School of Nursing Dissertations
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Publication ANTENATAL MILK EXPRESSION AND MILK SUPPLY IN MOTHERS OF INFANTS WITH CONGENITAL ANOMALIES(2023) Juntereal, Nina, Angelica SantiagoFor infants born with congenital anomalies, an exclusive human milk diet can reduce mortality, morbidity and improve quality of life, but their mothers are pump-dependent from birth and may experience challenges with milk production. Thus, these infants are at risk of not receiving an exclusive human milk diet and/or a long duration of human milk feeds.Antenatal milk expression (AME) is hand expression during pregnancy to collect colostrum and may support the lactation journey of these dyads. However, previous research has not clearly demonstrated adherence to AME and provided only subjective data on milk production and secretory activation. This dissertation used a prospective, longitudinal, observational design to describe AME and milk supply development in mothers of infants with congenital anomalies from 37 0/7 weeks gestation to postpartum day 14 via three aims that: 1. Examine adherence of participants willing to follow an AME recommended protocol 2. Verify the amount of colostrum that participants collected and stored through AME 3. Measure 24-hour milk supply and secretory activation onset by milk volume and human milk biomarkers of sodium and lactose A small group (antepartum, n = 19; postpartum, n = 16) of low risk women of infants with congenital anomalies were willing to initiate (94.7%) and maintain adherence (83.3%–100%) to an AME recommended protocol to attempt colostrum collection. Milk removal (80%–100%) was higher than no milk removal (0%–20%) from AME. The 24-hour colostrum volume (Median 0.35 mL, IQR 0.065-0.845) and the total colostrum volume (Median 3.99 mL, IQR 1.35-6.82) from AME varied. Following birth, four (25%) mothers experienced secretory activation onset. Pumping ≥5 times/day was manageable for 24-hour milk volume (Median 490 mL, IQR 329–6854) from days 5 to 14 postpartum, but only nine (56.25%) mothers obtained ≥500 mL of milk per day by postpartum day 14. Antenatal milk expression likely does not hasten time to secretory activation but offers an opportunity to build breastfeeding self-efficacy and duration by learning of biomechanics and skills involved for lactation.Publication CARDIOVASCULAR DISEASE RISK PREDICTION IN THE REPUBLIC OF KOREA(2023) Park, SooyoungCardiovascular disease (CVD) is a leading cause of death and disability in the Republic of Korea (hereafter “Korea”) and around the world. CVD is known to be associated with a variety of risk factors, and modification of modifiable risk factors is one of CVD prevention strategies. Risk prediction is a critical feature of disease prevention. Existing CVD prevention and management guidelines emphasize the importance of accurate risk prediction and subsequent decision making. However, there is no national clinical guideline for CVD risk estimation in Korea. Thus, this dissertation research aimed to explore the current use and application of CVD risk prediction in Korea and to examine the predictive accuracy of an existing CVD risk prediction model and to investigate the best fitting CVD risk prediction model in a Korean population based-cohort data. Existing literature was reviewed to explore the current use of the Framingham Risk Score (FRS) in Korea, and the National Health Insurance Service-Health Screening Cohort (NHIS-HELAS) was used to examine the predictive accuracy of FRS in Korea. A datamining approach, random survival forest, was adopted to find the best fitting model for Korean adults. The application of the FRS in Korea was categorized into three groups according to the purpose of use: to identify subjects’ CVD risk score, to present a standardized method for CVD risk prediction and to evaluate model performance. To the best of our knowledge, the FRS had not been validated with the general population of Korea. In this study, the FRS has adequate predictive ability to estimate 10-year CVD risk in NHIS-HEALS. The performance of the random survival forest-based models were comparable with the FRS although the random forest-based models demonstrated better agreement between predicted and observed CVD events than the FRS for both men and women in NHIS-HEALS. In conclusion, the FRS is in an early stage of validation in Korea and the FRS performed well in a Korean population-based cohort. The application of a data mining approach slightly improved the predictive accuracy of CVD risk prediction.Publication THE IMPACT OF EMPLOYMENT ON PHYSICAL HEALTH AND EMOTIONAL WELL-BEING AMONG TRANSITION-AGE YOUTH WITH AUTISM SPECTRUM DISORDER (TAY-ASD).(2023) Goodspeed, Brooke, LABSTRACTTHE IMPACT OF EMPLOYMENT ON PHYSICAL HEALTH AND EMOTIONAL WELL-BEING AMONG TRANSITION-AGE YOUTH WITH AUTISM SPECTRUM DISORDER (TAY-ASD). Brooke L. Goodspeed Matthew D. McHugh There is a dearth of literature examining employment as a social determinant of health among individuals with autism spectrum disorder (ASD) despite notable disparities in both employment rates and excess morbidity and mortality for individuals with ASD. This study explored the impact of participation in employment on health outcomes in transition-age young adults with autism spectrum disorder (TAY-ASD). Specifically, this dissertation aimed to determine if 1a) participation in employment in the past two years for TAY-ASD is associated with current ratings of physical health and emotional well-being (adjusted for demographics, and baseline health and baseline functional status) (Aim 1A); 2b) to determine if levels of baseline health and baseline functional status for TAY-ASD moderate the effect of employment on health outcomes (adjusted for demographics) (Aim 1B); and 2) to determine whether greater levels of cumulative employment exposure are associated with better current ratings of physical health and emotional well-being among TAY-ASD (adjusted for demographics and baseline health and baseline functional status) (Aim2). This study was a longitudinal and cross-sectional analysis of the National Longitudinal Transition Study-2 (NLTS2), a nationally representative sampling of secondary students receiving special education services. Logistic regression was used to model the impact of participation in employment on health outcomes. There was no significant influence of participation in employment in the past two years on current ratings of physical health or emotional well-being, and this relationship was not moderated by baseline functional status or baseline physical health. Longer duration of employment exposure was significantly associated with better current ratings of physical health and with better ratings of two (of five) measures of emotional well-being (feeling hopeful and people dislike