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1.  Community-based participatory research (CBPR) approach to study children’s health in China: Experiences and reflections 
Background
Community-based participatory research principles have been successfully applied to public health research in U.S. settings. While there is a long history of collaboration between government and communities in China, to date, community-based participatory research has not been used in children’s environmental health studies.
Method
This article describes how community-based participatory research principles were applied by an international research group to the China Jintan Child Cohort Study, a longitudinal study of malnutrition and lead exposure on cognitive and neurobehavioral development. Challenges emerged and lessons learned from implementing the study were discussed and recommendations were presented.
Conclusion
We conclude that the community-based participatory research model can be applied in conducting and promoting environmental health research in China and researchers should be prepared for special challenges and cultural constraints in the implementation of the research in regards to human subject regulations, information dissemination, and culture.
doi:10.1016/j.ijnurstu.2011.04.003
PMCID: PMC4247337  PMID: 21601204
Community-based participatory research; CBPR; Lead; Children; China; Environmental health
2.  Professional collegiality and peer monitoring among nursing staff: An ethnographic study 
Background
Patient safety and professional self-regulation systems both rely on professional colleagues to hold each other accountable for quality of care.
Objectives
To understand how staff nurses manage variations in practices within the group, and negotiate the rules-in-use for quality of care, collegiality, and accountability.
Design/Methods
Ethnographic case study; participant-observation, semi-structured interviews, policy analysis.
Setting
In-patient unit in an urban US teaching hospital.
Results
Explicit acknowledgement of conflicts and practice variations was perceived as risky to group cohesion. The dependence of staff on mutual assistance, and the absence of a system of group practice, led to the practice of “mutual deference”, a strategy of reciprocal tolerance and non-interference that gave wide discretion to each nurse’s decisions about care.
Conclusions
Efforts to improve professional accountability will need to address material constraints and the organization of nursing work, as well as communication and leadership skills.
doi:10.1016/j.ijnurstu.2012.12.022
PMCID: PMC3676441  PMID: 23332164
accountability; nursing practice; professionalism; professional regulation; work environment
4.  Outcomes of a Peer Mentor Implemented Fitness Program in Older Adults: A Quasi-Randomized Controlled Trial 
Objectives
To investigate the effectiveness of different applications of mentoring in an older adult exercise program, this study compared the physical fitness scores, the retention and participation rates of older adults trained by student mentors, peer mentors, peer mentors working independently of the researchers, and a non-exercising control group.
Methods
106 older adults were recruited and assigned to one of the groups using quasi-randomization. All three experimental groups completed a 14-week intervention. Pre- and post-training assessments of fitness were completed, and retention and participation rates were compared.
Results
High retention and participation rates, as well as significant improvements in fitness scores from baseline to post-test were observed in all three mentored groups. While the control group showed improvement only in one fitness test, subjects in the mentored groups improved similarly in all measures, regardless of the type of mentoring received.
Discussion
These findings indicated effectiveness of the peer mentor model and suggested that with adequate preparation peer mentors may be capable of guiding older adult participants effectively without assistance from professional staff.
doi:10.1016/j.ijnurstu.2012.12.006
PMCID: PMC3708998  PMID: 23279966
elderly exercise; layperson leadership; older adult fitness; peer counseling
5.  Factors associated with needlestick and sharp injuries among hospital nurses: A cross-sectional questionnaire survey 
Background
The current status of needlestick or sharp injuries of hospital nurses and factors associated with the injuries have not been systematically examined with representative registered nurse samples in South Korea.
Objective
To examine the incidence to needlestick or sharp injuries and identify the factors associated with such injuries among hospital nurses in South Korea.
Design, settings and participants
A cross-sectional survey of hospital nurses in South Korea. Data were collected from 3079 registered nurses in 60 acute hospitals in South Korea by a stratified random sampling method based on the region and number of beds.
Methods
The dependent variable was the occurrence of needlestick or sharp injuries in the last year, and the independent variables were protective equipment, nurse characteristics, and hospital characteristics. This study employed logistic regression analysis with generalized estimating equation clustering by hospital to identify the factors associated with needlestick or sharp injuries.
Results
The majority (70.4%) of the hospital nurses had experienced needlestick or sharp injuries in the previous year. The non-use of safety containers for disposal of sharps and needles, less working experience as a registered nurse, poor work environments in regards to staffing and resource adequacy, and high emotional exhaustion significantly increased risk for needlestick or sharp injuries. Working in perioperative units also significantly increased the risk for such injuries but working in intensive care units, psychiatry, and obstetrics wards showed a significantly lower risk than medical–surgical wards.
