Publications

Abstract

Context: State scope of practice (SoP) laws impose significant restrictions on the services that a nurse practitioner (NP) may provide in some states, yet evidence about SoP limitations on the quality of primary care is very limited. Method: This study uses six different classifications of state regulations and bivariate and multivariate analyses to compare beneficiaries attributed to primary care nurse practitioners and primary care physicians in 2013 testing two hypotheses: (1) chronic disease management, cancer screening, preventable hospitalizations, and adverse outcomes of care provided by primary care nurse practitioners are better in reduced and restricted practice states compared to states without restrictions and (2) by decreasing access to care, SoP restrictions negatively affect the quality of primary care. Findings: Results show a lack of consistent association between quality of primary care provided by NPs and state SoP restrictions. Conclusion: State regulations restricting NP SoP do not improve the quality of care.

Abstract

Background: While there is a growing interest in addressing social determinants of health in clinical settings, there are limited data on the relationship between unstable housing and both obstetric outcomes and health care utilization. Objective: The objective of the study was to investigate the relationship between unstable housing, obstetric outcomes, and health care utilization after birth. Study Design: This was a retrospective cohort study. Data were drawn from a database of liveborn neonates linked to their mothers’ hospital discharge records (2007–2012) maintained by the California Office of Statewide Health Planning and Development. The analytic sample included singleton pregnancies with both maternal and infant data available, restricted to births between the gestational age of 20 and 44 weeks, who presented at a hospital that documented at least 1 woman as having unstable housing using the International Classification of Diseases, ninth edition, codes (n = 2,898,035). Infants with chromosomal abnormalities and major birth defects were excluded. Women with unstable housing (lack of housing or inadequate housing) were identified using International Classification of Diseases, ninth edition, codes from clinical records. Outcomes of interest included preterm birth (<37 weeks’ gestational age), early term birth (37–38 weeks gestational age), preterm labor, preeclampsia, chorioamnionitis, small for gestational age, long birth hospitalization length of stay after delivery (vaginal birth, >2 days; cesarean delivery, >4 days), emergency department visit within 3 months and 1 year after delivery, and readmission within 3 months and 1 year after delivery. We used exact propensity score matching without replacement to select a reference population to compare with the sample of women with unstable housing using a one-to-one ratio, matching for maternal age, race/ethnicity, parity, prior preterm birth, body mass index, tobacco use during pregnancy, drug/alcohol abuse during pregnancy, hypertension, diabetes, mental health condition during pregnancy, adequacy of prenatal care, education, and type of hospital. Odds of an adverse obstetric outcome were estimated using logistic regression. Results: Of 2794 women with unstable housing identified, 83.0% (n = 2318) had an exact propensity score–matched control. Women with an unstable housing code had higher odds of preterm birth (odds ratio, 1.2, 95% confidence interval, 1.0–1.4, P < .05), preterm labor (odds ratio, 1.4, 95% confidence interval, 1.2–1.6, P < .001), long length of stay (odds ratio, 1.6, 95% confidence interval, 1.4–1.8, P < .001), emergency department visits within 3 months (odds ratio, 2.4, 95% confidence interval, 2.1–2.8, P < .001) and 1 year after birth (odds ratio, 2.7, 95% confidence interval, 2.4–3.0, P < .001), and readmission within 3 months (odds ratio, 2.7, 95% confidence interval, 2.2–3.4, P < .0014) and 1 year after birth (odds ratio, 2.6, 95% confidence interval, 2.2–3.0, P < .001). Conclusion: Unstable housing documentation is associated with adverse obstetric outcomes and high health care utilization. Housing and supplemental income for pregnant women should be explored as a potential intervention to prevent preterm birth and prevent increased health care utilization.

Abstract

Background: Readiness of the nursing workforce in quality and safety competencies is an essential indicator of a health system's ability to deliver high-quality and safe health care. A previous study identified important quality and safety education gaps between associate- and baccalaureate-prepared new nurses who graduated between 2004 and 2005. The purpose of this study was to assess changes in nursing workforce quality and safety education preparedness by examining educational gaps between associate and bachelor's degree graduates in two additional cohorts of new nurses who graduated between 2007–2008 and 2014–2015. Methods: A cross-sectional, comparative design and chi-square tests were used to trend the quality and safety educational preparedness differences between associate and bachelor's degree nurse graduates from 13 states and the District of Columbia licensed in 2007–2008 (N = 324) and 2014–2015 (N = 803). Results: The number of quality and safety educational gaps between bachelor's and associate degree nurse graduates more than doubled over eight years. In the 2007–2008 cohort, RNs with a bachelor's degree reported being significantly better prepared than RNs with an associate degree in 5 of 16 topics. In the 2014–2015 cohort, bachelor's degree RNs reported being significantly better prepared than associate degree RNs in 12 of 16 topics. Conclusion: Improving accreditation and organizational policies requiring baccalaureate education for all nurses could close quality and safety education gaps to safeguard the quality of patient care.

