Publications

Abstract

Some oncology outpatients experience a higher number of and more severe symptoms during chemotherapy (CTX). However, little is known about whether this high risk phenotype persists over time. Latent transition analysis (LTA) was used to examine the probability that patients remained in the same symptom class when assessed prior to the administration of and following their next dose of CTX. For the patients whose class membership remained consistent, differences in demographic and clinical characteristics, and quality of life (QOL) were evaluated. The Memorial Symptom Assessment Scale (MSAS) was used to evaluate symptom burden. LTA was used to identify subgroups of patients with distinct symptom experiences based on the occurrence of the MSAS symptoms. Of the 906 patients evaluated, 83.9% were classified in the same symptom occurrence class at both assessments. Of these 760 patients, 25.0% were classified as Low–Low, 44.1% as Moderate–Moderate and 30.9% as High–High. Compared to the Low–Low class, the other two classes were younger, more likely to be women and to report child care responsibilities, and had a lower functional status and a higher comorbidity scores. The two higher classes reported lower QOL scores. The use of LTA could assist clinicians to identify higher risk patients and initiate more aggressive interventions.

Abstract

Objective:To evaluate experiences regarding implementation of Neonatal Resuscitation Program (NRP) guideline changes in the context of a collaborative quality improvement (QI) project.Study Design:Focus groups were conducted with local QI leaders and providers from nine sites that participated in a QI collaborative. Thematic analysis identified facilitators and barriers to implementation of NRP guideline changes and QI in general.Results:Facilitators for QI included comparative process measurement and data tracking. Barriers to QI were shifting priorities and aspects of the project that seemed inefficient. Specific to NRP, implementation strategies that worked involved rapid feedback, and education on rationale for change. Changes that interrupted traditional workflow proved challenging to implement. Limited resources and perceptions of increased workload were also barriers to implementation.Conclusion:Collaborative QI methods are generally well accepted, particularly data tracking, sharing experience and education. Strategies to increase efficiency and manage workload may facilitate improved staff attitudes toward change.

Abstract

Background Childbirth is a leading reason for hospital admission in the USA, and most labour care is provided by registered nurses under physician or midwife supervision in a nurse-managed care model. Yet, there are no validated nurse-sensitive quality measures for maternity care. We aimed to engage primary stakeholders of maternity care in identifying the aspects of nursing care during labour and birth they believe influence birth outcomes, and how these aspects of care might be measured. Methods This qualitative study used 15 focus groups to explore perceptions of 73 nurses, 23 new mothers and 9 physicians regarding important aspects of care. Transcripts were analysed thematically. Participants in the final six focus groups were also asked whether or not they thought each of five existing perinatal quality measures were nurse-sensitive. Results Nurses, new mothers and physicians identified nurses' support of and advocacy for women as important to birth outcomes. Support and advocacy actions included keeping women and their family members informed, being present with women, setting the emotional tone, knowing and advocating for women's wishes and avoiding caesarean birth. Mothers and nurses took technical aspects of care for granted, whereas physicians discussed this more explicitly, noting that nurses were their 'eyes and ears' during labour. Participants endorsed caesarean rates and breastfeeding rates as likely to be nurse-sensitive. Conclusions Stakeholder values support inclusion of maternity nursing care quality measures related to emotional support and providing information in addition to physical support and clinical aspects of care. Care models that ensure labour nurses have sufficient time and resources to engage in the supportive relationships that women value might contribute to better health outcomes and improved patient experience.

