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1.  Using Temporal Mining to Examine the Development of Lymphedema in Breast Cancer Survivors 
Nursing research  2013;62(2):122-129.
Secondary lymphedema is a lifetime risk for breast cancer survivors and can severely affect quality of life. Early detection and treatment are crucial for successful lymphedema management. Limb volume measurements can be utilized not only to diagnose lymphedema but also to track progression of limb volume changes before lymphedema, which has the potential to provide insight into the development of this condition.
To identify commonly occurring patterns in limb volumes changes in breast cancer survivors before the development of lymphedema, and to determine if there were differences in these patterns between certain patient subgroups. Furthermore, pattern differences were studied between patients who developed lymphedema quickly and those whose onset was delayed.
A temporal data mining technique was used to identify and compare common patterns in limb volume measurements in patient subgroups of study participants (n = 232). Patterns were filtered initially by support and confidence values; then t-tests were used to determine statistical significance of the remaining patterns.
Higher body mass index and the presence of postoperative swelling are supported as risk factors for lymphedema. In addition, a difference in trajectory to the lymphedema state was observed.
The results have potential to guide clinical guidelines for assessment of latent and early-onset lymphedema.
PMCID: PMC4526254  PMID: 23458909
secondary lymphedema; breast cancer; temporal analysis; data mining
2.  Telomere Length: A Review of Methods for Measurement 
Nursing research  2014;63(4):289-299.
The exciting discovery that telomere shortening is associated with many health conditions, and that telomere lengths can be altered in response to social and environmental exposures, has underscored the need for methods to accurately and consistently quantify telomere length.
The purpose of this paper is to provide a comprehensive summary that compares and contrasts the current technologies used to assess telomere length.
Multiple methods have been developed for the study of telomeres. These techniques include quantification of telomere length by terminal restriction fragmentation—which was one of the earliest tools used for length assessment—making it the gold standard in telomere biology. Quantitative-PCR provides the advantage of being able to use smaller amounts of DNA, thereby making it amenable to epidemiology studies involving large numbers of people. An alternative method uses fluorescent probes to quantify not only mean telomere lengths, but also chromosome-specific telomere lengths; however, the downside of this approach is that it can only be used on mitotically active cells. Additional methods that permit assessment of the length of a subset of chromosome-specific telomeres, or the subset of telomeres that demonstrate shortening, are also reviewed.
Given the increased utility for telomere assessments as a biomarker in physiological, psychological and biobehavioral research, it is important that investigators become familiar with the methodological nuances of the various procedures used for measuring telomere length. This will ensure that they are empowered to select an optimal assessment approach to meet the needs of their study designs. Gaining a better understanding of the benefits and drawbacks of various measurement techniques is important not only in individual studies, but also to further establish the science of telomere associations with biobehavioral phenomena.
PMCID: PMC4292845  PMID: 24977726
nursing research; telomere; telomere length; telomere measurement
3.  A New Self-Report Measure of Self-Management of Type 1 Diabetes for Adolescents 
Nursing research  2009;58(4):228-236.
The development of instruments to measure self-management in youth with type 1 diabetes has not kept up with current understanding of the concept.
To report the development and testing of a new self-report measure to assess self-management of type 1 diabetes in adolescence (SMOD-A).
Following a qualitative study, items were identified and reviewed by experts for content validity. A total of 515 adolescents, 13 to 21 years old, participated in a field study by completing the SMOD-A (either once or twice) and additional measures of diabetes related self-efficacy (SEDS), quality of life (DQOL), self-management (DSMP), and adherence (SCI). Data were collected also on metabolic control (HbA1c).
The content validity of the scale (CVI) was .93. Exploratory alpha factor analyses revealed five subscales: Collaboration with Parents, Diabetes Care Activities, Diabetes Problem-Solving, Diabetes Communication, and Goals (α = .71 to .85). The stability of the SMOD-A ranged from .60 to .88 at 2 weeks (test-retest) to .59 to .85 at 3 months. Correlations of SMOD-A subscales with SEDS-Diabetes; DQOL satisfaction, impact, and worry; DSMP; and SCI were generally significant and in the expected direction. Collaboration with Parents and HbA1c values were related significantly and positively (r =.11); all other SMOD-A subscales were related significantly and negatively to HbA1c (r = −.10 to −.26), demonstrating that better self-management is associated somewhat with better metabolic control and supporting construct validity of the new measure.
The SMOD-A has been found to be a reliable, stable, and valid measure of self-management of type 1 diabetes in adolescence.
PMCID: PMC4465437  PMID: 19561555
self-management; type 1 diabetes; adolescence; instrument development
4.  A randomized trial of a peer resistance skill building game for Hispanic early adolescent girls: Impact and feasibility of DRAMA-RAMA™ 
Nursing research  2013;62(1):25-35.