Abstract

Background: Nurse scientists are highly sought after and find satisfaction in serving as members of interdisciplinary research teams. These teams also tend to be highly productive. However, nurse scientists in academia also have to reach certain productivity milestones to be promoted and receive tenure that may be incongruent with team science principles. Purpose: This study therefore sought to examine whether APT documents in research intensive nursing schools incorporate team science principles. Methods: Qualitatively analyzed the appointment, promotion and tenure documents of 18 U.S. based research intensive schools of nursing with over $2 million in NIH funding in fiscal year 2014. Findings: The study found that only 8 of 18 documents included any reference to team science principles and even these mentions were largely negligible. There were few best practices to recommend across documents. By not recognizing team science within these documents, nursing risks marginalization within the larger scientific community by limiting mentorship and learning opportunities for early career nurse scientists. Discussion: Schools of nursing should revisit their promotion and tenure criteria and include a greater commitment to encouragement of team science.

Abstract

Interprofessional collaborative education and practice is essential in the current complex healthcare climate. Barriers to interprofessional education include difficulty scheduling joint activities amid the silos of discipline-specific curricula and the lack of urgency by faculty to find innovative ways to commit to interprofessional training. Barriers in practice include poor understanding of the roles of different professionals and lack of awareness of the concept because the people in the workforce were mostly educated before interprofessional practice and education were prioritized by national bodies representing academic professions. The author of this paper describes opportunities for interprofessional education and practice and describes a way to create an educational-practice partnership to drive quality in healthcare settings.

Abstract

Objective: Although the purposes and outcomes of screening and diagnostic tests are different, they are often confused. Therefore, it is important to delineate the clinical concept of cancer screening tests to be clear in our communication not only among healthcare professionals but also with client populations. The aim of this study is to both describe and analyze the concept of cancer screening and explain their practical meaning in global contexts. Methods: Comparative case studies of cervical and liver cancer screening tests were used as the basis for developing an understanding of a specific concept (phenomenon) of cancer screening and for delineating the relationships between factors that cause screening to occur. Results: A cancer screening is defined as an action taken by both the patient and health-care provider to detect a possible pre-cancerous condition among healthy and asymptomatic individuals who are at sufficient risk of a specific disorder to warrant further investigation or treatment. The case study-based concept analysis has been shown to be useful for improving our understanding of the multi-dimensional nature of the concept in global contexts. Conclusions: New paradigms maximizing participation in cancer screening to detect diseases before symptoms are manifested rather than focusing on diagnosis and treatment of symptomatic infectious diseases need to be developed and implemented.

Abstract

In China, poor cardioprotective medication adherence is a key reason for the high mortality rate of coronary heart disease (CHD). The aims of this systematic review are to (1) describe and synthesise factors that influence medication adherence among Chinese people with CHD, (2) evaluate the current status of intervention studies, and (3) discuss directions of future research to improve medication adherence. A comprehensive search using PubMed, Cumulative Index to Nursing and Allied Health Literature, Embase, Scopus, Global Health and PsycINFO was undertaken to describe poor adherence in China. Thirty-three eligible articles were included in the study. The review shows that there are multiple contributing factors to poor medication adherence, including patients' sociodemographic characteristics, health status and medication characteristics. In addition, from patients' perspective, lack of medication-related knowledge, such as the name, function, dosage and frequency, contributes to poor adherence. From physicians' perspective, a gap exists between CHD secondary prevention guidelines and clinical practice in China. Follow-up phone calls, educational lectures, booklets and reminder cards were common methods found to be effective in improving medication adherence. This systematic review indicates that cardioprotective medications were commonly prescribed as secondary prevention medication to patients with CHD in China, but adherence to these medications gradually decreased during a follow-up period. Therefore, more research should be conducted on how to establish high-quality health educational programmes aimed at increasing patients' medication adherence.

