Publications

Abstract

INTRODUCTION: Certified nursing assistants (CNAs) constitute the largest segment of the nursing home workforce, with over 50% of the dementia care workforce comprised of racial and ethnic minoritized individuals. Despite their critical role in dementia care, CNAs face significant inequities in terms of salary, treatment, and working conditions. To enhance equity and improve working conditions, valid and reliable measures are essential for nursing homes to assess their current environment, track progress, and refine strategies. This paper synthesizes existing measures and tools that assess equity-related constructs among CNAs. METHODS: We conducted an environmental scan to identify existing measures, tools, and instruments assessing equity-related constructs among CNAs in nursing homes. Our search focused on nine key equity-related constructs: training, job satisfaction, compensation, staffing/workload, burnout, working conditions/environment, role, leadership, and turnover. RESULTS: Our environmental scan resulted in 15 measures, tools, or instruments relevant to CNA equity. These instruments focused on job satisfaction, retention and turnover, job commitment, leadership experiences, and work environment. Sixty percent of these tools lacked reported validity or reliability data. While the remaining 40% demonstrated strong psychometric properties, overall, the methodological rigor of available measures is inconsistent. A critical gap in the existing literature is the absence of tools measuring burnout or workload, among CNAs. DISCUSSION: The identified measures/tools offer potential for evaluating the effectiveness of interventions addressing CNA equity. However, it is imperative to establish the validity and reliability of these instruments across diverse populations, particularly among racial and ethnic minoritized groups, and develop or adapt tools that measure burnout and workload for CNAs. Furthermore, a deeper understanding of the underlying mechanisms driving these inequities through qualitative data is crucial for developing targeted and impactful interventions. Highlights: Measuring equity among CNAs is important to evaluate strategies intended to improve equity. The identified tools enable assessment of how CNAs feel about important constructs that are related to equity. We found no tools that comprehensively measured workload or burnout experienced by CNAs.

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The purpose of this article was to analyze the concept of "the fighter in the intensive care unit (ICU)"per the scientific literature and the impact this mentality has on care administered in the ICU. A literature review and a concept analysis based on Rodger's evolutionary method were performed to identify surrogate terms, antecedents, attributes, and consequences pertaining to the "fighter"in the ICU. Thirteen articles with a focus on "the fighter"were included in this analysis. There is a strong desire to remain optimistic and maintain high spirits as a coping mechanism in the face of extreme prognostic uncertainty. Themes that emerged from the literature were the need to find inner strength and persist in the face of adversity. The concept of "the fighter in the ICU"can serve as either adaptive or maladaptive coping, depending on the larger clinical picture. Patient experiences in the ICU are fraught with physical and psychological distress. How the patient and family unit cope during this anxiety-provoking time is based on the individual. Maintaining optimism and identifying as a fighter can be healthy ways to adapt to the circumstances. This concept analysis highlights the importance of holistic care and instilling hope particularly as patients may be nearing the end of life.

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Editor's note: This is the 21st article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice - from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204.

Abstract

Editor's note: This is the 23rd article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice-from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204.

Abstract

Editor's note: This is the 24th article in a series on clinical research by nurses. The series is designed to be used as a resource for nurses to understand the concepts and principles essential to research. Each column will present the concepts that underpin evidence-based practice - from research design to data interpretation. To see all the articles in the series, go to https://links.lww.com/AJN/A204.

