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1.  Factors Contributing to Preterm Infant Engagement During Bottle-Feeding 
Nursing research  2004;53(5):304-313.
Background:
Preterm infants have difficulty maintaining engagement throughout early oral feedings, which can lead to less efficient feeding and prolonged feeding skill development.
Objective:
To examine contributions of the infant, mother, and feeding context to infant engagement during bottle-feeding.
Methods:
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.
Results:
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).
Conclusions:
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
2.  Adaptation of a Communication Interaction Behavior Instrument for use in Mechanically Ventilated, Nonvocal Older Adults 
Nursing research  2014;63(1):3-13.
Background
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.
Objectives
To refine and evaluate preliminary validity and reliability of a Communication Interaction Behavior Instrument (CIBI) adapted for use with nonvocal, MV ICU patients.
Methods
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.
Results
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.
Conclusion
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.
doi:10.1097/NNR.0000000000000012
PMCID: PMC4006953  PMID: 24335909
3.  African American Men and Women's Attitude Toward Mental Illness, Perceptions of Stigma, and Preferred Coping Behaviors 
Nursing research  2013;62(3):185-194.
Background
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.
Objective
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.
Method
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.
Results
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.
Discussion
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.
doi:10.1097/NNR.0b013e31827bf533
PMCID: PMC4279858  PMID: 23328705
African Americans; mental illness; beliefs; coping behaviors
4.  Patient-Centered Communication and Health Assessment with Youth 
Nursing research  2013;62(6):383-393.
Background
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.
Objectives
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?
Method
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.
Results
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.
Discussion
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.
doi:10.1097/NNR.0000000000000005
PMCID: PMC4235338  PMID: 24165214
patient-centered communication; youth; event history calendars
5.  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.
Background
Depressive symptoms and clinical depression are highly prevalent in low-income mothers and negatively affect their infants and toddlers.
Objectives
To test interpersonal psychotherapy combined with parenting enhancement on depressive symptoms and parenting behavior, compared with usual care.
Method
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.
Results
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).
Discussion
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.
doi:10.1097/NNR.0b013e31828324c2
PMCID: PMC4235749  PMID: 23458906
mothers; depression; psychotherapy
6.  Linking Clinical Research Data to Population Databases 
Nursing research  2013;62(6):438-444.
Background
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.
Objectives
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.
Methods
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.
Results
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.
Discussion
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.
doi:10.1097/NNR.0000000000000002
PMCID: PMC3907268  PMID: 24165220
cancer; outcomes; population database; randomized controlled trials; record linkage
7.  Managing Threats against Control in Old Age: A Narrative Inquiry 
Nursing research  2013;62(6):430-437.
Background
The desire to retain personal control over self and life circumstances continues into old age; it exists in tension with late-life vulnerabilities.
Objectives
This article investigates how elders respond to threats against control in light of changes surrounding health and identity.
Methods
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.
Results
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.
Discussion
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.
doi:10.1097/NNR.0000000000000003
PMCID: PMC3940447  PMID: 24165219
aged; health threats; qualitative research; control; life course
8.  Healthcare Utilization in Women After Abdominal Surgery for Ovarian Cancer 
Nursing research  2011;60(1):47-57.
Background
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.
Objective
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.
Method
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.
Results
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.
Discussion
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.
doi:10.1097/NNR.0b013e3181ff77e4
PMCID: PMC4186259  PMID: 21127451
ovarian cancer; advanced practice nurse; health care utilization; coordination of care; primary care; clinical home
9.  Evidence of Nonconscious Stereotyping of Hispanic Patients by Nursing and Medical Students 
Nursing research  2013;62(5):362-367.
Background
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.
Objectives
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.
Methods
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.
Results
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.
Discussion
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.
doi:10.1097/NNR.0b013e31829e02ec
PMCID: PMC3763916  PMID: 23995470
Nonconscious processes; stereotyping; Hispanic Americans; health care disparities; minority health; Implicit Associations Test; prejudice
10.  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.
Background
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.
Objective
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.
Methods
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.
Results
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.
Discussion
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.
doi:10.1097/NNR.0b013e3182a0316b
PMCID: PMC3805179  PMID: 23995469
sickle cell disease; sickle cell trait; reproductive behavior; young adult; randomized controlled trial
11.  Parent and Child Perceptions of a Self-Regulated, Home-Based Exercise Program for Children with Cystic Fibrosis 
Nursing research  2013;62(5):305-314.