Abstract

Purpose: It is reported that while immigrants are, initially, healthier than the native-born upon resettlement, this advantage erodes over time. In the United States, uninsured aging immigrants are increasingly experiencing severe complications of cardiovascular disease (CVD). The purpose of this study was to compare overall CVD risk and explore the importance of health insurance coverage on CVD risk relative to other health access barriers, from 2007 to 2012, in recent and long-term immigrants >50 years of age. Methods: This study was based on secondary cross-sectional analysis of the National Health and Nutrition Examination Survey (N = 1,920). The primary outcome, CVD risk category (high or low), was determined using the American College of Cardiology and American Heart Association Pooled Cohort equation. Differences between immigrant groups were examined using independent-samples t tests and chi-square analysis. The association between insurance and CVD risk was explored using a hierarchical block logistic regression model, in which variables were entered in a predetermined order. Changes in pseudo R 2 measured whether health insurance explained variance in cardiac risk beyond other variables. Results: Recent immigrants had lower overall CVD risk than long-term immigrants but were twice as likely to be uninsured and had higher serum glucose and lipid levels. Based on regression models, being uninsured contributed to CVD risk beyond other health access determinants, and CVD risk was pronounced among recent immigrants who were uninsured. Conclusions: Health insurance coverage plays an essential part in a comprehensive approach to mitigating CVD risk for aging immigrants, particularly recent immigrants whose cardiovascular health is susceptible to deterioration. Clinical Relevance: Nurses are tasked with recognizing the unique social and physical vulnerabilities of aging immigrants and accounting for these in care plans. In addition to helping them access healthcare coverage and affordable medication, nurses and clinicians should prioritize low-cost lifestyle interventions that reduce CVD risk, especially diet and exercise programs.

Abstract

Background: Caregiver contribution to heart failure (HF) self-care maintenance and management is important in HF care. Literature remains unclear regarding which practices caregivers perform to contribute to self-care for patients with HF, especially in Southern Europe. Objective: The objective of this study was to describe caregiver contributions to HF self-care maintenance (ie, treatment adherence and symptom monitoring) and management (ie, managing HF symptoms when they occur). Methods: Forty HF caregivers were enrolled from 3 outpatient clinics in Italy for a qualitative descriptive study. Data were collected with a semistructured interview and analyzed using content analysis. Results: Caregivers were 53.6 years old on average and mostly female (63.5%). Caregiver contributions to self-care maintenance included practices related to (1) monitoring medication adherence, (2) educating patients about HF symptom monitoring, (3) motivating patients to perform physical activity, and (4) reinforcing dietary restrictions. However, some of these practices were incorrect (eg, weighing the patient only once a week). Caregiver contributions to self-care management included practices related to (1) symptom recognition and (2) treatment implementation. Caregivers were able to recognize symptoms of HF exacerbation (eg, breathlessness) but lacked confidence regarding treatment implementation (eg, administering an extra diuretic). Conclusions: Although caregivers described contributing to patients' HF self-care maintenance and management, some of their practices were incorrect. Because the caregiver contributions to HF self-care can improve patient outcomes, clinicians should routinely assess caregiver HF self-care practices and provide education and reinforcement regarding evidence-based practices.

Abstract

Background: The ceremonial use of psychoactive/hallucinogenic plant based drugs, such as ayahuasca, psilocybin and others, is a growing trend in the United States (US) and globally. To date, there has been little research documenting how many people are using psychoactive substances in this context, who the users are, what benefits/risks exist in the use of these drugs and the relationship between ceremonial drug use and recreational drug use. In this paper we describe a cohort of plant medicine facilitators in the US and explore how they differentiate plant medicine use from recreational drug use. Methods: Using modified ethnography, individual interviews were conducted in 2016 with 15 participants who are currently facilitating plant medicine ceremonies in the US. Descriptive content analysis was performed to discover themes and to inform a larger mixed-method study. Results: Ceremonial drug use was seen by participants as a natural healing and treatment modality used in the context of community and ritual. Three main themes were identified relating to participants’ differentiation between ceremonial plant medicine use and recreational drug use: (1) participants see a clear delineation between plant medicine use and recreational drug use; (2) plant medicine is seen as a potential treatment for addiction, but concerns exist regarding potential interference with recovery; and (3) plant medicine use may influence recreational use. Conclusions: More research is needed on who is using plant medicine, motivators for use, perceived and real risks and benefits of plant medicine use and harm reduction techniques regarding safe ingestion.

