Now showing items 1-20 of 272

    • The Impact of Simulation-based Ethical Education on Prelicensure Nursing Students' Levels of Moral Distress

      Dalton, Jennifer; Gordes, Karen L. (2023)
      Research demonstrates the prevalence of moral distress in licensed nurses often begins during undergraduate training. While the concept of moral distress is evolving, this study used a conceptual definition of moral distress defined as negative self-directed emotions in acknowledgement of involvement in morally difficult situations. The purpose of this study is to determine whether integrating an ethical simulation-based education (SBE) module into fourth semester undergraduate nursing students’ curriculum would affect moral distress levels as measured by a validated Moral Distress Scale for Nursing Students. Using a longitudinal embedded mixed methods design in a required final-semester undergraduate nursing leadership course, students participated in an ethical SBE module with debriefing and completed the It-ESMEE as a pretest. During weeks two and three of the semester participants completed the SBE module using role play to practice speaking up with integrity. The closing of the module included a recorded debriefing to collect qualitative data related to the module and feelings of moral distress and the It-ESMEE for a second time. The final It-ESMEE was completed 13 weeks after the SBE module the final week of the semester. The recorded debriefings were transcribed and thematically analyzed. A repeated measures analysis of variance tested the within-subject differences of mean total It-ESMEE moral distress scores across all time points. A total of 48 students were included in the study. There was no statistically significant difference among mean moral distress scores, (F (2, 94) = 1.369, p = .259). Analysis of recorded debriefings revealed four primary themes: 1) powerlessness as a student, 2) students have a basic moral understanding, 3) there is discomfort in speaking up with integrity, and 4) students understand the importance of emotional intelligence. In conclusion, the measurement of overall moral distress levels over three time points did not show a statistically significant difference. However, the mean 13-week post-intervention survey score (M = 173.85) was the lowest of all three perceived moral distress scores. Though not statistically significant, this data in conjunction with the results of the thematic analysis could indicate that integrating meaningful simulation-based ethical training throughout undergraduate nursing curriculum may affect perceived moral distress levels. Future studies should address integration of ethical SBE throughout curricula.
    • Smoking Cessation Among People With Severe Mental Illness

      Alghzawi, Hamzah Mohammad; Storr, Carla L. (2019)
      Introduction: People living with mental illnesses have a high rate of smoking and make up over half of those dependent on nicotine. A considerable body of research has shown that social support, stressful life events (SLE), receiving help for tobacco/nicotine use, intention to quit, and smoking use-related factors are associated with smoking cessation in the general population. Yet, little is known about these factors among people with severe mental illness (SMI). Purpose: This study aims to: 1) examine gender differences in the interrelations among social support, SLEs, and smoking cessation, 2) estimate the probability of remission from NUD by type of help/services received for tobacco/nicotine use (pharmacological, non-pharmacological, and both), and 3) estimate gender and racial/ethnic differences in the probability of smoking cessation among those with a history of intention to quit. Methods: A sample of 4610 people with SMI and a history of tobacco/nicotine use were identified in a public limited dataset of the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Four mediation and moderated mediation models were used in the first manuscript, whereas survival analyses were used in the second and third manuscripts. All analyses took into account the complex sampling design and controlled for possible confounders (i.e. sociodemographic characteristics) and covariates (i.e. comorbidity with another mental illness). Results: Total, appraisal, and tangible support in females exerted indirect effects on improving smoking cessation via decreased SLEs (total=.0094, appraisal=.0229, tangible=.0298; p<.05). The probability of remission from NUD was higher among those who received non-pharmacological services (28.5%, HR=1.95, p<.05) or those who received both services (19.6%, HR=1.52, p<.05) compared to those who only had pharmacological services (17.6%). Among those with a history of intention to quit, 31.7% had stopped. The probability of smoking cessation was highest for Hispanic females (HR=2.07, p<.05), non-Hispanic other females (HR=1.59, p<.05), non-Hispanic other males (HR=1.45, p<.05), Hispanic males (HR=1.40, p<.05), and non-Hispanic Black females (HR=1.35, p<.05) compared to non-Hispanic Black males. Conclusion: A greater understanding of subgroup differences and the correlates of smoking cessation among tobacco/nicotine users with SMI can enhance efforts to design and implement smoking cessation programs for people with SMI.
    • Nocifensive Behavior and Transcriptomic Biomarkers in a Translational Pig Model of Spared Nerve Injury

