Publications

Abstract

Women's health care providers have noted an increased infant mortality rate among Ghanaian immigrants. We conducted focus groups with 17 women in Ghana. We asked them how they maintained their health both before and during pregnancy. When discussing their health, women repeatedly described the conditions or context of their daily lives and the traditional practices that they used to stay healthy. Knowledge of women's lives, the health care system that they previously used, and their cultural practices can be utilized by health care providers to more fully assess their patients and design more culturally appropriate care for this group of women.

Abstract

An eight-point action plan is proposed for lowering costs associated with end-of-life health care in the United States, as well as improving the quality of life experienced by patients and their families. This action plan was derived from an analysis of the six articles presented in this special issue of Nursing Ecanomic$. The two major features of this action plan are: (a) expansion of hospice and palliative care, as well as (b) increased use of advance directives. Additionally, as pre-conditions for the effective operation of this action plan, the political, cultural, and legislative contexts that merit attention are discussed. Finally, arguments as to the desirability, feasibility, and sustainability of this action plan are offered.

Abstract

Background: Clinicians use CA125, a tumor-associated antigen, primarily to monitor epithelial ovarian cancer. However, CA125 lacks the sensitivity and specificity necessary for population-based screening in healthy women. The purpose of this study was to determine if serum concentrations of CA125 differed across the three phases of the menstrual cycle in healthy, premenopausal women using two commercially available assays. Methods: Healthy, Caucasian women between the ages of 18 and 39 were enrolled using strict criteria to exclude factors known to contribute to CA125 fluctuations. Menstrual cycle regularity was determined using calendars maintained by participants for 3 months. After cycle regularity was established, blood was drawn at three time points for CA125 determination using two commercial assays (i.e., Siemens and Panomics). Results: Regardless of the assay used, CA125 values were highest during menses. The CA125 values decreased 0.2 U/ml per day from menses to the end of the same cycle, which resulted in a net decrease of 5.8 U/ml across the cycle. Conclusions: The two commercial assays for CA125 determination demonstrated good concordance in terms of reference ranges regardless of epitope differences. While CA125 levels changed over the course of the menstrual cycle, these changes may not be clinically significant in healthy women. This study is the first to control for factors known to contribute to CA125 elevations; to quantify a decrease in CA125 levels across the menstrual cycle; and to confirm concordance in the relative decreases in serum CA125 levels across the menstrual cycle between two frequently used commercial assays.

Abstract

Context: Sleep disturbance is a significant problem in oncology patients. Objectives: To examine how actigraphy and self-report ratings of sleep disturbance changed over the course of and after radiation therapy (RT); investigate whether specific patient, disease, and symptom characteristics predicted the initial levels and/or the characteristics of the trajectories of sleep disturbance; and compare predictors of subjective and objective sleep disturbance. Methods: Patients (n = 73) completed self-report questionnaires that assessed sleep disturbance, fatigue, depressive symptoms, anxiety, and pain before the initiation of RT through four months after the completion of RT. Wrist actigraphy was used as the objective measure of sleep disturbance. Hierarchical linear modeling was used for data analyses. Results: Mean wake after sleep onset was 11.9% and mean total score on the General Sleep Disturbance Scale was 45. More than 85% of the patients had an abnormally high number of nighttime awakenings. Substantial interindividual variability was found for both objective and subjective measures of sleep disturbance. Body mass index predicted baseline levels of objective sleep disturbance. Comorbidity, evening fatigue, and depressive symptoms predicted baseline levels of subjective sleep disturbance, and depressive symptoms predicted the trajectory of subjective sleep disturbance. Conclusion: Different variables predicted sleep disturbance using subjective and objective measures. The slightly elevated wake after sleep onset found may be an underestimation of the degree of sleep disturbance when it is evaluated in the context of the high number of nighttime awakenings and patient's perception of poor sleep quality and quantity.