Abstract

Oral squamous cell carcinoma (OSCC) is a highly unpredictable disease with devastating mortality rates that have not changed over the past decades, in the face of advancements in treatments and biomarkers, which have improved survival for other cancers. Delays in diagnosis are frequent, leading to more disfiguring treatments and poor outcomes for patients. The clinical challenge lies in identifying those patients at the highest risk of developing OSCC. Oral epithelial dysplasia (OED) is a precursor of OSCC with highly variable behavior across patients. There is no reliable clinical, pathological, histological, or molecular biomarker to determine individual risk in OED patients. Similarly, there are no robust biomarkers to predict treatment outcomes or mortality in OSCC patients. This review aims to highlight advancements in artificial intelligence (AI)-based methods to develop predictive biomarkers of OED transformation to OSCC or predictive biomarkers of OSCC mortality and treatment response. Biomarkers such as S100A7 demonstrate promising appraisal for the risk of malignant transformation of OED. Machine learning-enhanced multiplex immunohistochemistry workflows examine immune cell patterns and organization within the tumor immune microenvironment to generate outcome predictions in immunotherapy. Deep learning (DL) is an AI-based method using an extended neural network or related architecture with multiple “hidden” layers of simulated neurons to combine simple visual features into complex patterns. DL-based digital pathology is currently being developed to assess OED and OSCC outcomes. The integration of machine learning in epigenomics aims to examine the epigenetic modification of diseases and improve our ability to detect, classify, and predict outcomes associated with epigenetic marks. Collectively, these tools showcase promising advancements in discovery and technology, which may provide a potential solution to addressing the current limitations in predicting OED transformation and OSCC behavior, both of which are clinical challenges that must be addressed in order to improve OSCC survival.

Abstract

Oral squamous cell carcinoma (OSCC) biomarker studies rarely employ multi-omic biomarker strategies and pertinent clinicopathologic characteristics to predict mortality. In this study we determine for the first time a combined epigenetic, gene expression, and histology signature that differentiates between patients with different tobacco use history (heavy tobacco use with ≥10 pack years vs. no tobacco use). Using The Cancer Genome Atlas (TCGA) cohort (n = 257) and an internal cohort (n = 40), we identify 3 epigenetic markers (GPR15, GNG12, GDNF) and 13 expression markers (IGHA2, SCG5, RPL3L, NTRK1, CD96, BMP6, TFPI2, EFEMP2, RYR3, DMTN, GPD2, BAALC, and FMO3), which are dysregulated in OSCC patients who were never smokers vs. those who have a ≥ 10 pack year history. While mortality risk prediction based on smoking status and clinicopathologic covariates alone is inaccurate (c-statistic = 0.57), the combined epigenetic/expression and histologic signature has a c-statistic = 0.9409 in predicting 5-year mortality in OSCC patients.

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INTRODUCTION: Clinical research in Alzheimer's disease (AD) lacks cohort diversity despite being a global health crisis. The Asian Cohort for Alzheimer's Disease (ACAD) was formed to address underrepresentation of Asians in research, and limited understanding of how genetics and non-genetic/lifestyle factors impact this multi-ethnic population. METHODS: The ACAD started fully recruiting in October 2021 with one central coordination site, eight recruitment sites, and two analysis sites. We developed a comprehensive study protocol for outreach and recruitment, an extensive data collection packet, and a centralized data management system, in English, Chinese, Korean, and Vietnamese. RESULTS: ACAD has recruited 606 participants with an additional 900 expressing interest in enrollment since program inception. DISCUSSION: ACAD's traction indicates the feasibility of recruiting Asians for clinical research to enhance understanding of AD risk factors. ACAD will recruit > 5000 participants to identify genetic and non-genetic/lifestyle AD risk factors, establish blood biomarker levels for AD diagnosis, and facilitate clinical trial readiness. HIGHLIGHTS: The Asian Cohort for Alzheimer's Disease (ACAD) promotes awareness of under-investment in clinical research for Asians. We are recruiting Asian Americans and Canadians for novel insights into Alzheimer's disease. We describe culturally appropriate recruitment strategies and data collection protocol. ACAD addresses challenges of recruitment from heterogeneous Asian subcommunities. We aim to implement a successful recruitment program that enrolls across three Asian subcommunities.