Research suggests that adolescents can use peer resistance skills to avoid being pressured into risky behavior, such as early sexual behavior. Avatar-based Virtual Reality (AVR) technology offers a novel way to build these skills.
Study aims were to: evaluate the feasibility of an AVR peer resistance skill building game (DRAMA-RAMA™); explore the impact of game play on peer resistance self-efficacy; and assess how positively the game was perceived.
45 low income early adolescent Hispanic girls were randomly assigned to either the intervention (DRAMA-RAMA™) or comparison game (Wii Dancing with the Stars™ [Wii DWTS™]) condition. All participants were offered a 5 session curriculum that included peer resistance skill content before playing their respective game for 15 minutes, once a week, for two weeks. Participants completed electronic surveys assessing demographics, peer resistance self-efficacy, and sexual behavior at baseline, after game play, and at 2 months. They also completed a paper-pencil game experience questionnaire immediately after playing their game. Data were analyzed using descriptive statistics, chi-square, and analyses of covariance.
The separate analyses of covariance showed a significant game effect at post-test for the peer resistance self-efficacy measure (F = 4.21, p < 0.05), but not at follow-up (F = 0.01, p = 0.92). DRAMA-RAMA™ was rated as positively as the Wii DWTS™ (p ≥ .26).
This randomized control trial provides initial support for the hypothesis that playing an AVR technology game can strengthen peer resistance skills, and early adolescent Hispanic girls will have a positive response to this game.
PMCID: PMC4459489  PMID: 23150043
Adolescence; Hispanic Americans; Peer Group
5.  Full Moon and Gastrointestinal Bleeding 
Nursing Research  2015;64(3):173-175.
PMCID: PMC4418774
6.  Leadership and Cultural Competence of Healthcare Professionals 
Nursing Research  2015;64(3):200-210.
Supplemental Digital Content is available in the text
International migration is a global phenomenon challenging healthcare professionals to provide culturally competent care.
The purpose of this study was to investigate the influence of leaders on the cultural competence of healthcare professionals.
A cross-sectional survey was conducted from 2010 to 2012 to obtain data for a social network analysis in 19 inpatient services and five primary care services in Belgium. The Competences in Ethnicity and Health questionnaire was used. A total of 507 healthcare professionals, including 302 nurses, identified their social relationships with other healthcare professionals working in their service. Highest in-degree centrality was used to identify the leaders within each health service. Multiple regressions with the Huber sandwich estimator were used to link cultural competence of leaders with the cultural competence of the rest of the healthcare staff.
Cultural competence of the healthcare staff was associated with the cultural competence of the leaders. This association remained significant for two specific domains of cultural competence—mediation and paradigm—after controlling for contextual and sociodemographic variables. Interaction analysis suggested that the leadership effect varied with the degree of cultural competence of the leaders.
Cultural competence among healthcare professionals is acquired partly through leadership. Social relationships and leadership effects within health services should be considered when developing and implementing culturally competent strategies. This requires a cautious approach as the most central individuals are not always the same persons as the formal leaders.
PMCID: PMC4418777  PMID: 25871625
Belgium; health equity; immigration; leadership; social network; transcultural nursing
7.  Rejoinder to Román, Gich, and Soriano (2015) 
Nursing Research  2015;64(3):175-176.
PMCID: PMC4418780
8.  No Evidence of Purported Lunar Effect on Hospital Admission Rates or Birth Rates 
Nursing Research  2015;64(3):168-175.
Studies indicate that a fraction of nursing professionals believe in a “lunar effect”—a purported correlation between the phases of the Earth’s moon and human affairs, such as birth rates, blood loss, or fertility.
This article addresses some of the methodological errors and cognitive biases that can explain the human tendency of perceiving a lunar effect where there is none.
This article reviews basic standards of evidence and, using an example from the published literature, illustrates how disregarding these standards can lead to erroneous conclusions.
Román, Soriano, Fuentes, Gálvez, and Fernández (2004) suggested that the number of hospital admissions related to gastrointestinal bleeding was somehow influenced by the phases of the Earth’s moon. Specifically, the authors claimed that the rate of hospital admissions to their bleeding unit is higher during the full moon than at other times. Their report contains a number of methodological and statistical flaws that invalidate their conclusions. Reanalysis of their data with proper procedures shows no evidence that the full moon influences the rate of hospital admissions, a result that is consistent with numerous peer-reviewed studies and meta-analyses. A review of the literature shows that birth rates are also uncorrelated to lunar phases.
Data collection and analysis shortcomings, as well as powerful cognitive biases, can lead to erroneous conclusions about the purported lunar effect on human affairs. Adherence to basic standards of evidence can help assess the validity of questionable beliefs.