Abstract

An important domain that emerged from the interpretation of 91 nurse manager (NM) narratives was achieving the right relationship between a NM and a recalcitrant staff member. This article depicts the qualitative distinctions in 2 stages of NM practice to show the importance of reflection on experiential learning in the development of expertise. This work confirms that NM development is more complex than teaching a curriculum of business and management theory and should include teaching for mastery of the skilled know-how of clinical leadership practice and formation of the person as manager.

Abstract

Background: This pilot study examines whether a novel diabetes screening approach using gingival crevicular blood (GCB) could be used to test for hemoglobin A1c (HbA1c) during periodontal visits. Methods: Finger-stick blood (FSB) samples from 120 patients and GCB samples from those patients with adequate bleeding on probing (BOP) were collected on special blood collection cards and analyzed for HbA1c levels in a laboratory. The Pearson correlation coefficient was used to measure correlation between FSB and GCB HbA1c values for 75 paired FSB and GCB samples. A receiver-operator characteristic curve (ROC) analysis was performed to determine an optimal GCB HbA1c criterion value for a positive diabetes screen. Results: For the 75 paired samples, the Pearson correlation coefficient was 0.842. The ROC analysis identified a criterion value of 6.3% for the GCB HbA1c test with high sensitivity (0.933) and high specificity (0.900), corresponding to FSB HbA1c values ≥6.5% (in the diabetes range). Using this GCB HbA1c criterion value for 27 additional paired samples, in which there was an unidentified component observed to coelute within the elution window of GCB HbA1c in the laboratory, there was agreement between FSB and GCB values for 24 of the pairs according to whether both were within or outside of the diabetes range. Conclusion: Using a criterion value of 6.3%, GCB samples are acceptable for HbA1c testing to screen for diabetes in most persons with BOP at the GCB collection site.

Abstract

Objective: Puerto Rico has one of the fastest growing HIV epidemics in the United States and - consistent with patterns observed in the Caribbean region as a whole - data on new infections shows the increased influence of sexual transmission in the local epidemic. Historically, both epidemiology and prevention activities have focused primarily on the islands' large heroin injector population. Although the available surveillance data indicate high rates of STIs and HIV among men who have sex with men (MSM), there has been little social and behavioral research among MSM and hence little empirical information to inform intervention development and planning. Methods: Given the absence of data on MSM and their importance in the emerging epidemic on the island, this paper describes a sample of MSM patients in an STI/ HIV treatment center in the San Juan metropolitan area between October 2009 and June 2011 (n=120). Assessment of sexual risk includes measures of onset of oral, vaginal, and anal sex, as well as current sexual practices and partner characteristics. Self-reported history of STI diagnoses and current HIV status are described. Results: Overall, MSM evidenced relatively large numbers of multiple, concurrent sexual partners, substantial age-discordance among partners, and limited condom use. Relative to HIV-negative MSM, HIV-positive MSM have had more cumulative male sexual partners in anal intercourse (p=0.005). HIV-negative MSM were more likely to have had sex without a condom at last receptive anal intercourse (p=0.012) as well as at last insertive anal sex intercourse (p=0.001). Conclusion: Priorities for advancing HIV interventions for MSM are delineated, including the need for targeted sexual health interventions, mental health services, and improved strategies for engaging and retaining MSM in health services.

Abstract

Background: Many women stop smoking during pregnancy. Factors associated with relapse are known, but no intervention prevents the return to smoking among pregnant women. The objective of this study was to determine why women return to smoking after prolonged abstinence during pregnancy by examining mothers' intention to smoke at the time of delivery and the perceptions that shape their intention. Methods: We conducted in-depth, semi-structured interviews during their postpartum hospital stay with 24 women who stopped smoking while pregnant. We asked participants whether they intended to resume smoking after pregnancy and why. Transcripts were analyzed using grounded theory-based qualitative methods to identify themes. Results: Participants ranged in age from 18 to 36years, and 63 percent were white. Three themes emerged from the interviews with the mothers: 1) they did not intend to return to smoking but doubted whether they would be able to maintain abstinence; 2) they believed that it would be possible to protect their newborns from the harms of cigarette smoke; and 3) they felt that they had control over their smoking and did not need help to maintain abstinence after pregnancy. Conclusions: Although most participants did not intend to resume smoking, their intentions may be stymied by their perceptions about second-hand smoke and by their overestimation of their control over smoking. Further study should quantify these barriers and determine their evolution over the first year after pregnancy with the goal of informing more successful, targeted interventions.

