Full text for dissertations and theses included in this collection dates back to 2011. For older dissertations, check the library’s catalog CatalogUSMAI or Dissertations and Theses database.

Recent Submissions

  • Mechanisms of Heart Failure Related Fatigue

    Hoch, Christine Renee; Klinedinst, N. Jennifer (2021)
    Background: Fatigue has been reported in 53-100% of patients with heart failure (HF). Fatigue in HF is described as a highly burdensome symptom that has a profoundly negative effect on quality of life and is associated with worsening prognosis and mortality. Despite its prevalence and deleterious outcomes, HF-related fatigue remains poorly understood with limited treatment modalities. Purpose: The purpose of this dissertation was to (1) describe known physiologic, psychologic, and situational correlates of HF-related fatigue, (2) evaluate the contribution of select physiologic variables to HF-related fatigue, and (3) identify correlates of excessive daytime sleepiness (EDS) in chronic stroke survivors as groundwork for future studies examining fatigue in HF. Methods: The first manuscript is a synthesis of the scientific literature on known correlates or mechanisms of HF-related fatigue. The second manuscript uses cross-sectional data from the 2015-2018 National Health and Nutrition Survey (NHANES). A complex sample design was used to assess the contribution of select physiologic variables on HF-related fatigue. Independent t tests and chi-square tests were used to explore differences between fatigued and non-fatigued adults and logistic regression to calculate the odds of having fatigue. Non-parametric correlations and descriptive statistics were used in the third manuscript to describe the relationship of EDS to sleep quality, body mass index (BMI), systemic inflammation, and energy metabolism of platelets in chronic stroke survivors. Results: Correlates of HF-related fatigue include age, sex, dyspnea, pain, disease severity, use of diuretics, volume status, anemia, oxygen uptake, depression, anxiety, perception of symptoms/health, sleep disturbances, poor social support, reduced quality of life. Concepts were grouped into 5 categories: individual, physiologic, psychologic, situational and outcome. Analysis of NHANES data revealed a low serum osmolality was significantly associated with fatigue (χ2 = -2.37, p = .03). Being female was predictive of experiencing fatigue when controlling for age, serum osmolality, serum hemoglobin and the presence of dyspnea (OR 4.68, 95% CI .34 – 2.75). The analysis of the pilot data found EDS in 27.3% of the sample. No statistical correlations were found between EDS, inflammatory markers, energy metabolism of platelets, sleep quality or BMI. A non-significant moderate effect size was noted with IL1-β (rho.42) and TNF-α (rho .35) and EDS. A small effect size was noted with IL-6 and EDS (rho .26). Conclusions: Improving our knowledge of mechanisms of HF-related fatigue will inform strategies to reduce or ameliorate the symptom. Future studies should continue to assess the relationship between serum osmolality, sex hormones and cellular energy metabolism to fatigue in patients with HF.
  • Fatigue in Adults with Chronic Obstructive Pulmonary Disease Before and During a Pandemic

    Clark, Lindsey Anne-Hertsenberg; Klinedinst, N. Jennifer (2021)
    Background: Over half of the 11 million people living with chronic obstructive pulmonary disease (COPD) suffer from debilitating fatigue almost every day. There is limited evidence on known mechanisms of COPD-related fatigue and factors that influence fatigue. Purpose: The purposes of this dissertation were to 1) survey the findings of existing literature on correlates and underlying potential mechanisms of COPD-related fatigue and test these findings in a model of situational factors, psychologic and physiologic factors in adults with COPD-related fatigue and physical functioning and 2) explore the lived experience of COPD-related fatigue during the COVID-19 pandemic. Methods: Chapter 2 is a scoping review to identify relevant studies on potential mechanisms and influential factors of COPD-related fatigue based on the Theory of Unpleasant Symptoms. The second manuscript is a descriptive correlational study that presents a path model from a population-based study on the relationships between physiologic, psychologic, and situational factors with fatigue and physical function. The third manuscript is a qualitative research study using a phenomenological descriptive approach and collected data from adults living with COPD and fatigue during the COVID-19 pandemic with attention to the influence of social support and physical function. Results: In Chapter 2, a conceptual model of COPD-fatigue was established from the scoping review based on the TOUS of physiologic, psychologic and situational factors contributing to COPD fatigue. When testing the model, depression (0.181, p<0.001), smoking (0.541, p=0.019), and stress (0.073, p=0.038) all had significant direct effects on fatigue. Social support (0.967, p=.016) and sleep (0.577, p=0.010) impacted physical functioning, but not fatigue. In Chapter 4, three main themes were found from interviews pertaining to the experience of fatigue during the COVID-19 pandemic: experience of general fatigue from the COVID-19 pandemic, changes in response to pandemic, and psychologic and social mentality. Conclusion: These findings lay groundwork for research on influential factors of COPD-related fatigue and physical function. Interventions geared toward reducing depression and stress management may reduce COPD related fatigue. There remains a gap on physiologic mechanisms of COPD fatigue that should be addressed in future studies.
  • Altering Mechanisms of Frailty in Persons Living with HIV