PMCID: PMC4418782  PMID: 25756232
bias; hemorrhage; lunar cycle; Moon; parturition; patient admission; Poisson distribution
9.  Cerebral Blood Flow Velocity and Vasomotor Reactivity during Autonomic Challenges in Heart Failure 
Nursing research  2014;63(3):194-202.
Significant alterations in autonomic nervous system (ANS) function, vasomotor reactivity, and cerebral blood flow may develop from damage to brain ANS regulatory areas in heart failure (HF). This preferentially right-sided injury occurs largely in autonomic structures perfused by the middle cerebral artery. Indications of altered, asymmetrical perfusion raise the potential for further neural damage.
To determine whether the extent of middle cerebral artery blood flow velocity and vasomotor reactivity is altered on one side of the brain over the other in HF vs. control subjects, three ANS challenges were administered—each challenge recruited ANS regulatory areas potentially injured in HF.
Transcranial Doppler ultrasonography was used to measure cerebral blood flow velocity and vasomotor reactivity in 40 HF (mean age = 52.7 years, SD = 7.5; 27 males; left ventricular ejection fraction 26.8, SD = 8.3) and 42 control subjects (mean age = 48.3 years; SD = 6.0; 22 males) during 5% CO2 and hyperventilation, Valsalva, and orthostatic (upper body tilt) challenges.
Lower cerebral blood flow velocity and abnormal vasomotor reactivity (p < .01) were noted in HF middle cerebral arteries during all challenges. More right-sided flow velocity reductions appeared in HF, with laterality differences noted during CO2 and orthostatic (p < .05), but not Valsalva challenges.
Diminished cerebral blood flow velocity and altered vasomotor reactivity were associated with HF, changes being preferentially on the right-side; the asymmetry was more pronounced during CO2 and orthostatic challenges. The impaired blood flow regulation may contribute to the lateralized brain pathology in ANS areas, undermining autonomic control in HF.
PMCID: PMC4024060  PMID: 24785247
asymmetrical brain injury; carbon dioxide; heart failure; orthostatic challenge; transcranial Doppler ultrasonography; Valsalva maneuver
10.  Cusp Catastrophe Model: A Nonlinear Model for Health Outcomes in Nursing Research 
Nursing research  2014;63(3):211-220.
Although health outcomes may have fundamentally nonlinearly relationships with relevant behavioral, psychological, cognitively, or biological predictors, most analytical models assume a linear relationship. Further, some health outcomes may have multimodal distributions but most statistical models in commun use assume a unimodal, normal distribution. Suitable nonlinear models should be developed to explain health outcomes.
The aim of this study is to provide an overview of a cusp catastrophe model for examining health outcomes, and to present an example using grip strength as an indicator of a physical functioning outcome to illustrate how the technique may be used. Results using linear regression, nonlinear logistic model and the cusp catastrophe model were compared.
Data from 935 participants from the Survey of Midlife Development in the United States (MIDUS) were analyzed. The outcome was grip strength; executive function (EF) and the inflammatory cytokine interleukin-6 (IL-6) were predictor variables.
Grip strength was bimodally distributed. Based on fit and model selection criteria, the cusp model was superior to the linear model and the nonlinear logistic regression model. The cusp catastrophe model identified IL-6 as a significant asymmetry factor and EF as a significant bifurcation factor.
The cusp catastrophe model is a useful alternative for for explaining the nonlinear relationships commonly seen between health outcome and its predictors. Considerations for the use of cusp catastrophe model in nursing research are discussed and recommended.
PMCID: PMC4066972  PMID: 24785249
cusp catastrophe model; health outcomes; stochastic nonlinear model
11.  Sleep Quality and Risk for Sleep Apnea in Incarcerated Women 
Nursing research  2014;63(3):158-169.
Little is known about characteristics of women's sleep during incarceration.
The study objectives were to: describe incarcerated women's sleep quality; document incarcerated women's risk for sleep apnea; and identify other factors that contribute to poor sleep quality during incarceration.
This cross-sectional descriptive exploratory investigation was conducted in a maximum security women's prison in the United States. Incarcerated women's sleep quality and their risk for sleep apnea was assessed by using the Pittsburgh Sleep Quality Index (PSQI) and the Multivariable Apnea Prediction Score (MAPS), respectively.
Four hundred thirty-eight incarcerated women participated in this investigation. Results indicate that 72% of the sample met the PSQI criteria for “poor sleepers.” Poor sleepers were significantly more likely to report sleep disturbances, and scored significantly higher on the risk for sleep apnea scale compared to women who did not meet the poor sleep threshold. Approximately 10% of the sample had a probability for sleep apnea higher than .50. Factors that contributed to poor sleep included: (a) “racing thoughts/worry/thinking about things”; (b) environmental noise and other factors; (c) physical health conditions/pain; (d) nightmares and flashbacks; and (e) not taking sleep medication.
