Publications

Abstract

Background: To meet the complex needs of patients with serious illness, health professional students require education in basics aspects of palliative care, including how to work collaboratively on an interprofessional team. Objectives: An educational program was created, implemented, and evaluated with students in medicine, nursing, chaplaincy, and social work. Five learning objectives emphasized spiritual, cultural, and interprofessional aspects of palliative care. Design: The program blended two sequential components: an online interactive, case-based learning module, and a live, dynamic simulation workshop. Measurements: Content analysis was used to analyze students' free-text responses to four reflections in the online case, as well as open-ended questions on students' postworkshop questionnaires, which were also analyzed quantitatively. Results: Analysis of 217 students' free-text responses indicated that students of all professions recognized important issues beyond their own discipline, the roles of other professionals, and the value of team collaboration. Quantitative analysis of 309 questionnaires indicated that students of all professions perceived that the program met its five learning objectives (mean response values>4 on a 5-point Likert scale), and highly rated the program and its two components for both educational quality and usefulness for future professional work (mean response values approximately>4). Conclusions: This innovative interprofessional educational program combines online learning with live interactive simulation to teach professionally diverse students spiritual, cultural, and interprofessional aspects of palliative care. Despite the challenge of balanced professional representation, this innovative interprofessional educational program met its learning objectives, and may be transferable for use in other educational settings.

Abstract

Objective: Treatment decision-making may be hindered by a lack of knowledge about the care options of curative, palliative, and hospice care. Our purpose was to create and validate an instrument to measure knowledge of these care options, the Knowledge of Care Options (KOCO) instrument. Methods: We began by generating a pool of true-false items. Experts (n=32) evaluated items in two rounds of review. For each round, we calculated Content Validity Indexes for each item and for the total scale (S-CVI). Items were revised or dropped as indicated. The clarity and acceptability of KOCO were assessed through cognitive interviews with 10 men and women with cancer. We pilot-tested KOCO with a target population sample of 23 women with metastatic breast cancer as part of larger study testing self-management training materials that included a module on care options. Results: Following expert review, the S-CVI was 85.2%, and the KOCO consisted of 11 items. Cognitive interviews showed KOCO to be clear and acceptable. The KR-20 test revealed high internal consistency of 0.89. In the pilot test, the mean pre-test score was 9.3 items correct (SD 1.29). The mean post-test score was 10.21 items correct (SD 0.92). KOCO captured change in knowledge of care options (signed rank test=42.5, p<0.006). Conclusions: KOCO is a brief, acceptable instrument capable of assessing knowledge of curative, palliative, and hospice care. Additional testing is needed with larger samples to assess the utility of KOCO for use with various patient populations, family caregivers, and clinicians.

Abstract

The National Consensus Project for Quality Palliative Care (NCP) has put forth eight domains of clinical practice guidelines that address the multidisciplinary nature of palliative and end-of-life (EOL) care. Extant surveys to assess education needs of palliative and EOL workers, however, have been constructed for individual professions. Thus we developed the End-of-life Professional Caregiver Survey (EPCS) as an instrument for assessing the palliative and EOL care-specific educational needs of multidisciplinary professionals.

Abstract

Data on the impact of student, teacher, and principal racial and gender composition in urban schools on teacher work outcomes are limited. This study, a secondary data analysis of White and Black urban public school teachers using data taken from the restricted use 2003-04 Schools and Staffing Survey (SASS), examines the effects of relational demography on teacher job satisfaction adjusting for other known determinants of job satisfaction. Relational demography is conceptualized as a set of racial and gender congruency items between teachers and principals, teachers and teachers, and teachers and students. The results of the study show that some components of relational demography directly affect teacher job satisfaction, over and above the effects of work-related attitudes.

