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1.  Contributors to Depressive Symptoms among Korean Immigrants with Type 2 Diabete 
Nursing research  2013;62(2):115-121.
Background
Patients with diabetes have a higher prevalence of depression than the general population. Korean immigrants with type 2 diabetes are understudied.
Objectives
To identify the prevalence and correlates of depressive symptoms in Korean immigrants.
Method
In this cross-sectional descriptive study, a community sample of 164 Korean immigrant adults with type 2 diabetes were assessed for depressive symptoms using the Center for Epidemiological Studies-Depression scale. Predictors of depression were grouped into three categories: demographic (age, gender, education, English proficiency); clinical (duration of diabetes, comorbidities, insulin use); and psychosocial (general health, diabetes-related quality-of-life, family support).
Results
Approximately 56% of participants had CES-D scores ≥ 16. Higher levels of depression were associated with greater impact of diabetes on QOL (b = 5.68, p = .001), worse overall health (b = -0.09, p = .012), and less family support (b = -4.02, p = .042). The relationship between depression and diabetes impact on quality-of-life was stronger for men than women (b = 6.67, p = .020).
Discussion
Depressive symptoms are common among Korean immigrants with type 2 diabetes. Assessing diabetes-related quality-of-life, general health, and family support may be of value in better understanding depressive symptoms among this population. Among Korean immigrant men with type 2 diabetes, specific attention should be paid to diabetes-related quality-of-life.
doi:10.1097/NNR.0b013e31827aec29
PMCID: PMC3594573  PMID: 23190692
depressive symptoms; Korean immigrants; gender differences; type 2 diabetes; quality-of-life
2.  Influence of Patient Characteristics on Assessment of Diabetes Self-Management Support 
Nursing research  2013;62(2):106-114.
Background
Factors contributing to patient-reported experiences of diabetes self-management support are not understood well, particularly over time.
Objectives
To identify the contribution of patient characteristics to patient-reported quality of SMS.
Method
Using secondary data from a prospective clinical trial (n = 339) comparing three approaches of providing diabetes self-management support (Group Medical Visits, Automated Telephone Support, and Usual Care) in a diverse, underserved population, the influence of patient characteristics (e.g., age, gender, income, health status) was examined on Patient Assessment of Chronic Illness Care ratings.
Results
At baseline, older age (p = .014), being female (p = .038), and having lower income (p = .001) were associated with lower ratings. Income and interactions involving income combined explained 12% of the variance in baseline ratings. Compared to White patients, African American and Asian patients tended to have higher baseline ratings (p = .076 and p = .045, respectively). Race or ethnicity influenced perceptions throughout the trial, explaining 5% of the variance at baseline and 2% of the variance in one-year changes in Patient Assessment of Chronic Illness Care (PACIC) ratings. As expected, over 1 year, ratings increased more for patients in both intervention groups compared to the control group (p < .001).
Discussion
Ratings of health care quality are influenced by patient characteristics independent of the nature of the care provided. Understanding more precisely how these differences are associated with differences in clinical processes will be particularly important for efforts aiming to integrate patient-reported measures into assessments of health care quality during routine clinical care and clinical trials.
doi:10.1097/NNR.0b013e3182843b77
PMCID: PMC3641001  PMID: 23458908
patient satisfaction; diabetes mellitus; self-care; vulnerable populations
3.  Strategies Used and Data Obtained During Treatment Fidelity Monitoring 
Nursing research  2013;62(1):59-65.
Background
Treatment fidelity, also called intervention fidelity, is an important component of testing treatment efficacy. Although examples of strategies needed to address treatment fidelity have been provided in several published reports, data describing variations that might compromise efficacy testing have been omitted.
Objectives
To describe treatment fidelity monitoring strategies and data within the context of a nursing clinical trial.
Method
A three-group, randomized, controlled trial compared intervention (paced respiration) to attention control (fast, shallow breathing) to usual care for management of hot flashes and other menopausal symptoms. Data from both staff and participants were collected to assess treatment fidelity.
Results
Staff measures for treatment delivery indicated good adherence to protocols. Participant ratings of expectancy and credibility were not statistically different between intervention and attention control; however, the attention control was significantly more acceptable (p < .05). Intervention participant data indicated good treatment receipt and enactment with mean breath rates at each time point falling within the target range. Practice log data for both intervention and attention control indicated lower adherence of once daily, rather than twice-daily practice.