Conclusions
The occurrence of needlestick or sharp injuries of registered nurses was associated with organizational characteristics as well as protective equipment and nurse characteristics. Hospitals can prevent or reduce such injuries by establishing better work environments in terms of staffing and resource adequacy, minimizing emotional exhaustion, and retaining more experienced nurses. All hospitals should make safety-engineered equipment available to registered nurses. Hospitals as well as specific units showing higher risk for needlestick and sharp injuries should implement organizational strategies to prevent such injuries. It is also necessary to establish a monitoring system of needlestick and sharp injuries at a hospital level and a reporting system at the national level in South Korea.
doi:10.1016/j.ijnurstu.2012.07.009
PMCID: PMC3996454  PMID: 22854116
Needlestick injuries; Burnout; Work environment; Hospitals; Nurses; Occupational health; Republic of Korea
6.  Health-risk behaviors among a sample of US pre- adolescents: Types, frequency, and predictive factors 
Background
Children as young as 10 years old report curiosity and participation in health-risk behaviors, yet most studies focus upon adolescent samples.
Objective
To document the types and frequencies of health risk behavior among pre-adolescents and to examine the child, family, and environment factors that predict them.
Method
A sample of 297 pre-adolescents (mean age = 10.5, SD = 0.6) from two Midwestern US cities and their parents (child-parent dyads) provided data about demographic characteristics, health risk behavior participation, child self-esteem, child pubertal development, child and adult perception of their neighborhood, and parent monitoring. Their participation was at intake to a 5-year clustered randomized controlled trial.
Results
Pre-adolescents participated in an average of 3.7 health-risk behaviors (SD = 2.0), primarily those that lead to unintentional (helmet and seatbelt use) and intentional (feeling unsafe, having something stolen, and physical fighting) injury. Factors predictive of unintentional injury risk behavior were self-esteem, pubertal development, parent monitoring, and parent perception of the neighborhood environment. Boys were 1.8 times less likely than girls to use helmets and seatbelts. Pre-adolescents whose parents were not partnered were 2.8 times more likely than pre-adolescents whose parents were partnered to report intentional risk behavior.
Recommendations
These data demonstrate trends that cannot be ignored. We recommend, focused specifically upon boys and non-partnered families, that (a) developmentally-appropriate, appealing prevention messages be developed and delivered for parents and pre-adolescents and community interventions targeting both parent and pre-adolescent together be provided to help them establish and monitor behavioral expectations and (b) organized nursing endorse policy in the US and globally that assures adequate family environments for children.
doi:10.1016/j.ijnurstu.2012.10.012
PMCID: PMC3594190  PMID: 23177901
7.  The Effects of a Tailored Cardiac Rehabilitation Program on Depressive Symptoms in Women: A Randomized Clinical Trial 
Background
Depression is known to co-occur with coronary heart disease (CHD). Depression may also inhibit the effectiveness of cardiac rehabilitation (CR) programs by decreasing adherence. Higher prevalence of depression in women may place them at increased risk for non-adherence.
Objective
To assess the impact of a modified, stage-of-change-matched, gender-tailored CR program for reducing depressive symptoms among women with CHD.
Methods
A 2-group randomized clinical trial compared depressive symptoms of women in a traditional 12-week CR program to those completing a tailored program that included motivational interviewing guided by the Transtheoretical Model of behavior change. Women in the experimental group also participated in a gender-tailored exercise protocol that excluded men. The Center for Epidemiological Studies Depression (CES-D) Scale was administered to 225 women at baseline, post-intervention, and at 6-month follow-up. Analysis of Variance was used to compare changes in depression scores over time.
Results
Baseline CES-D scores were 17.3 and 16.5 for the tailored and traditional groups, respectively. Post-intervention mean scores were 11.0 and 14.3; Six-month follow-up scores were 13.0 and 15.2, respectively. A significant group by time interaction was found for CES-D scores (F(2, 446) = 4.42, p = .013). Follow-up tests revealed that the CES-D scores for the traditional group did not differ over time (F(2, 446) = 2.00, p = .137). By contrast, the tailored group showed significantly decreased CES-D scores from baseline to post-test (F(1, 223) = 50.34, p < .001); despite the slight rise from post-test to 6-month followup, CES-D scores remained lower than baseline (F(1, 223) = 19.25, p < .001).
Conclusion
This study demonstrated that a modified, gender-tailored CR program reduced depressive symptoms in women when compared to a traditional program. To the extent that depression hinders CR adherence, such tailored programs have potential to improve outcomes for women by maximizing adherence. Future studies should explore the mechanism by which such programs produce benefits.
doi:10.1016/j.ijnurstu.2010.06.005
PMCID: PMC4108994  PMID: 20615504
depression; cardiac rehabilitation; motivational interviewing; women; transtheoretical model
8.  Overall perceived health predicts risk of hospitalizations and death in adults with heart failure: a prospective longitudinal study 
Background
Patient overall perception of health may provide an effective early warning for risk of hospitalization and death among heart failure patients.