Most participants reported poor sleep quality during incarceration. Poor sleep might exacerbate existing health conditions and contribute to the development of new health problems for incarcerated women. Furthermore, poor sleep quality may reduce a woman's ability to fully participate in beneficial prison programming. This investigation provides a first look at how women sleep in prison and offers recommendations for future research.
PMCID: PMC4381275  PMID: 24785244
forensic nursing; prisons; women's health; sleep
12.  RN jurisdiction over nursing care systems in nursing homes: application of latent class analysis 
Nursing research  2012;61(1):28-38.
In the context of declining registered nurse (RN) staffing levels in nursing homes, professional nursing jurisdiction over nursing care systems may erode.
The purpose of this study is to develop a typology of professional nursing jurisdiction in nursing homes in relation to characteristics of RN staffing, drawing upon Abbott's (1988) tasks and jurisdictions framework.
The study was a cross-sectional, observational study using the 2004 National Nursing Home Survey (N=1,120 nursing homes). Latent class analysis tested whether RN staffing indicators differentiated facilities in a typology of RN jurisdiction, and compared classes on key organizational environment characteristics. Multiple logistic regression analysis related the emergent classes to presence or absence of specialty care programs in 8 clinical areas.
Three classes of capacity for jurisdiction were identified, including ‘low capacity’ (41% of homes) with low probabilities of having any indicators of RN jurisdiction, ‘mixed capacity’ (26% of homes) with moderate to high probabilities of having higher RN education and staffing levels, and ‘high capacity’ (32% of homes) with moderate to high probabilities of having almost all indicators of RN jurisdiction. ‘High capacity’ homes were more likely to have specialty care programs relative to ‘low capacity’ homes; such homes were less likely to be chain-owned, and more likely to be larger, provide higher technical levels of patient care, have unionized nursing assistants, have a lower ratio of LPNs to RNs, and a higher education level of the administrator.
Findings provide preliminary support for the theoretical framework as a starting point to move beyond extensive reliance on staffing levels and mix as indicators of quality. Further, findings indicate the importance of RN specialty certification.
PMCID: PMC4360952  PMID: 22166907
nurse staffing; staff mix; organizational performance; authority; autonomy
13.  Factors Associated with Toileting Disability in Older Adults without Dementia Living in Residential Care Facilities 
Nursing research  2014;63(2):94-104.
Older adults without dementia living in residential care facilities with toileting disability have increased care costs and dependency. Understanding associated factors could guide prevention and management strategies.
To identify the prevalence of and factors associated with toileting disability in this population.
This was a cross-sectional analysis of the 2010 National Survey of Residential Care Facilities. A subsample (N = 2,395) of adults aged 65 years or older, without dementia, and with the potential to implement behavioral interventions was examined. Associated factors were classified according to the disablement process as pathologies, impairments, functional limitations, coexisting disabilities, intra- and extra-individual factors. Logistic regression models accounting for the stratified two-stage probability sampling design were used to identify factors associated with toileting disability.
Residents were mostly White women, aged 85 years and older. Prevalence of toileting disability was 15%. Associated factors included: reporting fair or poor health, living in a facility with four or less residents, living in a for-profit facility; having bowel incontinence, urinary incontinence, an increased number of physical impairments, visual and hearing impairments; and needing assistance with bathing, dressing, and transferring.
Multicomponent and multidisciplinary prevention and management efforts should be designed for residents without dementia. Future studies testing the efficacy of prevention efforts are needed and should include treatments for incontinence, physical activity programs targeting impairments with walking, standing, sitting, stooping, reaching, and grasping, and therapy to improve dressing, bathing, and transferring skills.
PMCID: PMC3947551  PMID: 24589646
aged; assisted living facilities; toileting disability
14.  Sleep in Persons with Frontotemporal Dementia and Their Family Caregivers 
Nursing research  2014;63(2):129-136.
Dementia is associated with disruptions in sleep and sleep quality for patients and their family caregivers. Little is known about the impact of frontotemporal dementia (FTD) on sleep.
The purpose of this study was to characterize sleep in patients with frontotemporal dementia and their family caregivers.
Twenty-two patient-caregiver dyads were enrolled: Thirteen behavioral variant FTD (bvFTD) and nine semantic dementia (SD). Sleep and sleep quality data were collected for two weeks using diaries and Actiwatches.