Background
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.
Objectives
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.
Methods
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).
Results
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.
Discussion
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.
doi:10.1097/NNR.0b013e3182a03503
PMCID: PMC4053557  PMID: 23995464
Exercise; children; cystic fibrosis; chronic disease; qualitative research
12.  An Integrative Review of Factors Associated with Telomere Length and Implications for Biobehavioral Research 
Nursing research  2014;63(1):36-50.
Background
Although telomere shortening occurs as a natural part of aging, there is now a robust body of research that suggests that there is a relationship between psychosocial, environmental, and behavioral factors and changes in telomere length. These factors need to be considered when integrating telomere measurement in biobehavioral research studies.
Objectives
This article provides a brief summary of the known facts about telomere biology and an integrative review of current human research studies that assessed relationships between psychosocial, environmental, or behavioral factors and telomere length.
Methods
An integrative review was conducted to examine human research studies that focused on psychosocial, environmental, and behavioral factors affecting telomere length and telomerase activity using the electronic databases PubMed/Medline and CINAHL from 2003 to the present. In addition to the known individual factors that are associated with telomere length, the results of the integrative review suggest that perceived stress, childhood adversities, major depressive disorder, educational attainment, physical activity, and sleep duration should also be measured.
Discussion
Multiple factors have been shown to affect telomere length. To advance understanding of the role of telomere length in health and disease risk, it will be important to further elucidate the mechanisms that contribute to telomere shortening.
doi:10.1097/NNR.0000000000000009
PMCID: PMC4112289  PMID: 24335912
aging; biobehavior; nursing research; oxidative stress; psychological stress; telomere
13.  Getting to “The Point:” The Experience of Mothers Getting Assistance for Their Violent, Mentally Ill, Adult Children 
Nursing research  2008;57(3):136-143.
Background
If mentally ill individuals become violent, mothers are most often victims, yet there is little available research addressing how, when, and from whom mothers seek help for themselves and/or their children when they become victims of this form of familial violence.
Objectives
The purpose of this research was to describe how mothers understood violence their mentally ill, adult children exhibited towards them and to articulate the process mothers used to get assistance and access mental health treatment when this violence occurred.
Method
Grounded Theory methods were used to explore and analyze mothers’ experiences of violence perpetrated by their mentally ill, adult children. Eight mothers of violent, adult children with a diagnosed DSM Axis I disorder participated in one to two open-ended interviews. Mothers were of diverse ethnic backgrounds.
Results
Getting immediate assistance involved a period of living on high alert, during which mothers waited in frustration for their children to meet criteria for involuntary hospitalization. This was a chaotic and fearful period. Fear and uncertainty eventually outweighed mothers’ abilities to manage their children’s behavior, at which time they called the police or psychiatric evaluation teams, who served as gatekeepers to mental health treatment. Mothers accepted the consequences of being responsible for their children’s involuntary hospitalization or of being left home with their children if the gatekeepers did not initiate involuntary hospitalization.
Discussion
Mothers can identify signs of decompensation in their ill children and recognize their need for hospitalization. They cannot, however, always access mental health treatment due to their children’s refusal and/or failure to meet legal criteria for involuntary hospitalization. Mothers’ inability to intervene early sometimes results in their own violent victimization.
doi:10.1097/01.NNR.0000319500.90240.d3
PMCID: PMC4107905  PMID: 18496098
family violence; mental illness; mental health services; access to health care
14.  Cost Effectiveness Analysis for Nursing Research 
Nursing research  2013;62(4):279-285.
Background
With ever increasing pressure to reduce costs and increase quality, nurses are faced with the challenge of producing evidence that their interventions and care provide value. Cost effectiveness analysis (CEA) is a tool that can be used to provide this evidence by comparative evaluation of the costs and consequences of two or more alternatives.
Objectives
The aim of this article is to introduce the essential components of CEA to nurses and nurse researchers with the protocol of a recently funded cluster randomized controlled trial as an example.
Methods
This article provides: (a) a description of the main concepts and key steps in CEA, and (b) a summary of the background and objectives of a CEA designed to evaluate a nursing led pain and symptom management intervention in rural communities compared to current usual care.