Objective
Determine whether overall perceived health predicts all-cause hospitalization or death in heart failure patients after adjusting for confounding factors in a sample of adults with heart failure.
Design
Prospective, longitudinal, observational study.
Settings
Three outpatient urban settings in the northeast United States between 2007 and 2010.
Participants
Adults with chronic Stage C heart failure confirmed by echocardiographic and clinical evidence.
Methods
A secondary analysis was conducted using data collected on 273 Stage C patients with heart failure. Participants in the parent study were followed for 6 months. Overall perceived health was measured by self-report. Hospitalization and death were assessed from electronic hospital records and confirmed with county death records as needed. Cox proportional hazards models were used to examine the association between perceptions of health and rates of hospitalization and death.
Results
Patients with poor or fair perceived health had over 5.5 times the rate of death or hospitalization over the 6-month period (hazard ratio; 95% confidence interval: 2.0-15.6; p=0.001) after controlling for model covariates. The predictive ability of perceived health attenuated over time such that at 30-days patients who reported poor or fair perceived health had only 1.2 times the rate of an event and virtually no difference in event rate by 60-days.
Conclusions
Overall perceived health is a powerful indicator of impending events and can be a quick tool for prioritizing heart failure patients who are at highest risk of imminent death and hospitalization. Questions about perceived health need to be asked of patients regularly in order to have clinical utility.
doi:10.1016/j.ijnurstu.2012.10.001
PMCID: PMC4083630  PMID: 23122888
10.  Nurse and patient activities and interaction on psychiatric inpatients wards: a literature review 
Background
Despite major developments in community mental health services, inpatient care remains an important yet costly part of the service system and patients who are admitted frequently spend a long period of time in hospital. It is, therefore, crucial to have a good understanding of activities that take place on inpatient wards.
Objective
To review studies that have measured nursing and patient activity and interaction on psychiatric inpatient wards.
Data sources and review methods
This literature review was performed by searching electronic databases and hand-checking reference lists.
Results
The review identified 13 relevant studies. Most used observational methods and found that at best 50% of staff time is spent in contact with patients, and very little time is spent delivering therapeutic activities. Studies also showed that patients spend substantial time apart from staff or other patients.
Conclusion
On inpatient psychiatric wards, evidence over 35 years has found little patient activity or patient social engagement. The reasons for this trend and recommendations for the future are discussed.
doi:10.1016/j.ijnurstu.2010.03.012
PMCID: PMC4018996  PMID: 20417514
acute mental health; acute psychiatric ward; literature review; mental health nursing activity
12.  Cultural adaptation of an evidence-based nursing intervention to improve medication adherence among people living with HIV/AIDS (PLWHA) in China 
BACKGROUND
Adapting nursing interventions to suit the needs and culture of a new population (cultural adaptation) is an important early step in the process of implementation and dissemination. While the need for cultural adaptation is widely accepted, research-based strategies for doing so are not well articulated. Non-adherence to medications for chronic disease is a global problem and cultural adaptation of existing evidence-based interventions could be useful.
OBJECTIVES
This paper aims to describe the cultural adaptation of an evidence-based nursing intervention to improve medication adherence among people living with HIV/AIDS and to offer recommendations for adaptation of interventions across cultures and borders.
SITE
The intervention, which demonstrated efficacy in a randomized controlled trial in North America, was adapted for the cultural and social context of Hunan Province, in south central China.
SOURCES OF DATA
The adaptation process was undertaken by intervention stakeholders including the original intervention study team, the proposed adaptation team, and members of a Community Advisory Board, including people living with HIV/AIDS, family members, and health care workers at the target clinical sites.
PROCEDURES
The adaptation process was driven by quantitative and qualitative data describing the new population and context and was guided by principles for cultural adaptation drawn from prevention science research.
RESULTS
The primary adaptation to the intervention was the inclusion of family members in intervention activities, in response to the cultural and social importance of the family in rural China. In a pilot test of the adapted intervention, self-reported medication adherence improved significantly in the group receiving the intervention compared to the control group (p=0.01). Recommendations for cultural adaptation of nursing interventions include 1) involve stakeholders from the beginning; 2) assess the population, need, and context; 3) evaluate the intervention to be adapted with attention to details of the original studies that demonstrated efficacy; 4) compare important elements of the original intervention with those of the proposed new population and context to identify primary points for adaptation; 5) explicitly identify sources of tension between intervention fidelity and cultural adaptive needs; 6) document the process of adaptation, pilot the adapted intervention, and evaluate its effectiveness before moving to dissemination and implementation on a large scale.
doi:10.1016/j.ijnurstu.2012.08.018
PMCID: PMC3548061  PMID: 22981372
Cultural adaptation; Nursing intervention; Medication adherence; HIV/AIDS; China
13.  A Systematic Survey Instrument Translation Process for Multi-Country, Comparative Health Workforce Studies 
Background
As health services research (HSR) expands across the globe, researchers will adopt health services and health worker evaluation instruments developed in one country for use in another. This paper explores the cross-cultural methodological challenges involved in translating HSR in the language and context of different health systems.
