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1.  Resilience, Stress, Stigma, and Barriers to Mental Healthcare in U.S. Air Force Nursing Personnel 
Nursing Research  2016;65(6):481-486.
Background
Stigma may deter military service members from seeking mental health (MH) services. Previously, substantial proportions of U.S. Air Force (USAF) registered nurses and medical technicians reported concerns about stigma with accessing MH services; in particular, that unit members might lose confidence in them or perceive them as weak, unit leadership might treat them differently, or accessing care might affect career advancement.
Objective
This study assessed the extent to which stigma and barriers to accessing MH services as perceived by USAF nursing personnel are associated with resilience, stress, previous deployment, or demographic characteristics.
Methods
An anonymous, online survey was administered to active-duty USAF registered nurses and medical technicians at three locations (N = 250). The survey included demographic items, the Stigma and Barriers to Care scales, Conner–Davidson Resilience Scale, and Perceived Stress Questionnaire.
Results
Mean resilience was high, and perceived stress was moderate. About half of participants agreed that unit members might have less confidence in me (54%) or unit leadership might treat me differently (58%). Many also had concerns that it would harm my career (47%), I would be seen as weak (47%), or there would be difficulty getting time off work for treatment (45%). Stigma was positively correlated with perceived stress (r = .40, p < .01) and negatively correlated with resilience (r = −.24, p < .01). Officers had significantly higher stigma and resilience scores and lower stress scores compared with enlisted personnel, but those differences were small.
Discussion
This study validated previous findings that substantial percentages of USAF nursing personnel have concerns that accessing MH services may adversely affect their careers and how they are viewed by unit leaders and peers. In addition, higher levels of concern about stigma were associated with higher levels of stress and lower levels of resilience. Limitations included a low response rate (18%) and self-selection biases.
doi:10.1097/NNR.0000000000000182
PMCID: PMC5091011  PMID: 27529539
mental health services; military personnel; nursing; psychological resilience; social stigma
2.  Diabetes LIVE (Learning in Virtual Environments): Testing the Efficacy of Self-Management Training and Support in Virtual Environments (RCT Protocol) 
Nursing research  2015;64(6):485-493.
Background
Ongoing self-management improves outcomes for those with type 2 diabetes (T2D); however, there are many barriers to patients receiving assistance in this from the healthcare system and peers. Findings from our pilot study showed that a virtual diabetes community on the Internet with real-time interaction among peers with T2D—and with healthcare professionals—is feasible and has the potential to influence clinical and psychosocial outcomes.
Objective
The purpose of this paper is to present the protocol for the Diabetes Learning in Virtual Environments (LIVE) trial.
Protocol
Diabetes LIVE is a two-group, randomized, controlled trial to compare effects of a virtual environment (VE) and traditional website on diet and physical activity. Our secondary aims will determine the effects on: metabolic outcomes; effects of level of engagement and social network formation in LIVE on behavioral outcomes; potential mediating effects of changes in self-efficacy; diabetes knowledge, diabetes-related distress, and social support on behavior change and metabolic outcomes. We will enroll 300 subjects at two sites (Duke/Raleigh-Durham and NYU/New York) who have T2D and do not have serious complications or comorbidities. Those randomly assigned to the intervention group have access to the LIVE site where they can find information, synchronous classes with diabetes educators, and peer support to enhance self-management. Those in the control group have access to the same informational and educational content in a traditional asynchronous web format. Measures of self-management, clinical outcomes, and psychosocial outcomes are assessed at baseline, 3, 6, 12 and 18 months.
Discussion
Should LIVE prove effective in improved self-management of diabetes, similar interventions could be applied to other prevalent chronic diseases. Innovative programs such as LIVE have potential for improving healthcare access in an easily disseminated alternative model of care that potentially improves the reach of self-management training and support.
doi:10.1097/NNR.0000000000000128
PMCID: PMC4624251  PMID: 26505161
e-health; randomized controlled trial; self-management; type 2 diabetes mellitus; virtual reality
4.  Biological and Sociocultural Differences in Perceived Barriers to Physical Activity among 5th–7th Grade Urban Girls 
Nursing research  2015;64(5):342-350.
Background
Inadequate physical activity (PA) contributes to the high prevalence of overweight and obesity among U.S. adolescent girls. Barriers preventing adolescent girls from meeting PA guidelines have not been thoroughly examined.
Objectives
The threefold purpose of this study was to: (a) determine pubertal stage, racial/ethnic, and socioeconomic status (SES) differences in ratings of interference of barriers to PA; (b) examine relationships between perceived barriers and age, body mass index (BMI), recreational screen time, sedentary activity, and PA; and (c) identify girls’ top-rated perceived barriers to PA.
Methods
Girls (N = 509) from eight Midwestern U.S. schools participated. Demographic, pubertal stage, perceived barriers, and recreational screen time data were collected via surveys. Height and weight were measured. Accelerometers measured sedentary activity, moderate-to-vigorous physical activity (MVPA), and light plus MVPA.
Results
Girls of low SES reported greater interference of perceived barriers to PA than those who were not of low SES (1.16 vs. 0.97, p = .01). Girls in early/middle puberty had lower perceived barriers than those in late puberty (1.03 vs. 1.24, p < .001). Girls’ perceived barriers were negatively related to MVPA (r = −.10, p = .03) and light plus MVPA (r = −.11, p = .02). Girls’ top five perceived barriers included lack of skills, hating to sweat, difficulty finding programs, being tired, and having pain.