Abstract

PURPOSE: Despite the importance of measuring delirium severity in patients with Alzheimer’s disease and related dementias (ADRD), no validated instrument currently exists. Our goal was to generate items for use in such an instrument. METHOD: An interdisciplinary expert panel developed items to assess seven domains and 21 subdomains of delirium severity. Nursing experts provided input on items. RESULTS: Experts achieved consensus on 21 items, including best respondents for each item, and appropriate look-back periods. Nursing experts emphasized the need for educating nursing staff and obtaining information from caregivers. CONCLUSION: Careful, nuanced identification of distinguishing features is key for generating items for measuring delirium severity in persons with ADRD. Once developed, engaging nurses will be essential to facilitate adoption and relevance of the tool.

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Purpose: Recent studies have demonstrated an increased risk of severe maternal morbidity (SMM) for people living in rural versus urban counties. Studies have not considered rurality at the more nuanced subcounty census-tract level. This study assessed the relationship between census-tract-level rurality and SMM for birthing people in California. Methods: We used linked vital statistics and hospital discharge records for births between 1997 and 2018 in California. SMM was defined by at least 1 of 21 potentially fatal conditions and lifesaving procedures. Rural-Urban Commuting Area codes were used to characterize census tract rurality dichotomously (2-category) and at 4 levels (4-category). Covariates included sociocultural-demographic, pregnancy-related, and neighborhood-level factors. We ran a series of mixed-effects logistic regression models with tract-level clustering, reporting risk ratios and 95% confidence intervals (CIs). We used the STROBE reporting guidelines. Findings: Of 10,091,415 births, 1.1% had SMM. Overall, 94.3% of participants resided in urban/metropolitan and 5.7% in rural tracts (3.9% micropolitan, 0.9% small town, 0.8% rural). In 2-category models, the risk of SMM was 10% higher for birthing people in rural versus urban tracts (95% CI: 6%, 13%). In 4-category models, the risk of SMM was 16% higher in micropolitan versus metropolitan tracts (95% CI: 12%, 21%). Conclusion: The observed rurality and SMM relationship was driven by living in a micropolitan versus metropolitan tract. Increased risk may result from resource access inequities within suburban areas. Our findings demonstrate the importance of considering rurality at a subcounty level to understand locality-related inequities in the risk of SMM.

Abstract

Background: Cognitive decline may be an early indicator of major health issues in older adults, though research using population-based data is lacking. Researchers objective was to assess the relationships between distinct cognitive trajectories and subsequent health outcomes, including health status, depressive symptoms, and mortality, using a nationally representative cohort. Methods: Data were drawn from the National Health and AgingTrends Study. Global cognition was assessed annually between 2011 and 2018. The health status of 4413 people, depressive symptoms in 4342 individuals, and deaths among 5955 living respondents were measured in 2019. Distinct cognitive trajectory groups were identified using an innovative Bayesian group-based trajectory model. Ordinal logistic, Poisson, and logistic regression models were used to examine the associations between cognitive trajectories and subsequent health outcomes. Results: Researchers identified five cognitive trajectory groups with distinct baseline values and subsequent changes in cognitive function. Compared with the group with stably high cognitive function, worse cognitive trajectories (ie, lower baseline values and sharper declines) were associated with higher risks of poor health status, depressive symptoms, and mortality, even after adjusting for relevant covariates. Conclusions: Among older adults, worse cognitive trajectories are strongly associated with subsequent poor health status, high depressive symptoms, and high mortality risks. Regular screening of cognitive function may help to facilitate early identification and interventions for older adults susceptible to adverse health outcomes.

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The purpose of this review is to synthesize results from studies examining the association between time-of-day for eating, exercise, and sleep with blood pressure (BP) in adults with elevated BP or hypertension. Six databases were searched for relevant publications from which 789 were identified. Ten studies met inclusion criteria. Four studies examined time-of-day for eating, five examined time-of-day for exercise, and one examined time-of-day for sleep and their associations with BP. Results suggested that later time-of-day for eating (n = 2/4) and later sleep mid-point (n = 1/1) were significantly related to higher BP in multivariable models, whereas morning (n = 3/5) and evening (n = 4/5) exercise were associated with significantly lower BP. Although this small body of work is limited by a lack of prospective, randomized controlled study designs and underutilization of 24 h ambulatory BP assessment, these results provide preliminary, hypothesis-generating support for the independent role of time-of-day for eating, exercise, and sleep with lower BP.