Discussion
Despite strengths in fidelity monitoring, some challenges were identified that have implications for other similar intervention studies.
doi:10.1097/NNR.0b013e31827614fd
PMCID: PMC3523275  PMID: 23222844
clinical trials as topic/standards; reproducibility of results; research design; health behavior
4.  A Theory-Based Online Hip Fracture Resource Center for Caregivers: Effects on Dyads 
Nursing research  2012;61(6):413-422.
Background
Hip fracture is a serious injury for older adults, usually requiring surgical repair and extensive therapy. Informal caregivers can help older adults make a successful recovery by encouraging them to adhere to the therapy plans and improve their health behaviors. Few resources, however, are available for these caregivers to learn about how to assist their care receivers and cope with their unique caregiving situations.
Objective
To develop a comprehensive theory-based online hip fracture resource center for caregivers, Caring for Caregivers, and conducted a feasibility trial.
Method
The resource center included self-learning modules, discussion boards, Ask the Experts, and a virtual library. The feasibility of the intervention was assessed by usage and usability. The feasibility of the future trial was tested using a one-group pre-post design on 36 caregiving-care receiver dyads recruited from six hospitals. The caregivers used the resource center for 8 weeks. The impact of the intervention was assessed on both caregivers (primary) and care receivers (secondary). The data were analyzed by descriptive statistics, paired t-tests, and content analyses.
Results
On average, caregivers reviewed five modules and used the discussion board 3.1 times. The mean perceived usability score for the resource center was 74.04 ± 7.26 (range = 12–84). Exposure to the resource center significantly improved caregivers’ knowledge about the care of hip fracture patients (t = 3.17, p = .004) and eHealth literacy (t = 2.43, p = .002). Changes in other caregiver outcomes (e.g., strain, coping, social support) and care receiver outcomes (e.g., self-efficacy for exercise, osteoporosis medication adherence) were favorable but not significant.
Discussion
The findings suggest that the resource center was user-friendly and could be beneficial for caregivers. Additional larger scale trials are needed to assess the effectiveness of the intervention on outcomes.
doi:10.1097/NNR.0b013e318270712a
PMCID: PMC3491116  PMID: 23052420
Internet resource; caregivers; hip fracture
5.  The Promise of the State Space Approach to Time Series Analysis for Nursing Research 
Nursing research  2012;61(6):388-394.
Background
Nursing research, particularly related to physiological development, often depends on the collection of time series data. The state space approach to time series analysis has great potential to answer exploratory questions relevant to physiological development but has not been used extensively in nursing.
Objectives
To introduce the state space approach to time series analysis and demonstrate potential applicability to neonatal monitoring and physiology.
Method
We present a set of univariate state space models; each one describing a process that generates a variable of interest over time. Each model is presented algebraically and a realization of the process is presented graphically from simulated data. This is followed by a discussion of how the model has been or may be used in two nursing projects on neonatal physiological development.
Results
The defining feature of the state space approach is the decomposition of the series into components that are functions of time; specifically, slowly varying level, faster varying periodic, and irregular components. State space models potentially simulate developmental processes where a phenomenon emerges and disappears before stabilizing, where the periodic component may become more regular with time, or where the developmental trajectory of a phenomenon is irregular.
Discussion
The ultimate contribution of this approach to nursing science will require close collaboration and cross-disciplinary education between nurses and statisticians.
doi:10.1097/NNR.0b013e318274d743
PMCID: PMC3601839  PMID: 23090442
time series analysis; the state space approach; physiological nursing research
6.  A Novel Quantitative Approach to Concept Analysis: The Internomological Network 
Nursing research  2012;61(5):369-378.
Background
When a construct such as patients’ transition to self-management of chronic illness is studied by researchers across multiple disciplines, the meaning of key terms can become confused. This results from inherent problems in language where a term can have multiple meanings (polysemy) and different words can mean the same thing (synonymy).
Objectives
To test a novel quantitative method for clarifying the meaning of constructs by examining the similarity of published contexts in which they are used.
Method
Published terms related to the concept transition to self-management of chronic illness were analyzed using the internomological network (INN), a type of latent semantic analysis to calculate the mathematical relationships between constructs based on the contexts in which researchers use each term. This novel approach was tested by comparing results to those from concept analysis, a best-practice qualitative approach to clarifying meanings of terms. By comparing results of the two methods, the best synonyms of transition to self-management, as well as key antecedent, attribute, and consequence terms, were identified.