    Nelson, Amy; Klinedinst, N. Jennifer (2021)
    Background: People with HIV experience frailty more often and earlier than others. Little is known about mechanisms driving early frailty in HIV. There are a lack of effective interventions for frailty in HIV. This study explored the mechanisms of musculoskeletal frailty in people living with HIV and the influence of baseline activity after a six-week aerobic exercise intervention. Methods: A literature review developed an adapted conceptual model for musculoskeletal frailty in HIV for the first manuscript. Due to COVID-19 restrictions, a secondary data analysis utilized the baseline activity measure (Yale Physical Activity Survey) from 11 healthy participants who completed a six-week moderate paced walking program, aged 50 to 65. Cellular energy production and inflammation markers were available pre- and post-intervention. Correlation with baseline activity was assessed using Kendall’s tau-b. Results: Mechanisms of musculoskeletal frailty in people living with HIV include increased inflammation, dysregulated energy metabolism, immune activation, and endocrine alterations. Aerobic exercise has the potential to moderate each of these. The relationship between baseline activity and changes in cellular energy metabolism was not statistically significant. However, strong positive associations were noted between body mass index and change in platelet spare respiratory capacity, the ability of mitochondria to produce more energy upon demand. In examining the effect of baseline activity on inflammatory markers, no significant relationships were found, and no markers showed significant change. Conclusion: Moderate walking did not make significant changes in inflammation after a six-week moderate paced walking intervention. Baseline activity levels did not play a significant role in the change of either inflammation or cellular energy production. This may be because healthy participants did not have impaired levels of inflammation or cellular energy metabolism at baseline. This study should be repeated in people living with HIV who have altered inflammation or cellular energy metabolism.
  • Individual, Caregiver, and Family Characteristics Associated with Obesity in Preschool-age Children

    Rahmaty, Zahra; Johantgen, Mary E.; 0000-0001-6165-0881 (2021)
    Background and Objectives: Eating habits start from early childhood and may contribute to the development of obesity. Food neophobia (FN) occurs among 50% of preschoolers and has shown inconsistent associations with obesity. Caregiver feeding practices (FPs) influence eating habits but have limited evidence about how they employ together and how they associate with childhood obesity. The first paper examines the relationship between FN and preschooler's obesity/overweight. The second paper assesses patterns of FPs and their associated factors. The third paper examines how the patterns of FP relate to preschoolers' Body Mass Index (BMIz), an objective measure of obesity. Method: Data from the Creating Healthy Habits Among Maryland Preschoolers (CHAMP) study including preschoolers (N=500) and caregivers from 50 Maryland childcare centers were examined. Children's weight and height were measured, and BMI percentile and z-score were calculated. Caregivers reported demographics, weight and height, FN, FPs, child temperament via an online survey. Mixed models, factor analysis, latent profile analysis, and structural equation models were used. Results: A quarter of children were obese/overweight; caregiver-reported FN was not associated with preschoolers' obesity/overweight, although children were more likely to be obese/overweight if their caregiver was overweight (aOR=2.6) or obese (aOR=3.9). Three patterns of FP were found. Controlling class had high coercive control and low autonomy practices (69%), Regulating class had high coercive control, but moderate structural and autonomy practices (16%), and Balancing class were moderate in all practices (15%). Caregivers who desired their child to be heavier (aOR=0.40, 95%CI=0.22-0.72), had higher poverty levels (aOR=0.80, 95%CI=0.65-0.98), were single (aOR=0.38, 95% CI=0.18-0.80), and were less likely to be in the Balanced versus Controlling class. Children’s difficult temperament (b=0.09, p=0.008), caregiver’s BMI (b= 0.26, p<0.001), desire for the child to be thinner (b=0.23, p<0.001), desire for child to be heavier (b=-0.37, p<0.001), and Regulating versus Controlling FP (b=-0.09, p=0.03) were associated with child BMIz. Conclusion: Childhood obesity is a multifactorial phenomenon, with interactive effects among the child, family, and environment. FP are associated with preschooler’s weight and should be assessed comprehensively. Caregivers’ perceptions of child size and temperament may also provide insight into FP and obesity.
  • Staff-resident Interactions in Assisted Living: Optimizing the Quality of Daily Care Interactions

    Paudel, Anju; Galik, Elizabeth; Resnick, Barbara; 0000-0002-1784-5427 (2021)
    Background: A considerable amount of research has focused on understanding and improving staff-resident interactions in long-term care. Much of this work has focused on social communications between staff and residents in nursing home settings. Attention to care interactions in assisted living (AL) is lacking. Purpose: The purpose of this dissertation was to: (1) describe the staff-resident interactions in AL; (2) explore the resident and facility factors associated with the care interactions in AL; and (3) test the feasibility and preliminary efficacy of the Promoting Positive Care Interactions (PPCI)—a four-step intervention designed to establish positive care interactions between the staff and residents with cognitive impairment or dementia in AL. Methods: Utilizing baseline data in a randomized trial that included 379 residents from 59 AL facilities, aim 1 used descriptive statistics to describe the quality of staff-resident interactions in AL and aim 2 used stepwise regression to examine factors influencing interactions. Aim 3 involved pilot-testing of PPCI intervention in one AL community in Maryland using a single group pretest-posttest design. Feasibility was demonstrated with the evidence of delivery, receipt, and enactment of PPCI. Preliminary efficacy was evaluated with repeated measures ANOVA for staff outcomes and descriptive change in summary scores for facility outcomes. Results: Although majority of the interactions observed were positive, almost 25% were negative and neutral suggesting a need to improve the interactions in ALs. Factors influencing interactions included resident agitation and facility ownership which accounted for 8.2% of variance. Additionally, PPCI was implemented as intended with 100% staff exposure to education and considerable staff engagement in mentoring sessions. While there was an improvement in AL environment and policy, no significant changes were observed in staff outcomes post PPCI. Conclusions: Understanding the quality of staff-resident interactions in AL and the factors that influenced these interactions guided the development of PPCI. Pilot testing supported the feasibility and preliminary staff adoption of PPCI in ALs. PPCI will be further tested with a randomized trial, and a hybrid model with both online education and in-person mentoring and coaching of staff to improve staff knowledge and behavior related to care interactions.
  • Behavioral symptoms associated with dementia and inappropriate psychotropic medication use in U.S nursing homes

