsardial infarction. Pain Reports.
Granot, M., Yaakov, S., Ramon, M. (2019). Enhanced itch intensity is associated with less‐efficient descending inhibition processing for itch but not pain attenuation in chronic dermatology patients. Pain Medicine. in press
Grinberg, K., Weissman‐Fogel, I., Lowenstein, L., Abramov, L., Granot, M. (2019). Myofascial manual therapy for women with chronic pelvic pain syndrome: The underlying bio‐psycho‐physiological mechanisms. Pain Research and Management (17 pages) doi: 10.1155/2019/6091257.
Grouper, H., Eisenberg, E., and Pud, D. (2019) The relationship between sensitivity to pain and conditioned pain modulation in healthy people Neuroscience Letters 708:134333. doi: 10.1016/j.neulet.2019.134333
Gur‐Yaish N, Shulyaev K, Zisberg A. Moderating Role of Attachment Orientation in the Association between the Level of Depressive Symptoms and Informal Support among Hospitalized Older Adults. Clin Gerontol. 2020 Feb 18:1‐9. doi: 10.1080/07317115.2020.1725702. [Epub ahead of print] PubMed PMID: 32066347.
Gur‐Yaish N, Tonkikh O, Shadmi E, Zisberg A. (2018). Informal support for older adults is negatively associated with walking and eating during hospitalization. Geriatric Nursing. 40(3):264‐268.doi: 10.1016/j.gerinurse.2018.11.003.
Gur‐Yaish, N., Cohen, D., & Shochat, T. (2020). Attachment orientations and sleep patterns: The moderating role of exchanges with spouse. Journal of Social and Personal Relationships 37(4) 1282–1295.
Gur‐Yaish, N., Tonkikh, O., Shadmi, E., Zisberg, A. (2019). Informal Support for Older Adults is Negatively Associated with Walking and Eating during Hospitalization. Geriatric Nursing. 40(3):264‐268. doi:10.1016/j.gerinurse.2018.11.003.
Jones, T., Drach‐Zahavy, A., Lopes, M. A., & Willis, E. (2020). Systems, economics and neoliberal politics: theories to understand missed nursing care. Nursing & Health Sciences.
Jones, T., Willis, E., Amorim‐Lopes, M., Drach‐Zahavy, A., & RANCARE Consortium COST–CA 15208. (2019). Advancing the science of unfinished nursing care: Exploring the benefits of cross‐disciplinary knowledge exchange, knowledge integration and transdisciplinarity. Journal of advanced nursing, 75(4), 905–917.
Kuperman, P., Granovsky, Y., Bahouth, H., Fadel, S., Ben Lulu, H., Bosak, N., Buxbaum, H., Sprecher, E., Crystal, S., Granot, M. Faculty Achievements and Recent Publications 28
(2020). Explaining Very‐Early Acute mTBI Post‐Motor Vehicle Collision Pain Variability: Additive Value of Pain Sensitivity Questionnaire. Pain Report 5(3), e821.
Lanier RK, Henningfield JE, Gudin J, Rauck R, Elder H, Erpelding N, Treister R, Gimbel J, Tagliaferri M, Doberstein SK, Di Fonzo CJ, Lu L, Siddhanti S, Katz NP. Assessment of potentially abuse‐related events in two phase 3 studies of NKTR‐181, a novel opioid analgesic, using the MADDERS® system (Misuse, Abuse, and Diversion Drug Event Reporting System). Curr Med Res Opin. 2019 Sep;35(9):1513‐1522.
Levy E, Warner LM, Fleig L, Kaufman MR, Deschepper R & Gidron Y. (in press). The effects of psychological inoculation on condom use tendencies and barriers; a randomized controlled trial. Psychology & Health, DOI: 10.1080/08870446.2020.1775832
Luz, S., Drach‐Zahavy A. & Shadmi E. (2019). Nursing innovation: The joint effects of championship behaviors, project types, and initiation levels. Nursing Outlook. 67(4):404‐418 .doi: 10.1007/s00520‐019‐04668‐6.