Patients with bvFTD and SD spent more time in bed at night compared to their caregivers. Nighttime behaviors were reported more frequently by caregivers for the bvFTD patients and strongly correlated with caregiver distress. Actigraphy data demonstrated normal sleep efficiency and timing of the nighttime sleep period for both patients and their caregivers. Caregivers of patients with bvFTD reported poorer sleep quality compared to the SD caregivers. A greater number of bvFTD caregivers compared to SD reported negative aspects of sleep quality for themselves and used sleep medications more frequently.
The clinical manifestations of bvFTD appear to be associated with different and more distressing impacts on the caregiver sleep quality than SD.
PMCID: PMC4151390  PMID: 24589648
frontotemporal dementia; semantic dementia; caregiving; actigraphy; sleep; sleep quality
15.  Factors Contributing to Preterm Infant Engagement During Bottle-Feeding 
Nursing research  2004;53(5):304-313.
Preterm infants have difficulty maintaining engagement throughout early oral feedings, which can lead to less efficient feeding and prolonged feeding skill development.
To examine contributions of the infant, mother, and feeding context to infant engagement during bottle-feeding.
Bottle-feedings of very-low-birthweight infants (n = 22) by their mothers were observed. Infant and maternal behaviors were coded and synchronized with physiologic measures. At completion of the feeding, the mothers were interviewed, and their working model of feeding coregulation was scored. Feedings were subdivided into feeding episodes (n = 114). Using multilevel linear regression analyses, four dyadic characteristics (working model of the caregiver's role as coregulator, birthweight, postconceptional age, baseline oxygen saturation) and five episode characteristics (readiness at episode onset, episode baseline oxygen saturation, mean oxygen saturation during the episode, maternal feeding behavior, and phase of feeding) were examined as potential predictors of feeding episode engagement.
Conditions observed during the feeding observation explained most of the variation in engagement. Engagement was more likely to occur during the early phase of feeding (p < .05), during feeding episodes that began with infant readiness (p < .05), and during feeding episodes with higher mean oxygen saturation during the episode (p < .05). Feeding episodes with less jiggling of the nipple had a significantly greater amount of engagement (p < .05).
The ability of the preterm infant to maintain engagement during bottle-feeding cannot be explained by characteristics of the infant or by the prefeeding condition of the infant alone. Rather, engagement is coregulated by the caregiver and the infant throughout the feeding. Strategies to assist infants in maintaining physiologic stability during bottle-feeding and further study of effective and contingent caregiver feeding behaviors are needed.
PMCID: PMC4336780  PMID: 15385867
feeding behavior; multilevel model; premature infant
16.  Adaptation of a Communication Interaction Behavior Instrument for use in Mechanically Ventilated, Nonvocal Older Adults 
Nursing research  2014;63(1):3-13.
Valid and reliable instruments are needed to measure communication interaction behaviors between nurses and mechanically ventilated (MV) intensive care unit (ICU) patients who are without oral speech.
To refine and evaluate preliminary validity and reliability of a Communication Interaction Behavior Instrument (CIBI) adapted for use with nonvocal, MV ICU patients.
Raters observed nurse-patient communication interactions using a checklist of nurse and patient behaviors, categorized as positive and negative behaviors. We used 3-minute video-recorded observations of 5 MV ICU adults (<60 years) and their nurses to establish preliminary inter-rater reliability and confirm appropriateness of definitions (4 observations per dyad, N=20). Based on expert input and reliability results, the behaviors and item definitions on the CIBI were revised. The revised tool was then tested in a larger sample of 38 MV ICU patients (≥60 years) and their nurses (4 observations per dyad, N=152) to determine inter-rater reliability.
For preliminary testing, percent agreement for individual items ranged from 60–100% for nurse behaviors and 20–100% for patient behaviors across the 5 pilot cases. Based on these results, 11 definitions were modified and 4 items were dropped. Using the revised 29-item instrument, percent agreement improved for nurse behaviors (73–100%) and patient behaviors (68–100%). Kappa coefficients ranged from 0.13–1.00, with lower coefficients for patient behaviors.
Preliminary results suggest that the revised CIBI has good face validity and demonstrates good inter-rater reliability for many of the behaviors but further refinement is needed. The use of dual raters with adjudication of discrepancies is the recommended method of administration for the revised CIBI.
PMCID: PMC4006953  PMID: 24335909
17.  African American Men and Women's Attitude Toward Mental Illness, Perceptions of Stigma, and Preferred Coping Behaviors 
Nursing research  2013;62(3):185-194.
Although research focused on African Americans with mental illness has been increasing, few researchers have addressed gender and age differences in beliefs, attitudes, and coping.
To examine African Americans' beliefs about mental illness, attitudes toward seeking mental health services, preferred coping behaviors, and whether these variables differ by gender and age.