Abstract

Introduction: Antiretroviral treatment (ART) and pre-exposure prophylaxis (PrEP) have demonstrated efficacy as new human immunodeficiency virus-1 (HIV-1) prevention approaches for HIV-1 serodiscordant couples. Methods: Among Kenyan HIV-1 serodiscordant heterosexual couples participating in a clinical trial of PrEP, we conducted a cross-sectional study and used descriptive statistical methods to explore couples' willingness to use antiretrovirals for HIV-1 prevention. The study was conducted before July 2011, when studies among heterosexual populations reported that ART and PrEP reduced HIV-1 risk. Results: For 181 couples in which the HIV-1-infected partner had a CD4 count 350 cells per microliter and had not yet initiated ART (and thus did not qualify for ART under Kenyan guidelines), 60.2% of HIV-1 infected partners (69.4% of men and 57.9% of women) were willing to use early ART (at CD4 350 cells per microliter) for HIV-1 prevention. Among HIV-1 uninfected partners, 92.7% (93.8% of men and 86.1% of women) reported willingness to use PrEP. When given a hypothetical choice of early ART or PrEP for HIV-1 prevention, 52.5% of HIV-1-infected participants would prefer to initiate ART early and 56.9% of HIV-1-uninfected participants would prefer to use PrEP. Conclusions: Nearly 40% of Kenyan HIV-1-infected individuals in known HIV-1 serodiscordant partnerships reported reservations about early ART initiation for HIV-1 prevention. PrEP interest in this PrEP-experienced population was high. Strategies to achieve high uptake and sustained adherence to ART and PrEP for HIV-1 prevention in HIV-1 serodiscordant couples will require responding to couples' preferences for prevention strategies.

Abstract

Background: The impact of registered nurse (RN) staffing on patient care quality has been extensively studied. Identifying additional modifiable work environment factors linked to patient care quality is critical as the projected shortage of approximately 250,000 RNs over the next 15 years will limit institutions' ability to rely on RN staffing alone to ensure high-quality care. Purpose: Weexamined the association between RNs' ratings of patient care quality and several novelwork environment factors adjusting for the effects of two staffing variables: reported patient-to-RN ratios and ratings of staffing adequacy. Methodology: We used a cross-sectional, correlational design and a mailed survey to collect data in 2009 from a national sample of RNs (n = 1,439) in the United States. A multivariate logistic regression was used to analyze the data. Findings: Workgroup cohesion, nurseYphysician relations, procedural justice, organizational constraints, and physical work environment were associated with RNs' ratings of quality, adjusting for staffing. Furthermore, employment in a Magnet hospital and job satisfaction were positively related to ratings of quality, whereas supervisory support was not. Practice Implications: Our evidence demonstrates the importance of considering RN work environment factors other than staffing when planning improvements in patient care quality. Health caremanagers can use the results of our study to strategically allocate resources toward work environment factors that have the potential to improve quality of care.

Abstract

Purpose: To examine the psychometric properties of the 9-item Fatigue Severity Scale (FSS) using a Rasch model application. Methods: A convenience sample of HIV-infected adults was recruited, and a subset of the sample was assessed at 6-month intervals for 2 years. Socio-demographic, clinical, and symptom data were collected by self-report questionnaires. CD4 T-cell count and viral load measures were obtained from medical records. The Rasch analysis included 316 participants with 698 valid questionnaires. Results: FSS item 2 did not advanced monotonically, and items 1 and 2 did not show acceptable goodness-of-fit to the Rasch model. A reduced FSS 7-item version demonstrated acceptable goodness-of-fit and explained 61.2% of the total variance in the scale. In the FSS-7 item version, no uniform Differential Item Functioning was found in relation to time of evaluation or to any of the socio-demographic or clinical variables. Conclusion This study demonstrated that the FSS-7 has better psychometric properties than the FSS-9 in this HIV sample and that responses to the different items are comparable over time and unrelated to socio-demographic and clinical variables.