    Yoon, Jung Min; Trinkoff, Alison M. (2021)
    Background: Behavioral symptoms associated with dementia often occur concurrently. Psychotropic medications are used to treat behavioral symptoms in nursing homes (NHs) despite limited efficacy and the risk of adverse effects. Psychotropics are considered an easier solution for behavioral symptoms with fewer nursing staff. Inappropriate psychotropic medication use has been the focus of policy attention due to safety issues. A NH deficiency of care can be cited for inappropriate psychotropics use (F-758 tag). Purpose: The purposes of this dissertation are to examine factors of co-occurring behavioral symptoms of dementia (Aim 1), the occurrence of F-758 tag citations in relation to nurse staffing (Aim 2) and to explore how NH deficiency citations describe inappropriate psychotropics use to manage behaviors (Aim 3). Methods: For aim 1, general linear mixed models were used to explore co-occurring behavior symptoms in relation to cognitive status, physical function and analgesics use among 336 NH older adults diagnosed with dementia. For aim 2, generalized linear mixed models estimated associations between the occurrence of F-758 tags and nurse staffing levels among 13,614 NHs from December 2017 to 2018. Aim 3 used a mixed-method study design that combined descriptive and content analysis of F-758 deficiency reports (n=444 NHs) during January to March 2018. Results: Having multiple behavioral symptoms was negatively associated with better cognitive status and regular analgesics use (p<.001 and p=.009, respectively) (Aim 1). NHs with greater hours per resident day for RNs (OR=0.54, 95% CI=0.44-0.67), certified nurse assistant (OR=0.87, 95% CI=0.77-0.99), total nurse staff (OR= 0.87, 95% CI= 0.79-0.96), and greater RN skill-mix (OR=0.10, 95% CI=0.04-0.26) had significantly lower odds of F-758 tags (Aim 2). Common reasons for inappropriate psychotropic medication use included failure to monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs) and maintain14 day limits on PRN psychotropic medication orders (121 NHs) (Aim 3). Conclusions: Consideration of cognitive function and pain management are important for multiple behavioral symptoms (Aim 1). NHs need to have adequate nurse staffing levels to reduce inappropriate psychotropic medication use (Aim 2). Aim 3 analysis suggests areas for improvement, that could potentially reduce F-758 citations.
  • Patient and Intimate Partner (IP) Illness Appraisals in Cancer: A Multi-Methods Study

    Francis, Martha Eileen; Johantgen, Mary E. (2021)
    Background: Psychological distress for patients with serious illness has been associated with increased physical and spiritual distress, decreased quality of life, and increased medical expenses at end of life (EOL). For both cancer patients and their intimate partners (IPs), appraising the illness and communicating about it can be challenging. Yet, there is little evidence on how best to support them. Objectives: Bodenmann’s Systemic-Transactional Model (STM) of dyadic coping provided foundation to study how living with cancer impacts communication at primary appraisal level in patient/ IP dyad. The purpose of this exploratory multi-methods study was to understand patient/IP illness appraisals. This was investigated through following aims: 1. Describe patient/IP perceptions of dyadic communication before and after diagnosis of advanced cancer (including barriers and facilitators to sharing emotionally vulnerable content); 2. Describe patterns (incongruent/congruent) of patient and IP communication during advanced cancer; and 3. Explore relationships between experiential suffering (Suffering Pictogram) and communication congruency (CCAT-PF measure). Methods: Descriptive phenomenology was used for the qualitative phase. In-depth, semi-structured interviews with dyads were done, followed by individual interviews. The quantitative phase assessed cancer communication and suffering using established measures. Results: The main findings from qualitative analyses included: 1) Vulnerable communication is complicated by balancing two opposing worlds: Hope/Positivity and Uncertainty/Fear of Death; and 2) Vulnerable communication about EOL and hospice is emotional and unfamiliar. Hearing the word ‘hospice’ ends dyad’s uncertainty, confirming death from cancer is definite. Patients and IPs articulated feeling unprepared and needing guidance about skills to cross this vulnerable environment toward open communication. Quantitative data from communication measures showed low to medium discrepancy between dyads yet, patients displayed more discrepant communication behavior than their IP counterparts. IPs consistently exhibited higher suffering scores than patients across Overall Suffering and in 6/8 suffering domains. Worry and Fear were identified as highest domains of suffering for both patients/IPs. Conclusion: For IP dyads to articulate preferences for care with providers they must first be provided external support to facilitate vulnerable conversations within the dyad itself. These dyadic conversations must be initiated early after diagnosis to strengthen available supports during illness and EOL.
  • Development and Usability Testing of a Mobile Health Game Application for Older Adults on Warfarin