Objectives
To describe the pre-data collection systematic translation process used in a twelve country, eleven language nursing workforce survey.
Design & Settings
We illustrate the potential advantages of Content Validity Indexing (CVI) techniques to validate a nursing workforce survey developed for RN4CAST, a twelve country (Belgium, England, Finland, Germany, Greece, Ireland, Netherlands, Norway, Poland, Spain, Sweden, and Switzerland), eleven language (with modifications for regional dialects, including Dutch, English, Finnish, French, German, Greek, Italian, Norwegian, Polish, Spanish, and Swedish), comparative nursing workforce study in Europe.
Participants
Expert review panels comprised of practicing nurses from twelve European countries who evaluated cross-cultural relevance, including translation, of a nursing workforce survey instrument developed by experts in the field.
Methods
The method described in this paper used Content Validity Indexing (CVI) techniques with chance correction and provides researchers with a systematic approach for standardizing language translation processes while simultaneously evaluating the cross-cultural applicability of a survey instrument in the new context.
Results
The cross-cultural evaluation process produced CVI scores for the instrument ranging from .61 to .95. The process successfully identified potentially problematic survey items and errors with translation.
Conclusions
The translation approach described here may help researchers reduce threats to data validity and improve instrument reliability in multinational health services research studies involving comparisons across health systems and language translation.
doi:10.1016/j.ijnurstu.2012.02.015
PMCID: PMC3395768  PMID: 22445444
14.  Changes in Hospital Nurse Work Environments and Nurse Job Outcomes: An Analysis of Panel Data 
Background
One strategy proposed to alleviate nursing shortages is the promotion of organizational efforts that will improve nurse recruitment and retention. Cross-sectional studies have shown that the quality of the nurse work environment is associated with nurse outcomes related to retention, but there have been very few longitudinal studies undertaken to examine this relationship.
Objectives
To demonstrate how rates of burnout, intention to leave, and job dissatisfaction changed in a panel of hospitals over time, and to explore whether these outcomes were associated with changes in nurse work environments.
Methods
A retrospective, two-stage panel design was chosen for this study. Survey data collected from large random samples of registered nurses employed in Pennsylvania hospitals in 1999 and 2006 were used to derive hospital-level rates of burnout, intentions to leave current positions, and job dissatisfaction, and to classify the quality of nurses’ work environments at both points in time. A two-period difference model was used to estimate the dependence of changes in rates of nurse burnout, intentions to leave, and job dissatisfaction on changes in nurse work environments between 1999 and 2006 in 137 hospitals, accounting for concurrent changes in nurse staffing levels.
Results
In general, nurse outcomes improved between 1999 and 2006, with fewer nurses reporting burnout, intentions to leave, and job dissatisfaction in 2006 as compared to 1999. Our difference models showed that improvements in work environment had a strong negative association with changes in rates of burnout (β =−6.42%, p<0.01) intentions to leave (β =−4.10%, p<0.01), and job dissatisfaction (β =−8.00%, p<0.01).
Conclusions
Improvements in nurse work environments over time are associated with lower rates of nurse burnout, intentions to leave current positions, and job dissatisfaction.
doi:10.1016/j.ijnurstu.2012.07.014
PMCID: PMC3589738  PMID: 22902135
burnout; intention to leave; job satisfaction; nurse management; nurse staffing; nurse retention; nurse work environments
15.  Development and validation of a quality of life instrument for patients with drug dependence: Comparisons with SF-36 and WHOQOL-100 
Aim
Our goal was to develop a self-administered quality of life scale for patients with drug addiction/dependence (QOL-DA) and compare it with the SF-36 and the WHOQOL-100.
Methods
Employing theory and methodology of rating scale construction, a self-administered quality of life instrument for individuals with drug dependence QOL-DA was developed and evaluated utilizing responses from 212 drug-dependent subjects at the Kunming Municipal Mandatory Detoxification and Rehabilitation Center in China. Quality of life was measured using the SF-36, WHOQOL-100 and QOL-DA three times during the detoxification.
Results
Test-retest reliability in the domains of physical function, psychological function, social function and toxicity were 0.82, 0.64, 0.78, and 0.76, respectively. Cronbach's coefficient α for the 4 domains was 0.87,0.89,0.93 and 0.86, respectively. Correlations and factor analysis showed good construct validity. Criterion-related and convergent validity was confirmed by using the SF-36 and the WHOQOL-100 simultaneously. The instrument does show the change in QOL after two weeks of detoxification with higher standardized response mean higher than that of SF-36 and WHOQOL-100.