Results
Results from INN analysis were consistent with those from concept analysis. The potential synonyms self-management, transition, and adaptation had the greatest utility. Adaptation was the clearest overall synonym, but had lower cross-disciplinary use. The terms coping and readiness had more circumscribed meanings. The INN analysis confirmed key features of transition to self-management, and suggested related concepts not found by the previous review.
Discussion
The INN analysis is a promising novel methodology that allows researchers to quantify the semantic relationships between constructs. The method works across disciplinary boundaries, and may help to integrate the diverse literature on self-management of chronic illness.
doi:10.1097/NNR.0b013e318250c199
PMCID: PMC3422604  PMID: 22592387
chronic disease; concept analysis; construct validity; factor analysis; self-management
7.  Impact of a Rural Village Women (Asha) Intervention on Adherence to Antiretroviral Therapy in Southern India 
Nursing research  2012;61(5):353-362.
Background
Despite the increased prevalence of HIV in the rural female population of India, adherence to antiretroviral therapy continues to be low due to several barriers which discourage rural women.
Objectives
To assess the effectiveness of an intervention (Asha-Life) delivered by Accredited Social Health Activists to improve antiretroviral therapy adherence of rural women living with AIDS in India compared to that of a usual care group.
Method
A total of 68 rural women living with AIDS, aged 18–45 years, participated in a prospective, randomized pilot clinical trial and were assessed for several factors affecting adherence, such as sociodemographic characteristics, health history, CD4 cell count, enacted stigma, depressive symptomology, help getting antiretroviral therapy, and perceived therapy benefits.
Results
Findings at 6 months revealed that, while both groups improved their adherence to antiretroviral therapy, there was greater improvement in the Asha-Life group (p < .001), who reported a greater reduction in barriers to antiretroviral therapy than those in the usual care group.
Discussion
Antiretroviral therapy adherence showed significant increase in the Asha-Life cohort, in which basic education on HIV/AIDS, counseling on antiretroviral therapy, financial assistance, and better nutrition was provided. The Asha-Life intervention may have great potential in improving antiretroviral therapy adherence and decreasing barriers among rural women living with AIDS in India.
doi:10.1097/NNR.0b013e31825fe3ef
PMCID: PMC3509934  PMID: 22872107
HIV/AIDS; antiretroviral therapy; adherence; rural women; India
9.  Qualitative Inquiry of Patient-Reported Outcomes: The Case of Lower Urinary Tract Symptoms 
Nursing Research  2012;61(4):283-290.
Background
Patient-reported outcomes are a valuable tool for assessing healthcare, particularly for symptom-based conditions that lack definitive physiological measures of treatment efficacy.
Objective
To explore the value of qualitative methods for understanding and developing patient-reported outcomes of medical care for symptom-based conditions by examining the case of lower urinary tract symptoms.
Method
Semi-structured interviews were conducted with a diverse, community sample of 90 respondents who had spoken with a provider about their urinary symptoms. Content and thematic analyses were conducted for the areas of symptom relief, patient adherence, and satisfaction with care according to gender, race or ethnicity, and socioeconomic status.
Results
Across social groups, most patients experienced either no symptom relief or partial relief, reported that they adhered to recommendations, and were satisfied with the care received. The primary reason for no symptom relief was not receiving a treatment recommendation. For patients, even partial relief made symptoms more manageable both physically and emotionally. Satisfaction with care was mediated by the quality of the patient-provider relationship as well as expectations other than symptom relief, particularly for patients of low socioeconomic status.
Discussion
Patients’ assessments of the outcomes of seeking medical care for this symptom-based condition broadened the criteria for quality of care beyond providing a cure. For health care providers, this can widen the path for meeting patient needs, even without complete symptom relief. For providers and researchers, as the evidence base expands to include patient reports, the context provided by a qualitative approach can enhance understanding of patients’ perspectives and the ability to construct meaningful quantitative measures.
doi:10.1097/NNR.0b013e318251d8f6
PMCID: PMC3398610  PMID: 22565104
patient outcomes assessment; qualitative research; urinary tract symptoms
11.  Care Planning Integrity in Nursing Facilities 
Nursing research  2008;57(4):271-282.
Background
Although there is some evidence of improved quality in nursing home care after the implementation of the 1987 Omnibus Budget Reconciliation Act regulations, the nursing processes that contribute to that improvement are not well understood. Assumptions that the mandated tools for resident assessment and care planning account for the change remain uninvestigated.