    Opoku-Agyemang, Ernest; Johantgen, Mary E.; Nahm, Eun-Shim (2020)
    Background: Chronic disease management constitutes a special challenge in the United States due to deficiencies in the healthcare system. Chronic disease self-management (CDSM) using technology and gaming principles is a promising way to overcome these challenges. Yet, there are few disease-specific apps to benefit the populations likely to benefit from such innovations. Purpose: This proof of concept study evaluated the feasibility of a Warfarin game app for older adults. The aims were to: 1) Design and develop a mobile game app to educate patients on Warfarin; and 2) Conduct usability testing of the game app among patients on Warfarin receiving care at an anticoagulation clinic. Methods: Following the design and development of a Warfarin app called Coumadin Hero, the usability testing of the app was conducted with 25 participants. Heuristics and user testing were conducted. The Technology Acceptance Model (TAM) was the theory that informed the study design and implementation. An adaptation of the Perceived Health Web Site Usability Questionnaire (PHWSUQ) was used to assess the participant usability. Descriptive and correlational statistics were used to analyze game play data and responses to survey questionnaires. Results: The median percent correct of Vitamin K food identification was 79%. Generally, participants had higher knowledge of Vitamin K levels in green vegetables (92% - 96%). User technology experience and demographic characteristics were not associated with Vitamin K food knowledge or level of satisfaction. The overwhelming majority of users found the app easy to learn and use. The ease of reading and finding information were 68 – 72%, respectively. Conclusion: Because self-management is vital for people taking Warfarin, using a game app as a supplement to traditional teaching could have significant positive impact on their health. As apps are increasingly easy to develop and smartphone use increases, apps should be developed to help people manage chronic diseases. Findings from this study support people’s interest and ability to use apps.
  • Expanding Post-Stroke Telerehabilitation: A Qualitative Study of User Experience Piloting VA Secure Messaging Use in a Telerehabilitation Format

    Keldsen, Linda; Storr, Carla L.; 0000-0002-5395-1358 (2020)
    BACKGROUND: Stroke is the fourth leading cause of death and primary cause of long-term disability in the U.S. As many as 40% of stroke survivors are discharged home without any inpatient or outpatient comprehensive stroke rehabilitation leading to the need for continued care for basic activities of daily living (grooming, toileting and feeding). Barriers to post-discharge comprehensive stroke rehabilitation are distance to travel, lack of transportation and inadequate social support. Telerehabilitation has been suggested as a possible solution for the delivery of low cost, convenient, home-based rehabilitative care. OBJECTIVE: To understand the experience of researchers and stroke survivors piloting the use of the My HealtheVet personal health record and secure messaging for stroke telerehabilitation. METHODS: A retrospective qualitative study using semi-structured interviews with a convenience sample of five study participants from the intervention arm of VA funded stroke rehabilitation single-blinded randomized controlled trail was conducted in addition to a focus group of three of the research team members. A descriptive phenomenological approach was used to describe the study participants and selected research team members experience using the VA’s My HealtheVet personal health record and secure messaging in telerehabilitation research. RESULTS: Researchers and study participants reported benefits from using the My HealtheVet personal health record with secure messaging that included the ability to send and or respond to secure messages at a time and place of their choosing, flexibility in scheduling the time of their therapy, ability to use any internet-enable device to access their My HealtheVet account, and the ability to retrieve and reread or watch education provided by the therapist when needed. Barriers to use were outweighed by the increased flexibility in scheduling, feeling empowered and having caregiver support. CONCLUSIONS: This small feasibility pilot suggests My HealtheVet with secure messaging may be an appropriate telecommunication tool for telerehabilitation. The study researchers caution that this was a small pilot and consideration should be given to ensuring adequate resources to support a larger study panel if expanded.
  • Evaluating Antidepressant Use in Nursing Home Residents with Moderate to Severe Cognitive Impairment

