Allison Squires

Background: Patients with limited English proficiency (LEP) experience poorer health outcomes and face persistent barriers to interpreter use. Although language access is essential to high-quality care, little is known about how home health care (HHC) managers operationalize language services in this setting. Objectives: To explore HHC managers’ perspectives on delivering care to patients with LEP and identify organizational challenges and strategies related to language access. Methods: We conducted a qualitative secondary analysis of semistructured interviews collected between 2016 and 2017 as part of a parent study examining language barriers in HHC. Participants included 14 managers from a large U.S. home health agency serving a high volume of patients with LEP. Interviews explored experiences managing care delivery, including communication strategies, staffing decisions, and system-level constraints. Results: Five themes and several subthemes emerged from the data. Major themes included strategies for ensuring language-concordant care; structural factors impeding language-concordant care; staff using ad hoc strategies to “get by”; perceived impacts on outcomes; and interventions to address structural factors impeding language-concordant care. Managers described multiple strategies to address language barriers with patients. However, these approaches were constrained by shortages of bilingual clinicians, competing demands that prioritized clinical expertise over language concordance, and variability in language needs across patient populations. Interpreter services, particularly telephone-based language lines, were often perceived as inefficient or unreliable, leading some clinicians to rely on ad hoc communication strategies or “getting by.” These and other barriers were perceived to contribute to communication breakdowns, reduced care quality, patient confusion, and potentially avoidable health care utilization, including emergency department visits and readmissions. Discussion: Improving language access in HHC requires system-level interventions, including investment in a linguistically diverse workforce, clearer protocols for interpreter use, improved communication across care transitions, and organizational support for culturally and linguistically appropriate care. Addressing these challenges is essential to advancing equity, patient safety, and quality of care for patients with LEP.

Background: The COVID-19 pandemic placed unprecedented demands on nurses and midwives worldwide, exacerbating existing workforce shortages and contributing to high rates of mental health issues and altered labor market dynamics. Nurses and midwives in low- and middle-income countries remain underrepresented in the literature. Objective: The aim of this study is to describe and compare the impact of pandemic response implementation across countries and contexts on the global nursing and midwifery workforce who worked and delivered care between March 2020 and December 2023. Methods: A pragmatic design guides this multinational, online, descriptive study. Eligible participants are nurses and midwives who cared for at least 1 patient with suspected or confirmed COVID-19. Country teams use opt-in convenience and network sampling, targeting 300 participants per country, or 60 participants for small island states. The self-administered 79-question instrument, hosted on Qualtrics XM software and available in 27 languages, was developed with country teams. It includes 8 open-ended free-text questions; 46 questions examining the impact of pandemic response implementation on mental health, career mobility, economics, and occupational exposures; and 25 demographic questions. After pilot-testing, data collection took place between July 2022 and June 2026. Summative content analysis combined with natural language processing techniques analyzed the qualitative data. Descriptive and bivariate analyses analyzed quantitative responses. Cross-country comparative analyses of quantitative data use funnel plots with binomial control limits to compare country responses and can accommodate unequal sample sizes. Psychometric evaluation of instruments developed and tested in this study is planned. Funding and ethics approval for the study were provided by the lead author’s university. Results: At the conclusion of data collection in June 2026, a total of more than 23,000 nurses and midwives from 108 countries engaged with this study’s online instrument, with over 14,000 completing more than 50% of all the questions. Descriptive analyses of partial samples have been published, as have the pilot tests of the methodology. The analyses specified here will use the complete dataset and are underway, with the first multinational analyses expected in 2027. Country teams will lead analyses specific to their country. Conclusions: Upon completion, this study will identify the common and unique factors that influenced pandemic response implementation relative to nurses and midwives during the COVID-19 pandemic, from low-resource to high-resource settings. Data may provide multilevel insights into the postpandemic workforce. Finally, this study will provide data that can inform country-level preparation to meet key articles of the World Health Organization Pandemic Agreement.

Critiques of traditional content validation is its limitation to a positivist approach to quantifying a question's relevance while cognitive interviewing is labor and resource‐intensive. The purpose of this study is to describe a novel approach to developing a new survey instrument that combines content validity indexing and cognitive interviewing to address the limitations of both approaches. Guided by language planning theory for health services research, the a priori target constructs for instrument development included: (1) organizational language access resources and policies; (2) nursing workflow and decision‐making related to interpreter use; and (3) perceived quality and outcomes of care in the presence of language barriers. Content validation with 50 expert raters was the first step, followed by four recorded qualitative cognitive interviews focused on poorly performing items. Transcripts were analyzed using a qualitative descriptive approach. Scores revealed items where raters lacked consensus. Limiting cognitive interviewing to these items enabled rich discussions of why items were potentially problematic, improved phrasing, and determined the optimal scaling. Three new survey instruments resulted from the process. The approach reduced instrument development time and proved to be highly complementary. Replication of the approach is recommended to further refine and test it.