Discussion
Innovative interventions, particularly focusing on skill development, are needed to assist girls in overcoming their perceived barriers to PA.
doi:10.1097/NNR.0000000000000113
PMCID: PMC4558914  PMID: 26325276
adolescent; female; physical exercise; puberty
5.  Perceived Transcultural Self-Efficacy of Nurses in General Hospitals in Guangzhou, China 
Nursing Research  2016;65(5):371-379.
Background
Conflicts arising from cultural diversity among patients and hospital staff in China have become intense. Hospitals have an urgent need to improve transcultural self-efficacy of nurses for providing effective transcultural nursing.
Objective
The purpose of the research was to (a) evaluate the current status of perceived transcultural self-efficacy of nurses in general hospitals in Guangzhou, China; (b) explore associations between demographic characteristics of nurses and their perceived transcultural self-efficacy; and (c) assess the reliability and validity of scores on the Chinese version of the Transcultural Self-Efficacy Tool (TSET).
Methods
A cross-sectional survey of registered nurses from three general hospitals was conducted. Quota and convenience sampling were used. Participants provided demographic information and answered questions on the TSET.
Results
A total of 1,156 registered nurses took part. Most nurses had a moderate level of self-efficacy on the Cognitive (87.9%), Practical (87%), and Affective (89.2%) TSET subscales. Nurses who were older; who had more years of work experience, higher professional titles, higher incomes, and a minority background; and who were officially employed (not temporary positions) had higher perceived transcultural self-efficacy. Reliability estimated using Cronbach’s alpha was .99 for the total TSET score; reliability for the three subscales ranged from .97 to .98. Confirmatory factor analysis of TSET scores showed good fit with a three-factor model.
Conclusion
The results of this study can provide insights and guidelines for hospital nursing management to facilitate design of in-service education systems to improve transcultural self-efficacy of nurses.
doi:10.1097/NNR.0000000000000174
PMCID: PMC5008044  PMID: 27454552
China; continuing education; immigration; in-migration; nurse; self-efficacy; transcultural nursing
6.  Motion Sensor Use for Physical Activity Data: Methodological Considerations 
Nursing research  2015;64(4):320-327.
Background
Physical inactivity continues to be a major risk factor for cardiovascular disease, and only one half of adults in the United States meet physical activity (PA) goals. PA data are often collected for surveillance or for measuring change after an intervention. One of the challenges in PA research is quantifying exactly how much and what type of PA is taking place—especially because self-report instruments have inconsistent validity.
Objective
The purpose is to review the elements to consider when collecting PA data via motion sensors, including the difference between PA and exercise; type of data to collect; choosing the device; length of time to monitor PA; instructions to the participants; and interpretation of the data.
Methods
The current literature on motion sensor research was reviewed and synthesized to summarize relevant considerations when using a motion sensor to collect PA data.
Results
Exercise is a division of PA that is structured, planned, and repetitive. Pedometer data includes steps taken, and calculated distance and energy expenditure. Accelerometer data includes activity counts and intensity. The device chosen depends on desired data, cost, validity, and ease of use. Reactivity to the device may influence the duration of data collection. Instructions to participants may vary depending on purpose of the study. Experts suggest pedometer data be reported as steps—since that is the direct output—and distance traveled and energy expenditure are estimated values. Accelerometer count data may be analyzed to provide information on time spent in moderate or vigorous activity.
Discussion
Thoughtful decision making about PA data collection using motion sensor devices is needed to advance nursing science.
doi:10.1097/NNR.0000000000000098
PMCID: PMC4487413  PMID: 26126065
accelerometer; pedometer; physical activity
7.  Longitudinal Association of Registered Nurse National Nursing Specialty Certification and Patient Falls in Acute Care Hospitals 
Nursing Research  2015;64(4):291-299.
Supplemental Digital Content is available in the text
Background
Researchers have studied inpatient falls in relation to aspects of nurse staffing, focusing primarily on staffing levels and proportion of nursing care hours provided by registered nurses (RNs). Less attention has been paid to other nursing characteristics, such as RN national nursing specialty certification.
Objective
The aim of the study was to examine the relationship over time between changes in RN national nursing specialty certification rates and changes in total patient fall rates at the patient care unit level.
Methods
We used longitudinal data with standardized variable definitions across sites from the National Database of Nursing Quality Indicators. The sample consisted of 7,583 units in 903 hospitals. Relationships over time were examined using multilevel (units nested in hospitals) latent growth curve modeling.
Results
The model indices indicated a good fit of the data to the model. At the unit level, there was a small statistically significant inverse relationship (r = −.08, p = .04) between RN national nursing specialty certification rates and total fall rates; increases in specialty certification rates over time tended to be associated with improvements in total fall rates over time.
Discussion
Our findings may be supportive of promoting national nursing specialty certification as a means of improving patient safety. Future study recommendations are (a) modeling organizational leadership, culture, and climate as mediating variables between national specialty certification rates and patient outcomes and (b) investigating the association of patient safety and specific national nursing specialty certifications which test plans include patient safety, quality improvement, and diffusion of innovation methods in their certifying examinations.
doi:10.1097/NNR.0000000000000107
PMCID: PMC4894769  PMID: 26049719
certification; multilevel models; patient falls; patient safety; quality improvement
8.  Electronic Alerts for Triage Protocol Compliance Among Emergency Department Triage Nurses: A Randomized Controlled Trial 
Nursing research  2015;64(3):226-230.