Abstract

Objective: In a sample of 368 postmenopausal women, we (1) determined within-cohort and between-cohort relationships between adjuvant systemic therapy for breast cancer and self-reported cognitive function during the first 18 months of therapy and (2) evaluated the influence of co-occurring symptoms, neuropsychological function, and other covariates on relationships. Methods: We evaluated self-reported cognitive function, using the Patient Assessment of Own Functioning Inventory (PAOFI), and potential covariates (e.g., co-occurring symptom scores and neuropsychological function z-scores) in 158 women receiving aromatase inhibitor (AI) therapy alone, 104 women receiving chemotherapy followed by AI therapy, and 106 non-cancer controls. Patients were assessed before systemic therapy and then every 6 months, for a total of four assessments over 18 months. Controls were assessed at matched time points. Mixed-effects modeling was used to determine longitudinal relationships. Results: Controlling for covariates, patients enrolled before chemotherapy reported poorer global cognitive function (p < 0.001), memory (p < 0.001), language and communication (p < 0.001), and sensorimotor function (p = 0.002) after chemotherapy. These patients reported poorer higher-level cognitive and intellectual functions from before chemotherapy to 12 months after initiation of AI therapy (p < 0.001). Higher levels of depressive symptoms (p < 0.001), anxiety (p < 0.001), and fatigue (p = 0.040) at enrollment were predictors of poorer cognitive function over time. PAOFI total score was a predictor of executive function (p = 0.048) and visual working memory (p = 0.005) z-scores, controlling for covariates. Conclusions: Findings provide further evidence of poorer self-reported cognitive function after chemotherapy and of relationships between co-occurring symptoms and cognitive changes. AI therapy alone does not have an impact on self-reported cognitive function.

Abstract

Background: Obesity research has typically focused on weight change patterns using the whole sample in randomized clinical trials (RCTs), ignoring subsets of individuals with varying weight change trajectories (e.g., continuing to lose, or maintaining weight). The purpose was to explore possible trajectories of weight change and their associated predictors. Methods: We conducted a secondary analysis of data from two RCTs using standard behavioral treatment for weight loss. Group-based trajectory modeling was used to identify distinct classes of percent weight change trajectories over 18 months. Results: The sample (N = 338) was primarily female (85.2%), White (73.7 %), 45.7 ± 9.0 years old, with 15.6 ± 2.8 years of education. Three trajectory groups were identified: good responders (>15% weight loss), fair responders (5%–10% weight loss), and poor responders (<5% weight loss). The good responders had a significantly larger decrease in perceived Barriers to Healthy Eating subscale scores than the fair and poor responders (p <.01). Compared to the poor responders, there was a significant decrease in fat gram intake in the good responders (p =.01). Conclusions: Good responders differed from poor responders in decreasing their perceived barriers to healthy eating (e.g., managing emotions, social support, and daily mechanics of adopting a healthy diet) and reducing fat intake. Good responders differed from fair responders in perceived barriers to healthy eating. Clinical Relevance: Clinicians need to focus on how we can assist those who are being unsuccessful in adopting some of the behaviors observed among those who have experienced successful weight loss and maintainers.

Abstract

Background: Ineffective medication management contributes to repeated hospitalisation and death among patients with heart failure. The meaning ascribed to medications and the influence of meaning on how patients manage medications is unknown. The purpose of this study was to explore the meaning and expectations associated with medication use in high-risk, non-adherent patients with heart failure. Methods and results: Patients (n=265) with heart failure were screened for adherence to prescribed medication using the Morisky medication adherence scale (MMAS). Patients (MMAS score <6; n=44) participated in semistructured interviews, analysed using qualitative content analysis. Of 17 initial themes (223 representative segments), the overarching theme 'unmet expectations' consisted of two subthemes 'working to be heard' by professionals and 'resignation' to both the illness and medications. Patients' expectations were challenged by unexpected work to communicate with providers in general (72 representative segments), and specifically regarding medications (118 representative segments) and feelings of resignation regarding the medication regimen (33 representative segments). Conclusions: These findings suggest that unmet expectations contribute to poor medication management. Improved listening and communication by providers, to establish a common understanding and plan for managing medications may strengthen patient beliefs, resolve feelings of resignation and improve patients' ability to manage medications effectively.