Abstract

Background: Studies of the nursing work environment are increasingly common in developed countries, but few exist in developing countries. Because of resource differences between the two contexts, researchers need to clarify what aspects of the work environments are similar and different. Objectives: To study the perspectives of Mexican nurses about their work environments to determine similarities and differences to results from developed world studies. Design: A secondary, directed content analysis of qualitative data from 46 Spanish language interviews using workplace-oriented themes. Setting: Purposively selected Mexican states from four regions of the country that reflect the country's socioeconomic differences. Participants: Practicing Mexican nurses with at least 1. year of clinical experience and currently working in nursing. Participants were recruited through convenience and snowball sampling techniques. Methods: Initial data collection occurred in 2006 and 2008 during a broader study about professionalization processes that occurred in Mexican nursing between 1980 and 2005. The secondary, directed content analysis focused on an in-depth exploration of a central theme that emerged from the two original studies: the workplace. The directed content analysis used themes from the global nursing work environment literature to structure the analysis: professional relationships, organizational administrative practices, and quality of care and services. Results: The three themes from the global literature were relevant for the Mexican context and a new one emerged related to hiring practices. By category, the same factors that created positive or negative perceptions of the work environment matched findings from other international studies conducted in developed countries. The descriptors of the category, however, had different conceptual meanings that illustrate the health system challenges in Mexico. Conclusions: Findings from this study suggest that studies that seek to measure nursing work environments will most likely apply in Mexico and other Latin American or middle-income countries. Instruments designed to measure the work environment of nurses in these countries may prove relevant in those contexts, but require careful adaptation and systematic translations to ensure it.

Abstract

Background. Efavirenz exhibits marked interindividual variability in plasma levels and toxicities. Prior pharmacogenetic studies usually measure exposure via single plasma levels, examine limited numbers of polymorphisms, and rarely model multiple contributors. We analyzed numerous genetic and nongenetic factors impacting short-term and long-term exposure in a large heterogeneous population of human immunodeficiency virus (HIV)-infected women. Methods. We performed 24-hour intensive pharmacokinetic studies in 111 women receiving efavirenz under actual-use conditions and calculated the area-under-the-concentration-time curve (AUC) to assess short-term exposure; the efavirenz concentration in hair was measured to estimate long-term exposure. A total of 182 single-nucleotide polymorphisms (SNPs) and 45 haplotypes in 9 genes were analyzed in relationship to exposure by use of multivariate models that included a number of nongenetic factors. Results. Efavirenz AUCs increased 1.26-fold per doubling of the alanine aminotransferase level and 1.23-fold with orange and/or orange juice consumption. Individuals with the CYP2B6 516TT genotype displayed 3.5-fold increases in AUCs and 3.2-fold increases in hair concentrations, compared with individuals with the TG/GG genotype. Another SNP in CYP2B6 (983TT) and a p-glycoprotein haplotype affected AUCs without substantially altering long-term exposure. Conclusions. This comprehensive pharmacogenomics study showed that individuals with the CYP2B6 516TT genotype displayed >3-fold increases in both short-term and long-term efavirenz exposure, signifying durable effects. Pharmacogenetic testing combined with monitoring of hair levels may improve efavirenz outcomes and reduce toxicities.

