Publications

Abstract

Objective: The aim of this study was to describe (1) nurses' physical and mental health; (2) the relationship between health and medical errors; and (3) the association between nurses' perceptions of wellness support and their health. Methods: A cross-sectional descriptive survey was conducted with 1790 nurses across the U.S. Results: Over half of the nurses reported suboptimal physical and mental health. Approximately half of the nurses reported having medical errors in the past 5 years. Compared with nurses with better health, those with worse health were associated with 26% to 71% higher likelihood of having medical errors. There also was a significant relationship between greater perceived worksite wellness and better health. Conclusion: Wellness must be a high priority for health care systems to optimize health in clinicians to enhance high-quality care and decrease the odds of costly preventable medical errors.

Abstract

Reports have indicated that nursing programs in the United States are not generally effective in teaching nursing science, natural science, the social sciences, and the humanities. The value of the lifelong study of humanities for nurses is the invitation for contemplation on the human experience so we can make informed moral, spiritual, and intellectual sense of the world. In essence, when we understand, we become more empathetic. This article adds to the call for teaching for a sense of salience in nursing through the meaningful synthesis of humanities in baccalaureate education.

Abstract

Knowledge of nutrition among breast cancer patients is insufficient, despite their motivation to seek valid information about healthy food choices. This study examines the feasibility of nutrition education workshops for cancer survivors, to inform the design of a multi-center intervention. Fifty-nine female English-speaking breast cancer patients, who had completed treatment, were enrolled. Participants were randomized to the intervention or control group. The intervention group attended six nutrition education sessions, and the control group received brochures. Measurements were done at baseline and 3-month follow-up and included the Assessment Instrument for Breast Cancer (NLit-BCa), fruit/vegetable and general health literacy screeners. Height and weight were measured. Changes in nutrition literacy, health literacy, and food intake from baseline to follow-up (within-group change) were calculated for both groups (effect sizes were reported as Cohen’s d). Participants were mostly white, with a mean age of 58 years, BMI of 31.6 kg/m2, and had college degrees. Follow-up rates were high (89% = control and 77% = intervention group). At baseline, participants scored high for most NLit-BCa assessment components except food portions in both groups. At the 3-month follow-up, effect sizes (d) on the NLit-BCa ranged from −0.5 to 0.16. The study met its recruitment goals within 6 months. Focus groups indicated that (a) attending six sessions was acceptable, (b) patients found social/emotional support, (c) improvements should include information for special diets and booster sessions. This pilot study suggests that the intervention was acceptable and that scaling up of this intervention is feasible and could provide benefit to breast cancer survivors.

Abstract

Context: Although recommendations are for goals of care (GoC) conversations to happen early and often, their timing and content over the disease course remain unclear. Objectives: To describe perceptions of the timing and content of GoC conversations among oncologists and patients with advanced cancer. Methods: Semi-structured interviews with oncologists and patients at four hospitals in New York and Connecticut. We analyzed data using interpretive description. Results: Oncologists (n = 21) were 67% male, averaged 46 years old (range 34–68 years), and had a mean 20 years (range 8–42 years) in practice. Advanced cancer patients (n = 39) were 59% female with a mean age of 58 years (range 26–88 years). Oncologists and patients viewed GoC conversations along an initial, intermediate, and final continuum. Oncologists reported having initial GoC conversations to build rapport, provide disease information, and clarify and consider treatment intent and options. Intermediate conversations focused on changes in treatment and side effects. Final conversations occurred when patients were hospice-eligible and covered the shift to comfort care, a treatment summary, and advance directives. Timing and content were influenced by cancer type, disease status, and emotional state. Patients supported beginning GoC conversations early, but had different preferences for content of initial conversations. Some wanted complete information; others found this overwhelming. Patients felt intermediate GoC conversations should occur at decision points with time for processing. Content of intermediate and final conversations was dependent on patients’ prognosis, questions, and treatment decisions. Conclusion: Although GoC conversations should follow individual patient preferences, our findings offer structure for their timing and content.