Background
Alerts embedded in electronic health records are designed to improve processes at the point of care.
Objective
To determine if an electronic health record (EHR) alert—at emergency department (ED) triage—increases the ED triage nurse’s utilization of triage protocols.
Methods
ED triage nurses were randomized to receive either a passive EHR alert or no intervention for patients with the following complaints: minor trauma with extremity injuries or females with abdominal pain. The EHR alert notified the nurse that the patient was eligible for diagnostic testing: radiographs (XR) for patients with injured extremities or urinalysis (UA) for females with abdominal pain.
Results
Twenty-eight nurses triaged 20,410 patients in the six months prior to intervention and 19,157 in the six months post. Prior to intervention, the UA protocol was implemented in 101/624 (16.2%) patients triaged by the intervention group and 116/711 (16.3%) triaged by the control group. After the intervention, the UA protocol was implemented in 146/530 (27.6%) patients triaged by the intervention group and 174/679 (25.6%) triaged by the control group. Prior to intervention, the XR protocol was implemented in 58/774 (7.5%) patients triaged by the intervention group and 45/684 (6.6%) triaged by the control group. After the intervention, the XR protocol was implemented in 78/614 (12.7%) patients triaged by the intervention group and 79/609 (13.0%) triaged by the control group.
Conclusion
The use of a passive EHR alert to promote ED triage protocols demonstrated little benefit. Prior to widespread implementation of EHR alerts for patient care, rigorous studies are required to determine the best alert methods and the impacts of such interventions.
doi:10.1097/NNR.0000000000000094
PMCID: PMC4418031  PMID: 25932701
electronic medical record; emergency services; triage
9.  Nursing Case Management, Peer Coaching, and Hepatitis A and B Vaccine Completion Among Homeless Men Recently Released on Parole: Randomized Clinical Trial 
Nursing research  2015;64(3):177-189.
Background
Although hepatitis A virus (HAV) and hepatitis B virus (HBV) infections are vaccine-preventable diseases, few homeless parolees coming out of prisons and jails have received the hepatitis A and B vaccination series.
Objectives
The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of three levels of peer coaching and nurse-delivered interventions was compared at 12-month follow up: (a) intensive peer coaching and nurse case management (PC-NCM); (b) intensive peer coaching (PC) intervention condition, with minimal nurse involvement; and a (c) usual care (UC) intervention condition, which included minimal PC and nurse involvement. Further, we assessed predictors of vaccine completion among this targeted sample.
Methods
A randomized control trial was conducted with 600 recently paroled men to assess the impact of the three intervention conditions (PC-NCM vs. PC vs. UC) on reducing drug use and recidivism; of these, 345 seronegative, vaccine-eligible subjects were included in this analysis of completion of the Twinrix HAV/HAB vaccine. Logistic regression was added to assess predictors of completion of the HAV/HBV vaccine series and chi-squared analysis to compare completion rates across the three levels of intervention.
Results
Vaccine completion rate for the intervention conditions were 75.4% (PC-NCM), 71.8% (PC), and 71.9% (UC) (p =. 78). Predictors of vaccine noncompletion included being Asian and Pacific Islander, experiencing high levels of hostility, positive social support, reporting a history of injection drug use, being released early from California prisons, and being admitted for psychiatric illness. Predictors of vaccine series completion included reporting six or more friends, recent cocaine use, and staying in drug treatment for at least 90 days.
Discussion
Findings allow greater understanding of factors affecting vaccination completion in order to design more effective programs among the high-risk population of men recently released from prison and on parole.
doi:10.1097/NNR.0000000000000083
PMCID: PMC4418035  PMID: 25932697
accelerated Twinrix hepatitis A/B vaccine; ex-offenders; homelessness; parolees; prisoners; substance abuse
10.  Factors Associated with Feeding Progression in Extremely Preterm Infants 
Nursing research  2015;64(3):159-167.
Background
Among infants born prematurely, competence at oral feeding is necessary for growth and hospital discharge. Extremely preterm infants (EP, ≤ 28 weeks gestational age [GA]) are at risk for a variety of medical complications, which can limit the infant’s capacity to develop oral feeding competence.
Objective
This study examined feeding progression by assessing timing of acquisition of five early feeding milestones among EP infants, and the impact of immaturity and medical complications.
Design
A chart review was conducted for 94 EP infants who participated in a larger longitudinal randomized study. Feeding progression was defined as infants’ postmenstrual age (PMA) at five milestones: first enteral feeding, full enteral feeding, first oral feeding, half oral feeding, and full oral feeding. GA at birth and five medical complications (neurological risk, bronchopulmonary dysplasia [BPD], necrotizing entercolitis [NEC], patent ductus arteriosus [PDA], and gastroesophageal reflux disease [GERD]) were used as potential factors influencing the feeding progression. Linear mixed models were used to examine feeding progression across the milestones and contributions of GA at birth, and five medical complications on the progression, after controlling for milk type as a covariate.
Result
EP infants gradually achieved feeding milestones; however, the attainment of the feeding milestones slowed significantly for infants with younger GA at birth and the presence of medical complications, including neurological risk, BPD, NEC, and PDA, but not GERD. Milk type was a significant covariate for all analyses, suggesting infants fed with breast milk achieved each of five milestones earlier than formula-fed infants.