Conclusion
The instrument developed has good validity, reliability and better responsiveness than instruments currently used, and can be employed effectively to measure the quality of life of individuals with drug dependence.
doi:10.1016/j.ijnurstu.2011.02.012
PMCID: PMC3779790  PMID: 21397228
Drug dependency; Psychometric properties; Standardized response mean; SF-36; WHOQOL-100
16.  Impact of a nurse-directed, coordinated school health program to enhance physical activity behaviors and reduce body mass index among minority children: A parallel-group, randomized control trial 
Background
Underserved children, particularly girls and those in urban communities, do not meet the recommended physical activity guidelines (>60 min of daily physical activity), and this behavior can lead to obesity. The school years are known to be a critical period in the life course for shaping attitudes and behaviors. Children look to schools for much of their access to physical activity. Thus, through the provision of appropriate physical activity programs, schools have the power to influence apt physical activity choices, especially for underserved children where disparities in obesity-related outcomes exist.
Objectives
To evaluate the impact of a nurse directed, coordinated, culturally sensitive, school-based, family-centered lifestyle program on activity behaviors and body mass index. Design, settings and participants: This was a parallel group, randomized controlled trial utilizing a community-based participatory research approach, through a partnership with a University and 5 community schools. Participants included 251 children ages 8–12 from elementary schools in urban, low-income neighborhoods in Los Angeles, USA.
Methods
The intervention included Kids N Fitness©, a 6-week program which met weekly to provide 45 min of structured physical activity and a 45 min nutrition education class for parents and children. Intervention sites also participated in school-wide wellness activities, including health and counseling services, staff professional development in health promotion, parental education newsletters, and wellness policies for the provision of healthy foods at the school. The Child and Adolescent Trial for Cardiovascular Health School Physical Activity and Nutrition Student Questionnaire measured physical activity behavior, including: daily physical activity, participation in team sports, attending physical education class, and TV viewing/computer game playing. Anthropometric measures included height, weight, body mass index, resting blood pressure, and waist circumference. Measures were collected at baseline, completion of the intervention phase (4 months), and 12 months post-intervention.
Results
Significant results for students in the intervention, included for boys decreases in TV viewing; and girls increases in daily physical activity, physical education class attendance, and decreases in body mass index z-scores from baseline to the 12 month follow-up.
Conclusions
Our study shows the value of utilizing nurses to implement a culturally sensitive, coordinated, intervention to decrease disparities in activity and TV viewing among underserved girls and boys.
doi:10.1016/j.ijnurstu.2012.09.004
PMCID: PMC3654538  PMID: 23021318
Community based participatory research; Gender; Health disparities; Obesity in children; Physical activity; School-based interventions
17.  Attributing the responsibility for ambulating patients: A qualitative study 
Background
Functional decline has been identified as a leading negative outcome of hospitalization for older person. Functional decline is defined as a loss in ability to perform activities of daily living including a loss of independent ambulation. In the hospital literature, a patient’s loss in ability to independently ambulate during the hospital stay varies between 15 and 59%. Lack of ambulation and deconditioning effects of bed rest are one of the most predictable causes of loss of independent ambulation in hospitalized older persons. Nurses have been identified as the professional most capable of promoting walking independence in the hospital setting. However, nurses do not routinely walk patients.
Objective
The purpose of this study was to explore the relationship between nurses’ attributions of responsibility for ambulating hospitalized patients and their decisions about whether to ambulate.
Methods
A descriptive, secondary analysis of data gathered for a parent study was conducted. Grounded dimensional analysis was used to analyze the data. Participants consisted of 25 registered nurses employed on medical or surgical units from two urban hospitals in the United States.
Results
Nurses fell into two groups: those who claimed ambulation of patients within their responsibility of practice and those who attributed the responsibility to another discipline. Nurses who claimed responsibility for ambulation focused on patient independence and psychosocial well-being. This resulted in actions related to collaborating with physical therapy, determining the appropriateness of activity orders, diminishing the risk and adjusting to resource availability. Nurses who attributed the responsibility deferred decisions about initiating ambulation to either physical therapy or medicine. This resulted in actions related to waiting, which involved, waiting for physical therapy clearance, physician orders, risks to decrease, and resources to improve before ambulating.
Conclusions
Nurses who claimed responsibility for ambulating patients within their domain of practice described actions that promoted patient independent function and were more likely to get patient s up to ambulate.
doi:10.1016/j.ijnurstu.2013.02.007
PMCID: PMC3711943  PMID: 23465958
Hospital; Nursing care; Ambulating; Older patients; Grounded dimensional analysis
18.  A Qualitative Study of the Work Environments of Mexican Nurses 
Background
Studies of the nursing work environment are increasingly common in developed countries, but few exist in developing countries. Because of resource differences between the two contexts, researchers need to clarify what aspects of the work environments are similar and different.