    Nalls, Victoria; Galik, Elizabeth; Resnick, Barbara (2020)
    Background: Antidepressants are commonly prescribed medications among nursing home residents and used to treat symptoms of dementia. Concerns have been raised, however, about disparities and potential inappropriate use of these medications within this population. Purpose: The purpose of this dissertation was to: (1) Describe factors associated with antidepressant use in nursing home residents with moderate to severe cognitive impairment; (2) Describe differences in antidepressant use between white and black nursing home residents with moderate to severe cognitive impairment; (3) Evaluate trends in antidepressants and antipsychotics prescribing among nursing home residents with moderate to severe cognitive impairment. Methods: This secondary data analysis used data from the Function and Behavior Focused Care (FBFC) for Nursing Home Residents with Dementia randomized control trial. A total of 336 residents were included in the study, who were mostly white, female, severely cognitively impaired (MMSE=7.8, SD=5.1) and the average age was 82. Data collection was done at baseline and 12 months and based on chart reviews, input from staff, and observation of residents. Descriptive statistics and logistic regression were used to address aims 1 and 2. Generalized linear mixed modeling with a binary distribution and logit link function was used for aim 3. Results: At baseline, 59% of the sample was taking an antidepressant. Race was significantly associated with antidepressant use (β=0.51; p=0.01). Black residents were half as likely to be on antidepressants compared to white residents (OR=0.499 CI=0.305-0.817) and received lower dosages of sertraline (t=2.68; p=0.01). There was no significant change in antidepressant or antipsychotic use at 12 months. Conclusions: Black nursing home residents with moderate to severe cognitive impairment were significantly less likely to be on antidepressants and when treated, were likely to be on lower dosages of some antidepressants. It is unknown if this is due to misdiagnoses and disparities in treatment or lack of need for antidepressants or differences in responses to specific drug classes. Further research is needed to explore these differences and evaluate the influence of resident, prescriber, and facility factors on the use of antidepressants among nursing home residents with moderate to severe dementia.
  • Burden and Mental Health of Family Caregivers of Cancer Patients: The Impact of Spirituality

    La, In Seo; Johantgen, Mary E. (2020)
    Background: As the primary source of care for individuals with cancer, family caregivers are relied on for treatment support and emotional care during the cancer trajectory. Studies on caregiver burden and psychological sequelae among cancer caregivers have been conducted cross-sectionally. Spirituality has been suggested as a potential buffer between burden and sequelae. Yet, there have been very few longitudinal studies addressing burden, depression, and spirituality, and there is limited information on psychometric properties of the spirituality measures in cancer caregivers. Purpose: The aims of this study were to: 1) evaluate validity of the Spiritual Perspective Scale (SPS) and explore differences in spirituality across caregiver and patient characteristics, 2) describe caregiver burden during active cancer treatment and explore caregiver and patient factors influencing caregiver burden, and 3) examine changes in caregiver burden, spirituality, and depression and explore the moderating effect of spirituality on burden-depression relationship over time. Methods: A secondary analysis of data from a longitudinal study of cancer caregivers from the NIH Clinical Center was conducted. Caregivers completed measures, including the Spiritual Perspective Scale (SPS), Caregiver Reaction Assessment (CRA), and NIH Toolbox and PROMIS® measures. Structural equation modeling and linear mixed modeling were used for testing study aims. Results: The SPS was found to have satisfactory psychometric properties in cancer caregivers. Adjusting for a direct effect of race did not alter the pattern of results, and caregivers who were older, female, racial/ethnic minorities, less educated, affiliated with a religion, and who provided care to anyone other than the patient reported higher levels of spirituality. Baseline mutuality between the caregiver and patient was negatively associated with initial burden. Changes in caregiver burden were related to being spouse caregivers, sole caregivers, and income. Scores on total burden, spirituality, and depression remained stable over time. Caregivers’ spirituality moderated the link between burden and depression (-1.26, p = .025). Conclusions: Higher levels of spirituality may act as a protective factor in the relationship between burden and depression during active cancer treatment. Identified factors related to burden and strategies to strengthen spirituality should be considered to improve caregiver mental health.
  • Adult Patients’ Experience Using Patient Portal: The Impact of Perceived Usability on Portal Use Behavior

    Son, Hyojin; Nahm, Eun-Shim (2020)
    Background: Patient portals (PPs) are a robust tool that can engage patients into their care. PPs can be especially helpful for older adults who have complex healthcare conditions. Usability of PPs is a major influencing factor for PP use. PP usability is more important for older adults who tend to be less familiar with technologies and may need additional support for using PPs. Currently, there has been a lack of studies that examined PP usability perceived by patients after PP implementation in healthcare settings. Objectives: The primary aim of the study was to test a modified PP Acceptance Model that explains factors affecting patients’ PP use. The secondary aim was to compare the difference in PP usability, PP self-efficacy, and PP use between older adults recruited from community settings and older adults recruited from hospital settings. Methods: To test the primary aim, an anonymous cross-sectional online survey was conducted with adult patients in an integrated healthcare system. Data from 743 patients who used PPs in the past 12 months were subject to structural equation modeling (SEM). For the secondary aim, a secondary data analysis was performed using descriptive statistics and content analysis (272 community-residing older adults). From this sample, those who used PPs (n=126) were compared with hospital/clinic-based older adults (n=174) by conducting regression analyses. Results: Among 743, about two-thirds were White and female (mean age, 53.1; range, 18-92). Mean PP usability was 36.6 (range, 6-42). The SEM revealed that the final model fit the data: CFI=.983, RMSEA=.059. PP self-efficacy and privacy/security concerns had a direct impact on PP use. PP use was indirectly influenced by PP usefulness, PP ease of use, eHealth literacy, education, and age. The secondary data analysis indicated that older adults recognized PP benefits and were willing to use PPs. However, their PP use was limited due to several challenges. The relationship between PP usability and PP use was stronger in the community sample. Conclusion: Findings suggest a strong potential for using PPs to engage patients in healthcare and strategies to improve patients’ PP use. Further studies need to include more diverse populations in various settings.
  • The Experiences and Expressions of Compassion Among Experienced Critical Care Nurses