Objectives
To generate an empirically supported conceptual model of care planning integrity, incorporating five subconstructs: coordination, integration, interdisciplinary team, restorative perspective, and quality.
Methods
A correlational, model generation-model selection design guided the study. Using a random sample of 107 facilities, the research team combined primary data collected from care planning team members (n = 508) via a telephone survey, with variables extracted from the Medicaid Cost Reports and the Centers for Medicaid and Medicare Services Online Survey, Certification, and Reporting System (OSCAR) database. Primary and alternative models of care planning integrity were examined for fit to the data using structural equation modeling procedures.
Results
Using preliminary analyses, 18 observed indicators to represent the five latent subconstructs were identified. Fit indices for the primary model were borderline (comparative fit index = .892; root mean square error of approximation = .048), but were excellent for the alternative model (comparative fit index = .972; root mean square error of approximation = .026). Care planning integrity is demonstrated within nursing facilities through direct relationships with coordination, integration, and quality, and indirect relationships through integration with interdisciplinary team and restorative perspective.
Discussion
Care planning integrity captures differences in the way nursing facilities implement the care planning process, using the mandated standardized tools, that may make a difference in resident outcomes. Subsequent research is indicated to address those dynamics.
doi:10.1097/01.NNR.0000313493.79659.8f
PMCID: PMC3653618  PMID: 18641496
care planning; nursing home residents; nursing homes
12.  Pain Barriers: Psychometrics of a 13-Item Questionnaire 
Nursing research  2010;59(2):93-101.
Background
Research instruments that effectively measure key pain constructs without needlessly taxing participants are invaluable to investigative processes.
Objectives
The purpose of this series of studies was to eliminate the redundancy of the commonly used 27-item pain tool the Barriers Questionnaire (BQ-27), retain its theoretical domains, and maintain its psychometric properties in a new shortened version.
Method
We reduced the BQ-27 to 13 items using data from 259 patients with cancer, by selecting the single item from each domain with the highest frequency of endorsement and including all of the items in the side effects subscale. We tested reliability of the BQ-13 using data from additional studies (N = 221) and (N = 167) and used ANCOVA (N = 221) to determine instrument sensitivity.
Results
Confirmatory factor analysis revealed that the BQ-13 contained two constructs: pain management and side effects. The BQ-13 demonstrated internal consistency as a total scale (α = 0.73) and stability via 4-week test-retest reliability. Additionally, the BQ-13 was sensitive (F(1, 218) = 7.7, p = .006) to effects of a tailored, multimedia educational intervention.
Discussion
We demonstrated that the BQ-13 retained theoretical constructs, eliminated redundant items likely to contribute to floor effects, maintained adequate internal consistency and stability reliability, and had sensitivity to intervention effects.
doi:10.1097/NNR.0b013e3181d1a6de
PMCID: PMC3650024  PMID: 20216011
outpatient; cancer pain; measurement; patient-related barriers
13.  Establishing Measurement Invariance: English and Spanish Paediatric Asthma Quality of Life Questionnaire 
Nursing Research  2012;61(3):171-180.
Background
Registered nurses and nurse researchers often use questionnaires to measure patient outcomes. When questionnaires or other multiple item instruments have been developed using a relatively homogeneous sample, the suitability of even a psychometrically well-developed instrument for the new population comes into question. Bias or lack of equivalence can be introduced into instruments through differences in perceptions of the meaning of the measured items, constructs, or both, in the two groups.
Objective
To explain measurement invariance and illustrate how it can be tested using the English and Spanish versions of the Paediatric Asthma Quality of Life Questionnaire (PAQLQ).
Method
A sample of 607 children from the Phoenix Children's Hospital Breathmobile was selected for this analysis. Ages were 6 to 18 years in age; 61.2% completed the PAQLQ in Spanish. Testing measurement invariance using multiple group confirmatory factor analysis, a series of hierarchical nested models, is demonstrated. In assessing the adequacy of the fit of each model at each stage, both χ2 tests and goodness-of-fit indexes were used.
Results
The test of measurement invariance for the one-factor model showed that the English and Spanish versions of the scale met the criteria for measurement invariance. The level of strict invariance (equal factor loadings, intercepts, and residual variances between groups) was achieved.