Discussion
As the example highlights, incorporating CEA into nursing research studies is feasible. The burden of the additional data collection required is off-set by quantitative evidence of the given intervention's cost and impact using humanistic and economic outcomes. At a time when US health care is moving toward accountable care, the information provided by CEA will be an important additional component of the evidence produced by nursing research.
doi:10.1097/NNR.0b013e318298b0be
PMCID: PMC3706029  PMID: 23817285
cost effectiveness; cluster randomized clinical trial; pain management; rural health
15.  Nurse Care Coordination and Technology Effects on Health Status of Frail Elderly via Enhanced Self-management of Medication: Randomized Clinical Trial to Test Efficacy 
Nursing research  2013;62(4):269-278.
Background
Self-management of complex medication regimens for chronic illness is challenging for many older adults.
Objectives
The purpose of this study was to evaluate health status outcomes of frail older adults receiving a home-based support program that emphasized self-management of medications using both care coordination and technology.
Design
Randomized controlled trial with three arms and longitudinal outcome measurement.
Setting
Older adults having difficulty self-managing medications (N = 414) were recruited at discharge from three Medicare-certified home health care agencies in a Midwestern urban area.
Methods
All participants received baseline pharmacy screens. The control group received no further intervention. A team of advanced practice nurses and registered nurses coordinated care for 12 months to two intervention groups who also received either an MD.2 medication-dispensing machine or a medplanner. Health status outcomes (Geriatric Depression Scale, Mini-Mental Status Examination, Physical Performance Test, and the SF-36 Physical Component Summary and Mental Component Summary) were measured at baseline, 3, 6, 9, and 12 months.
Results
After covariate and baseline health status adjustment, time by group interactions for the MD.2 and medplanner groups on health status outcomes were not significant; time by group interactions were significant for medplanner and control group comparisons.
Discussion
Participants with care coordination had significantly better health status outcomes over time than those in the control group, but addition of the MD.2 machine to nurse care coordination did not result in better health status outcomes.
doi:10.1097/NNR.0b013e318298aa55
PMCID: PMC3706033  PMID: 23817284
health services for the aged; care coordination; medication therapy management; quality of life; randomized controlled trial
16.  Pretreatment Predictors of Short-term Nonadherence to Oral Hormonal Therapy for Women with Breast Cancer 
Nursing research  2013;62(4):243-251.
Background
Adjuvant treatment with oral hormonal therapy improves clinical outcomes for breast cancer, but women have difficulty adhering to the five-year regimen.
Objective
To explore pretreatment predictors of short-term nonadherence to oral hormonal therapy for women with early stage breast cancer from the pretreatment assessment to six months after initiation of hormonal therapy.
Method
A secondary analysis was performed using data collected from 198 women enrolled in one of two longitudinal studies. Nonadherence was defined as the percentage of prescribed doses of hormonal therapy not taken during the first six months of therapy measured using electronic medication event monitoring. Information on predictor variables was measured at pretreatment using self-report and medical record review. Linear regression analysis was performed to examine associations between predictor variables and six-month nonadherence in a bivariate manner to first identify candidate predictors variables at p < .20 and then multivariately considering candidate predictors identified through stepwise and backward elimination regression methods.
Results
Participants were white (98.3%), well educated (M = 15.0; SD = 2.9 years of schooling), and on average 59.1 years of age (SD = 7.5). Mean nonadherence was 11.3%. Stepwise and backward elimination modeling algorithms identified a similar set of predictors associated with six-month nonadherence and explained 13.0% of the variance (adjusted R2 = .11, standard error of the estimate = 0.28). Ductal carcinoma in situ tumor type (p = .004) and higher weight concern scores (p = .003) were associated with nonadherence.
Discussion
The findings suggest that additional examinations of associations of tumor type and symptom burden with nonadherence are indicated.
doi:10.1097/NNR.0b013e318298fd70
PMCID: PMC3723138  PMID: 23817282
medication nonadherence; breast neoplasms; tamoxifen; aromatase inhibitors
17.  Daytime Observed Emotional Expressions of People with Dementia 
Nursing research  2013;62(4):218-225.
Background
Emotional expression among people with dementia (PWD) may inform person-centered approaches to care and improvements in dementia-related quality of life.
Objectives
To examine frequency and variability of positive emotional expression and negative emotional expression, personal factors influencing positive and negative emotional expression, and trajectories of emotional expression among PWD during daytime hours.