Abstract

This book explores the various features of work environments that affect nurses' experiences of their work, their interactions with co-workers and patients, and ultimately health care quality and patient outcomes. Using a broad and comprehensive approach, the authors identify the most extensively researched and best-understood concepts in the field and presents a critical and up-to-date review of the evidence regarding causes and effects of work environment features. It then presents evidence regarding organizational interventions aimed at broad ranges of clinical practices and outcomes, such as team-based interventions and management practices to improve practice climate. The ideas, approaches, and evidence are presented by a team of researchers and experienced practitioner/leaders; taken together, they form a state-of-the-science toolkit. Unique features of this book include a systematic presentation of best practices in nursing and healthcare leadership, along with the conceptual grounding and empirical support for these approaches, and extensive demonstrations of how these practices, many of which originated in North America, apply to European contexts.

Abstract

A 10-year research program systematically examined organizational features of nurses' workplaces in relation to nurse and patient outcomes. Its major results have been published in peer-reviewed international journals and presented here with replicated analyses and largely new datasets. First, a set of measures of nurse practice environment features and nurse work characteristics such as workload, decision latitude, and social capital along with burnout and work engagement as well as nurses' self-assessed job outcomes and quality of care was developed. These were examined in various populations of nurses such as those working in acute care hospitals and in long-term facilities. Secondly, models to explain associations between these selected variables were developed and tested in samples of acute hospital nurses. Thirdly, multilevel analyses of the associations between these variables confirmed that the phenomenon of organizational influences on work experiences occurred not only at the individual level but also at the team level in various study populations and across healthcare domains. Next, a longitudinal study design was set up to investigate the impact of planned transformations in the hospital organization as well as the implementation of the Productive Ward-Releasing Time to Care program aimed at strengthening practice environments and outcomes in a university hospital. Finally, a phenomenological study was undertaken to examine staff nurse and nurse manager perceptions and experiences of structural empowerment and the extent to which structural empowerment supports high-quality patient care. In addition, an explanatory sequential mixed methods design blended qualitative study results regarding staff nurses' experiences and perceptions of workload with prior quantitative results regarding structural empowerment to explain and interpret the findings of both models.

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Purpose: Strategies to decrease societal and cultural barriers for ethnic minorities to participate in health research are well established. However, limited data are available regarding participation of ethnic minorities in mobile and Internet technology–based interventions to self-manage type 2 diabetes where health disparities are predominant. Thus, the purpose was to understand the participation of ethnic minorities in technology-based intervention programs to manage type 2 diabetes. Design/Method: A scoping review was used to review a total of 21 intervention studies containing participant information about ethnic minorities and one qualitative study discussing participation of ethnic minorities. Findings: There was limited enrollment and participation of ethnic minorities. Technological barriers in addition to existing societal and cultural barriers were identified. Strategies to decrease the barriers were recommended. Conclusions: Technological barriers were identified on top of the societal and cultural barriers in traditional interventions. Further research to reduce the barriers is warranted.

Abstract

Background: Patient activation - or knowledge, confidence, and skill managing overall health - is associated with improved health behaviors such as exercise; it is unknown whether it is associated with advance care planning (ACP). Objective: To determine whether patient activation is associated with ACP. Design: This is a cross-sectional study. Setting/Subjects: A total of 414 veterans (≥60 years) with serious and chronic illness enrolled in an ACP trial. Measures: Patient characteristics and self-report surveys included the validated 13-item patient activation measure (PAM, five-point Likert) (e.g., "Taking an active role in your own healthcare is the most important factor⋯") categorized into four levels (e.g., Level 1: "disengaged and overwhelmed" to Level 4: "maintaining behaviors"). ACP was measured with the ACP Engagement Survey including 57-item process scores (i.e., knowledge, contemplation, self-efficacy, readiness, 5-point Likert scale) and 25-item action scores (i.e., surrogate designation, yes/no items). Associations were determined with linear regression. Results: Participants were 71.1 ± 7.8 years of age, 43% were non-white, 9% were women, and 20% had limited health literacy. Higher PAM levels were associated with higher finances, having adult children, lower comorbidity, and more social support (p < 0.05). After adjusting for these characteristics, higher PAM (Level 4 vs. Level 1) was associated with higher ACP engagement (ACP process scores, 2.8 ± 0.7 vs. 3.8 ± 0.7 and action scores 9.7 ± 4.4 vs. 15.1 ± 6.0, p < 0.001). Conclusions: Higher patient activation to manage one's overall healthcare is associated with higher engagement in ACP. Interventions designed to foster general patient activation and self-efficacy to engage in health behaviors and disease management may also improve engagement in the ACP process.