Abstract

Abstract. Background: Over the last decades, converging forces in hospital care, including cost-containment policies, rising healthcare demands and nursing shortages, have driven the search for new operational models of nursing care delivery that maximize the use of available nursing resources while ensuring safe, high-quality care. Little is known, however, about the distinctive features of these emergent nursing care models. This article contributes to filling this gap by presenting a theoretically and empirically grounded taxonomy of nursing care organization models in the context of acute care units in Quebec and comparing their distinctive features. Methods. This study was based on a survey of 22 medical units in 11 acute care facilities in Quebec. Data collection methods included questionnaire, interviews, focus groups and administrative data census. The analytical procedures consisted of first generating unit profiles based on qualitative and quantitative data collected at the unit level, then applying hierarchical cluster analysis to the units profile data. Results: The study identified four models of nursing care organization: two professional models that draw mainly on registered nurses as professionals to deliver nursing services and reflect stronger support to nurses professional practice, and two functional models that draw more significantly on licensed practical nurses (LPNs) and assistive staff (orderlies) to deliver nursing services and are characterized by registered nurses perceptions that the practice environment is less supportive of their professional work. Conclusions: This study showed that medical units in acute care hospitals exhibit diverse staff mixes, patterns of skill use, work environment design, and support for innovation. The four models reflect not only distinct approaches to dealing with the numerous constraints in the nursing care environment, but also different degrees of approximations to an ideal nursing professional practice model described by some leaders in the contemporary nursing literature. While the two professional models appear closer to this ideal, the two functional models are farther removed.

Abstract

In the current educational environment, increasing numbers of advanced practice nursing (APN) students compete for decreasing numbers of clinical sites where patient safety is paramount. Clinical simulations with high-fidelity human patient simulators provide APN students opportunities to demonstrate clinical skills and judgment in a safe supportive environment. Development, implementation, and preliminary evaluation of a scenario for APN students are discussed. Faculty and student evaluations are reviewed as well as recommendations for future simulations.

Abstract

Ongoing antiretroviral therapy (ART) adherence and secondary HIV transmission-risk reduction (positiveprevention) support are needed in resource-limited settings. We evaluated a nurse-delivered counseling intervention in Kenya. We trained 90 nurses on a brief counseling algorithm that comprised ART and sexual-risk assessment, risk-reduction messages, and health-promotion planning. Self-reported measures were assessed before, immediately after, and 2 months post-training. Consistent ART adherence assessment was reported by 29% of nurses at baseline and 66% at 2 months post-training (p < .001). Assessment of patient sexual behaviors was 25% at baseline and 60% at 2 months post-training (p < .001). Nurse practice behaviors recommended in the counseling algorithm improved significantly at 2 months post-training compared with baseline, odds ratios 4.30-10.50. We found that training nurses in clinical counseling for ART adherence and positive prevention is feasible. Future studies should test impact of nurse counseling on patient outcomes in resource-limited settings.

Abstract

A growing body of literature suggests that lesbian, gay, bisexual, and transgender (LGBT) persons have significant health disparities as compared to heterosexuals. Although the reasons for this are complex and multifactorial, one area of research has examined the real or perceived negative attitudes of health-care providers. This integrative review critically appraises and synthesizes data from 17 articles regarding nurses' attitudes towards LGBT patients. Every study analyzed showed some evidence of negative attitudes. However, the literature revealed major limitations, including a paucity of well-designed studies; a dearth of qualitative studies; inconsistent use of validated, reliable instruments; and a lack of measures examining attitudes towards lesbian, bisexual, and transgender persons. Increased knowledge in this area could lead to interventions to improve nurses' cultural competency; resource allocation to nursing research, education, and services related to LGBT health; and inclusion of more LGBT content in nursing curricula.