Methods
We conducted a secondary analysis of daytime positive and negative emotional expressions of 30 PWD living in residential long term care who completed twelve 20-minute observation periods occurring hourly as part of a multi-site study of wandering behavior. Hierarchical linear modeling was used to examine relationships between influencing factors and frequency of emotional expressions; group-based trajectory analysis was applied to identify clusters of individuals with similar daytime patterns of emotional expression.
Results
Time of day (rate ratio [RR] = 1.05) and impaired mobility (RR = 1.37) significantly influenced positive emotional expression; gender (RR = 1.85), age (RR = 1.03), and education (RR = 0.54) were significantly related to negative emotional expression. Three distinct trajectory groups were identified for positive emotional expression: a low stable group, a fluctuating group displaying afternoon peaking, and a fluctuating group displaying morning peaking. Two trajectory groups were identified for negative emotional expression: a consistent pattern and an inconsistent pattern.
Discussion
PWD showed a broad range of emotional expression and significant within-person variation in daytime positive and negative emotional expressions. Observed emotional display is a promising measure of psychological well-being among PWD that, if more fully understood, could guide care approaches to improve quality of life.
doi:10.1097/NNR.0b013e31829999d7
PMCID: PMC3743662  PMID: 23817279
affect; dementia; group-based trajectory model; psychological well-being
18.  Using the Rasch Measurement Model in Psychometric Analysis of the Family Effectiveness Measure 
Nursing research  2013;62(3):149-159.
Background
Valid assessment of family functioning can play a vital role in optimizing client outcomes. Because family functioning is influenced by family structure, socioeconomic context, and culture, existing measures of family functioning--primarily developed with nuclear, middle class European American families--may not be valid assessments of families in diverse populations. The Family Effectiveness Measure was developed to address this limitation.
Objectives
To test the Family Effectiveness Measure with data from a primarily low-income African American convenience sample, using the Rasch measurement model.
Method
A sample of 607 adult women completed the measure. Rasch analysis was used to assess unidimensionality, response category functioning, item fit, person reliability, differential item functioning by race and parental status, and item hierarchy. Criterion-related validity was tested using correlations with five other variables related to family functioning.
Results
The Family Effectiveness Measure measures two separate constructs: The effective family functioning construct was a psychometrically sound measure of the target construct that was more efficient due to the deletion of 22 items. The ineffective family functioning construct consisted of 16 of those deleted items but was not as strong psychometrically. Items in both constructs evidenced no differential item functioning by race. Criterion-related validity was supported for both.
Discussion
In contrast to the prevailing conceptualization that family functioning is a single construct, assessed by positively and negatively worded items, use of the Rasch analysis suggested the existence of two constructs. While the effective family functioning is a strong and efficient measure of family functioning, the ineffective family functioning will require additional item development and psychometric testing.
doi:10.1097/NNR.0b013e31828eafe6
PMCID: PMC3678382  PMID: 23636342
19.  Underestimation of Adolescent Obesity 
Nursing research  2013;62(3):195-202.
Background
Previous studies assessing the validity of adolescent self-reported height and weight for estimating obesity prevalence have not accounted for potential bias due to non-response in self-reports.
Objectives
The purpose of this study was to assess the implications of selective non-response in self-reports of height and weight for estimates of adolescent obesity.
Methods
The authors analyzed 613 adolescents ages 12-17 from the 2006-08 Los Angeles Family and Neighborhood Survey, a longitudinal study of Los Angeles County households with an oversample of poor neighborhoods. Obesity prevalence estimates based on (1) self-report, (2) measured height and weight for those who did report, and (3) measured height and weight for those who did not report were compared.
Results
Among younger teens, measured obesity prevalence was higher for those who did not report height and weight compared to those who did (40% vs. 30). Consequently, obesity prevalence based on self-reported height and weight underestimated measured prevalence by 12 percentage points (when accounting for non-response) vs. 9 percentage points (when non-response was not accounted for). Results were robust to the choice of difference child growth references (i.e,, CDC vs. International Obesity Task Force).
Discussion
Adolescent obesity surveillance and prevention efforts must take into account selective non-response for self-reported height and weight, particularly for younger teens. Results should be replicated in a nationally-representative sample.
doi:10.1097/NNR.0b013e318286b790
PMCID: PMC4006016  PMID: 23636345
Adolescent; Obesity; Self Report
20.  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
21.  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
22.  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
23.  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
24.  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
25.  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

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