Abstract

Background: Despite the exponential growth in telemedicine visits in clinical practice due to the COVID-19 pandemic, it remains unknown if telemedicine visits achieved similar adherence to prescribed medications as in-person office visits for patients with heart failure. Objective: Our study examined the association between telemedicine visits (vs in-person visits) and medication adherence in patients with heart failure. Methods: This was a retrospective cross-sectional study of adult patients with a diagnosis of heart failure or an ejection fraction of ≤40% using data between April 1 and October 1, 2020. This period was used because New York University approved telemedicine visits for both established and new patients by April 1, 2020. The time zero window was between April 1 and October 1, 2020, then each identified patient was monitored for up to 180 days. Medication adherence was measured by the mean proportion of days covered (PDC) within 180 days, and categorized as adherent if the PDC was ≥0.8. Patients were included in the telemedicine exposure group or in-person group if all encounters were video visits or in-person office visits, respectively. Poisson regression and logistic regression models were used for the analyses. Results: A total of 9521 individuals were included in this analysis (telemedicine visits only: n=830 in-person office visits only: n=8691). Overall, the mean age was 76.7 (SD 12.4) years. Most of the patients were White (n=6996, 73.5%), followed by Black (n=1060, 11.1%) and Asian (n=290, 3%). Over half of the patients were male (n=5383, 56.5%) and over half were married or living with partners (n=4914, 51.6%). Most patients’ health insurance was covered by Medicare (n=7163, 75.2%), followed by commercial insurance (n=1687, 17.7%) and Medicaid (n=639, 6.7%). Overall, the average PDC was 0.81 (SD 0.286) and 71.3% (6793/9521) of patients had a PDC≥0.8. There was no significant difference in mean PDC between the telemedicine and in-person office groups (mean 0.794, SD 0.294 vs mean 0.812, SD 0.285) with a rate ratio of 0.99 (95% CI 0.96-1.02; P=.09). Similarly, there was no significant difference in adherence rates between the telemedicine and in-person office groups (573/830, 69% vs 6220/8691, 71.6%), with an odds ratio of 0.94 (95% CI 0.81-1.11; P=.12). The conclusion remained the same after adjusting for covariates (eg, age, sex, race, marriage, language, and insurance). Conclusions: We found similar rates of medication adherence among patients with heart failure who were being seen via telemedicine or in-person visits. Our findings are important for clinical practice because we provide real-world evidence that telemedicine can be an approach for outpatient visits for patients with heart failure. As telemedicine is more convenient and avoids transportation issues, it may be an alternative way to maintain the same medication adherence as in-person visits for patients with heart failure.

Abstract

Background: Despite advances in medical therapy for heart failure with reduced ejection fraction (HFrEF), major gaps in medication adherence to guideline-directed medical therapies (GDMT) remain. Greater continuity of care may impact medication adherence and reduced hospitalizations. Methods: We conducted a cross-sectional study of adults with a diagnosis of HF and EF ≤40% with ≥2 outpatient encounters between January 1, 2017 and January 10, 2021, prescribed ≥1 of the following GDMT: 1) Beta Blocker, 2) Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker/Angiotensin Receptor Neprilysin Inhibitor, 3) Mineralocorticoid Receptor Antagonist, 4) Sodium Glucose Cotransporter-2 Inhibitor. Continuity of care was calculated using the Bice-Boxerman Continuity of Care Index (COC) and the Usual Provider of Care (UPC) index, categorized by quantile. The primary outcome was adherence to GDMT, defined as average proportion of days covered ≥80% over 1 year. Secondary outcomes included all-cause and HF hospitalization at 1-year. We performed multivariable logistic regression analyses adjusted for demographics, insurance status, comorbidity index, number of visits and neighborhood SES index. Results: Overall, 3,971 individuals were included (mean age 72 years (SD 14), 71% male, 66% White race). In adjusted analyses, compared to individuals in the highest COC quartile, individuals in the third COC quartile had higher odds of GDMT adherence (OR 1.26, 95% CI 1.03-1.53, P = .024). UPC tertile was not associated with adherence (all P > .05). Compared to the highest quantiles, the lowest UPC and COC quantiles had higher odds of all-cause (UPC: OR 1.53, 95%CI 1.23-1.91; COC: OR 2.54, 95%CI 1.94-3.34) and HF (UPC: OR 1.81, 95%CI 1.23-2.67; COC: OR 1.77, 95%CI 1.09-2.95) hospitalizations. Conclusions: Continuity of care was not associated with GDMT adherence among patients with HFrEF but lower continuity of care was associated with increased all-cause and HF-hospitalizations.