Abstract

PURPOSE: The purpose of our study was to explore how foreign-born Chinese women living in California engage in various traditional and American birth practices.STUDY DESIGN AND METHODS: A descriptive qualitative study was conducted using a grounded theory approach. Chinese women from Mainland China, Hong Kong, and Taiwan who had childbirth experiences in the United States were purposively sampled. Semistructured interviews were conducted with 13 women, with follow-up interviews with 5 women. Interview data were analyzed using grounded theory according to the method of Strauss and Corbin.RESULTS: There are many traditional practices for pregnancy and childbirth. Women investigated the traditions through various means, and built their own perspective on each tradition by integrating an evaluation of the Chinese perspective and an evaluation of the American perspective. Women considered several factors in the process of evaluating the Chinese and American perspectives to reach their own integrated perspective on each tradition. These factors included whether or not the tradition made sense to them, how the traditional practice affected their comfort, nature of available options, attitudes of female elders, previous experiences of their peers and themselves, and outcomes of temporary trials of traditional or nontraditional practices.CLINICAL IMPLICATIONS: Healthcare providers should respect women's diverse perspectives on traditional practices and encourage flexible arrangements. Including the elder generation in health education may be useful in helping women manage conflicts and to support their decisions.

Abstract

Health care policy is never easy and always fraught with concerns about quality, access, and cost. Currently, uncertainty abounds regarding new federal and state policies on the horizon for older adult care and quality. Empirics undergird most policy-making decisions regarding risk/benefit, cost, and knowing the best action to put in place for the best results. However, in times of great change in policy direction and political viewpoints, empirical knowledge must be combined with ethical knowledge for planning and implementation. Ethical and moral judgment has long been a mainstay of nursing practice and organizational leadership. Using ethical knowledge as a framework will be a crucial guide for nurses and health professionals and society to prioritize action and decisions in policy.

Abstract

We aimed to examine the psychometric properties of a modified 16-item Attitudinal Index (AI), a measure of Chinese older adults’ beliefs about preventive health screenings. We used the 2013 Shanghai Elderly Life and Opinion data including 3,418 respondents age 60+ who were randomly split into training and validation samples. We examined the validity and reliability of the modified AI. Psychometric evaluation of the modified AI revealed good response patterns. The overall scale had good reliability (Cronbach’s α =.835). Exploratory factor analysis yielded four factors: barriers, fatalism, unnecessary, and detects (Cronbach’s α =.815-.908). Confirmatory factor analysis of the modified AI’s factor structure verified its four-factor structure (comparative fit index = 0.913, standardized root mean square residual = 0.048). The validity and reliability of the modified AI support its cultural appropriateness in measuring health beliefs among Chinese elderly. Further psychometric evaluation should focus on testing concurrent and criterion validity.

Abstract

Objective To examine variation in the cesarean birth rates of women cared for by labor and delivery nurses. Design Retrospective cohort study. Setting One high-volume labor and delivery unit at an academic medical center in a major metropolitan area. Participants Labor and delivery nurses who cared for nulliparous women who gave birth to term, singleton fetuses in vertex presentation. Methods Data were extracted from electronic hospital birth records from January 1, 2013 through June 30, 2015. Cesarean rates for individual nurses were calculated based on the number of women they attended who gave birth by cesarean. Nurses were grouped into quartiles by their cesarean rates, and the effect of these rates on the likelihood of cesarean birth was estimated by a logit regression model adjusting for patient-level characteristics and clustering of births within nurses. Results Seventy-two nurses attended 3,031 births. The mean nurse cesarean rate was 26% (95% confidence interval [23.9, 28.1]) and ranged from 8.3% to 48%. The adjusted odds of cesarean for births attended by nurses in the highest quartile was nearly 3 times (odds ratio = 2.73, 95% confidence interval [2.3, 3.3]) greater than for births attended by nurses in the lowest quartile. Conclusion The labor and delivery nurse assigned to a woman may influence the likelihood of cesarean birth. Nurse-level cesarean birth data could be used to design practice improvement initiatives to improve nurse performance. More precise measurement of the relative influence of nurses on mode of birth is needed.