Discussion
Improved understanding of the timing of essential feeding milestones among EP infants, and the contribution of specific medical conditions to the acquisition of these milestones may allow for more targeted care to support feeding skill development.
doi:10.1097/NNR.0000000000000093
PMCID: PMC4418036  PMID: 25932696
breast milk; extremely preterm infant; feeding milestones; health trajectory; human milk; medical complications
11.  Neighborhood Socioeconomic Status During Childhood Versus Puberty in Relation to Endogenous Sex Hormone Levels in Adult Women 
Nursing research  2015;64(3):211-220.
Background
Socioeconomic adversity in early life is related to cardiovascular risk in adulthood; however, no studies have examined whether such adversity may be related to endogenous sex hormones—which are themselves associated with cardiovascular outcomes—or whether the timing of adversity exposures (childhood versus puberty) matters.
Objective
The goal of the current study was to separately examine neighborhood socioeconomic status (SES) during periods of childhood and puberty in relation to adulthood levels of endogenous sex hormones (estradiol [E2], testosterone), sex hormone binding globulin (SHBG), and a derived index of bioavailable testosterone (free androgen index [FAI]).
Methods
In a sample of 143 premenopausal women (mean age 36.8 [SD = 5.5]; 51.7% White, 32.2% African American, 5.6% Latina, 7.0% Chinese, and 3.5% Filipina), retrospective reports of residential address information in designated periods of childhood and puberty was used to derive U.S. census-based neighborhood SES composite scores characterizing the socioeconomic environments of women during these periods.
Results
In covariate-adjusted analyses, higher neighborhood SES in puberty predicted higher levels of SHBG in adulthood, but neighborhood SES during childhood did not (standardized regression coefficient = .24, p = .01 vs. standardized regression coefficient = .04, p = .75, respectively). Neighborhood SES was not predictive of other hormones (E2, testosterone, and FAI).
Discussion
The current findings suggest that puberty may be a time of particular vulnerability to the effects of neighborhood SES on SHBG levels, which have been previously linked to cardiovascular risk factor profiles and atherosclerotic disease progression.
doi:10.1097/NNR.0000000000000096
PMCID: PMC4841463  PMID: 25932699
cardiovascular disease; early life adversity; life course; puberty; sex hormones; socioeconomic status
12.  Memory Performance, Health Literacy, and Instrumental Activities of Daily Living of Community Residing Older Adults 
Nursing research  2012;61(1):70-75.
Background
Health literacy is associated with cognitive function across multiple domains in older adults, and these older adults may face special memory and cognitive challenges that can limit their health literacy and, in turn, their ability to live independently.
Objectives
The aim of this study was to evaluate if an association existed among health literacy, memory performance, and performance-based functional ability in community-residing older adults.
Methods
Forty-five adults participated in this study. Designed to reflect everyday memory, the Rivermead Behavioral Memory Test (RBMT) bridges laboratory-based measures of memory and assessments obtained by self-report and observation. The RBMT classifies individuals into four categories of memory performance: normal, poor, mildly impaired, and severely impaired. The participants were recruited in the two categories of normal (≥22) or impaired (≤16) category on the RBMT. The sample consisted of 14 who were in the impaired category and 31 in the normal group. Their average age was 77.11 years, and their average number of years of education was 15.33 years. Health literacy scores measured with the Rapid Estimate of Adult Literacy in Medicine.
Results
Health literacy scores were high (M = 65.09, SD = 2.80). Thirty-four participants or 76% of the sample scored a 66 out of a possible score of 80. Pearson correlations were calculated for the study variables. Health literacy scores with education and cognition (.30), memory performance groups (normal vs. poor; .25), and performance-based instrumental activities (.50) were associated significantly.
Discussion
The development of a broader assortment of health literacy instruments would improve the ability of researchers to both compare studies and build on the knowledge and results of others.
doi:10.1097/NNR.0b013e31823b18f4
PMCID: PMC4839182  PMID: 22166912
health literacy; memory performance; older adults; performance-based instrumental activities
13.  Staff Knowledge, Awareness, Perceptions, and Beliefs About Infection Prevention in Pediatric Long-term Care Facilities 
Nursing research  2016;65(2):132-141.
Background
The burden of healthcare-associated infection worldwide is considerable, and there is a need to improve surveillance and infection control practices such as hand hygiene.
Objectives
The aims of this study were to explore direct care providers’ knowledge about infection prevention and hand hygiene, their attitudes regarding their own and others’ hand hygiene practices, and their ideas and advice for improving infection prevention efforts.
Methods
This exploratory study included interviews with direct care providers in three pediatric long-term care facilities. Two trained nurse interviewers conducted semistructured interviews using an interview guide with open-ended questions. Two other nurse researchers independently transcribed the audio recordings and conducted a thematic analysis using a strategy adapted from the systematic text condensation approach.
Results
From 31 interviews, four major thematic categories with subthemes emerged from the analysis: (a) hand hygiene products; (b) knowledge, awareness, perceptions, and beliefs; (c) barriers to infection prevention practices; and (d) suggested improvements. There was confusion regarding hand hygiene recommendations, use of soap or sanitizer, and isolation precaution policies. There was a robust “us” and “them” mentality between professionals.