Luz, S., Shadmi, E., & Drach‐Zahavy, A. (2019). Nursing innovation: The joint effects of championship behaviors, project types, and initiation levels. Nursing outlook, 67(4), 404–418.
Luz, S., Shadmi, E., Admi, H., Peterfreund, I., & Drach‐Zahavy, A. (2019). Characteristics and behaviours of formal versus informal nurse champions and their relationship to innovation success. Journal of Advanced Nursing. 75(1):85‐95 doi: 10.1111/jan.13838.
Madjar B, Shachaf S, & Zlotnick C. (2019) Changing the current health system’s vision for disease prevention and health promotion. International Nursing Review, 66, 490‐497. DOI: 10.1111/inr.12535
Rayan‐Gharra, N. , Shadmi, E. , Tadmor, B., Flaks‐Manov, N., Balicer, R.D. (2019). Patients’ ratings of the in‐hospital discharge briefing and post‐discharge primary care follow‐up: The association with 30‐day readmissions. Patient Education and Counseling. 102:1513–1519. doi: 10.1016/j.pec.2019.03.018.
Rayan‐Gharra, N., Tadmor, B., Balicer, R.D., & Shadmi E. (2019). Association between cultural factors and readmissions: the mediating effect of hospital discharge practices and care‐transition preparedness. British Medical Journal Quality & Safety. 28(11):866‐874doi: 10.1136/bmjqs‐2019‐009317.
Reynders T, Gidron Y, De Ville J, Bjerke M, Weets I, Van Remoortel A, Devolder L, D’haeseleer M, De Keyser J, Nagels G, D’hooghe MB. (2019). Relation between Heart Rate Variability and Disease Course in Multiple Sclerosis. Journal of Clinical Medicine, 18;9(1).
Roth, N., Lev‐Weizel, R., & Shochat, T. (2019). “How Do You Sleep?” Sleep in Self‐Figure Drawings of Young Adolescents in Residential Care Facilities‐ An Exploratory Study. Sleep Medicine 60: 116‐122.
Saad, O., Zysberg, L., Heinik, J., Ben‐Itzhak, R. & Zisberg, A. (2019). The Right Kind of Smart: Emotional Intelligence’s Relationship to Cognitive Status in Community‐Dwelling Older Adults. 30:1‐7. doi: 10.1017/S1041610218002284
Saban Mor, Efrat Dagan, Anat Drach‐Zahavy. (2019) The relationship between mindfulness, triage accuracy, and patient satisfaction in the emergency department: A moderation‐mediation model. Journal of Emergency Nursing. 45 (6), 644‐ 660. doi: 10.1016/j.jen.2019.08.003.
Saban, M., Dagan, E., & Drach‐Zahavy, A. (2019). The relationship between mindfulness, triage accuracy, and patient satisfaction in the emergency department: A moderation‐mediation model. Journal of Emergency Nursing, 45(6), 644– 660. Faculty Achievements and Recent Publications 29
Shahaf, S., Ravid, C., Grossman, Y., Dadush, A., Zisberg, A. (2019)s. Are you ready to talk about death? Gerontology [Hebrew]. Pages‐25.
Shani, A., Granot, M. Mochalov, G., Raviv, B., Rahamimov, R. (2020). Matching actual treatment with patient administration‐ route‐preference improves analgesic response among acute‐low‐back‐pain patients – a randomized prospective trial. Journal of Orthopedic Surgery and Research 15, 1‐8.
Shochat, T., Hadish‐Shogan, S., Banin, M., Recanati, A., & Tzischinsky, O. (2019). Burnout, sleep and sleepiness during day and night shifts in transition from 8‐ to 12‐hour shift rosters among airline ground crew managers. Clocks & Sleep 1(2), 226‐239; https://doi.org/10.3390/clockssleep1020020.