Abstract

Background: Sub-Saharan Africa accounts for approximately 66% of global maternal deaths. Poor person-centered maternity care, which emphasizes the quality of patient experience, contributes both directly and indirectly to these poor outcomes. Yet, few studies in low resource settings have examined what is important to women during childbirth from their perspective. The aim of this study is to examine women's facility-based childbirth experiences in a rural county in Kenya, to identify aspects of care that contribute to a positive or negative birth experience. Methods: Data are from eight focus group discussions conducted in a rural county in western Kenya in October and November 2016, with 58 mothers aged 15 to 49 years who gave birth in the preceding nine weeks. We recorded and transcribed the discussions and used a thematic approach for data analysis. Results: The findings suggest four factors influence women's perceptions of quality of care: responsiveness, supportive care, dignified care, and effective communication. Women had a positive experience when they were received well at the health facility, treated with kindness and respect, and given sufficient information about their care. The reverse led to a negative experience. These experiences were influenced by the behavior of both clinical and support staff and the facility environment. Conclusions: This study extends the literature on person-centered maternity care in low resource settings. To improve person-centered maternity care, interventions need to address the responsiveness of health facilities, ensure women receive supportive and dignified care, and promote effective patient-provider communication.

Abstract

Reflective functioning (RF), the capacity to envision thoughts, feelings, needs and intentions within the self and others, is thought to be central to sensitive parenting, yet this capacity has been unexamined among pregnant adolescents. We explored how RF was related to the emotional experience of adolescent pregnancy. Design and Methods: This qualitative study was guided by interpretive description. Participants were 30 Latina and African-American adolescents (mean age 17.7 + 1.5 years) residing in a low-income urban community. All adolescents were interviewed with the Pregnancy Interview (a 22 question semi-structured interview) in their third trimester of pregnancy. Interview transcripts had been previously coded for levels of RF (1-9 with higher levels denoting higher reflectiveness), and this secondary analysis focused on the teens' experience of pregnancy and their emerging reflective capacities. We used a priori and inductive coding with all interviews and developed patterns and themes. Results: These interviews provided an in-depth understanding of the complex adolescent emotional experiences of pregnancy. We identified five themes that create a picture of how the participants reflected upon their pregnancies, unborn babies, emerging parental roles, and complicated relationships with family and partners. Conclusions and Practice Implications: Adolescent developmental issues and harsh family and neighborhood environments permeated the teens' experience of pregnancy and limited capacity for RF. Understanding distinctive features of RF in pregnant adolescents may contribute to developing conceptual models and tailored clinical approaches for enhancing parental reflectiveness and sensitivity in these vulnerable young women as they enter into the transition to parenthood.

Abstract

In November 2015, President Obama signed the Program of All-Inclusive Care for the Elderly (PACE) Innovation Act, which expands a proven model of care to serve high-cost and high-need populations. Specifically, the law provides the Centers for Medicare & Medicaid Services with the authority to waive Medicaid requirements that could not be waived without additional statutory authority. Those requirements include the age of the beneficiary to be served and nursing home eligibility as a condition for PACE enrollment. The law also allows providers and other entities who are not current PACE providers the opportunity to become PACE providers and serve a predominately dually eligible population that has high needs and high cost through a coordinated, integrated model. The current article describes the impact of nursing on the legislation and policy that has shaped the evolution of the PACE program for more than 40 years.