Discussion
One essential driver of staff behavior change is having expectations that are meaningful to staff, and many staff members stated that they wanted more in-person staff meetings with education and hands-on, practical advice. Workflow patterns and/or the physical environment need to be carefully evaluated to identify systems and methods to minimize cross-contamination. Further studies need to evaluate if personal sized containers of hand sanitizer (e.g., for the pocket, attached to a belt or lanyard) would facilitate improvement of hand hygiene in these facilities.
doi:10.1097/NNR.0000000000000136
PMCID: PMC4822544  PMID: 26938362
hand hygiene; infection prevention; long-term care; pediatrics
14.  Factors Associated With Unplanned Hospitalizations Among Patients With Nonmetastatic Colorectal Cancers Intended for Treatment in the Ambulatory Setting 
Nursing research  2016;65(1):24-34.
Background
Chemotherapy administration and supportive management for solid tumors is intended to take place in the ambulatory setting, but little is known about why some patients experience treatment-related, adverse events so severe as to require acute inpatient care.
Objective
Identify predictors of initial and repeated unplanned hospitalizations and potential financial impact among Medicare patients with early-stage (stages I–III) colorectal cancer receiving outpatient chemotherapy.
Methods
Advanced statistical modeling was used to analyze a cohort of patients (N = 1485) from the Surveillance, Epidemiology and End Results (SEER)–Medicare database diagnosed from 2003–2007 with colorectal cancer as their first primary malignancy. Patients were age 66 and older at diagnosis, had uninterrupted Medicare Parts A and B coverage with no health maintenance organization (HMO) component, and received chemotherapy at least one time.
Results
Female sex, younger age, multiple comorbidities, rural geography, higher high school completion rates, and lower median income per census tract were significant predictors of the likelihood of initial unplanned hospitalizations. Non-White race, receipt of radiation therapy, rural geography and higher weighted comorbidity scores were factors associated with the number of hospitalizations experienced. The total Medicare charges calculated for these admissions was $38,976,171, with the median charge per admission at $20,412.
Discussion
Demographic and clinical factors were identified that form the foundation of work towards development of a risk factor profile for unplanned hospitalization. Further work is needed to incorporate additional clinical data to create a clinically applicable model.
doi:10.1097/NNR.0000000000000134
PMCID: PMC4811187  PMID: 26657478
colorectal neoplasms; comorbidity; chemotherapy; hospitalization; outpatients; SEER-Medicare
15.  “Conceptions of Reliability Revisited, and Practical Recommendations” 
Nursing research  2015;64(2):137-139.
Sijtsma and van der Ark (2015) present a broad set of models and methods for reliability estimation and their discussion of similarities and differences provides clear information for nurse researchers to move forward in their instrument development projects. In particular, we applaud the authors’ clear exposition of the factor analytic model and its utility for providing a framework for unifying reliability and validity. However, we do not want to be constrained only to the point estimates. We also need to ascertain the uncertainty in the point estimate—usually in the form of a 95% confidence interval—or as the Bayesians refer to a credible interval. Another issue not discussed by Sijtsma and van der Ark is conditional standard errors of measurement (CSEM) along the score scale measuring latent traits or true scores. In our response, practical tools for estimating intervals and a brief discussion of CSEMs are presented.
doi:10.1097/NNR.0000000000000078
PMCID: PMC4386879  PMID: 25738625
Bayes; factor analysis; instrument development; intervals; measurement; reliability
16.  Evaluation of Dynamic Weight Bearing for Measuring Nonevoked Inflammatory Hyperalgesia in Mice 
Nursing research  2015;64(2):81-87.
Background
Animal models in pain research have suggested that inclusion of both evoked and nonevoked behavioral measures are needed to better reflect the human pain experience. Individuals with chronic pain are known to experience spontaneous pain, in addition to pain, following exposure to an external stimulus. Recently, the Dynamic Weight Bearing (DWB) apparatus was developed to assess for nonevoked hyperalgesia by capturing weight bearing and surface distribution in the paws of mice following acute inflammation.
Objectives
The aim of this study was to evaluate the DWB test as a measure of nonevoked hyperalgesia.
Method
The experimental group received an intraplantar injection to the left hind paw of the inflammatory agent—Complete Freund's Adjuvant (CFA)—while the vehicle control group received a saline injection, and the naïve control group had no treatment. Caliper and plethysmometer were used to verify inflammation, and the hot-plate test was used as a measure for stimulus evoked hyperalgesia. Data were collected at baseline, three hours, one, three, and seven days after injection.
Results
Mice injected with CFA showed a statistically significant higher mean paw thickness and volume displacement compared to vehicle and naïve control groups. In the hot-plate testing, CFA-treated mice showed lower response temperature at seven days compared to other groups. On the DWB test, CFA-treated mice showed a reduction in the ipsilateral paw load and surface area compared to the contralateral paw load at Day 1, Day 3 and Day 7.
Discussion
Mice with inflammation demonstrated alterations in weight bearing, as well as increased thermal hyperalgesia in comparison to controls groups. These findings support the use of the DWB test as a tool for measuring nonevoked inflammatory hyperalgesia in a mouse model.
doi:10.1097/NNR.0000000000000082
PMCID: PMC4351786  PMID: 25738619
animal models; hyperalgesia; inflammatory pain; weight bearing
17.  Multilevel Drivers of HIV/AIDS among Black Philadelphians: Exploration Using Community Ethnography and Geographic Information Systems 
Nursing research  2015;64(2):100-110.