Shochat, T., Santhi, N., Herer, P., Flavell, S.A., Skeldon, A.C., & Dijk, D‐J. (2019). Sleep timing in late autumn and late spring associates with light exposure rather than sun time in college students. Frontiers in Neuroscience 13:882.
Smichenko J, Gil E, Zisberg A. Relationship between Changes in Sedative Hypnotic Medications Burden and Cognitive Outcomes in Hospitalized Older Adults. The Journals of Gerontology Series A‐Biological Sci. and Medical Sci. 2020 Jan 14. pii: glaa015. doi: 10.1093/gerona/glaa015. [Epub ahead of print] PubMed PMID: 31942612.
Sperling, D. (2019). Revising the requirement of informed consent in an era of privatization, managed care and ACOs: Implications for bioethics and the connection between law and ethics. Journal of Comparative and International Aging Law & Policy, 10, 45–114.
Sperling, D. (2019). Suicide tourism: Understanding the legal, philosophical and socio‐political dimensions, 224 pages. Oxford and New York: Oxford University Press
Sperling, D. (forthcoming, 2020). Advance directive or physician’s obligation to hold a brain‐dead pregnant woman on life support: Which should prevail? American Medical Association Journal of Ethics
Sperling, D. (forthcoming, 2020). Training nurses to better deal with ethical dilemmas in disasters. Disaster Medicine and Public Health Preparedness
Spitzer‐Shohat, S. , Goldfracht, M., Key, C., Hoshen, M., and Balicer, R.D., & Shadmi, E. (2019). Primary Care Networks and Team Effectiveness in a Large‐Scale Disparity Reduction Intervention. Journal of Interprofessional Care. 13:1‐9. doi: 10.1080/13561820.2018.1538942.
Stefanova, E., Dubljević, O., Herbert, C., Fairfield, B., Schroeter, M. L., Stern, E. R., . . . & Drach‐Zahavy, A. (2020). Anticipatory feelings: neural correlates and linguistic markers. Neuroscience & Biobehavioral Reviews.
Sznitman, S.R., Shochat, T., & Greene, T. (2020). Is time elapsed between cannabis use and sleep start time associated with sleep continuity? An experience sampling method. Drug and Alcohol Dependence 208(1):107846.
Tonkikh, O. & Shadmi, E. & Zisberg, A. (2019). Food‐intake assessment in acutely ill older internal medicine patients. Geriatrics & Gerontology International. (9):890‐895.
Tonkikh, O., Shadmi, E., Zisberg, A. . (2019). Food‐intake assessment in acutely ill older internal medicine patients. Geriatrics & Gerontology International. doi: 10.1111/ggi.13744
Tonkikh, O., Zisberg, A., Shadmi, E. Association between continuity osf nursing care and older adults’ hospitalization outcomes: retrospective observational study. J Nurs Manag. doi: 10.1111/jonm.13031.
Treister R, Honigman L, Lawal OD, Lanier RK, Katz NP. A deeper look at pain variability and its relationship with the placebo response: results from a randomized, double‐blind, placebo‐controlled clinical trial of naproxen in osteoarthritis of the Faculty Achievements and Recent Publications 30
knee. Pain. 2019 Jul;160(7):1522‐1528
Treister R, Mirski Y, Honigman L, Yarnitsky D. Small Fiber Polyneuropathy in Yung Patients. Harefuah. 2020 Mar;159(3):181‐ 185.
Tzemah Shahar, R., Koren, O., Matarasso, S., Shochat, T., Magzal, F. Tamir, S., & Agmon, M. (2020). Attributes of physical activity and gut‐microbiome in adults: A systematic review. International Journal of Sports Medicine 10.1055/a‐1157‐ 9257.