Objectives
To study the perspectives of Mexican nurses about their work environments to determine similarities and differences to results from developed world studies.
Design
A secondary, directed content analysis of qualitative data from 46 Spanish language interviews using workplace-oriented themes
Setting
Purposively selected Mexican states from four regions of the country that reflect the country’s socioeconomic differences.
Participants
Practicing Mexican nurses with at least one year of clinical experience and currently working in nursing. Participants were recruited through convenience and snowball sampling techniques.
Methods
Initial data collection occurred in 2006 and 2008 during a broader study about professionalization processes that occurred in Mexican nursing between 1980 and 2005. The secondary, directed content analysis focused on an in-depth exploration of a central theme that emerged from the two original studies: The Workplace. The directed content analysis used themes from the global nursing work environment literature to structure the analysis: Professional relationships, organizational administrative practices, and quality of care and services.
Results
The three themes from the global literature were relevant for the Mexican context and a new one emerged related to hiring practices. By category, the same factors that created positive or negative perceptions of the work environment matched findings from other international studies conducted in developed countries. The descriptors of the category, however, had different conceptual meanings that illustrate the health system challenges in Mexico.
Conclusions
Findings from this study suggest that studies that seek to measure nursing work environments will most likely apply in Mexico and other Latin American or middle-income countries. Instruments designed to measure the work environment of nurses in these countries may prove relevant in those contexts, but require careful adaptation and systematic translations to ensure it.
doi:10.1016/j.ijnurstu.2012.02.001
PMCID: PMC3383907  PMID: 22386989
Cross-language research; Mexico; nurses; secondary analysis; qualitative research; work-environment
19.  A staff intervention targeting resident-to-resident elder mistreatment (R-REM) in long-term care increased staff knowledge, recognition and reporting: Results from a cluster randomized trial 
Background
Elder abuse in long term care has received considerable attention; however, resident-to-resident elder mistreatment (R-REM) has not been well researched. Preliminary findings from studies of R-REM suggest that it is sufficiently widespread to merit concern, and is likely to have serious detrimental outcomes for residents. However, no evidence-based training, intervention and implementation strategies exist that address this issue.
Objectives
The objective was to evaluate the impact of a newly developed R-REM training intervention for nursing staff on knowledge, recognition and reporting of R-REM.
Design
The design was a prospective cluster randomized trial with randomization at the unit level.
Methods
A sample of 1405 residents (685 in the control and 720 in the intervention group) from 47 New York City nursing home units (23 experimental and 24 control) in 5 nursing homes was assessed. Data were collected at three waves: baseline, 6 and 12 months. Staff on the experimental units received the training and implementation protocols, while those on the comparison units did not. Evaluation of outcomes was conducted on an intent-to-treat basis using mixed (random and fixed effects) models for continuous knowledge variables and Poisson regressions for longitudinal count data measuring recognition and reporting.
Results
There was a significant increase in knowledge post-training, controlling for pre-training levels for the intervention group (p<0.001), significantly increased recognition of R-REM (p<0.001), and longitudinal reporting in the intervention as contrasted with the control group (p=0.0058).
Conclusions
A longitudinal evaluation demonstrated that the training intervention was effective in enhancing knowledge, recognition and reporting of R-REM. It is recommended that this training program be implemented in long term care facilities.
doi:10.1016/j.ijnurstu.2012.10.010
PMCID: PMC3677710  PMID: 23159018
Resident-to-resident elder mistreatment (R-REM); nursing homes; long term care; older people; elder abuse; staff education; staff training
20.  The presence of resilience is associated with a healthier psychological profile in ICU nurses: Results of a national survey 
Objective
ICU nurses are repeatedly exposed to work related stresses resulting in the development of psychological disorders including posttraumatic stress disorder and burnout syndrome. Resilience is a learnable multidimensional characteristic enabling one to thrive in the face of adversity. In a national survey, we sought to determine whether resilience was associated with healthier psychological profiles in intensive care unit nurses.
Design
Surveys were mailed to 3500 randomly selected ICU nurses across the United States and included: demographic questions, the Posttraumatic Diagnostic Scale, Hospital Anxiety and Depression Scale, Maslach Burnout Inventory and the Connor-Davidson Resilience Scale.