Background
Unequal HIV/AIDS distribution is influenced by certain social and structural contexts that facilitate HIV transmission and concentrate HIV in disease epicenters. Thus, one of the first steps in designing effective community-level HIV/AIDS initiatives is to disentangle the influence of individual, social, and structural factors on HIV risk. Combining ethnographic methodology with geographic information systems (GIS) mapping can allow for a complex exploration of multilevel factors within communities that facilitate HIV transmission in highly affected areas.
Objectives
We present the formative comparative community-based case study findings of an investigation of individual-, social- , and structural-level factors that contribute to the HIV/AIDS epidemic among Black Philadelphians.
Methods
Communities were defined using census tracts. The methodology included ethnographic and GIS mapping, observation, informal conversations with residents and business owners, and secondary analyses of census tract-level data in four Philadelphia neighborhoods.
Results
Factors such as overcrowding, disadvantage, permeability in community boundaries, and availability and accessibility of health-related resources varied significantly. Further, HIV/AIDS trended with social and structural inequities above and beyond the community’s racial composition.
Discussion
This study was a first step to disentangle relationships between community-level factors and potential risk for HIV in an HIV epicenter. The findings also highlight stark sociodemographic differences within and across racial groups, and further substantiate the need for comprehensive, community-level HIV prevention interventions. These findings from targeted United States urban communities have potential applicability for examining the distribution of HIV/AIDS in broader national and international geosocial contexts.
doi:10.1097/NNR.0000000000000076
PMCID: PMC4352720  PMID: 25738621
ethnography; geographic mapping; HIV; public health
18.  The Problem with Cronbach's Alpha: Comment on Sijtsma and Van der Ark (2015) 
Nursing research  2015;64(2):140-145.
Knowledge of a scale's dimensionality is an essential preliminary step to the application of any measure of reliability derived from classical test theory—an approach commonly used is nursing research. The focus of this article is on the applied aspects of reliability and dimensionality testing. Throughout the article, the Self-Care of Heart Failure Index is used to exemplify real-world data challenges of quantifying reliability, and to provide insight into how to overcome such challenges.
doi:10.1097/NNR.0000000000000079
PMCID: PMC4351779  PMID: 25738626
psychological measurement; psychometrics; questionnaires; reliability; reproducibility of results; Self-Care of Heart Failure Index
19.  Self-Management Intervention for Long-Term Indwelling Urinary Catheter Users: Randomized Clinical Trial 
Nursing research  2015;64(1):24-34.
Background
People using long-term indwelling urinary catheters experience multiple recurrent catheter problems. Self-management approaches are needed to avoid catheter-related problems.
Objectives
The aim was to determine effectiveness of a self-management intervention in prevention of adverse outcomes (catheter-related urinary tract infection, blockage, and accidental dislodgement). Healthcare treatment associated with the adverse outcomes and catheter-related quality of life was also studied.
Method
A randomized clinical trial was conducted. The intervention involved learning catheter-related self-monitoring and self-management skills during home visits by a study nurse (twice during the first month and at four months—with a phone call at two months). The control group received usual care. Data were collected during an initial face-to-face home interview followed by bimonthly phone interviews. A total of 202 adult long-term urinary catheter users participated. Participants were randomized to treatment or control groups following collection of baseline data. Generalized estimating equations (GEE) were used for the analysis of treatment effect.
Results
In the intervention group, there was a significant decrease in reported blockage in the first six months (p = .02), but the effect did not persist. There were no significant effects for catheter-related urinary tract infection or dislodgment. Comparison of baseline rates of adverse outcomes with subsequent periods suggested that both groups improved over 12 months.
Discussion
A simple–to–use catheter problems calendar and the bimonthly interviews might have functioned as a modest self-monitoring intervention for persons in the control group. A simplified intervention using a self-monitoring calendar is suggested—with optimal and consistent fluid intake likely to add value.
doi:10.1097/NNR.0000000000000071
PMCID: PMC4268883  PMID: 25502058
longitudinal research; quality of life; randomized clinical trial; self-management; urinary catheterization
20.  Using Electronic Health Record (EHR) “Big Data” to Examine the Influence of Nurse Continuity on a Hospital-Acquired Never Event 
Nursing research  2015;64(5):361-371.
Background
There is little research demonstrating the influence of nurse continuity on patient outcomes despite an intuitive belief that continuity of care makes a difference in care outcomes.
Objective
To examine the influence of nurse continuity (the number of consecutive care days by the same/consistent RN[s]) on the prevention of hospital-acquired pressure ulcers (HAPU).
Method
A secondary use of data from the Hands on Automated Nursing Data System (HANDS) was performed for this comparative study. The HANDS is a nursing plan of care (POC) “big data” database containing 42,403 episodes documented by 787 nurses, on 9 units, in four hospitals and includes nurse staffing and patient characteristics. Via data mining, we created an analytic dataset of 840 care episodes, 210 with and 630 without HAPUs, matched by nursing unit, patient age, and patient characteristics. Logistic regression analysis determined the influence of nurse continuity and additional nurse-staffing variables on the presence of HAPUs.