An exploratory, cross-sectional survey design was used. Participants were 272 community-dwelling African Americans aged 25-72 years. Data analysis included descriptive statistics and general linear regression models.
Depression was the most common mental illness and there were no gender differences in prevalence. Both men and women believed they knew some of the symptoms and causal factors of mental illness. Their attitudes suggested they are not very open to acknowledging psychological problems, are very concerned about stigma associated with mental illness, and are somewhat open to seeking mental health services, but they prefer religious coping. Significant gender and age differences were evident in attitudes and preferred coping.
Our findings have implications for gender and age-specific psychoeducation interventions and future research. For instance, psychoeducation or community awareness programs designed to increase openness to psychological problems and reducing stigma are needed. Also, exploration of partnerships between faith-based organizations and mental health services could be helpful to African Americans.
PMCID: PMC4279858  PMID: 23328705
African Americans; mental illness; beliefs; coping behaviors
18.  Patient-Centered Communication and Health Assessment with Youth 
Nursing research  2013;62(6):383-393.
Patient-centered communication is the hallmark of care that incorporates the perspective of patients to provide tailored care that meets their needs and desires. However, at this time there has been limited evaluation of patient-provider communication involving youth.
This manuscript will report on results from secondary analysis of data obtained during a participatory research-based randomized control trial designed to test a sexual risk event history calendar intervention with youth to address the following research questions: (a) Based on the event history calendar’s (EHC) inclusion of contextual factors, does the EHC demonstrate improved communication outcomes (i.e., amount, satisfaction, mutuality, client involvement, client satisfaction, patient-provider interaction, and patient-centeredness) when compared to the Guidelines for Adolescent Preventive Services (GAPS) tool? and (b) How do patients and providers describe the characteristics of each tool in regards to patient-centered communication?
This report will utilize a sequential explanatory mixed methods approach to evaluate communication. A split plot design with one between factor (i.e., communication structure between EHC and GAPS) and one within factor (i.e., time between pretest and posttest) was used for analyses of data collection from male and female youth (n=186) and providers (n=9). Quantitative analysis of survey data evaluated changes in communication from pre-test to post-test. Qualitative data collected from open-ended questions, audio-taped visits, and exit interviews was employed to enhance interpretation of quantitative findings.
Patient-centered communication using assessment tools (EHC and GAPS) with youth demonstrated improved communication outcomes both quantitatively and qualitatively. Additional analyses with subgroups of males and Arab-Americans demonstrated better post-intervention scores among the EHC group in certain aspects of communication. Qualitative results revealed that the EHC demonstrated improved outcomes in the four components of patient-centered communication including: validation of the patient’s perspective; viewing the patient within context; reaching a shared understanding on needs and preferences; and helping the patient share power in the healthcare interaction.
Though both tools provided a framework from which to conduct a clinical visit, the integrated time-linked assessment captured by the EHC enhanced the patient-centered communication in select groups compared to GAPS.
PMCID: PMC4235338  PMID: 24165214
patient-centered communication; youth; event history calendars
19.  Parenting Enhancement, Interpersonal Psychotherapy to Reduce Depression in Low-Income Mothers of Infants and Toddlers: A Randomized Trial 
Nursing research  2013;62(2):82-90.
Depressive symptoms and clinical depression are highly prevalent in low-income mothers and negatively affect their infants and toddlers.
To test interpersonal psychotherapy combined with parenting enhancement on depressive symptoms and parenting behavior, compared with usual care.
Mothers (n = 226) of Early Head Start infants and toddlers from the southeastern and northeastern United States were randomized to the intervention delivered in-home by psychiatric mental health advanced practice nurses or usual care delivered by generalist nurses. Rigorous clinical depressive symptom and depression assessments and videotaped, coded mother-child interactions were used as baseline and 14-, 22-, and 26-week postintervention measures.
Both the intervention and control groups had significantly reduced Hamilton Rating Scale for Depression scores at each subsequent time point compared to baseline (p < .0001). However, only mothers receiving the intervention showed a significant increase in positive involvement with their child, as measured by closeness, positive affect, affection, and warm touch at T4 (t = 2.22, df = 156, p < .03).
Both intervention and control conditions resulted in symptom reduction, but only the intervention mothers showed significant interaction changes with their child, an essential step in reducing the negative child outcomes associated with maternal depressive symptoms. Results suggest that a combination of generalist and specialist nurses could be used to treat depressive symptoms in these mothers. Further study with longer postintervention observation is needed to see if, over time, the intervention led to longer-lasting symptom reduction.
PMCID: PMC4235749  PMID: 23458906
mothers; depression; psychotherapy
20.  Linking Clinical Research Data to Population Databases 
Nursing research  2013;62(6):438-444.