Measurements and Main Results
Overall, 1239 of the mailed surveys were returned for a response rate of 35%, and complete data was available on a total of 744 nurses. Twenty-two percent of the intensive care unit nurses were categorized as being highly resilient. The presence of high resilience in these nurses was significantly associated with a lower prevalence of posttraumatic stress disorder, symptoms of anxiety or depression, and burnout syndrome (<0.001 for all comparisons). In independent multivariable analyses adjusting for five potential confounding variables, the presence of resilience was independently associated with a lower prevalence of posttraumatic stress disorder (p < 0.001), and a lower prevalence of burnout syndrome (p < 0.001).
Conclusions
The presence of psychological resilience was independently associated with a lower prevalence of posttraumatic stress disorder and burnout syndrome in intensive care unit nurses. Future research is needed to better understand coping mechanisms employed by highly resilient nurses and how they maintain a healthier psychological profile.
doi:10.1016/j.ijnurstu.2011.09.015
PMCID: PMC3276701  PMID: 21974793
Resilience; posttraumatic stress disorder; burnout syndrome; ICU nurses
21.  Comparison of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection: results of a randomized controlled trial 
Background
Ethnic minority adolescent women with a history of sexual or physical abuse and sexually transmitted infections represent a vulnerable population at risk for HIV. Community-based interventions for behavior modification and subsequent risk reduction have not been effective among these women.
Objectives
To evaluate the effects of a theory-based (AIDS Risk Reduction Model) cognitive behavioral intervention model versus enhanced counseling for abused ethnic minority adolescent women on infection with sexually transmitted infection at 6 and 12 months follow-up.
Design
Controlled randomized trial with longitudinal follow-up
Settings
Southwestern United States, Metropolitan community-based clinic
Participants
Mexican-and-African American adolescent women aged 14-18 years with a history of abuse or sexually transmitted infection seeking sexual health care
Methods
Extensive preliminary study for intervention development was conducted including individual interviews, focus groups, secondary data analysis, pre-testing and feasibility testing for modification of an evidence-based intervention prior to testing in the randomized controlled trial. Following informed consents for participation in the trial, detailed interviews concerning demographics, abuse history, sexual risk behavior, sexual health and physical exams were obtained. Randomization into either control or intervention groups was conducted. Intervention participants received workshop, support group and individual counseling sessions. Control participants received abuse and enhanced clinical counseling. Follow-up including detailed interview and physical exam was conducted at 6 and 12 months following study entry to assess for infection. Intention to treat analysis was conducted to assess intervention effects using chi-square and multiple regression models.
Results
409 Mexican-(n=342) and African-(n=67) American adolescent women with abuse and sexually transmitted infection histories were enrolled; 90% intervention group attendance; longitudinal follow-up at 6 (93%) and 12 (94%) months. Intervention (n=199) versus control (n=210) group participants experienced fewer infections at 0-6 (0% vs. 6.6%, p=0.001), 6-12 (3.6% vs. 7.8%, p=0.005, CI 95% lower-upper .001-.386) and 0-12 (4.8% vs. 13.2%, p=0.002, CI 95% lower-upper, .002-.531) month intervals.
Conclusions
A cognitive behavioral intervention specifically designed for ethnic minority adolescent women with a history of abuse and sexually transmitted infection was effective for prevention of infection. These results provide evidence for development of evidence-based interventions for sexually transmitted infection/HIV. Implications include translation to community-clinic-based settings for prevention of adverse outcomes regarding sexual health of adolescent women.
doi:10.1016/j.ijnurstu.2011.08.010
PMCID: PMC3251725  PMID: 21937041
Adolescent; Randomized Controlled Trial; Sexual Risk Reduction; Cognitive Behavioral Intervention; Ethnicity
22.  Patient demographic characteristics and facial expressions influence nurses’ assessment of mood in the context of pain: A Virtual Human and lens model investigation 
Background
Sex, race, and age disparities in pain assessment and treatment have been reported in the literature. However, less is known about how these demographic characteristics influence nurses’ assessment of the emotional experiences of patients who are in pain.
Objectives
To investigate the influence of patient demographic characteristics and facial expressions on nurses’ assessment of patient mood in the context of pain.
Design
A cross-sectional study employing Virtual Human (VH) technology and lens model methodology.
Settings
The current study was delivered via the internet.
Participants
Participants consisted of 54 registered nurses currently engaged in clinical practice. Nurses were recruited from healthcare settings across the United States.
Methods
Nurses viewed 32 patient vignettes consisting of a video clip of the VH patient and text-based clinical summary information describing a post-surgical context. Patient sex, race, age, and facial expression of pain were systematically manipulated across vignettes. Participants made positive and negative mood assessment ratings on computerized visual analogue scales. Idiographic multiple regression analyses were used to examine the patient characteristics that were significant predictors of nurses’ assessment ratings. Nomothetic paired samples t-tests were used to compare ratings within cue for the entire sample.