Results
Poor nurse continuity (Continuity Index=.21-.42 [1.0=optimal continuity]) was noted on all nine study units. Nutrition, mobility, perfusion, hydration, and skin problems on admission as well as patient age were associated with HAPUs (p<.001). Controlling for patient characteristics, nurse continuity and the interactions between nurse continuity and other nurse-staffing variables were not significantly associated with HAPU development.
Discussion
Patient characteristics including nutrition, mobility, and perfusion were associated with HAPUs, but nurse continuity was not. One study implication is that to reduce the incidence of HAPUs the most effective resource utilization might be in the continued development of best practices to address patient characteristics that lead to pressure ulcer vulnerability rather than a focus on nurse staffing.
doi:10.1097/NNR.0000000000000112
PMCID: PMC4692274  PMID: 26325278
Health information technology; data mining; nurse continuity; pressure ulcers
21.  Individual Differences Among Children in Sucrose Detection Thresholds 
Nursing Research  2015;65(1):3-12.
Background
Little research has focused on whether there are individual differences among children in their sensitivity to sweet taste and, if so, the biological correlates of such differences.
Objectives
Our goal was to understand how variations in children’s sucrose detection thresholds relate to their age and gender, taste genotype, body composition, and dietary intake of added sugars.
Methods
Sucrose detection thresholds in 7- to 14-year-old children were tested individually using a validated, two-alternative, forced-choice, paired-comparison tracking method. Five genetic variants of taste genes were assayed: TAS1R3 and GNAT3 (sweet genes; one variant each) and the bitter receptor gene TAS2R38 (three variants). All children were measured for body weight and height. A subset of these children were measured for the percentage of body fat and waist circumference and provided added sugar intake by 24-hour dietary recall.
Results
Sucrose thresholds ranged from 0.23 to 153.8 mM with most of the children completing the threshold task (216/235; 92%). Some children were biologically related (i.e., siblings), and for the genetic analysis, one sibling from each family was studied. Variants in the bitter but not the sweet genes were related to sucrose threshold and sugar intake; children with two bitter-sensitive alleles could detect sucrose at lower concentrations (F(2,165) = 4.55, p = .01; rs1726866) and reported eating more added sugar (% kcal; F(2, 62) = 3.64, p = .03) than did children with less sensitive alleles. Age, gender, and indices of obesity also were related to child-to-child differences in sucrose threshold; girls were more sensitive than boys (t(214) = 2.0, p = .05), older children were more sensitive than younger children (r(214) = −.16, p = .02), and fatter (r(84) = −.22, p = .05) or more centrally obese children (r(84) = −.26, p = .02) were more sensitive relative to others.
Discussion
Inborn differences in bitter sensitivity may affect childhood dietary sugar intake with long-term health consequences. There may be a more complex interplay between the developing bitter and sweet taste systems than previously understood.
doi:10.1097/NNR.0000000000000138
PMCID: PMC4679349  PMID: 26633761
anthropometry; bitter; children; genotype; sensory thresholds; sweet; taste
22.  Meta-Analysis of Fitness Outcomes from Motivational Physical Activity Interventions 
Nursing research  2013;62(5):294-304.
Background
Motivational physical activity (PA) interventions are effective in increasing PA behavior among healthy adults; however, the impact of these interventions on cardiorespiratory fitness (CRF) has not yet been examined.
Objective
The purpose of this meta-analysis is to quantitatively synthesize CRF outcomes of motivational PA interventions among healthy adults.
Methods
Comprehensive searching identified studies testing motivational PA interventions with CRF outcomes. Two independent coders extracted data. Data were synthesized using standardized mean difference effect sizes (ESs, d) under a random-effects model. Heterogeneity was assessed and moderator analyses were conducted using subgroup analyses and meta-regression.
Results
Data were analyzed from 11,458 primary study subjects. The overall mean ES for CRF was 0.48 (p < .01), which corresponds to a difference in VO2 max of 2.5 mL/kg/min between treatment and control groups. Studies were significantly heterogeneous (Q = 133.29, p < .01). Significant moderators included age (β = −0.02, p = .01) and recommending endurance plus resistance exercises (d = 1.04) versus recommending only endurance exercise (d = .47).
Discussion
Motivational interventions designed to increase PA can improve CRF among healthy adults. Clinicians should recommend endurance and resistance exercise to improve CRF in this population. Future primary research should test interventions longitudinally and across more diverse populations. Although other moderators examined in this study did not demonstrate a significant effect on ES, the number of comparisons available for moderator analyses was small.
doi:10.1097/NNR.0b013e3182a0395c
PMCID: PMC4629242  PMID: 23995463
Meta-analysis; exercise; physical endurance; cardiorespiratory fitness
23.  Assessing the Immune Status of Critically Ill Trauma Patients by Flow Cytometry 
Nursing research  2014;63(6):426-434.
Background
Unintentional injury or trauma remains the leading cause of death among young adults. About one fifth of these trauma patients require care in an intensive care unit (ICU) due to severity of injuries and comorbidities. Patients hospitalized in an ICU are at increased risk for nosocomial infections, such as urinary tract infections, pneumonia, bacteremia, and wound infections. Many of these patients will develop sepsis or septic shock, and some will progress to multiple organ failure (MOF) and death. The balance between the pro-inflammatory and counter-inflammatory immune response appears to be a driving factor in this progression. At present, there is no proposed method for the timely detection of the immune status in trauma patients; making rational decisions to use immune-altering therapies difficult.