Abstract

Objective: Family members can significantly impact advanced cancer patients' treatment and are important participants in goals of care (GoC) conversations. Yet, research on patient and physician perspectives about family involvement and influence on GoC conversations is limited. Our purpose was to describe patients' and oncologists' perspectives about family involvement and influence on GoC conversations among patients with advanced cancer. Methods: We conducted semi-structured interviews at academic, community, and municipal hospitals (n = 4) with patients with advanced cancer (n = 39) and their oncologists (n = 21). Interviews were audiotaped and transcribed. We analyzed data using interpretive description. Three coders independently coded transcripts, compared codes, and resolved discrepancies. Results: We identified 4 themes common to patients and oncologists regarding family involvement in GoC conversations: (1) Presence and Duration of Family Involvement; (2) Family Expectations; (3) Protecting patients'/Family Members' Feelings; and (4) Patient-Family Disagreement. For patients, we identified 2 additional themes: (1) Family and Oncologist Relationship and (2) Effects of Cancer on Family. Both patients and oncologists emphasized the importance of family support for the patient's understanding of their illness and on patients' emotions. We also identified ways in which family involvement may benefit or prove challenging to GoC conversations. Conclusions: Patients and oncologists have similar views about family involvement in GoC conversations. Learning how to communicate with family members should be a critical component of physician education in palliative care.

Abstract

Objective: This study examines how older residents’ social support and perceived empowerment are associated with their quality of life (QOL) in long-term care (LTC) facilities in Shanghai, China, controlling for their health-related conditions, facility type, and other socio-demographic characteristics. Method: Using a convenient sampling approach, we selected nine LTC facilities in Shanghai, China. We surveyed 515 older residents from these facilities. Results: Older participants in this study rate their QOL, social support, and perceived empowerment as moderate, and these variables are positively associated with their QOL. Older residents who live in government-owned and private-run LTC facilities are more likely to have a higher level of perceived QOL compared with those living in government-run facilities. Discussion: There is an urgent need to increase staff awareness and capacity to empower older residents, and to engage them in their care plan and delivery. LTC facilities could provide more opportunities for older residents’ social networking within and outside LTC facilities. Improvement of older residents’ QOL is critical in the future development of resident-centered care models in LTC facilities.

Abstract

Irritable bowel syndrome (IBS) is a chronic, common disorder of the gastrointestinal tract associated with high psychological comorbidity and diminished quality of life. Patients with IBS display a heightened sensitivity to stress, although the literature is inconsistent as to whether they have a dysregulated stress response. The purpose of the present investigation, a substudy of a larger research effort, was to examine physiological correlates of perceived stress in patients with IBS (cortisol and adrenocorticotropic hormone) and to explore associations between perceived stress and quality of life. A total of 101 participants (35 with IBS [predominant subtypes IBS-constipation and IBS-diarrhea] and 66 healthy controls [HCs]) completed self-report inventories regarding perceived stress and quality of life, and fasting peripheral blood was drawn. Participants with IBS did not differ from the HC in demographic or physiological measures but did differ in psychological measures, reporting significantly higher levels of perceived stress and lower levels of quality of life. Perceived stress and quality of life were not significantly associated in IBS participants. However, differential findings of the stress response were found within IBS participants by sex, race, and subtype. These findings illustrate the heterogeneity of the IBS patient population, underscore the necessity of evaluating larger sample sizes and increasing the diversity of such samples to include males and ethnic minorities, and demonstrate the importance of taking an individualized approach to evaluation and treatment in the IBS patient population.