Abstract

Purpose: The purpose of this qualitative descriptive study undergirded by Meleis’s Transition Framework was to explore developmental, situational, and organizational challenges experienced by a diverse group of emerging adults (18-29 years old) with type 1 diabetes (T1DM). Their perspectives on creating a developmentally informed diabetes self-management (DSM) program that supports transitional care were also explored. Methods: A purposive sample of emerging adults with T1DM was recruited from the pediatric and adult diabetes clinics of an urban academic medical center. Those who consented participated in either a single focus group or a single interview. Self-reported demographic and clinical information was also collected. Results: The sample was comprised of 21 emerging adults, with an average age of 23.6 ± 2.6 years, diabetes duration of 14.7 ± 5.0 years, and 71% female. Four main themes emerged: (1) finding a balance between diabetes and life, (2) the desire to be in control of their diabetes, (3) the hidden burden of diabetes, and (4) the desire to have a connection with their diabetes provider. Use of insulin pumps and continuous glucose monitors and attendance at diabetes camp decreased some of the DSM challenges. Different groups of individuals had different perspectives on living with diabetes and different approaches to DSM. Conclusions: The emerging adults in this study had a strong desire to be in good glycemic control. However, all participants described having a hard time balancing DSM with other competing life priorities. They also desired personalized patient-provider interactions with their diabetes care provider in clinical follow-up services. Even though the study sample was small, important themes emerged that warrant further exploration.

Abstract

Introduction: Hypertension is a leading global risk factor for death and disability. Seeking new ways to prevent and treat hypertension is a priority for scientists and healthcare professionals worldwide. In November 2017, the American College of Cardiology (ACC) and the American Heart Association (AHA) issued a new hypertension guideline shifting the definition of hypertension from 140/90 mm Hg to 130/80 mm Hg for systolic/diastolic blood pressure. This new diagnostic threshold of hypertension has sparked a lively discussion worldwide over whether it should be applied in clinical settings to diagnose and treat hypertension. China, the world’s most populous country, is facing a hypertension crisis. According to the 140/90 mm Hg guideline, China has an estimated 244.5 million population aged ≥ 18 years with hypertension, and another 435.3 million with pre-hypertension. If the new guideline is adopted, the prevalence of hypertension in China would double. This change would significantly impact patients, healthcare professionals, scientists, and policy makers in terms of the delivery of care and needed resources. Aim: This study aims to investigate whether Chinese physicians will use the 130/80 mm Hg threshold to diagnose hypertension in clinical practice. Methods: In March 2018, we launched a mobile app-based survey to study 253 Chinese physicians’ perspectives on the ACC/AHA Guideline. Results: A total of 253 physicians from 21 Chinese provinces completed the survey. Nearly 80% of the participants had already noticed the ACC/AHA guideline change. The proportion of participants who said they would use the new threshold to diagnoses hypertension was 41%, while 59% said they would not use the new threshold. The primary reason for those who said “yes” was that they believed early diagnosis of hypertension can trigger early actions to prevent the increasing blood pressure. For those who said “no”, they argued that their decision was based on the fact that the Chinese Hypertension Prevention Guideline had not yet changed the diagnostic threshold from 140/90 to 130/80 mm Hg. Conclusions: Different understanding of hypertension prevention and treatment exists among Chinese physicians. It is an emergent need to form an evidence-based authoritative answer to guide Chinese physicians’ future clinical practice.

Abstract

It is time for nurses to step up and see themselves as a part of the solution to climate change. Propelling our efforts in policy, research, scholarship, clinical practice, and service as nurses and engaging our interprofessional colleagues are critical efforts as we move ahead in our call to action.

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This clinical pilot research project evaluated clinical outcomes for asthmatic children enrolled in a home-based Asthma Outreach Program. Through a quasi-experimental single-group intervention design, a convenience sample of 37 children, ranging in age from 6 to 16 years, was used for this study. At 6 months after enrollment in the Asthma Outreach Program, patients reported significantly fewer nighttime symptoms and primary care provider visits compared with the 6 months preceding enrollment. Patients also reported significantly fewer hospital and intensive care unit admissions and courses of oral steroids. Adherence to therapy and asthma control was also significantly improved.