Objective
We demonstrate that flow cytometry, with its capabilities to characterize and/or enumerate (a) leukocyte subtypes; (b) leukocyte activation markers; (c) leukocyte-derived cytokines and microvesicles; and (d) leukocyte function is well suited to monitor the immune status of critically ill trauma patients.
Methods
Information for the review was obtained from the extant literature.
Discussion
We suggest that flow cytometry is a research method that might aid nurse scientists in investigating the immune status of critically ill patients, the recovery status of conditions—such as hemorrhagic shock and tissue injury—and the relationship between cancer disease progression and symptoms. Therefore, flow cytometry has the potential to broaden nursing research priority areas so that a comprehensive approach to understanding the cellular response is attained.
doi:10.1097/NNR.0000000000000061
PMCID: PMC4212210  PMID: 25350542
cytokines; flow cytometry; inflammation; microvesicles; monocytes; neutrophils; T cells
24.  Neuroimaging of Goal-Directed Behavior in Midlife Women 
Nursing research  2014;63(6):388-396.
Background
Motivational interventions to improve health behaviors based on conventional cognitive and behavioral theories have been extensively studied; however, advances in neuroimaging technology make it possible to assess the neurophysiological basis of health behaviors, such as physical activity. The goals of this approach are to support new interventions to achieve optimal outcomes.
Objectives
This study used functional magnetic resonance imaging (fMRI) to assess differences in brain responses in healthy weight to obese midlife women during a goal-directed decision task.
Methods
Thirty nondiabetic, midlife (age 47-55 years) women with body mass index (BMI) ranging from 18.5 to 40 kg/m2 were recruited. A descriptive, correlational design was used to assess the relationship between brain activations and weight status. Participants underwent a goal-directed behavior task in the fMRI scanner consisting of a learning and implementation phase. The task was designed to assess both goal-directed and habitual behaviors. One participant was omitted from the analysis due to excessive motion (> 4 mm), and six were omitted due to fewer than 50% correct responses on the exit survey. Four participants developed claustrophobia in the scanner and were disqualified from further participation. The remaining 19 participants were included in the final analysis.
Results
Brain responses while participants learned goal-directed behavior showed a positive correlation with BMI in the dorsal medial prefrontal cortex (dmPFC) and a negative correlation with BMI in the insula. During the implementation of goal-directed behavior, brain responses in the dorsolateral prefrontal cortex (dlPFC) negatively correlated with BMI.
Discussion
These results indicate that overweight women activate regions associated with cognitive control to a greater degree than healthy weight women during goal-directed learning. The brain regions activated (dmPFC, dlPFC, insula) are associated with cognitive control and self-regulation. On the other hand, healthy weight women activate regions associated with emotion processing, planning, and self-regulation (lateral orbitofrontal cortex, anterior insula) to a greater degree than overweight women during goal-directed learning and implementation of goal-directed behavior. Overweight women activate cognitive control regions while learning associations between actions and outcomes; however, this is not the case during the implementation phase—which may make it more difficult to transform goals into action (e.g., maintain PA over time). Overall, these results indicate that overweight midlife women respond differently during learning and implementation of actions that lead to positive outcomes during a general test of goal-directed behavior. Future study is needed to assess the transfer of goal-directed and habitual behavior to specific aspects of energy balance to improve health outcomes.
doi:10.1097/NNR.0000000000000060
PMCID: PMC4213232  PMID: 25186027
fMRI; health behavior; neuroimaging; neurophysiology; obesity; women's health
25.  Matching Doses of Distraction With Child Risk for Distress During a Medical Procedure 
Nursing research  2014;63(6):397-407.
Background
Parents often want to provide support to their children during medical procedures, but not all parents are effective in providing distraction after brief training.
Objective
The aim of this study was to investigate the effects of three doses of distraction intervention for children at high and medium risk for procedure-related distress.
Methods
Children undergoing scheduled intravenous insertions for diagnostic or treatment purposes and their parents participated. A computerized application, Children, Parents and Distraction, was used to predict distress risk. Doses of intervention were basic (parents trained on providing distraction), enhanced (basic training plus tailored instructions, environmental modifications, and support and guidance from the research assistant), and professional (a trained research assistant provided distraction). Outcome measures were Observational Scale of Behavioral Distress-Revised for behavioral distress, Oucher for self-reported pain, parent report of child distress, and salivary cortisol for physiological distress.
Results
A total of 574 children, ages 4–10, and their parents participated. The Children, Parents and Distraction predicted that the risk for distress was high for 156 children, medium for 372, and low for 46. Children predicted to have higher risk for distress displayed more behavioral distress (p < .01). Children in the medium-risk group who had the professional intervention displayed significantly less behavioral distress (p < .001). Children in the high-risk group tended to have less behavioral distress when receiving the professional intervention (p = .07). There were no significant group differences for self-report of pain, parent report of distress, or cortisol levels.
Discussion
Some parents may need additional training in providing distraction to their children during procedures, and some children at medium and high risk for distress may need professional support. Parents should be asked about their preferences in acting as the distraction coach and, if willing, be provided as much training and support as possible in the clinical situation.
doi:10.1097/NNR.0000000000000056
PMCID: PMC4282990  PMID: 25350539
children; distraction; nursing; pain; pain management; parents; procedures

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