    Walker, Mark; Scrandis, Debra (2020)
    BACKGROUND: Compassion is a core attribute of nursing practice and is associated with improved patient satisfaction and outcomes. For the last several decades, nurse researchers have been focused on the concept of compassion fatigue. Only recently has compassion appeared in nursing literature. Therefore, the purpose of this study was to explore the experiences and expressions of compassion among critical care nurses. METHODS: This dissertation includes a literature review of compassion within nursing education and practice, how it is currently defined, and a review of the empirical data. Next, two interpretative phenomenological qualitative studies were conducted. One study explored the experiences of compassion among experienced critical care nurses recognized as being highly compassionate. In the second study, leaders who had identified the compassionate nurses addressed how compassion is expressed. RESULTS: The review of the literature determined that the concept of compassion is not consistently operationalized in nursing practice. The qualitative study of the experiences of compassion revealed that these critical care nurses are motivated to connect emotionally with their patients. These meaningful connections facilitate an understanding of the patient’s circumstances which enables the nurse to identify how to best provide compassion. Three themes emerged from their experiences: presence, actions and being genuine. Additionally, the nurses obtain a deep sense of satisfaction and joy from this care that is self-sustaining. In the second study it was found that the compassionate nurses are recognized for prioritizing patient care over tasks and were able to balance the emotional and physical care of their patients. Expressions of compassion were actions that humanized the patient experience and being present with patients ANALYSIS: By exploring both the personal experiences, observations of what compassion means and how it is expressed we have a deeper insight into how compassion is operationalized in critical care settings. CONCLUSION: This study validated similar findings from previous studies that sought to define and operationalize compassion in nursing. The two studies revealed that compassionate nurses are sustained by their resilience, and deep meaningful relationships with patients and families.
  • The Use of Naltrexone Among Young Adults with Opioid Use Disorder

    Rozenberg, Ilya; Storr, Carla L. (2020)
    Background: The rapid growth of opioid addiction carries catastrophic consequences for the young generation affecting families and society at large. To address problems of compliance and retention in treatment, new, innovative approaches synthesizing available interdisciplinary models with both medical and psychosocial approaches adapted to the user’s environment are necessary. Purpose: This dissertation explored the evidence in literature on the use of naltrexone (XR-NTX) in adolescents and young adults. It also examined relationships between retention in treatment and 1) family engagement, 2) assertive community outreach and 3) use of other substances in a sample of youth being treated for opioid use disorders (OUD). Methods: A scoping literature review provided a synthesis of the current state of evidence on safety and efficacy of XR-NTX use in treating youth with OUD and alcohol use disorders. Relationships between retention in treatment and family engagement, assertive outreach, and comorbid substance use were explored using data from a retrospective chart review of 41 young adults (16-26 years of age) who participated in a randomized open-label pilot study of OUD treatment at a community-based substance use disorder treatment program. Results: Family sessions contributed to increased retention in treatment, evidenced by the increase in number of injections. More frequent communication resulted in a higher number of received injections. There is a positive correlation between number of family sessions and number of doses. The total number of significant other contacts does not have a significant effect on the number of injections while the total number of patient contacts was significant. The study showed that most young adults seeking treatment for opioid use disorder are also using other substances and that the longer they stay in treatment, the greater the chance of decreasing use of other drugs. The review of 13 studies with 462 young adults found that Naltrexone is effective in improving treatment retention, extending abstinence, and preventing relapses in adolescents and young adults with OUD. Conclusion: Family support and ongoing communications could result in increasing retention in treatment. The study allowed for a better understanding of the relationship between treatment of opioid use and use of other substances.
  • Psychosocial Care Needs of Children with Cancer and Their Families: Perceptions and Experiences of Omani Oncologists and Nurses

    Al Balushi, Amal Juma; Johantgen, Mary E.; Mooney-Doyle, Kim (2019)
    Background: Much evidence demonstrates the psychosocial impact of childhood cancer on children and their families. While many health care systems are evolving to integrate psychosocial services into clinical care, barriers exist that must be understood before changes can be implemented in systems new to this care. Oncologists and nurses are on the front lines of care and have unique perspectives about the needs of their patients and families. Objectives: The purposes of this study were: 1) describe the experiences and perceptions of pediatric oncology physicians and nurses in Oman regarding the psychosocial care needs of children with cancer and their families; and 2) describe the barriers and facilitators to providing psychosocial care. Methods: A qualitative, phenomenological study was conducted. Purposive sampling strategy was used to recruit 26 oncologists and nurses with experience caring for children with cancer and their families. Individual, semi-structured interviews were conducted and recorded. Colaizzi's method of data analysis was utilized to inductively determine themes, clusters, and categories. Data saturation was achieved, and methodical rigor was established. Result: Four themes emerged from the data. The first was “perceived need for care beyond medicine.” The oncologists and nurses recognized that more psychosocial assessment, care, and services were needed. The second theme was “recognition of pediatric oncology as a challenging clinical practice area,” which had two subthemes: emotional burden and challenging situations. Participants described the challenges they faced trying to meet the needs of children and extended families. The third theme was “barriers to providing effective psychosocial care,” which had three subthemes: barriers related to the health care system, barriers related to health care providers, and barriers related to infrastructure and environment. The fourth theme was “providing optimal supportive care within the available facilities,” which had two subthemes: supportive care and facilitating factors. Cultural and community factors were highlighted. Conclusion: As the pediatric oncology services in Oman mature, clinicians are eager to develop the psychosocial assessments and needed services. Future research is needed to elicit the perspectives of Omani children with cancer and their families. Resources will be needed from higher authorities to design, implement, and evaluate the recommended changes.
  • Caregiver Distress and Burden and Patient Distress Across the Outpatient Peri-Allogenic Bone Marrow Transplantation Period