      Weiss, Miriam; Nahm, Eun-Shim (2023)
      Neuropathic pain is a prevalent condition that significantly impacts quality of life. Translational animal models are needed to understand the mechanisms and develop novel treatments. The spared nerve injury (SNI) model is a well-validated neuropathic pain model that causes allodynia and hyperalgesia. While the SNI was originally developed in rats, rodent models have translational limitations. Pigs, by contrast, share many characteristics with humans, making them uniquely suitable for modeling painful conditions. Objective: The goal of this study was to test the feasibility and efficacy of a translational pig model of SNI. Methods: The left common peroneal nerve of SNI pigs was ligated, while the nerve remained untouched in sham pigs. Mechanical and dynamic allodynia, thermal hyperalgesia, pressure, and gait alterations were assessed over four weeks. Video footage was recorded during testing and analyzed for a pig grimace scale. Blood and spinal cord tissue were harvested and sequenced to determine the presence of differentially expressed genes and associated enriched pathways. Results: Surgical ligation of the common peroneal nerve was feasible and safe. However, there were significant floor and ceiling effects for mechanical and dynamic allodynia and thermal hyperalgesia testing. Females showed lower pressure tolerance than males over time at the medial left (p=0.003), medial right (p=0.003), lateral left (p=0.041), and lateral right (p=0.003) testing locations. The left side had a lower threshold tolerance than the right side for both medial (p<0.001) and lateral (p=0.03) locations, although this difference was not significant over time. There was no significant difference in threshold tolerance between the sham and SNI groups. There were no significant changes in gait. The grimace scale showed substantial interrater reliability for ear position (kappa=0.73) and moderate interrater reliability for snout tension (kappa=0.43). Several pathways related to inflammation and wound healing were differentially expressed between the SNI versus sham groups and left versus right sides of the SNI animals. Conclusion: While the pig model of SNI is feasible, special considerations are needed when acclimating animals and calibrating study equipment to avoid floor and ceiling effects. Relevant enriched pathways may be targets of interest for future neuropathic pain research.
    • Nurses’ Well-being and the Work Environment During the COVID-19 Pandemic

      Baek, Hyang; Baek, Hyang; Trinkoff, Alison M. (2023)
      Problem: The Coronavirus Disease 2019 pandemic, despite the improved current situation, has lasted longer than expected and has had a severe impact on the nursing profession. Nurses continue to face heightened levels of stress, frustration, exhaustion, and overwork. As a result, many nurses have either retired or left their positions, further worsening the existing nursing shortage. This shortage poses a significant threat to the efficiency and resources of the healthcare system. Therefore, it is crucial to gain a better understanding of how work-related factors affect the well-being of nurses. Purpose: The aims of this study were to 1) Examine the relationship between work-related factors and personal well-being during the pandemic; 2) Examine the degree and severity of workplace bullying in nurses and work-related factors; and 3) Examine the relationship between well-being and intention to stay while examining the potential moderating effect of workplace support on this relationship. Methods: This cross-sectional study analyzed survey responses from 1170 registered nurses across the US. The study data are from the Nurse Worklife and Wellness Study, 2020-21 (Trinkoff et al., 2021a). Results: Nurses who were younger, less experienced, working in hospitals, a staff or charge nurse, or on the frontlines reported lower well-being than their counterparts. Factors such as sufficient staffing and enough time to complete tasks significantly influenced nurses’ well-being. In aim 2, over 40% of nurses experienced workplace bullying, with 13.4% experiencing severe bullying in the past year. Inadequate staffing, insufficient time to complete tasks, and lack of breaks away from the work area were significantly related to severe bullying. For aim 3, only 75% of the nurses expressed their intention to stay at their current job for the next year. The intention to stay significantly differed by age and work-related factors, but workplace support had a significant moderating effect. As workplace support increased, the positive relationship between well-being and intention to stay was strengthened. Conclusion: This study provides guidance for organizations and management to address adverse work-related factors and to establish a healthy work environment. By ensuring sufficient staffing, providing adequate time for tasks, and actively addressing workplace bullying, nursing management can create an improved environment, ultimately promoting nurse retention.
    • The Relationship of Resilient Factors to Chronic Orofacial and Patient Expectations of Analgesia