Abstract

Background: Copper (Cu), an essential trace mineral regulating multiple actions of inflammation and oxidative stress, has been implicated in risk for preterm birth (PTB). Objectives: This study aimed to determine the association of maternal Cu concentration during pregnancy with PTB risk and gestational duration in a large multicohort study including diverse populations. Methods: Maternal plasma or serum samples of 10,449 singleton live births were obtained from 18 geographically diverse study cohorts. Maternal Cu concentrations were determined using inductively coupled plasma mass spectrometry. The associations of maternal Cu with PTB and gestational duration were analyzed using logistic and linear regressions for each cohort. The estimates were then combined using meta-analysis. Associations between maternal Cu and acute-phase reactants (APRs) and infection status were analyzed in 1239 samples from the Malawi cohort. Results: The maternal prenatal Cu concentration in our study samples followed normal distribution with mean of 1.92 μg/mL and standard deviation of 0.43 μg/mL, and Cu concentrations increased with gestational age up to 20 wk. The random-effect meta-analysis across 18 cohorts revealed that 1 μg/mL increase in maternal Cu concentration was associated with higher risk of PTB with odds ratio of 1.30 (95% confidence interval [CI]: 1.08, 1.57) and shorter gestational duration of 1.64 d (95% CI: 0.56, 2.73). In the Malawi cohort, higher maternal Cu concentration, concentrations of multiple APRs, and infections (malaria and HIV) were correlated and associated with greater risk of PTB and shorter gestational duration. Conclusions: Our study supports robust negative association between maternal Cu and gestational duration and positive association with risk for PTB. Cu concentration was strongly correlated with APRs and infection status suggesting its potential role in inflammation, a pathway implicated in the mechanisms of PTB. Therefore, maternal Cu could be used as potential marker of integrated inflammatory pathways during pregnancy and risk for PTB.

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Food insecurity is a major social determinant of health (SDH). However, further research is needed on the associations between SDH and diet among individuals living in urban food deserts. We designed a pilot study to examine the associations between diet and seven measures of SDH. Forty-five participants were enrolled in the study and were scheduled for an in-person or telephone interview. Food insecurity was significantly associated with greater intakes of fast food and refined grains. Employment was significantly associated with higher intake of alcohol. Findings from this pilot study confirm the importance of examining SDH in relation to diet.

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AbstractBackground: Experiential learning activities on care for people with disabilities (PWD) would help nursing students develop the knowledge, skills, and attitudes (KSAs) needed to provide quality care for PWD.Purpose: The purpose of this study was to evaluate the perceived changes in nursing students’ KSAs related to the care for PWD following participation in health assessment and prevention (HAP) experiential learning activities.Methods: This was a quasi-experimental, pre- and posttest educational intervention study. Nursing students (n = 160) attended multiple experiential learning activities as a required part of their HAP coursework and completed a pre and posttest survey to assess changes in their KSAs.Results: Participation in experiential learning activities on care for PWD was associated with significant increases in perceived knowledge, skills and positive attitudes toward PWD.Conclusions: Experiential learning activities aligned with core competencies for health care providers caring for PWDs have the potential to change nursing care and address health inequities for this population.