    Caves, Meredid Soto; Storr, Carla L. (2019)
    Background: Outpatient allogenic bone marrow transplants (alloBMT) are feasible due to improved vigilance and decreased transplant-related toxicities. The outpatient setting compels caregivers to fulfill non-physician roles. Few studies have examined the relationship between caregiver distress and burden and how they are manifested in the context of outpatient alloBMT; there is also scarce information on how distress manifests itself within the patient/caregiver dyad when faced with a life-threatening treatment. Purpose: Aim 1 examined the trajectory and association of caregiver distress and burden, and the movement of caregivers between caregiving states longitudinally. Aim 2 examined the distress trajectory of patients and caregivers, and assessed how they moved between low/high distressed states both individually and as a dyad. Aim 3 explored the possible association between absolute neutrophil count (ANC) and patient distress. Methods: This observational longitudinal repeated-measures study recruited patients and caregivers undergoing outpatient alloBMT. Surveys were administered at 3 time-points: infusion of donated bone marrow (T0), ANC recovery (T1), and discharge (T2). Caregivers were asked to respond to distress and burden questions using the Distress Thermometer (DT) and Caregiver Burden Scale, which measured objective and subjective demand, and subjective stress burden. Patients completed the DT surveys. ANC values for patients were extracted through medical chart review at the same time surveys were completed. Results: Caregiver distress and subjective stress burden were associated at all time points. Increase in burden leads to increase in distress. For patients and caregivers, distress was the highest at baseline and improved over time. As a dyad, the transition between high/low distressed states was ever-changing, demonstrating the dynamic nature of the alloBMT process. No significant differences were found in the distress scores of patients and caregivers, but there was a difference in distress scores along the alloBMT period, suggesting a temporal effect. ANC and patient symptomology were not consistently associated with patient distress. Conclusion: Caregiver distress and burden are related throughout the duration of the alloBMT period. As the dyad moves through the alloBMT period, they display the mutuality of distress, influencing each other as they face this difficult but life-saving journey together.
  • Humor & Opioid Recovery

    Canha, Benjamin; Scrandis, Debra (2019)
    Abstract Background: The prevalence and mortality rates of opioid use disorders (OUD) have drastically increased in recent years in the United States. Narcotics Anonymous (N.A.) is a successful behavioral program supporting recovery for individuals with OUD. Humor may play an important role in maintaining group involvement and continuing support within the culture of the N.A. program. Purpose: The purpose of this study was to understand the ideas, beliefs, attitudes and behaviors of humor in individuals recovering from OUD who are participating in the N.A. program. Design: Qualitative ethnography design was used with three types of complementary data collection methods: observations at meetings and social gatherings, personal interviews, and a focus group session. Results: Instances of humor between N.A. members were noted in observations. Recorded one-on-one interviews with ten members recovering from OUD provided details of various experiences of humor and led to development of five essential themes: Feels Good, Social, Lighten Up, Healing and Alienate. These findings highlight the mostly positive personal and social benefits participants experienced, as well as possible negative effects. A focus group of seven N.A. members provided interactive discussion of humor and discussed the need to become more conscientious of the detrimental effects of humor. Conclusion: The implications of this study suggest the need to explore various humor interventions to assess their relative effectiveness in enhancing recovering, and reducing relapses. Due to the small number of participants, results may not be generalizable to all those with OUD in N.A. or represent the possibly wide range of N.A. meetings. This study added to the depth of knowledge about the effects of humor on this population and their recovery process. The importance of humor and having fun in the recovery of OUD should be more widely recognized by nurses as they help those with OUD, as humor definitely has a role to play in supporting N.A. members’ recovery from OUD.
  • Prescription Medication Adherence among Socioeconomically Diverse Black Men