Discussion
Confirmatory factor analysis is used to evaluate the structural integrity of a measurement instrument; multiple confirmatory factor analyses are used to assess measurement invariance across different groups, and to stamp the data as valid or invalid. The PAQLQ, a widely used instrument having evidence to support reliability and validity was used separately in English- and Spanish-speaking groups. Traditional methods for evaluating measurement instruments have been less than thorough, and this paper demonstrates a well-developed approach allowing for confident comparisons between populations.
doi:10.1097/NNR.0b013e3182544750
PMCID: PMC3361901  PMID: 22551991
patient outcomes; confirmatory factor analysis; measurement bias
14.  Causal Mediation of a Human Immunodeficiency Virus Preventive Intervention 
Nursing Research  2012;61(3):224-230.
Background
Assessing mediation is important because most interventions are specifically designed to affect an intermediate variable or mediator; this mediator, in turn, is hypothesized to affect outcome behaviors. Although there may be randomization to the intervention, randomization to levels of the mediator is not generally possible. Therefore, drawing causal inferences about the effect of the mediator on the outcome is not straightforward.
Objectives
We introduce an approach to causal mediation analysis that uses the potential outcomes framework for causal inference, and then discuss this approach in terms of the scientific questions addressed and the assumptions needed for identifying and estimating the effects.
Method
We illustrate the approach using data from the Criminal Justice Drug Abuse Treatment studies: Reducing Risky Relationships HIV intervention (RRR-HIV) implemented with 243 incarcerated women reentering the community. The intervention was designed to affect various mediators at 30 days post-intervention including risky relationship thoughts, beliefs, and attitudes, which were then hypothesized to affect engagement in risky sexual behaviors such as unprotected sex at 90 days post-intervention.
Results
Using propensity score weighting, we found the intervention resulted in a significant decrease in risky relationship thoughts (−0.529, p = .03); risky relationship thoughts resulted in an increase in the odds of unprotected sex (.447, p < .001). However, the direct effect of the intervention on unprotected sex was not significant (0.388, p = .479).
Discussion
By reducing bias, propensity score models improve the accuracy of statistical analysis of interventions with mediators and allow researchers to determine not only if their intervention works, but also how it works.
doi:10.1097/NNR.0b013e318254165c
PMCID: PMC3377683  PMID: 22551997
causal inference; potential outcomes framework; incarcerated women
15.  An Internet Coping Skills Training Program for Youth With Type 1 Diabetes 
Nursing research  2012;61(6):395-404.
Background
Managing Type 1 diabetes (T1D) during adolescence can be challenging, and there is a need for accessible interventions to help adolescents cope with diabetes-related stress.
Objectives
The aim of this study was to compare an Internet coping skills training (TEENCOPE) intervention to an Internet educational intervention (Managing Diabetes) for adolescents with T1D. Moderators of program efficacy were evaluated.
Methods
The study was a multisite clinical trial (n = 320) with data collected at baseline, 3 months, and 6 months. Data were collected on the primary outcomes of physiologic (A1C) and psychosocial (quality of life) and on the secondary outcomes of behavioral (self-management) and psychosocial (stress, coping self-efficacy, social competence, family conflict) variables consistent with the conceptual framework. Data were analyzed using mixed-model analyses with an intent-to-treat approach.
Results
There were no significant between-group treatment effects 6 months postintervention on primary outcomes. The Managing Diabetes youth showed a significant increase in social competence compared to the TEENCOPE youth. There were significant time effects for TEENCOPE (decreased stress and increased coping) and Managing Diabetes (improved diabetes quality of life).
Discussion
Youth with T1D transitioning to adolescence may need both structured diabetes education and coping skills to improve health outcomes. There may be a higher potential to reach adolescents with Type 1 diabetes of varying race and ethnicity via Internet interventions.
doi:10.1097/NNR.0b013e3182690a29
PMCID: PMC3623558  PMID: 22960587
coping skills training; interactive diabetes education; internet; Type 1 diabetes
17.  Maternal Employment Effects On Family and Preterm Infants at Three Months 
Nursing research  1991;40(5):272-275.
The purpose of this study was to investigate the effects of maternal employment status and the mother’s degree of choice and satisfaction regarding her employment status on family functioning and, on the preterm infant’s development at three months chronologic age. Families with preterm infants (N = 110) were categorized as employed, nonemployed, and on leave of absence based on the mother’s employment status at three months postpartum. There were no significant differences across employment groups on family functioning and child development. The infant’s motor development was positively correlated with number of hours employed per week and degree of choice for the employed, mother families, but negatively correlated with choice for the nonemployed mother families. These results suggest that maternal employment may not be detrimental for infants born prior to term. Indeed, it may be beneficial, especially if the mother has a choice in the matter.