Language barriers present challenges in the school health office, particularly for students and families with limited English proficiency (LEP). This study examines how these barriers affect school nurses’ ability to deliver effective healthcare and their perceptions of how language may affect student health. This qualitative descriptive study includes semistructured interviews with 16 school nurses. The data were analyzed through qualitative content analysis. The analysis revealed one overarching theme, Communication Inconsistencies Require Adapting in the Moment, with three subthemes: Accessing, Implementing, and Trusting Interpretation and Translation; Navigating Role Strain; and Missing or Delayed Care as a Result of Miscommunication . When language barriers exist, school nurses must navigate added complexities to provide student care. Applying Leininger's Transcultural Nursing Theory to the School Nursing Practice Framework ^TM aims to enhance culturally congruent school nursing practices, including advocating for policies and procedures that assist school nurses in meeting the needs of LEP students and families.

What nurses can do at the bedside to ensure equitable care

Workplace violence against nurses and midwives intensified during the COVID‐19 pandemic, exposing and amplifying longstanding structural marginalization in health systems across Latin America. This study analyzes how different forms of violence were experienced and described by nursing professionals during this period. A secondary qualitative analysis was conducted using text‐based responses from an international online survey developed by the Global Consortium, which included 3860 nurses and midwives from 18 Latin American and Caribbean countries. Data were examined through Descending Hierarchical Classification using IRaMuTeQ, followed by reflective thematic analysis for interpretive integration. The analysis identified five lexical classes, reorganized into three interconnected themes: direct violence related to care delivery and system collapse; stigma, fear, and disruption of social belonging; and ethical–political suffering associated with structural blame, moral suffering, and moral injury. Despite contextual differences across countries, narratives revealed recurring patterns of emotional overload, professional delegitimization, and exposure to multiple forms of violence. These findings position violence against nursing professionals during the pandemic as a structural and multifaceted phenomenon rooted in historical inequities and institutional fragility, underscoring the need for sustained policies that strengthen workforce protection, ethical accountability, and institutional support in both routine healthcare settings and future public health emergencies.

The global HIV pandemic disproportionately affects adolescents and young adults (aged 15–24 years), making comprehensive sex education a crucial preventive strategy. This integrative review synthesized 19 studies from 2014 to 2024 to evaluate the effectiveness and comprehensiveness of structured sex education programs against international guidelines. A systematic database search and critical appraisal were conducted on studies featuring multi-session programs targeting adolescents. Short-term outcomes consistently showed significant increases in HIV knowledge and self-efficacy. However, long-term effectiveness was mixed, constrained by methodological weaknesses (e.g., participant dropout) and a thematic overreliance on individual behavioral theories. Content analysis revealed critical gaps in addressing gender and power dynamics (covered by 32% of programs) and modern biomedical prevention (pre-exposure prophylaxis). Although immediately effective, the sustainable public health impact of these programs is limited by structural deficiencies. Future research must shift toward a socio-ecological framework, prioritize longitudinal studies, and integrate programs directly with sexual and reproductive health services.

Background: Precision oncology (PO) improves and extends the lives of patients living with cancer, but multiple studies have documented its underuse in practice. Specifically, studies note a significant lack of PO use within the Veterans Affairs (VA) medical system. A paucity of implementation of PO in oncologic practice poses a significant barrier to providing the most up-to-date guideline-based care. Objective: While several studies have explored determinants of PO use, we sought to contribute to the body of knowledge by additionally focusing on the unique perspectives of patients, as well as conducting a comprehensive study within the VA medical system, the United States’ largest single-payer health care system. We conducted interviews with both patients and providers at multiple VA sites to identify and characterize barriers and facilitators of PO use in clinical care. Methods: Using a qualitative descriptive approach, we conducted semistructured interviews with 17 patients with cancer and 16 oncology providers recruited from multiple VA sites. Cancer types included prostate, gastrointestinal, and lung. Data were analyzed via a team-based coding approach using directed content analysis. Data were coded and then aggregated into themes and mapped to the Theoretical Domains Framework (TDF) and Behavior Change Wheel sources of behavior (Capability, Opportunity, and Motivation) based on the consensus of the study team. Results: The patient sample consisted of 17 all-male veterans seen at VA oncology clinics in 2022. Participants predominantly self-identified as White (n=9, 52.9%) or Black (n=6, 35.3%), and the majority (n=11, 64.7%) held a high school degree or a higher level of education. The provider sample consisted of 16 physicians, all of whom held MD degrees and practiced oncology. The provider sample represented 6 states, was 50% (8/16) female, and participants averaged 14 years in their current position. The overarching theme was the “Precision Oncology Feedback Loop,” which captured the essence of the complex processes involved in facilitating PO care in the VA system. The TDF and Behavior Change Wheel helped categorize findings to identify where issues in the feedback loop could facilitate or generate barriers to care. Conclusions: Our findings expand on the current literature by highlighting both patient and provider experiences across key TDF domains (Environmental Context and Resources, Knowledge, Memory, and Attention). The conceptual model produced by the analysis illustrates the complexities associated with the implementation. Our findings support the design of multilevel interventions that target increased knowledge or education, improved workflow, and ease of communication to enhance PO delivery.