    DeVance-Wilson, Crystal Lynn; Storr, Carla L. (2019)
    Abstract Background: Non-adherence to prescription medications may at least partially explain high rates of morbidity and mortality from chronic illness among Black men. Black men from lower socioeconomic backgrounds have previously been identified as low adherers but little is known about Black men with adequate incomes and access to healthcare resources. The Ecological Model is used as a framework to examine barriers and facilitators of medication adherence among Black men. Purpose: The purpose of this study is to estimate the prevalence and identify barriers and facilitators to medication adherence among a socioeconomically diverse group of Black men with a range of chronic illnesses. Methods: A cross-sectional study using a 105 item anonymous survey questionnaire was conducted. A convenience sample of 276 Black men (age 35-75 years) was recruited from 15 churches in Baltimore City, and Baltimore, Montgomery and Prince George’s counties. Mann-Whitney U, Kruskall-Wallis and Chi-square analysis were used to examine group differences and multinomial logistic regression provided odds ratio estimates of the association between various factors and low (reference), medium and high medication adherence. Results: Half the sample (49%) were low adherers. Socioeconomic differences in medication adherence were identified by homeownership (X2 = 6.327, p = .042). No statistically significant differences were found for education, employment, income and health insurance coverage. Personal and interpersonal factors found to be associated with medium adherence were coping (AOR=.91, 95% CI=.84-.99), self-efficacy (AOR=6.74, 95% CI=2.79-16.27), income – (low - AOR=10.94, 95% CI=2.42-49.51, middle –AOR=3.34, 95% CI=1.38-8.10), marriage or having a significant other (AOR=5.40, 95% CI=1.83-15.92) and homeownership (AOR=3.37, 95% CI=1.04-10.92). Personal and interpersonal factors found to be associated with high adherence were self-efficacy (AOR=6.63, 95% CI=1.89-23.27), homeownership (AOR=9.32, 95% CI=1.41-61.60), income (low - AOR=8.55, 95% CI=1.31-55.68) and not sharing information with others (AOR=2.89, 95% CI=1.17-7.13). No associations were identified for community, organizational or government/policy level factors. Conclusions: Higher self-efficacy, homeownership and marital status were facilitators and higher coping, higher income and some forms of social support were barriers to medication adherence. This study illuminates opportunities for improving prescription medication education and implementing practice innovations to increase rates of adherence among Black men across the socioeconomic spectrum.
  • Participation and Effectiveness of Worksite Health Promotion Program

    Han, Myeunghee; Doran, Kelly; Storr, Carla L. (2019)
    Background: Worksite Health Promotion Programs (WHPPs) are limited by low participation and engagement. However, little is known about what factors influence participation and the relationship between participation and changes in body weight and composition. Mobile health technology (mHealth) may facilitate participation and engagement in WHPPs as mhealth is not limited by time or location, which are known barriers to participation and engagement. Yet, few studies have examined the use and effectiveness of WHPPs using mHealth interventions that aimed to change body weight and composition. Purpose: To explore the features and effectiveness of WHPPs in previous studies that used mHealth interventions. To identify factors influencing participation and engagement in a WHPP and the relationship between participation and changes in body weight and composition. Methods: A systematic literature review was conducted to explore features of WHPPs using mHealth that aimed to change body weight and composition. A secondary data analysis was conducted using data obtained from participants in the intervention group of a WHPP to identify: 1) factors that influence participation and engagement and 2) the relationship between participation and body weight and composition changes. Results: From the systematic review, 10 out of 12 WHPP studies using mHealth significantly improved body weight and composition. The most commonly used mHealth interventions were providing information, goal setting, and data entry. Based on the secondary data analysis, low levels of stress, anxiety, or high job satisfaction were significantly related to high participation in a WHPP. Significant relationships between participation and body weight and composition changes were not found due to a small sample size. However, this study found that those who reduced five pounds of body weight at six months among overweight or obese participants showed high participation in physical activity and/or diet components of a WHPP. Conclusions: WHPPs using mHealth can significantly improve body weight and composition. Employees’ psychological factors should be considered to increase participation in WHPPs. Further studies with larger sample size are needed to identify the relationship between participation and changes in body weight or body composition.
  • Neonatal Nurses' Work in a Single Family Room NICU

    Doede, Megan; Trinkoff, Alison M. (2019)
    Background: In the past twenty years, neonatal intensive care units (NICUs) have undergone changes in layout from open-bay (OPBY) to single family room (SFR). SFR layout may be advantageous to nurses’ work in that it improves the quality of the physical environment, patient care, and parent-nurse interactions. SFR layout may disadvantage nurses’ work in terms of decreased interaction among the NICU patient care team, increased nurse workload, and decreased visibility on the unit. It is unclear exactly how SFR layout is producing these changes. Purpose: This study asked: what is it like for neonatal nurses to work in a SFR NICU? Methods: Interpretive description, a qualitative methodology, guided this study. Interviews and observations were conducted in one SFR NICU over a six-month period. Data were coded broadly, then collapsed into themes as patterns within the data emerged. The Systems Engineering Initiative for Patient Safety model aided interpretation of nurses’ job demands. Emotional work was conceptualized as being preceded by emotional demands and anteceded by stress and burnout. Results: A total of 15 nurses participated. Overall, privacy, visibility, and proximity were integral in shaping nurses’ work. Regarding job demands, four themes emerged: challenges in infant surveillance and informal communication, alarm fatigue, and increased walking distances. Regarding emotional work, four themes emerged: families “living on the unit,” isolation of infants, ability to form trust and bonds, and sheltering. Emotional demands increased when families were living on the unit or when infants were left in isolation but were absent when nurses were able to form trusting relationships with parents and shelter them. Privacy gains on SFR NICUs may serve to balance losses in visibility and proximity for nurses. Conclusions: NICU layout impacts nurses’ job demands and emotional work. Future research should investigate unit layouts that maximize visibility and proximity for nurses while maintaining privacy. Neonatal clinicians transitioning to SFR layout should consider overall visibility and proximity of patients, equipment, and staff members from any point on the unit as a primary avenue for decreasing nurses’ work demands. Neonatal nurses will benefit from tactics that improve their communication skills with families.

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