Zeleníková, R., Drach‐Zahavy, A., Gurková, E., Papastavrou, E., RANCARE Consortium COST, Papastavrou, E., . . . & Riklikiene, O. (2019). Understanding the concept of missed nursing care from a cross‐cultural perspective. Journal of advanced nursing, 75(11), 2995–3005.
Zeltzer, D., Balicer, R.D., Shir, T., Flaks‐Manov, N., Einav, L., Shadmi, E. (2019). Prediction Accuracy with Electronic Medical Records versus Administrative Claims. Medical Care. 57(7):551‐559. doi: 10.1097/MLR.0000000000001135.
Zion, N. & Shochat, T. (2019). Let them sleep: The effects of a scheduled nap during the night shift on sleepiness and cognition in hospital nurses. Journal of Advanced Nursing 75:2603–2615.
Zlotnick C & #Dryjanska L. (2020) Immigrants’ Health, Acculturation, and the Work‐Retirement Continuum. Health & Social Work, 45 (1), 13‐22. DOI: 10.1093/hsw/hlz039
Zlotnick C, #Dryjanska L, & Suckerman S. (2020) The Association Between Acculturation Variables and Life Satisfaction Among Israeli Immigrants from Four English‐Speaking Countries. Journal of Happiness Studies, 21(4):1437‐1444. DOI: 10.1007/s10902‐019‐00137‐3
Zlotnick C, Goldblatt H, Carmeli D, Tayshaw O, & Shadmi E (2019) The Impact of Adolescents’ Racial and Ethnic Self‐Identity on Hope. Health & Social Care in the Community, 27(5), e705‐e715. DOI: 10.1111/hsc.12795
Zlotnick, C., Birenbaum‐Carmeli, D., Goldblatt , H., Dishon, Y., Taychaw, O. & Shadmi, E. (2019). The Impact of Adolescents’ Racial and Ethnic Self‐Identity on Hope. Health & Social Care in the Community. 27(5):e705‐e715.
Zysberg, L., Band‐Winterstein, T., Doron, I., Shulyaev. K, Siegel, E.O., Zisberg, A. (2019). The Health Care Aide Position in Nursing Homes: A Comparative Survey of Nurses’ and Aides’ perceptions. International Journal of Nursing Studies. 94, 98‐106. doi.org/10.1016/j.ijnurstu.2019.03.007 News and Updates 31
At the beginning of the 2019–2020 academic year, the Cheryl Spencer Department of Nursing moved to a new Social Welfare and Health Sciences Building. The building houses the Schools of Social Work and Public Health, the Department of Nursing, and the Departments of Occupational Therapy and Community Mental Health. The building includes classrooms, seminar rooms, computer rooms, administrative offices, laboratories, and public areas for informal meetings and social activities.
Prof. Tamar Shochat has been appointed the next head of the Cheryl Spencer Department of Nursing, beginning in October 2020. She has been part of the senior faculty in the department since 2003, and has served over the years as director of the BA supplement program for registered nurses in the English Hospital School of Nursing, as founding editor of the department newsletter, and as a member of the Master’s committee. She has served as chair of the Cheryl Spencer Institute of Nursing Research (CSINR) since April 2018. Prof. Shochat graduated from the Faculty of Medicine at the Technion – Israel Institute of Technology in 1997 and is an expert in sleep and chronobiology. Her research focuses on identifying underlying factors, as well as health and functional outcomes, associated with sleep patterns, particularly in ecological settings in populations that are vulnerable to sleep disruption and circadian misalignment, such as shift workers, adolescents, and older adults. The Department of Nursing wishes to thank Prof. Anat Drach‐Zahavy for leading the department to its excellent achievements in research, teaching, and community service. 32
We’re on the Web! Visit us at:
The Cheryl Spencer Department of http://hw.haifa.ac.il/nursing‐ home Nursing
Address University of Haifa, 199 Aba Khoushy Ave. Mount Carmel, Haifa, Israel 3498838 Phone: 4‐828804–972 Fax: 4‐8288017–972 E-Mail: [email protected]