Abstract

Aim: To identify factors that may serve as facilitators and barriers to self-management described by adults living with chronic illness by conducting a qualitative metasynthesis. Background: Self-management is an individuals' active management of a chronic illness in collaboration with their family members and clinicians. Design: Qualitative metasynthesis. Data sources: We analysed studies (N = 53) published between January 2000–May 2013 that described factors affecting self-management in chronic illness as reported by adults aged over 18 years with chronic illness. Review methods: Sandelowsi and Barroso approach to qualitative metasynthesis: literature search; quality appraisal; analysis and synthesis of findings. Results: Collectively, article authors reported on sixteen chronic illnesses, most commonly diabetes (N = 28) and cardiovascular disease (N = 20). Participants included men and women (mean age = 57, range 18-94) from 20 countries representing diverse races and ethnicities. We identified five categories of factors affecting self-management: Personal/Lifestyle Characteristics; Health Status; Resources; Environmental Characteristics; and Health Care System. Factors may interact to affect self-management and may exist on a continuum of positive (facilitator) to negative (barrier). Conclusion: Understanding factors that influence self-management may improve assessment of self-management among adults with chronic illness and may inform interventions tailored to meet individuals' needs and improve health outcomes.

Abstract

RationaleHospital chaplains provide spiritual care that helps patients facing serious illness cope with their symptoms and prognosis, yet because mechanically ventilated patients cannot speak, spiritual care of these patients has been limited.ObjectivesTo determine the feasibility and measure the effects of chaplain-led picture-guided spiritual care for mechanically ventilated adults in the intensive care unit (ICU).MethodsWe conducted a quasi-experimental study at a tertiary care hospital between March 2014 and July 2015. Fifty mechanically ventilated adults in medical or surgical ICUs without delirium or dementia received spiritual care by a hospital chaplain using an illustrated communication card to assess their spiritual affiliations, emotions, and needs and were followed until hospital discharge. Feasibility was assessed as the proportion of participants able to identify spiritual affiliations, emotions, and needs using the card. Among the first 25 participants, we performed semistructured interviews with 8 ICU survivors to identify how spiritual care helped them. For the subsequent 25 participants, we measured anxiety (on 100-mm visual analog scales [VAS]) immediately before and after the first chaplain visit, and we performed semistructured interviews with 18 ICU survivors with added measurements of pain and stress (on ±100-mm VAS).Measurements and main resultsThe mean (SD) age was 59 (±16) years, median mechanical ventilation days was 19.5 (interquartile range, 7-29 d), and 15 (30%) died in-hospital. Using the card, 50 (100%) identified a spiritual affiliation, 47 (94%) identified one or more emotions, 45 (90%) rated their spiritual pain, and 36 (72%) selected a chaplain intervention. Anxiety after the first visit decreased 31% (mean score change, -20; 95% confidence interval, -33 to -7). Among 28 ICU survivors, 26 (93%) remembered the intervention and underwent semistructured interviews, of whom 81% felt more capable of dealing with their hospitalization and 0% felt worse. The 18 ICU survivors who underwent additional VAS testing during semistructured follow-up interviews reported a 49-point reduction in stress (95% confidence interval, -72 to -24) and no significant change in physical pain that they attributed to picture-guided spiritual care.ConclusionsChaplain-led picture-guided spiritual care is feasible among mechanically ventilated adults and shows potential for reducing anxiety during and stress after an ICU admission.

Abstract

Approximately one quarter of all Medicare beneficiaries hospitalized for heart failure (HF) are discharged to long-term care (LTC) for skilled nursing care, and, of those, 25% are readmitted to the hospital within 30 days. We implemented a 3-month pilot quality improvement project using a pre-post design that included an educational intervention for certified nursing assistants (CNAs) conducted by a nurse practitioner (NP). The three aims of the project were to: (1) improve CNAs' knowledge of heart failure (HF) management strategies; (2) improve CNAs' reporting of acute changes in the condition of residents with HF; and (3) reduce rehospitalizations of the facility's skilled unit residents with HF. The percentage of HF resident 30-day hospital readmission rates fell 7.8% during the project's 3-month implementation period. The results of this project support future NP-led clinical education for CNAs working in this facility.