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Couple-based HIV interventions that increase uptake of two or more effective biomedical HIV prevention methods may be a promising HIV prevention strategy for young Black and Latino heterosexual couples. We conducted in-depth, semi-structured individual interviews with 23 Black and Latino adolescent and young adult heterosexual couples that explored their attitudes toward using combination HIV prevention methods (CHPMs). A qualitative hybrid thematic analysis approach was used to identify key themes. Themes included: (a) attitudes that encouraged uptake—CHPMs increased assurance of safety against HIV/sexually transmitted infections and (b) attitudes that impeded uptake—CHPMs are too much to do and are not appropriate for serious relationships. Although Black and Latino adolescents and young adults may recognize the combined protective benefits of using multiple HIV prevention methods, personal and relational considerations play an instrumental role in uptake of CHPMs.

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BACKGROUND: As the quality of cancer care improves, oncology patients face a rapidly increasing number of treatment options. Thus, it is vital that they are full and active partners in the treatment decision-making process. Awareness of disease status has been investigated in the literature; it has been inconsistently conceptualized and operationalized.OBJECTIVE: The aim of this integrative review was to develop a conceptual definition and model of the awareness of disease status among patients with cancer.METHODS: Whittemore and Knafl's integrative review methodology guided this article. We obtained data through a systematic search of 8 databases. Key terms utilized were awareness, perception, truth disclosure, diagnosis, prognosis, terminal illness, status, neoplasm, and metastasis. Dates through January 2020 were searched to capture all relevant articles. Sixty-nine articles met inclusion criteria.RESULTS: The integrative review methodology guided the development of a conceptual definition and model. The concept of "awareness of disease status" was defined as the individual patient's understanding of being diagnosed and treated for cancer based on the multifactorial components of individual patient characteristics and contextually driven communication practices of healthcare providers. This understanding is dynamic and changes throughout the disease trajectory.CONCLUSION: These findings will inform consistency in the literature. Such consistency may improve person-centered clinical communication, care planning practices, and, ultimately, cancer-related outcomes.IMPLICATIONS FOR PRACTICE: With a greater understanding of the complexity of patients' awareness of disease status, nurses will be able to guide their patients to make informed decisions throughout their disease trajectory.

Abstract

Background As the quality of cancer care improves, oncology patients face a rapidly increasing number of treatment options. Thus, it is vital that they are full and active partners in the treatment decision-making process. Awareness of disease status has been investigated in the literature; it has been inconsistently conceptualized and operationalized. Objective The aim of this integrative review was to develop a conceptual definition and model of the awareness of disease status among patients with cancer. Methods Whittemore and Knafl's integrative review methodology guided this article. We obtained data through a systematic search of 8 databases. Key terms utilized were awareness, perception, truth disclosure, diagnosis, prognosis, terminal illness, status, neoplasm, and metastasis. Dates through January 2020 were searched to capture all relevant articles. Sixty-nine articles met inclusion criteria. Results The integrative review methodology guided the development of a conceptual definition and model. The concept of "awareness of disease status"was defined as the individual patient's understanding of being diagnosed and treated for cancer based on the multifactorial components of individual patient characteristics and contextually driven communication practices of healthcare providers. This understanding is dynamic and changes throughout the disease trajectory. Conclusion These findings will inform consistency in the literature. Such consistency may improve person-centered clinical communication, care planning practices, and, ultimately, cancer-related outcomes. Implications for Practice With a greater understanding of the complexity of patients' awareness of disease status, nurses will be able to guide their patients to make informed decisions throughout their disease trajectory.

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This chapter explores the case of a four-year-old male, Javier, who is presented to the primary care office with his mother, Carol, with a complaint of bedwetting. Carol states that Javier consistently wets the bed each night although he remains dry throughout the day. Javier's nutrition history reveals that he has a balanced diet with enough dairy, protein, fruits, and vegetables. Javier does have occasional constipation that is relieved with an over-the-counter laxative. The chapter provides essential guidance and information for understanding how to diagnose and manage this case. This includes differential diagnosis and a series of critical thinking questions ideal for the family nurse practitioner.