      Thomas, Sharon L; Colloca, Luana (2023)
      Background: Adults with chronic orofacial pain experience significantly impaired daily functioning and reduced quality of life. Patient expectations are recognized as useful in medical treatment. However, we know little about coping behaviors, beliefs, and attitudes influencing disability or expectations in adults with chronic orofacial pain. Purpose: Positive psychological factors are protective against functional impairment and are implicated in placebo and expectations of analgesia. Examining the relationships between psychological factors, pain-related disability, and patient expectations will help identify correlates of disability, and individual susceptibility to placebo effects, a useful pain management modality. Methods: Three cross-sectional studies explored the correlates of pain-related disability and determined the influence of resilience on pain-related disability and patient expectations in adults with temporomandibular disorder. This study used secondary data from a clinical trial of placebo manipulation to examine the relationships between patient expectations of analgesia and psychological factors (resilience, dispositional optimism ) and a correlational observation design to explore the relationship between personal characteristics and psychological factors and pain-related disability in adults with TMD. The Aims were to 1) determine how positive and negative psychological constructs, jaw function, and chronic overlapping pain conditions contribute to pain-related disability; 2) describe the coping strategy patterns which patients engage in and compare the differences in these patterns based on pain characteristics; and 3) determine the relationship between pain resilience, pain interference, and patients expectations. Results Study 1 found that Resilience factors, optimism, and positive affect had a positive relationship with pain-related disability. Study 2 demonstrated chronic orofacial pain patients used both wellness and illness coping strategies. High Pain interference, Pain intensity, and Pain catastrophizing were associated with higher frequency use of all coping strategies. Study 3 revealed that pain resilience had an inverse relationship with pain disability and a direct and positive relationship with patient expectations. Conclusion: Psychosocial factors are important targets for clinical management of chronic pain. The effect of pain resilience on pain interference and reinforced expectations of analgesia means that clinicians focus efforts on building pain-resilient mechanisms, which can result in improved pain outcomes, augment its effect on expectations, and directly influence placebo treatment outcomes.
    • Clinician Resilience after Traumatic Child Birth Exposure

      Robinson, Keisha; Ogbolu, Yolanda (2023)
      Background: Traumatic Childbirths (TCE) involving actual or threatened serious injury or death to a mother or child are documented sources of occupational stressors. Maternity care is a profession often perceived as filled with joy. However, TCEs may affect both professional practice and personal life and can contribute to burnout. Clinician resilience may play an important role in coping with TCEs. Purpose: The aims of this study were to describe and explore the frequency and severity of TCE experiences in OB clinicians, assess associations between TCEs and levels of resilience, and determine if TCE exposure and resilience are associated with OB clinician burnout. Methods: An anonymous survey was administered via a web link to obstetrical clinicians in five Maryland hospitals. The survey had four sections: demographics, TCE (frequency, severity, and influence on personal and professional practice), resilience (25-item Connor-Davidson Resilience Scale), and burnout (Maslach Burnout–Human Services Survey for Medical Personnel). Multi-level modeling explored factors influencing resilience and burnout nested within hospitals. Results: The 160 usable surveys included registered nurses (N=104), certified nurse-midwives (N=17), attending physicians (N=28), and resident physicians (N=11). Nearly all had experienced at least one TCE during their careers, with shoulder dystocia and stillbirth being the most frequent. The frequency of TCE exposure was associated with influencing the OB clinician’s professional practice (r=.415, p<.001) and personal life (r=.386, p<.001). Perception of severity strongly influenced professional practice (=.52, p<.001) and personal life (=.46, p<.001). Resilience scores were significantly lower in clinicians aged 35-54 years compared to the 55 or older group (B=-7.60, p=.011). TCE exposure was not associated with burnout. However, nearly a third (31%) of the convenience sample reported high emotional exhaustion, and 13% reported high depersonalization. Conclusion: TCE exposure can affect the professional practice and personal life of maternity care clinicians. While TCE did not have a strong relationship with resilience and burnout, a third of the respondents reported high emotional exhaustion, a dimension of burnout. Longitudinal research is needed to understand the short and long-term effects of TCEs and the role of resilience in helping clinicians cope with occupational stress.
    • The Effects of Spiritual Needs on Spiritual Well-being in Patients with Brain Tumors: A Structural Equation Modeling Approach