PMCID: PMC3601192  PMID: 1896324
18.  Factors Related to Maternal Employment Status Following The Premature Birth of an Infant 
Nursing research  1990;39(4):237-240.
A sample of 110 two-parent families whose preterm infants were less than 37 weeks gestation, appropriate for gestational age, and free of major congenital anomalies were recruited from two level-III intensive care nurseries. At 3 months postpartum, 40 mothers (36.4%) were employed, 15 (13.6%) stated they were on a leave of absence, and the remaining 55 mothers (50%) were not employed. Although not significantly different on demographic or infant morbidity variables, employed mothers were significantly more employment-oriented and reported less choice and satisfaction with employment status than nonemployed mothers. In addition, employed mothers were employed more hours prenatally and reported prenatal plans to be employed sooner after the infant's birth than nonemployed mothers. Employed mothers also perceived more support from others for their employment and greater financial necessity and availability of child care than nonemployed mothers. Higher scores on employment orientation were correlated with higher maternal education level, fewer children, more hours employed, higher total support for their employment, higher financial necessity, and less choice and satisfaction with employment status.
PMCID: PMC3601195  PMID: 2367205
19.  Factors Explaining Children’s Responses to Intravenous Needle Insertions 
Nursing research  2010;59(6):407-416.
Background
Previous research shows that numerous child, parent, and procedural variables affect children’s distress responses to procedures. Cognitive-behavioral interventions such as distraction are effective in reducing pain and distress for many children undergoing these procedures.
Objectives
The purpose of this report was to examine child, parent, and procedural variables that explain child distress during a scheduled intravenous insertion when parents are distraction coaches for their children.
Methods
A total of 542 children, between 4 and 10 years of age, and their parents participated. Child age, gender, diagnosis, and ethnicity were measured by questions developed for this study. Standardized instruments were used to measure child experience with procedures, temperament, ability to attend, anxiety, coping style, and pain sensitivity. Questions were developed to measure parent variables, including ethnicity, gender, previous experiences, and expectations, and procedural variables, including use of topical anesthetics and difficulty of procedure. Standardized instruments were used to measure parenting style and parent anxiety, whereas a new instrument was developed to measure parent performance of distraction. Children’s distress responses were measured with the Observation Scale of Behavioral Distress–Revised (behavioral), salivary cortisol (biological), Oucher Pain Scale (self-report), and parent report of child distress (parent report). Regression methods were used for data analyses.
Results
Variables explaining behavioral, child-report and parent-report measures include child age, typical coping response, and parent expectation of distress (p < .01). Level of parents’ distraction coaching explained a significant portion of behavioral, biological, and parent-report distress measures (p < .05). Child impulsivity and special assistance at school also significantly explained child self-report of pain (p < .05). Additional variables explaining cortisol response were child’s distress in the morning before clinic, diagnoses of attention deficit hyperactivity disorder or anxiety disorder, and timing of preparation for the clinic visit.
Discussion
The findings can be used to identify children at risk for high distress during procedures. This is the first study to find a relationship between child behavioral distress and level of parent distraction coaching.
doi:10.1097/NNR.0b013e3181f80ed5
PMCID: PMC3546606  PMID: 20962698
children; cortisol; distress; distraction; pain
20.  Barriers to Meditation by Gender and Age Among Cancer Family Caregivers 
Nursing research  2012;61(1):22-27.
Background
Despite solid basic science research supporting meditation’s physiologic benefits, meditation remains a marginalized practice for many Westerners; observational and descriptive studies indicate a spectrum of barriers to meditation practice.
Objectives
To determine differences in barriers to meditation by gender and age.
Method
A cross-sectional survey study was conducted of 150 family caregivers to adults with cancer visiting an outpatient chemotherapy center in Connecticut, United States. The primary outcome was the Determinants of Meditation Practice Inventory. Explanatory variables included demographic characteristics, Center for Epidemiologic Studies Depression scale, Big Five Inventory, and Caregiver Reactions Assessment.
Results
Participants included 98 women and 52 men. Age range was 18–84 years (M = 52.3 years). The highest frequency of barriers for both genders related to misconceptions about meditation. The total number of barriers to meditation did not significantly vary by gender (p = .10) nor age (p = .27). After adjusting for personality trait, reactions to caregiving, and emotional distress, gender (adjusted β = 0.81, SE = 1.70, p = .63) and age (adjusted β = 0.02, SE = 0.05, p = .67) still did not predict number of barriers to meditation. Backward elimination model building showed personality trait and reactions to caregiving account for 32% of the variability in barriers.