Abstract

UNLABELLED: Previous studies have shown familial aggregation of insulin resistance and nonalcoholic fatty liver disease (NAFLD). Therefore, we aimed to examine whether family history of diabetes mellitus (DM) is associated with nonalcoholic steatohepatitis (NASH) and fibrosis in patients with NAFLD. This was a cross-sectional analysis in participants of the NAFLD Database study and PIVENS trial who had available data on family history of DM. One thousand and sixty-nine patients (63% women), with mean age of 49.6 (± 11.8) years and body mass index (BMI) of 34.2 (± 6.4) kg/m(2) , were included. Thirty percent had DM, and 56% had a family history of DM. Both personal history of DM and family history of DM were significantly associated with NASH, with an odds ratio (OR) of 1.93 (95% confidence interval [CI]: 1.37-2.73; P <0.001) and 1.48 (95% CI: 1.11-1.97; P = 0.01) and any fibrosis with an OR of 3.31 (95% CI: 2.26-4.85; P < 0.001) and 1.66 (95% CI: 1.25-2.20; P < 0.001), respectively. When the models were adjusted for age, sex, BMI, ethnicity, and metabolic traits, the association between diabetes and family history of DM with NASH showed an increased adjusted OR of 1.76 (95% CI: 1.13-2.72; P < 0.001) and 1.34 (95% CI: 0.99-1.81; P = 0.06), respectively, and with any fibrosis with a significant adjusted OR of 2.57 (95% CI: 1.61-4.11; P < 0.0001) and 1.38 (95% CI: 1.02-1.87; P = 0.04), respectively. After excluding patients with personal history of diabetes, family history of DM was significantly associated with the presence of NASH and any fibrosis with an adjusted OR of 1.51 (95% CI: 1.01-2.25; P = 0.04) and 1.49 (95% CI: 1.01-2.20; P = 0.04), respectively.CONCLUSIONS: Diabetes is strongly associated with risk of NASH, fibrosis, and advanced fibrosis. Family history of diabetes, especially among nondiabetics, is associated with NASH and fibrosis in NAFLD.

Abstract

Because multiple symptoms associated with " sickness behavior" have a negative impact on functional status and quality of life, increased information on the mechanisms that underlie inter-individual variability in this symptom experience is needed. The purposes of this study were to determine: if distinct classes of individuals could be identified based on their experience with pain, fatigue, sleep disturbance, and depression; if these classes differed on demographic and clinical characteristics; and if variations in pro- and anti- inflammatory cytokine genes were associated with latent class membership.Self-report measures of pain, fatigue, sleep disturbance, and depression were completed by 168 oncology outpatients and 85 family caregivers (FCs). Using latent class profile analysis (LCPA), three relatively distinct classes were identified: those who reported low depression and low pain (83%), those who reported high depression and low pain (4.7%), and those who reported high levels of all four symptoms (12.3%). The minor allele of IL4 rs2243248 was associated with membership in the " All high" class along with younger age, being White, being a patient (versus a FC), having a lower functional status score, and having a higher number of comorbid conditions.Findings suggest that LPCA can be used to differentiate distinct phenotypes based on a symptom cluster associated with sickness behavior. Identification of distinct phenotypes provides new evidence for the role of IL4 in the modulation of a sickness behavior symptom cluster in oncology patients and their FCs.

Abstract

The purposes of this study were to determine the occurrence rate for preoperative breast pain; describe the characteristics of this pain; evaluate for differences in demographic and clinical characteristics; and evaluate for variations in pro- and anti-inflammatory cytokine genes between women who did and did not report pain. Patients (n = 398) were recruited prior to surgery and completed self-report questionnaires on a number of pain characteristics. Genotyping was done using a custom genotyping array. Women (28.2%) who reported breast pain were significantly younger (P <.001); more likely to be nonwhite (P =.032); reported significantly lower Karnofsky Performance Status scores (P =.008); were less likely to be postmenopausal (P =.012); and had undergone significantly more biopsies (P =.006). Carriers of the minor allele for a single nucleotide polymorphism in interleukin (IL)1-receptor 1 (IL1R1) (rs2110726) were less likely to report breast pain prior to surgery (P =.007). Carriers of the minor allele for a single nucleotide polymorphism in IL13 (rs1295686) were more likely to report breast pain prior to surgery (P =.019). Findings suggest that breast pain occurs in over a quarter of women who are about to undergo breast cancer surgery. Based on phenotypic and genotypic characteristics found, inflammatory mechanisms contribute to preoperative breast pain. Perspective: In women with breast cancer, preoperative pain may be associated with increases in inflammatory responses associated with an increased number of biopsies. In addition, differences in cytokine genes may contribute to this preoperative breast pain.