Abstract

Aim: To assess the impact of adding nursing support workers to ward staffing. Background: Nurses' capacity to provide safe care is compromised by increased workloads and nursing shortages. Use of unregulated workers is an alternative to increasing the number of regulated nurses. The impact of adding nursing support workers on patient, nurse and system outcomes has not been systematically evaluated. Design: A mixed longitudinal and cross-sectional design using administrative data sets and prospective data from a sample of wards. Methods: Payroll data will identify wards on which unregulated staff work. To assess the impact on nursing-sensitive outcomes, retrospective analysis of morbidity and mortality data of all patients admitted to Western Australia hospitals for over 24 hours across 4 years will be undertaken. For the cross-sectional study, a sample of 20 pairs of matched wards will be selected: 10 with unregulated workers added and 10 where they have not. From this sample the impact on patients will be assessed using the Patient Evaluation of Emotional Care during Hospitalisation survey. The impact on nurses will be assessed by a nurse survey used extensively which includes variables such as job satisfaction and intention to leave. The impact on system outcomes will be explored using work sampling of staff activities and the Practice Environment Scale. Interviews will determine nurses' experience of working with nursing support workers. Discussion: The study aims to provide evidence about the impact of adding nursing support workers to ward staffing for patients, staff and the work environment.

Abstract

Objective To explore factors contributing to intentional and unintentional medication nonadherence in adults with chronic heart failure (HF). Background Medication nonadherence is prevalent in HF but the factors contributing to it are not well understood. Methods This secondary data analysis of qualitative data explored narrative accounts about medication adherence from four previous studies (N = 112). The Necessity–Concerns–Framework derived from the Common Sense Model (CSM) of Self-Regulation guided the interpretation of themes. Results In this diverse sample (39% Black, 6% Hispanic, 63% male; mean age 59 ± 15 years), 90% reported at least intermittent nonadherence. For many (60%), missing medication was unintentional but 27% reported intentional nonadherence. Four interconnected patterns of behavior emerged: 1) rarely nonadherent, 2) frequently nonadherent, 3) intentionally nonadherent, and 4) reformed nonadherent. Misperceptions about HF, beliefs, concerns, and contextual factors contributed to both intentional and unintentional nonadherence. Conclusion Medication nonadherence is prevalent in HF and influenced by modifiable factors.

Abstract

Background: Approximately half of veterans with low-risk prostate cancer receive guideline-discordant imaging. Our objective was to identify and describe (1) physician knowledge, attitudes, and practices related to the use of imaging to stage prostate cancer, (2) patient attitudes and behaviors related to use of imaging, and (3) to compare responses across three VA medical centers (VAMCs). Methods: A qualitative approach was used to explore patient and provider knowledge and behaviors relating to the use of imaging. We conducted 39 semi-structured interviews total-including 22 interviews with patients with newly diagnosed with prostate cancer and 17 interviews with physicians caring for them-between September 2014 and July 2015 at three VAMCs representing a spectrum of inappropriate imaging rates. After core theoretical concepts were identified, the Theoretical Domains Framework (TDF) was selected to explore linkages between themes within the dataset and existing domains within the framework. Interviews were audio-recorded, transcribed verbatim, and then coded and analyzed using Nvivo software. Results: Themes from patient interviews were categorized within four TDF domains. Patients reported little interest in staging as compared to disease treatment (goals), and many could not remember if they had imaging at all (knowledge). Patients tended to trust their doctor to make decisions about appropriate tests (beliefs about capabilities). Some patients expressed a minor concern for radiation exposure, but anxiety about cancer outcomes outweighed these fears (emotion). Themes from physician interviews were categorized within five TDF domains. Most physicians self-reported that they know and trust imaging guidelines (knowledge) yet some were still likely to follow their own intuition, whether due to clinical suspicion or years of experience (beliefs about capabilities). Additionally, physicians reported that medico-legal concerns, fear of missing associated diagnoses (beliefs about consequences), influence from colleagues who image frequently (social influences), and the facility where they practice influences rates of imaging (environmental context). Conclusions: Interviews with patients and physicians suggest that physicians are the primary (and in some cases only) decision-makers regarding staging imaging for prostate cancer. This finding suggests a physician-targeted intervention may be the most effective strategy to improve guideline-concordant prostate cancer imaging.