Discussion
Total number of barriers to meditation were examined and a difference was not found by age or gender. It is possible differences by age and gender exist at the item level of evaluation, but were not evident when evaluating total scores. Further study is needed with samples large enough to have statistical power for item-level analysis.
doi:10.1097/NNR.0b013e3182337f4d
PMCID: PMC3237795  PMID: 22048558
caregivers; meditation
21.  Advances in Mediation Analysis Can Facilitate Nursing Research 
Nursing research  2011;60(5):333-339.
Background
Two recent advances in the statistical methods for testing hypotheses about mediation effects are important for nursing science. First, bootstrap sampling distributions provide more accurate tests of hypotheses about mediated effects. Second, methods for testing statistical hypotheses about subgroup differences in mediation models (moderated mediation) are now well developed.
Objective
The aims of this study were to demonstrate the use and relatively simple computation of bootstrap sampling distributions in tests of mediation effects and to demonstrate a recently refined method for testing hypotheses about moderated mediation.
Method
Using hypothetical data, a step-by-step demonstration was provided of the construction of a bootstrap sampling distribution for a correlation coefficient. Then, tests of mediation and moderated mediation were demonstrated using data from a clinical trial of an intervention for caregivers of patients with Parkinson’s disease or Alzheimer’s disease. In a model hypothesizing that mutuality between caregiver and care recipient mediates the effect of objective on subjective levels of caregiver burden, the bootstrap sampling distribution was calculated of the mediation effect and, from that, two types of 95% confidence intervals for it. Then the hypothesis was tested that the mediating effect of mutuality was stronger for caregivers of patients with Parkinson’s disease than for caregivers of patients with Alzheimer’s disease.
Conclusions
Statistical hypothesis testing should never dictate all conclusions. However, the statistical advances in mediation analysis described here will facilitate nursing research as both nurse scientists and methodologists understand their assumptions and logic.
doi:10.1097/NNR.0b013e318227efca
PMCID: PMC3532930  PMID: 21873916
bootstrap sampling distribution; mediation; moderated mediation
22.  Testing of the Decisional Conflict Scale: Genetic Testing Hereditary Breast, Ovarian Cancer 
Nursing research  2011;60(6):368-377.
Background
Hereditary Breast and Ovarian Cancer (HBOC) syndrome is attributed mostly to mutations in the Breast Cancer 1 and Breast Cancer 2 genes (BRCA1/2). HBOC is associated with significantly higher risk for developing breast cancer compared to the general population (55-85% vs. 12%) and ovarian cancer (20-60% vs. 1.5%). The availability of genetic testing enables mutation carriers to make informed decisions about managing their cancer risk (e.g., risk-reducing surgery). However, uptake of testing for HBOC among high-risk individuals is low, indicating the need to better understand how women decide to pursue genetic testing.
Objective
To evaluate the reliability and validity of the modified Decisional Conflict Scale for use in decisions associated with genetic testing for HBOC.
Method
In this cross-sectional, cohort study, women were recruited who pursued genetic testing for HBOC, and also recruited was one of their female relatives who did not pursue testing from two Genetic Risk Assessment clinics affiliated with a large Comprehensive Cancer Center in the Midwest. The final sample consisted of 342 women who completed all 16 items of the Decisional Conflict Scale. The psychometric properties of the scale were assessed using tests of reliability and validity including face, content, construct, contrast, convergent, and divergent validity.
Results
Factor analysis using principal axis factoring with oblimin rotation elicited a three-factor structure (a) Lack of Knowledge about the Decision (a = .97), (b) Lack of Autonomy in Decision Making (a = .94), and (c) Lack of Confidence in Decision Making (a = .87). These factors explained 82% of the variance in decisional conflict about genetic testing. Cronbach’s alpha coefficient was .96.
Discussion
The instrument is an important tool for researchers and healthcare providers working with women at risk for HBOC who are deciding whether or not genetic testing is the right choice for them.
doi:10.1097/NNR.0b013e3182337dad
PMCID: PMC3223734  PMID: 22048556
decisional conflict scale; hereditary breast and ovarian cancer (HBOC); psychometric testing
23.  Establishing Treatment Fidelity in a Web-Based Behavioral Intervention Study 
Nursing research  2011;60(6):430-435.