Results
The results of idiographic and nomothetic analyses indicated that VH sex, race, age, and facial expression cues were significant predictors of the mood assessment ratings of many nurses. The age cue had the largest impact among the demographic variables.
Conclusions
The results of the current study suggest that patient demographic characteristics and facial expressions may influence how nurses assess patient emotional status in the clinical pain context. These findings may lead to greater awareness by individual nurses and nursing administrators about the influence of patient demographic characteristics on clinical decision-making. Future research is needed to better understand these relationships, with the ultimate goal of improving patient care.
doi:10.1016/j.ijnurstu.2011.05.002
PMCID: PMC3170511  PMID: 21596378
Decision making; Disparities; Lens model; Mood; Virtual Human technology
23.  Psychometric properties of the Chinese version of the Parental Bonding Instrument 
Background
The Parental Bonding Instrument (PBI) is a widely used assessment tool for measuring parental characteristics that affect parent-child bonds. The measure was developed for and has been most administered in Western populations. Psychometric analyses have yielded discrepant results as to whether the PBI is best represented by a two-factor model (care and overprotection) or a three-factor model (care, overprotection, and autonomy).
Objectives
Little is known about how the PBI performs in Chinese samples, and there is limited data from Eastern populations as a whole. The purpose of this study is to 1) explore the data and identify the underlying structural model that best fits the Chinese culture, and 2) to further compare the factor structure that emerges in a Chinese sample with that which has emerged in other Eastern cultures (i.e., Japanese) and Western countries.
Methods
The present study investigated the psychometric properties of a Chinese translation of the PBI among a sample (N = 1417) of mothers of kindergarten children. Confirmatory factor analysis was used to identify the best-fitting model.
Results
Results supported a four-factor model that included an indifference factor (χ2/df < 3.0; RMSEA ≤ 0.06; SRMR < 0.08). Both the two-factor and three-factor models performed poorly (χ2/df > 5.0; RMSEA > 0.08; SRMR > 1.0; CFI < 0.90 for both). In this sample, use of a Chinese translated version of the PBI was successful. Support for the four-factor model is consistent with findings from previous studies of Eastern populations and discrepant from those among Western samples.
Conclusions
The indifference factor may reflect aspects of parenting specific to Eastern cultures, which tend to value group cohesion over individualization and independence. More research is needed to determine whether these findings are generalizable to all Eastern countries and whether aspects of Chinese culture (e.g., the single-child law) produce unique effects that may impact PBI administration in China.
doi:10.1016/j.ijnurstu.2010.10.008
PMCID: PMC3080463  PMID: 21094942
PBI; Parent Bonding; Construct Validity; Cross-Cultural; Chinese
24.  A randomised, controlled study of outcome and cost effectiveness for RA patients attending nurse-led rheumatology clinics: Study protocol of an ongoing nationwide multi-centre study 
Background
The rise in the number of patients with arthritis coupled with understaffing of medical services has seen the deployment of Clinical Nurse Specialists in running nurse-led clinics alongside the rheumatologist clinics. There are no systematic reviews of nurse-led care effectiveness in rheumatoid arthritis. Few published RCTs exist and they have shown positive results for nurse-led care but they have several limitations and there has been no economic assessment of rheumatology nurse-led care in the UK.
Objective
This paper outlines the study protocol and methodology currently being used to evaluate the outcomes and cost effectiveness for patients attending rheumatology nurse-led clinics.
Design and methods
A multi-centred, pragmatic randomised controlled trial with a non-inferiority design; the null hypothesis being that of ‘inferiority’ of nurse-led clinics compared to physician-led clinics. The primary outcome is rheumatoid arthritis disease activity (measured by DAS28 score) and secondary outcomes are quality of life, self-efficacy, disability, psychological well-being, satisfaction, pain, fatigue and stiffness. Cost effectiveness will be measured using the EQ-5D, DAS28 and cost profile for each centre.
Power calculations
In this trial, a DAS28 change of 0.6 is considered to be the threshold for clinical distinction of ‘inferiority’. A sample size of 180 participants (90 per treatment arm) is needed to reject the null hypothesis of ‘inferiority’, given 90% power. Primary analysis will focus on 2-sided 95% confidence interval evaluation of between-group differences in DAS28 change scores averaged over 4 equidistant follow up time points (13, 26, 39 and 52 weeks). Cost effectiveness will be evaluated assessing the joint parameterisation of costs and effects.
Results
The study started in July 2007 and the results are expected after July 2011.
Trial registration
The International Standard Randomised Controlled Trial Number ISRCTN29803766.
doi:10.1016/j.ijnurstu.2011.01.010
PMCID: PMC3629570  PMID: 21334623
Nurse-led care; Clinical nurse specialists; Rheumatoid arthritis; Randomised controlled trial; Economic evaluation; Protocol

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