Abstract

Objectives: To explore the relationship between inpatient mortality and implicit rationing of nursing care, the quality of nurse work environments and the patient-to-nurse staffing ratio in Swiss acute care hospitals. Design: Cross-sectional correlational design. Setting: Eight Swiss acute care hospitals examined in a survey-based study and 71 comparison institutions. Participants: A total of 165 862 discharge abstracts from patients treated in the 8 RICH Nursing Study (the Rationing of Nursing Care in Switzerland Study) hospitals and 760 608 discharge abstracts from patients treated in 71 Swiss acute care hospitals offering similar services and maintaining comparable patient volumes to the RICH Nursing hospitals. Main outcome measures: The dependent variable was inpatient mortality. Logistic regression models were used to estimate the effects of the independent hospital-level measures. Results: Patients treated in the hospital with the highest rationing level were 51% more likely to die than those in peer institutions (adjusted OR: 1.51, 95% CI: 1.34-1.70). Patients treated in the study hospitals with higher nurse work environment quality ratings had a significantly lower likelihood of death (adjusted OR: 0.80, 95% CI: 0.67-0.97) and those treated in the hospital with the highest measured patient-to-nurse ratio (10:1) had a 37% higher risk of death (adjusted OR: 1.37, 95% CI: 1.24-1.52) than those in comparison institutions. Conclusions: Measures of rationing may reflect care conditions that place hospital patients at risk of negative outcomes and thus deserve attention in future hospital outcomes research studies.

Abstract

HIV-infected patients have considerable need for alcohol reduction support, and HIV care providers are strategically placed to implement a " prevention for positives" alcohol-reduction approach through alcohol screening and brief interventions (SBIs). To facilitate this approach, we provided alcohol SBI education and training to HIV care providers in four hospital-based, New York City HIV Care Centers in 2007. Interviews with the medical directors and 14 of the HIV care providers who attended the training identified barriers to implementing alcohol SBIs. These included limited time for alcohol screening, patients' incomplete disclosure of alcohol use, providers' perceptions that alcohol use is not a major problem for their patients, and provider specialization that assigns patients with problematic alcohol use to specifically designated providers. Identified facilitators for alcohol SBI implementation included adequate time to conduct the SBI; availability of information, tools, and key points to emphasize with HIV-infected patients; and use of a brief alcohol screening tool.

Abstract

Drawing from role theory, this study sought to explore the effects of assuming a new role on Latina community health workers (CHW) participating in a cervical cancer prevention program in a new Latino immigrant community located on the East Coast of the United States. Through a series of in-depth, Spanish language interviews with the 4 participants, the researchers explored the process and effects of assuming and enacting the CHW role through a narrative analysis approach. Themes that emerged from the analysis included "Reasons for becoming a promotora," "Vision and reality of the role," "Structuring interactions: The hierarchy of knowledge transmission," and "Transforming identities." Findings showed that assuming the CHW role had transformative effects on the participants that, in the end, allowed them to reconcile disparate aspects of their own immigrant identities. The findings have multiple implications for designing prevention programs employing CHWs and immigrant community strengthening.

Abstract

We examined beliefs about promoting cognitive health among Filipino Americans who care for persons with dementia, their awareness of media information about cognitive health, and their suggestions for communicating such information to other caregivers. We conducted three focus groups (25 participants). The constant comparison method compared themes across focus groups. Caregivers most frequently described cognitive health benefits of social engagement and leisure; next in emphasis were benefits of healthy diets. There was less emphasis on physical activity. Participants had heard from television that avoiding smoking, alcohol, and drugs might promote cognitive health. Ways to inform others about cognitive health included information in Filipino newspapers, and handouts in Filipino languages, distributed in Filipino stores, workplaces, community organizations, and health care facilities. Findings suggest an opportunity to develop public health messages promoting cognitive health that are in-language, published in ethnic-specific media, and that are culturally appropriate for Filipino and other Asian Americans.