Abstract

Background: The place of residence has been linked to cognitive function among adults in developed countries. This study examined how urban and rural residence was associated with cognitive function among adults in India. Methods: The World Health Organization Study on Global AGEing and Adult Health data was used to examine cognition among 6,244 community-residing adults age 50+ in 6 states in India. Residential status was categorized as urban, rural, urban-to-urban, rural-to-urban, rural-to-rural, and urban-to-rural. Cognition was assessed by immediate and delayed recall tests, digit span test, and verbal fluency test. Multilevel models were used to account for state-level differences and adjusted for individual-level sociodemographic, psychosocial, and health-related factors. Results: Urban residents and urban-to-urban migrants had the highest levels of cognition, whereas rural residents and those who migrated to (or within) rural areas had the lowest cognition. The differences largely persisted after adjustment for multiple covariates; however, rural-to-urban migrants had no difference in cognition from urban residents once socioeconomic factors were taken into account. Conclusion: Cognition among adults in India differed significantly according to their current and past place of residence. Socioeconomic factors played an important role in the cognitive function of adults in urban areas.

Abstract

Purpose: To examine which characteristics of the practice environment were associated with missed nursing care in U.S. acute care hospital units. Design: A descriptive, correlational study used secondary analysis of the 2015 National Database of Nursing Quality Indicators® Registered Nurse (RN) Survey data. Subscales of the Practice Environment Scale of the Nursing Work Index were used to measure practice environment characteristics. The sample included 1,583 units in 371 hospitals, containing survey responses from 31,650 RNs. Methods: Multilevel logistic regression was performed to estimate the effects of the practice environment characteristics on missed care, controlling for hospital and unit characteristics. Results: About 84.1% of unit RNs reported missing at least one of the 15 necessary care activities. Good environment units had 63.3% significantly lower odds of having RNs miss care activities than poor environment units. Units had 81.5% lower odds of having RNs miss any necessary activities with 1 point increase of the staffing and resource adequacy score; 21.9% lower odds for 1 point increase in the nurse–physician relations score; and approximately 2.1 times higher odds with 1 point increase in the nurse participation in hospital affairs score. Conclusions: Good environments were significantly associated with lower levels of missed care. The impact on missed care differed by the characteristics of the practice environment. Clinical Relevance: Hospital and nursing administrators should maintain good practice environments for nurses to reduce missed care activities and thus potentially improve patient outcomes. Specifically, their efforts should be targeted on improving staffing and resource adequacy and nurse–physician relations and on reducing workloads on hospital affairs.

Abstract

Objective To develop a pre-pregnancy or first-trimester risk score to identify women at high risk of preterm birth. Study design In this retrospective cohort analysis, the sample was drawn from California singleton livebirths from 2007 to 2012 with linked birth certificate and hospital discharge records. The dataset was divided into a training (2/3 of sample) and a testing (1/3 of sample) set for discovery and validation. Predictive models for preterm birth using pre-pregnancy or first-trimester maternal factors were developed using backward stepwise logistic regression on a training dataset. A risk score for preterm birth was created for each pregnancy using beta-coefficients for each maternal factor remaining in the final multivariable model. Risk score utility was replicated in a testing dataset and by race/ethnicity and payer for prenatal care. Results The sample included 2,339,696 pregnancies divided into training and testing datasets. Twenty-three maternal risk factors were identified including several that were associated with a two or more increased odds of preterm birth (preexisting diabetes, preexisting hypertension, sickle cell anemia, and previous preterm birth). Approximately 40% of women with a risk score ≥ 3.0 in the training and testing samples delivered preterm (40.6% and 40.8%, respectively) compared to 3.1–3.3% of women with a risk score of 0.0 [odds ratio (OR) 13.0, 95% confidence interval (CI) 10.7–15.8, training; OR 12.2, 95% CI 9.4–15.9, testing). Additionally, over 18% of women with a risk score ≥ 3.0 had an adverse outcome other than preterm birth. Conclusion Maternal factors that are identifiable prior to pregnancy or during the first-trimester can be used create a cumulative risk score to identify women at the lowest and highest risk for preterm birth regardless of race/ethnicity or socioeconomic status. Further, we found that this cumulative risk score could also identify women at risk for other adverse outcomes who did not have a preterm birth. The risk score is not an effective screening test, but does identify women at very high risk of a preterm birth.