Most clinical nursing research is limited to funded study periods. Researchers can study relationships between study measures and long-term outcomes if clinical research data can be linked to population databases.
The objective was to describe feasibility of linking research participant data to data from population databases in order to study long-term poststudy outcomes. As an exemplar, participants were linked from a completed oncology nursing research trial to outcomes data in two state population databases.
Participant data from a previously completed symptom management study were linked to the Utah Population Database and the Utah Emergency Department Database. The final dataset contained demographic, cancer diagnosis and treatment, and baseline data from the oncology study linked to poststudy long-term outcomes from the population databases.
One hundred twenty-nine of 144 (89.6%) study participants were linked to their individual data in the population databases. Of those, 73% were linked to hospitalization records, 60% to emergency department visit records, and 28% were identified as having died.
Study participant data were successfully linked to population databases data to describe poststudy emergency department visit and hospitalization numbers and mortality. The results suggest that data linkage success can be improved if researchers include linkage and human subjects protection plans related to linkage in the initial study design.
PMCID: PMC3907268  PMID: 24165220
cancer; outcomes; population database; randomized controlled trials; record linkage
21.  Managing Threats against Control in Old Age: A Narrative Inquiry 
Nursing research  2013;62(6):430-437.
The desire to retain personal control over self and life circumstances continues into old age; it exists in tension with late-life vulnerabilities.
This article investigates how elders respond to threats against control in light of changes surrounding health and identity.
Community-dwelling African-American (n = 10) and European-American elders (n = 10), aged 70 years and older, with varied self-reported health statuses were qualitatively interviewed. Open-ended interviews explored elders’ perceptions of control and threats to control in older age.
Three themes linked elders’ responses to threats to control. Elders: (a) proactively monitored physical and mental health; (b) maintained roles that shaped important aspects of identity, and (c) fostered personal growth and development by generative practices. Responses of participants who had difficulty countering threats to control are also offered.
This study shows that the construct of control is not abstract; it is interpreted and applied by elders in the contexts of everyday life. Respondents used personal resources honed throughout the life course to respond to threats to control. Elders viewed control as a cultural construct with nuanced meanings that recalled past roles and current changes that occur with age. Suggestions are offered for how health professionals can assist elders with the cognitive and emotional tasks required to deal with threats to personal control surrounding health and identity.
PMCID: PMC3940447  PMID: 24165219
aged; health threats; qualitative research; control; life course
22.  Healthcare Utilization in Women After Abdominal Surgery for Ovarian Cancer 
Nursing research  2011;60(1):47-57.
Women undergoing surgery for ovarian cancer are severely ill and are high users of health services. Contributing to these increased utilization rates are the multiple modalities used to treat ovarian cancer, and the complications and side effects from those treatments.
To evaluate the effectiveness of an intervention provided by advanced practice nurses and a psychiatric consultation-liaison nurse on patients' self-report of health care utilization compared to an attention control intervention in women undergoing surgery for a suspected diagnosis of ovarian cancer.
A two-group, experimental, longitudinal design was used to compare women who were assigned randomly to the intervention group or to an attention control group at baseline within 48 hours after surgery and 1, 3, and 6 months after surgery. Healthcare utilization was measured as the number of self-reported inpatient admissions and outpatient visits, including emergency room visits, oncology outpatient visits, and primary care visits. Nurse interventions consisted of 16 contacts: symptom management, counseling, education, direct nursing care, coordination of resources, and referrals. The attention control interventions consisted of 9 contacts that included instructions on use of a symptom management toolkit and strategies on how to manage symptoms.
There were no differences in hospitalizations and oncology outpatient visits between the two groups. The main finding of this study was a significant difference in the number of primary care visits between the two groups. Women in the attention control group went to their primary care providers more often than the intervention group. The women who reported more visits also reported more depressive symptoms. In addition, a trend was found in the number of emergency room visits between the two groups. The intervention group visited the emergency room more often because the nurse instructed patients to go when they recognized symptoms that needed urgent care after hours.
Women in the intervention group appropriately used the emergency room to manage their problems after hours, whereas more women in the attention control group reported significantly more primary care visits. These findings highlight the need for health care providers representing various disciplines to coordinate services across specialties, especially for women who have depressive symptoms.
PMCID: PMC4186259  PMID: 21127451
ovarian cancer; advanced practice nurse; health care utilization; coordination of care; primary care; clinical home
23.  Evidence of Nonconscious Stereotyping of Hispanic Patients by Nursing and Medical Students 
Nursing research  2013;62(5):362-367.
Current research on nonconscious stereotyping in health care is limited by an emphasis on practicing physicians’ beliefs about African American patients and by heavy reliance on a measure of nonconscious processes that allows participants to exert control over their behavior if they are motivated to appear nonbiased.