      Kim, Kyu; Trinkoff, Alison M. (2023)
      Background: For patients living with the diagnosis of a brain tumor, the extent of unmet supportive care needs is high as brain tumors are perceived as a devastating source of morbidity and mortality. Patients with cancer often find spirituality to be valuable in coping with uncertainty from their illness. The integration of spiritual care for patients with cancer has proven its values in promoting patients’ positive experiences across the cancer trajectory; therefore, it is imperative to inquire about patient spirituality regardless of patient’s religious preference. Purpose: This study was designed to examine how spirituality is interconnected with other important dimensions of patient care. The primary objective of this study was to test a theoretical model of spiritual strength that explains how spiritual well-being (SWB) of patients with brain tumors is affected by symptom burden, psychological distress, spiritual needs, and spirituality. Methods: This study was conducted with a cross-sectional online survey design using standardized questionnaires and reviewing a participant’s electronic medical records for data collection. A structural equation model (SEM) tested the theory on SWB and explained how SWB is affected by symptom burden, psychological distress, spiritual needs, and spirituality. A multigroup analysis (MGA) examined the impacts of demographic and clinical moderators. Results: The SEM analysis found that symptom burden (r= -.365) had significant negative influence on SWB and significant positive influence on spiritual needs (r = .378). Spirituality and spiritual needs had a significant influence on SWB (r = .429, r = -.204, respectively). The predictors accounted for 47.2% of the variance of SWB with spirituality contributing the most to SWB. The MGA found a higher tendency of moderating effects on above relationships if patients, compared to their counterparts, were aged <50; newly diagnosed (< 1year); primary brain tumor. The moderating effects of gender and religious affiliation/preference were minimal. Conclusion: Increased symptom burden, psychological distress, and spiritual needs are key factors in explaining low spiritual well-being. However, elevating spirituality and early screening for high-risk patients could alleviate such negative impacts. The findings of this research support the applicability of Eriksson’s theory of spiritual well-being in care of patients with brain tumors.
    • Measurement of Protein Intake and Physical Activity in Hospitalized Older Adults

      Chakravarthy, Ameera; Resnick, Barbara (2022)
      Background: Understanding and improving measurement of protein intake and measurement of physical activity is an important first step in being able to accurately test interventions in hospitalized older adults to optimize physical activity and recovery. Purpose: The aims of this dissertation were to: (1) describe measures of protein intake used with older adults across any setting of care; (2) test the reliability, validity and feasibility of PHOTOFOOD, an investigator developed tool and approach developed to measure protein intake in hospitalized adults; and (3) to compare two different estimation approaches when measuring intensity of physical activity with the MotionWatch 8. Methods: A systematic literature review was conducted to describe methods used to measure protein intake in studies conducted with older adults in all settings. A pilot study was conducted to evaluate the initial reliability and validity of PHOTOFOOD. A secondary data analysis was conducted using data obtained from participants in the intervention group from an acute care trial to compare Freedson and Landry’s cut-points for physical activity in hospitalized older adults. Results: The systematic review indicated that Food Frequency Questionnaires were the most common method used to measure protein intake. The PHOTOFOOD measure was subsequently developed to more accurately measure protein intake and a pilot study included evaluation of 12 meals. Participants consumed a mean of 19 grams of protein and there was evidence of inter-rater reliability based on 0.82 (P < 0.001) and validity based on a significant correlation between the PHOTOFOOD evaluation and direct tray visualization by the evaluator (r = 0.93, p<.01). The secondary data analysis supported the use of the of Landry cut points over Freedson cut points in that the Landry sedentary cut-point were significantly associated with function. Conclusions: There is support for the use of PHOTOFOOD and photo assisted dietary recall to obtain accurate protein intake in older adults and value in using the Landry cut points over Freedson when measuring physical activity intensity in older hospitalized adults. Future studies using PHOTOFOOD and direct measures of physical activity such as VO2 are needed to better measure these outcomes in hospitalized older adults.
    • The feasibility of actigraphy and care journals to examine sleep-wake patterns of preterm infants in the NICU

      Hunt, Natalie; Johantgen, Mary E. (2022)
      Problem: Sleep disruption in preterm infants can have negative short- and long-term effects, such as behavioral changes, poor emotional regulation, and poor verbal skills. Purpose: Assess the feasibility of using actigraphy and infant care journals to examine sleep-wake patterns and care activities of premature infants in the NICU. Methods: An observational study was done in a level IV NICU with clinically stable infants 28-32 weeks gestation at DOL 2-7. Sleep-wake patterns were examined using the Actiwatch 2 and care activities were assessed using an infant care journal over 84 hours continuously. Scoring rules for actigraph data were developed to determine rest intervals. Sleep variables collected included total sleep time, percent of sleep, and number of wake bouts during sleep period. Care activities were documented in journals, including length of activities and whether infants were asleep or awake prior to and after the activity. Actigraphy data was assess using the Actiware software and, along with care activity data, were analyzed using SPSS. Feasibility is assessed through acceptability, implementation, practicality, and limited efficacy. Results: Data were analyzed on 10 infants. Rest intervals were 155 minutes ±5.3 minutes on average with infants spending an average of 67.1% ± 11.1% asleep. Average daily total sleep time was 902.5 minutes ±158.6 minutes, or 64.3% (± 10.85%) and care clustered with routine care made up 75.5% of the documented care activities. Conclusions: The feasibility of using actigraphy to examine sleep-wake patterns was supported, despite subjectivity. Sleep data were similar to previous literature, though the this sample is of younger gestation. While the amount of activities were less than previous studies, with modifications to methodology, data collection could be improved.
    • 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.