Abstract

Objectives: There is inconclusive evidence that cognitive function is associated with oral health in older adults. This study investigated the association between cognitive function and oral health among older adults in England. Methods: This longitudinal cohort study included 4416 dentate participants aged 50 years or older in the English Longitudinal Study of Ageing during 2002-2014. Cognitive function was assessed at baseline in 2002/2003 using a battery of cognitive function tests. The self-reported number of teeth remaining and self-rated general oral health status was reported in 2014/2015. Ordinal logistic regression was applied to model the association between cognitive function at baseline and tooth loss or self-rated oral health. Results: Cognitive function at baseline was negatively associated with the risk of tooth loss (per each 1 standard deviation lower in cognitive function score, OR: 1.13, 95% CI: 1.05-1.21). When cognitive function score was categorized into quintiles, there was a clear gradient association between cognitive function and tooth loss (P-trend = 0.003); people in the lowest quintile of cognitive function had higher risk of tooth loss than those in the highest quintile (OR: 1.39, 95% CI: 1.12-1.74). A similar magnitude and direction of association were evident between cognitive function and self-rated oral health. Conclusion: This longitudinal study in an English ageing population has demonstrated that poor cognitive function at early stage was associated with poorer oral health and higher risk of tooth loss in later life. The gradient relationship suggests that an improvement in cognitive function could potentially improve oral health and reduce the risk of tooth loss in the ageing population.

Abstract

Purpose: Improved second-tier tools are needed to reduce false-positive outcomes in newborn screening (NBS) for inborn metabolic disorders on the Recommended Universal Screening Panel (RUSP). Methods: We designed an assay for multiplex sequencing of 72 metabolic genes (RUSPseq) from newborn dried blood spots. Analytical and clinical performance was evaluated in 60 screen-positive newborns for methylmalonic acidemia (MMA) reported by the California Department of Public Health NBS program. Additionally, we trained a Random Forest machine learning classifier on NBS data to improve prediction of true and false-positive MMA cases. Results: Of 28 MMA patients sequenced, we found two pathogenic or likely pathogenic (P/LP) variants in a MMA-related gene in 24 patients, and one pathogenic variant and a variant of unknown significance (VUS) in 1 patient. No such variant combinations were detected in MMA false positives and healthy controls. Random Forest–based analysis of the entire NBS metabolic profile correctly identified the MMA patients and reduced MMA false-positive cases by 51%. MMA screen-positive newborns were more likely of Hispanic ethnicity. Conclusion: Our two-pronged approach reduced false positives by half and provided a reportable molecular finding for 89% of MMA patients. Challenges remain in newborn metabolic screening and DNA variant interpretation in diverse multiethnic populations.

Abstract

Commercial sexual exploitation of children (CSEC) is the sexual abuse of children through buying, selling, or trading their sexual services. This may involve engaging a child under the age of 18 years in prostitution, pornography, stripping, exotic dancing, escort services, or other sexual services. CSEC is a problem of epidemic proportions throughout the world including the United States; however, the actual number of CSEC victims in the United States is unknown. Studies indicate that most child victims are seen by a healthcare provider while being trafficked and that many victims receive care at a pediatric hospital within 1 year of their identification as a victim. CSEC is a significant pediatric healthcare problem. It is vital that forensic nurses possess a thorough understanding of the problem and be poised to better identify, intervene, and prevent CSEC. In this article, we focus on risk factors commonly experienced by victims, recruitment strategies used by traffickers, indicators to identify child victims, and intervention and educational strategies of relevance to forensic nurses.

Abstract

Background: In the era of the Patient Protection and Affordable Care Act, quality of care and patient safety in health care have never been more visible to patients or providers. Registered nurses (nurses) are key players not only in providing direct patient care but also in evaluating the quality and safety of care provided to patients and families. Purpose: We had the opportunity to study a unique cohort of nurses to understand more about the common predictors of nurse-reported quality of care and patient safety across acute care settings. Approach: We analyzed cross-sectional survey data that were collected in 2015 from 731 nurses, as part of a national 10-year panel study of nurses. Variables selected for inclusion in regression analyses were chosen based on the Systems Engineering Initiative for Patient Safety model, which is composed of work system or structure, process, and outcomes. Results: Our findings indicate that factors from three components of the Systems Engineering Initiative for Patient Safety model-Work System (person, environment, and organization) are predictive of quality of care and patient safety as reported by nurses. The main results from our multiple linear and logistic regression models suggest that significant predictors common to both quality and safety were job satisfaction and organizational constraints. In addition, unit type and procedural justice were associated with patient safety, whereas better nurse-physician relations were associated with quality of care. Conclusion: Increasing nurses' job satisfaction and reducing organizational constraints may be areas to focus on to improve quality of care and patient safety. Practical Implications: Our results provide direction for hospitals and nurse managers as to how to allocate finite resources to achieve improvements in quality of care and patient safety alike.