Abstract

Objective:: To evaluate if mid-pregnancy immune and growth-related molecular factors predict preterm birth (PTB) with and without (±) preeclampsia. Study design:: Included were 400 women with singleton deliveries in California in 2009–2010 (200 PTB and 200 term) divided into training and testing samples at a 2:1 ratio. Sixty-three markers were tested in 15–20 serum samples using multiplex technology. Linear discriminate analysis was used to create a discriminate function. Model performance was assessed using area under the receiver operating characteristic curve (AUC). Results:: Twenty-five serum biomarkers along with maternal age <34 years and poverty status identified >80% of women with PTB ± preeclampsia with best performance in women with preterm preeclampsia (AUC = 0.889, 95% confidence interval (0.822–0.959) training; 0.883 (0.804–0.963) testing). Conclusion:: Together with maternal age and poverty status, mid-pregnancy immune and growth factors reliably identified most women who went on to have a PTB ± preeclampsia.

Abstract

Background: Between 45% and 94% of registered nurses (RNs) experience verbal abuse, which is associated with physical and psychological harm. Although several studies examined predictors of RNs’ verbal abuse, none examined predictors of RNs’ experiences of verbal abuse by RN colleagues. Purpose: To examine individual, workplace, dispositional, contextual, and interpersonal predictors of RNs’ reported experiences of verbal abuse from RN colleagues. Methods: In this secondary analysis, a cross-sectional design with multiple linear regression analysis was used to examine the effect of 23 predictors on verbal abuse by RN colleagues in a sample of 1,208 early career RNs. Finding: Selected variables in the empirical intragroup conflict model explained 23.8% of variance in RNs’ experiences of verbal abuse by RN colleagues. Conclusion: A number of previously unstudied factors were identified that organizational leaders can monitor and develop or modify policies to prevent early career RNs’ experiences of verbal abuse by RN colleagues.

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Purpose: The purpose of this study is to assess the weighted prevalence and odds ratios of obesity, prediabetes, and diabetes by (1) female sexual orientation (lesbian, bisexual, and straight) with racial/ethnic (Hispanic, non-Hispanic black, and non-Hispanic white) groups combined and (2) across and within racial/ethnic groups by sexual orientation. Methods: A secondary analysis of pooled 2014-2015 Behavioral Risk Factor Surveillance System data from 28 states (N = 136 878) was conducted. Rao-Scott chi-square test statistics were computed and logistic regression models were developed to assess weighted prevalence and odds ratios of obesity, prediabetes, and diabetes with adjustments for demographics (age, income, and education), depression, and health care access factors. Results: With racial/ethnic groups combined, lesbian and bisexual women, relative to straight women, had a significantly increased likelihood for obesity when controlling for demographics. Bisexual women were found to have significantly reduced odds for diabetes, compared with straight women, with adjustments for demographics, depression, and health care access factors. Compared with their non-Hispanic white counterparts, Hispanic lesbian women had significantly increased odds for obesity and diabetes, while non-Hispanic black bisexual women had a significantly greater likelihood for obesity, holding demographics, depression, and health care access factors constant. Non-Hispanic white lesbian women had an increased likelihood for obesity relative to their straight, ethnic/racial counterparts. Prediabetes subsample analysis revealed the prevalence was low across all female sexual orientation groups. Conclusion: Sexual minority women, particularly those of color, may be at increased risk for obesity and diabetes. Research is needed to confirm the findings.