Abstract

Background: Diabetes technology has the potential to provide useful data for theory-based behavioral counseling. The aims of this study are to evaluate the feasibility, acceptability, and preliminary efficacy of a continuous glucose monitoring and problem-solving counseling intervention to change physical activity (PA) behavior in women with type 2 diabetes. Methods: Women (n=29) with type 2 diabetes were randomly assigned to one of two treatment conditions: continuous glucose counseling and problem-solving skills or continuous glucose monitoring counseling and general diabetes education. Feasibility data were obtained on intervention dose, implementation, and satisfaction. Preliminary efficacy data were collected at baseline and 12 weeks on the following measures: PA amount and intensity, diet, problem-solving skills, self-efficacy for PA, depression, hemogoloin A1c, weight, and blood pressure. Demographic and implementation variables were described using frequency distributions and summary statistics. Satisfaction data were analyzed using Wilcoxon rank. Differences between groups were analyzed using linear mixed-modeling. Results: Women were mostly white/non-Latina with a mean age of 53 years, a 6.5-year history of diabetes, and suboptimal glycemic control. Continuous glucose monitoring plus problem-solving group participants had significantly greater problem-solving skills and had greater, although not statistically significant, dietary adherence, moderate activity minutes, weight loss, and higher intervention satisfaction pre-to post-intervention than did participants in the continuous glucose monitoring plus education group. Conclusion: A continuous glucose monitoring plus problem-solving intervention was feasible and acceptable, and participants had greater problem-solving skills than continuous glucose monitoring plus education group participants.

Abstract

During the past 2 decades, life-course social-ecological frameworks have emerged across health, developmental, social, behavioral, and public health disciplines as useful models for explaining how health trajectories develop over an individual's lifetime and how this knowledge can guide and inform new approaches to clinical and public health practice, multilevel policies, and research. Viewed from this perspective, and with emphasis on global cardiovascular health promotion and prevention of cardiovascular disease (CVD), this article summarizes evidence on the early origins and progression of CVD processes across the life course of individuals and diverse populations. Current evidence-based guidelines for CVD prevention are summarized, and recommendations for future research are suggested.

Abstract

During the past 2 decades, life-course social-ecological frameworks have emerged across health, developmental, social, behavioral, and public health disciplines as useful models for explaining how health trajectories develop over an individual's lifetime and how this knowledge can guide and inform new approaches to clinical and public health practice, multilevel policies, and research. Viewed from this perspective, and with emphasis on global cardiovascular health promotion and prevention of cardiovascular disease (CVD), this article summarizes evidence on the early origins and progression of CVD processes across the life course of individuals and diverse populations. Current evidence-based guidelines for CVD prevention are summarized, and recommendations for future research are suggested.

Abstract

Aims. This paper is a report of a descriptive comparative pilot study of use of a method that simultaneously tests the content validity and quality of translation of English-to-Chinese translations of two patient satisfaction questionnaires: the La Monica-Oberst Patient Satisfaction Scale and Hospital Consumer Assessment of Healthcare Providers and Systems. Background. Patient satisfaction is an important indicator of the quality of healthcare services. In China, however, few good translations of patient satisfaction instruments sensitive to nursing services exist. Methods. The descriptive pilot study took place in 2009 and used content validity indexing techniques to evaluate the content, context and criterion relevance of a survey question. The expert raters were 10 nursing faculty and 10 patients who evaluated the two patient satisfaction questionnaires. The experts evaluated the relevance of each item on a scale of 1-4 and the research team compared their responses to choose the most appropriate. Only the nurse faculty experts, who were bilingual, evaluated the quality of the translation using a binary rating. Results. The 'Nurse Rater' relevance scores of the LaMonica-Oberst Patient Satisfaction Scale and the Hospital Consumer Assessment of Healthcare Providers and Systems were 0·96 and 0·95 respectively, whereas the patient's overall relevance scores were 0·89 and 0·95. A Mann-Whitney U-test demonstrated that results between the two groups were statistically significantly different (P=0·0135). Conclusions. Using content validity indexing simultaneously with translation processes was valuable for selecting and evaluating survey instruments in different contexts.

Abstract

Background: Most heart failure (HF) patients have other comorbid conditions. HF self-care requires medication and diet adherence, daily weight monitoring, and a thoughtful response to symptoms when they occur. Self-care is complicated when other chronic conditions have additional self-care requirements. The purpose of this study is to explore how comorbidity influences HF self-care. Methods: Using qualitative descriptive meta-analysis techniques, transcripts from 3 mixed methods studies (n = 99) were reexamined to yield themes about perceptions about HF and self-care and to explore the influence on HF self-care. The Charlson Comorbidity Index identified comorbid conditions. Results: The sample was 74% Caucasian, 66% male (mean age of 59.6 years ± 15 years). Fifty-three percent of the sample was New York Heart Association Class III. All had at least 1 other chronic condition. Narrative accounts revealed that adherence to diet, symptom monitoring, and differentiating symptoms from multiple conditions were the most challenging self-care skills. Emerging themes included 1) attitudes drive self-care prioritization and 2) fragmented self-care instruction leads to poor self-care integration and self-care skill deficits. Conclusions: Individuals with multiple chronic conditions are vulnerable to poor self-care. Research testing coaching interventions that integrate self-care requirements and focus on developing skill in self-care across multiple chronic conditions is needed.