Background
Treatment fidelity pertains to the methodological strategies used to monitor and enhance the reliability and validity of behavioral interventions. Approaches to establishing treatment fidelity in Web-based interventions differ from those used in interventions that are delivered in person.
Objective
To describe a methodology for ensuring treatment fidelity in a Web-based cognitive behavioral stress management intervention.
Methods
The intervention Coping with Cancer Workbook, adapted for Web-based delivery from an in-person intervention, was tested in a randomized controlled trial with 123 breast cancer survivors. Strategies for ensuring treatment fidelity were implemented and assessed.
Results
The National Institutes of Health Behavior Change Consortium Treatment Fidelity Guidelines were relevant to establishing treatment fidelity for the Web-based intervention.
Discussion
Web-based delivery of behavioral interventions is both a strength and a threat to treatment fidelity. Investigators must be cognizant of the elements of treatment fidelity and implement strategies to monitor and improve the reliability and validity of Web-based interventions.
doi:10.1097/NNR.0b013e31823386aa
PMCID: PMC3235349  PMID: 22048559
treatment fidelity; Web-based intervention; cognitive behavioral stress management
24.  Predictors of Dietary Quality in Low-Income Pregnant Women: A Path Analysis 
Nursing research  2011;60(5):286-294.
Background
Despite the potential importance of nutrition to pregnancy outcomes, little is known about the factors influencing dietary quality, especially during the first trimester.
Objective
To examine the relationships among distress (an index of depression and stress), social support, and eating habits with dietary quality in low-income pregnant women.
Method
A cross-sectional design and path analytic methods was used in a clinic-based sample of low-income women (n = 118) in their first trimester of pregnancy. Women completed questionnaires and received training on estimating food portion sizes. Three 24-hour dietary recalls were collected over 2 weeks. Overall dietary quality was assessed using the Dietary Quality Index: Pregnancy.
Results
The final path model fit well (CFI = .97; RMSEA = .05) and revealed that distress had a direct effect on poor eating habits (β = .36), and a direct (β = −.23) and indirect effect on dietary quality (β = −.30). Poor eating habits had a direct effect on dietary quality (β = −.18). Social support had no effect on dietary quality. Age had significant direct effects on education (β = .39) and nutritional knowledge (β = .18) and an indirect effect on dietary quality (total effect, β = .19). Maternal age, education, and nutritional knowledge did not have significant effects on psychosocial variables.
Discussion
Psychosocial distress and poor eating habits contributed to inadequate dietary quality. Assessing for depression, stress, poor eating habits, and overall dietary quality during the crucial first trimester may identify women needing more intensive dietary monitoring and intervention throughout pregnancy.
doi:10.1097/NNR.0b013e3182266461
PMCID: PMC3164915  PMID: 21873919
25.  Tailoring a Treatment Fidelity Framework for an Intensive Care Unit Clinical Trial 
Nursing research  2011;60(5):348-353.
Background
Treatment fidelity refers to methodological strategies and practices used to monitor and enhance the reliability and validity of behavioral interventions. Treatment fidelity monitoring enhances internal and external validity and is needed for study replication and generalizability.
Objectives
To describe the implementation, monitoring, and impact of treatment fidelity in an intensive care unit-based clinical trial testing music for anxiety self-management with mechanically ventilated patients.
Method
Development of the criteria was based on the five-component Treatment Fidelity Framework from the Treatment Fidelity Workgroup. Descriptive statistics were used to evaluate adherence rates to the key TF criteria and the reasons criteria were unmet. Descriptive and nonparametric statistics were used to evaluate the impact of TF on participants’ use of the assigned intervention.
Results
The Treatment Fidelity Framework was adapted easily to fit the study interventions. After the initial implementation phase of monitoring, adherence to key criteria was maintained at the targeted level of 80%. The majority of barriers to adherence affected the research nurses’ opportunity to interact with the participant and encourage use of the intervention. There was a trend toward increased use of equipment associated with the assigned condition after initiation of treatment fidelity; however this difference was not statistically significant.
Discussion
Treatment fidelity monitoring is an iterative process that requires ongoing vigilance. Identification of barriers and the implementation of methods to enhance protocol adherence are needed in order to enhance reliability, validity, and generalizability of clinical trials in the dynamic and challenging research environment of the ICU.
doi:10.1097/NNR.0b013e31822cc0cf
PMCID: PMC3164965  PMID: 21878797
clinical trial; intensive care; intervention studies; research design

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