The present research examined whether nursing and medical students exhibit nonconscious activation of stereotypes about Hispanic patients using a task that subliminally primes patient ethnicity. It was hypothesized that participants would exhibit greater activation of noncompliance and health risk stereotypes following subliminal exposure to Hispanic faces compared with non-Hispanic White faces and, because ethnicity was primed outside of conscious awareness, that explicit motivations to control prejudice would not moderate stereotype activation.
Nursing and medical students completed a sequential priming task that measured the speed with which they recognized words related to noncompliance and health risk following subliminal exposure to Hispanic and non-Hispanic White faces. They then completed explicit measures of their motivation to control prejudice against Hispanics.
Both nursing and medical students exhibited greater activation of noncompliance and health risk words after subliminal exposure to Hispanic faces, compared with non-Hispanic White faces. Explicit motivations to control prejudice did not moderate stereotype activation.
These findings show that, regardless of their motivation to treat Hispanics fairly, nursing and medical students exhibit nonconscious activation of negative stereotypes when they encounter Hispanics. Implications are discussed.
PMCID: PMC3763916  PMID: 23995470
Nonconscious processes; stereotyping; Hispanic Americans; health care disparities; minority health; Implicit Associations Test; prejudice
24.  Reproductive Health CHOICES for Young Adults with Sickle Cell Disease or Trait: Randomized Controlled Trial Immediate Posttest Effects 
Nursing research  2013;62(5):352-361.
People with sickle cell disease (SCD) or sickle cell trait (SCT) may not have information about genetic inheritance needed for making informed reproductive health decisions. CHOICES is a web-based, multimedia educational intervention that provides information about reproductive options and consequences to help those with SCD or SCT identify and implement an informed parenting plan. Efficacy of CHOICES compared with usual care must be evaluated.
The purpose was to compare immediate posttest effects of CHOICES versus an attention control usual care intervention (e-Book) on SCD/SCT-related reproductive health knowledge, intention, and behavior.
In a randomized controlled study, we recruited subjects with SCD/SCT from clinics, community settings, and online networks with data collected at sites convenient to the 234 subjects with SCD (n = 136) or SCT (n = 98) (age ranged from18-35 years, 65% were female, and 94% were African American). Subjects completed a measure of sickle cell reproductive knowledge, intention, and behavior before and immediately after the intervention.
Compared to the e-Book group, the CHOICES group had significantly higher average knowledge scores and probability of reporting a parenting plan to avoid SCD or SCD and SCT when pretest scores were controlled. Effects on intention and planned behavior were not significant. The CHOICES group showed significant change in their intention and planned behavior; the e-Book group did not show significant change in their intention, but their planned behavior differed significantly.
Initial efficacy findings are encouraging but warrant planned booster sessions and outcome follow-ups to determine sustained intervention efficacy on reproductive health knowledge, intention, and actual behavior of persons with SCD/SCT.
PMCID: PMC3805179  PMID: 23995469
sickle cell disease; sickle cell trait; reproductive behavior; young adult; randomized controlled trial
25.  Parent and Child Perceptions of a Self-Regulated, Home-Based Exercise Program for Children with Cystic Fibrosis 
Nursing research  2013;62(5):305-314.
Despite recognized benefits, many children with cystic fibrosis (CF) do not consistently participate in physical activities. There is little empirical literature regarding the feelings and attitudes of children with CF toward exercise programs, parental roles in exercise, or factors influencing exercise experiences during research participation.
To describe the exercise experiences of children with CF and their parents during participation in a six-month program of self-regulated, home-based exercise.
This qualitative descriptive study nested within a randomized controlled trial of a self-regulated, home-based exercise program used serial semi-structured interviews conducted individually at two and six months with 11 purposively selected children with CF and their parent(s).
Six boys and five girls, ages 10–16, and parents (nine mothers, four fathers) participated in a total of 44 interviews. Five major thematic categories describing child and parent perceptions and experience of the bicycle exercise program were identified in the transcripts: (a) motivators; (b) barriers; (c) effort/work; (d) exercise routine; (e) sustaining exercise. Research participation, parent-family participation, health benefits, and the child’s personality traits were primary motivators. Competing activities, priorities and responsibilities were the major barriers to implementing the exercise program as prescribed. Motivation waned and the novelty wore off for several (approximately half) parent-child dyads, who planned to decrease or stop the exercise program after the study ended.
We identified motivators and barriers to a self-regulated, home-based exercise program for children with CF that can be addressed in planning future exercise interventions to maximize the health benefits for children with CF and the feasibility and acceptability to the children and their families.
PMCID: PMC4053557  PMID: 23995464
Exercise; children; cystic fibrosis; chronic disease; qualitative research

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