Abstract

Objective: The findings from several studies suggest that palliative care patients with advanced cancer experience multiple symptoms, and that these symptoms may be related to demographic and clinical factors as well as to patient outcomes. However, no systematic review has summarized the findings from studies that assessed multiple symptoms, predictors, and outcomes in these patients. The purposes of this review, focused on palliative care patients with advanced cancer, are to: 1) describe the relationships among multiple symptoms; 2) describe the predictors of multiple symptoms; and 3) describe the relationships between multiple symptoms and patient outcomes. Method: Comprehensive literature searches were completed using the following databases: PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsychInfo. The key words: cancer or advanced cancer or neoplasm, AND palliative care or terminal care or hospice or end-of-life, AND symptoms or multiple symptoms or symptom clusters were combined.Results: Twenty-two studies met the inclusion criteria and examined at least one of our purposes. The majority of these studies were descriptive and used one of four common symptom assessment scales. Fifty-six different signs and symptoms were evaluated across various dimensions (i.e., prevalence, severity, distress, frequency, control). Pain, dyspnea, and nausea were the only symptoms measured in all 22 studies. Relationships among concurrent symptoms were examined in nine studies. Relationships among symptoms and predictors (i.e., demographics, cancer type, healthcare delivery environment) were examined in seven studies. Relationships among symptoms and outcomes (i.e., functional status, psychological status, quality-of-life, survival time) were examined in 14 studies. Significant methodological variation was found among these studies.Significance of results: It is difficult to draw conclusions about the relationships among multiple symptoms, predictors, and outcomes due to the heterogeneity of these studies. Future research is needed to determine which symptoms and symptom dimensions to assess in order to better understand how multiple symptoms relate to each other as well to as predictors and outcomes in palliative care patients with advanced cancer.

Abstract

Purpose: The mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and to promote equitable maternity care in California. This article describes California Maternal Quality Care Collaborative's (CMQCC's) statewide multistakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success. Project Design and Approach: In partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multidisciplinary, multistakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage. Project Description: The OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multilevel strategy to disseminate the guideline, including an open access toolkit, a minimal support-mentoring model, a county partnership model, and a 30-hospital learning collaborative. Clinical Implications: In participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 (or greater) hemorrhage, hosting skills stations for measuring blood loss, and running obstetric (OB) hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the statewide initiative in which nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multidisciplinary, multistakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkit's enthusiastic adoption at the unit/service level in facilities across the state.

Abstract

This paper examines changes in the interval between first heroin smoking and onset of injection in a large, out-treatment sample of male heroin users in Hanoi, Vietnam (n = 1,115). Mean age at initiation of heroin use (smoking) was 18.4 and mean age of onset of heroin injection was 20.9 years. Full multivariate analysis indicates that the interval between first heroin use (smoking) and first heroin injection has been significantly attenuated among more recent heroin initiates (P = 0.0043), suggesting that heroin users in Vietnam may be at increased risk for exposure to HIV relatively soon after onset of heroin use, highlighting the need for behavioral interventions that target heroin smokers. Critical intervention goals include delaying the onset of injection and improved education about safer drug sharing and drug injection practices.

Abstract

Substance misusers are at risk for contracting HIV/AIDS, and substance user treatment programs (SUTPs)1 are uniquely situated to address their HIV-related needs. In New York State, some SUTPs have implemented a centralized model of substance user treatment and HIV care. We synthesize past literature and use data from semistructured interviews with SUTP staff, analyzed with qualitative software, to describe implementation barriers. These interviews were conducted in 2003-2004 at three SUTPs in Texas and New York as part of a study funded by the National Institutes of Health. With study limitations noted, main implications include a need for a combined medical-addiction treatment philosophy to facilitate multidisciplinary care.