me) among TAY-ASD. The findings from this dissertation highlight the complex relationship that exists for TAY-ASD between employment and health outcomes, and how duration of employment exposure is a critical factor to consider when evaluating the influence of employment on health and well-being.Publication THE INFLUENCE OF PATIENT-PROVIDER COMMUNICATION ON PATIENT CKD AWARENESS, RISK FOR KIDNEY FAILURE, AND SELF-MANAGEMENT(2023) Iroegbu, ChristinChronic kidney disease (CKD) is a global and national health crisis affecting 10% of the global population and 15% of Americans. These individuals often experience a diminished quality of life, an increased risk for cardiovascular disease, and a markedly reduced life expectancy. Even with the significant costs and prevalence associated with CKD, 90% of adults in the United States are unaware of their diagnosis. Healthcare providers are key contributors to patient CKD awareness, yet the nature of CKD conversations between providers and patients is not well understood and the influence of provider communication on patient awareness and self-management of CKD has been significantly understudied. This dissertation explores how patient-provider communication impacts patients’ awareness and self-management of their chronic disease. This dissertation is composed of three papers and uses a multi-method study design to quantitatively investigate if provider communication style is associated with patient CKD awareness and risk for kidney failure. Qualitative methods are used to explore patients’ experiences communicating with their primary care providers (PCPs) and the influence it may have had on their self-management. Secondary data analysis revealed that age is associated with patient awareness of CKD status, with older participants less likely to be aware of their CKD. Qualitative data analysis revealed that patients desire more information from providers regarding the self-management of their CKD. To fulfill this desire for information, participants describe how they build a relationship with their provider, come to clinic visits prepared with questions to facilitate communication, and independently sought out information on CKD management. This is the first study to examine the link between provider communication style and patient CKD awareness and patient-provider communication and CKD self-management. Findings from this dissertation study showed an impact of patient-provider communication on patient self-management of CKD. Additional work is needed to evaluate the influence of provider communication style on patient CKD awareness and risk for kidney failure in a larger study population. Further qualitative investigation into the influence of patient-provider communication on patient self-management of CKD among marginalized and vulnerable populations is also warranted.Publication SKIN HYDRATION, INJURY PREVALENCE AND FREQUENCY: UNDERSTANDING THE INFLUENCE OF PHYSIOLOGIC, BEHAVIORAL AND DEMOGRAPHIC FACTORS(2023) Clements, Carla, PatriceSkin is the largest and most visible organ of the body. It is the direct interface between the external and internal environment. The skin has compensatory mechanisms to sustain its functions, but external threats may make it susceptible to injury. Although increasing evidence describes the biomechanical properties of the skin, limited clinical studies explore the effects of factors on the skin’s outer surface and its susceptibility to injury. Factors associated with skin injury, such as body mass index (BMI), smoking, sun exposure, and age are not always integrated into study designs. This dissertation provided a secondary analysis of pre-existing data (N = 351) from two parent studies describing injury prevalence and frequency in women following consensual sexual intercourse. Data were transferred from the principal investigator of the parent study to this investigator according to human subjects procedures and analyzed using path analysis. Skin hydration was the central focus of the study and is defined as the water content of the stratum corneum. The study showed that both age and BMI were negatively associated with skin hydration, but skin hydration was not a mediator for any of the identified variables, skin color, or viscoelasticity. Additionally, neither the physiologic (BMI), behavioral (smoking and sun exposure) or demographic (age) variables were significantly associated with skin injury prevalence and frequency. Skin color L-value significantly predicted skin injury prevalence, not injury frequency. The results demonstrated that viscoelasticity was not a significant mediator for any relationship between the set predictors and the outcomes of skin injury prevalence and frequency. Viscoelasticity mediated the relationship between age and skin hydration and age was negatively associated with viscoelasticity. Therefore, although skin hydration did not predict skin injury, skin color (i.e., lightness) predicted skin injury prevalence. Further exploration of all related variables is necessary when identifying patients who are at high risk for skin injury. Future knowledge development can inform multi-level interventions that may target modifiable risk factors to maintain the skin’s integrity.Publication ASSOCIATIONS BETWEEN HOSPITAL NURSING RESOURCES AND THE OUTCOMES OF SURGICAL PATIENTS WITH PROLONGED SURGICAL TIME(2023) Dougherty, MauraProlonged surgical time is associated with a greater risk of death, longer stays in the hospital, and higher rates of postoperative complication. The current literature on outcomes of patients with prolonged surgical time is limited to descriptive research and offers no evidence about prevention of or early intervention for postoperative complications. This study examined the association between the outcomes of patients that experience prolonged surgical time and modifiable nursing resources within hospitals. Decades of research has shown that in hospitals with lower patient-to-nurse ratios, high proportions of bachelor-prepared nurses, high proportions of registered nurses to total nursing staff (i.e., skill mix), and a good nurse work environment, patients are more likely to have favorable postoperative outcomes. The benefits of these good nursing resources are most pronounced among patients with the highest clinical risk. This study aimed: 1) to evaluate whether and to what extent differences in hospital nursing resources are associated with outcomes of patients with and without prolonged surgical time and 2) to determine whether the effects of hospital nursing resources on patient outcomes are conditional on surgical time for patients with prolonged surgical times. Multiple linked secondary data sources including patient data from the Centers from Medicare and Medicaid Services (CMS), hospital data about nursing resources from the RN4CAST-US survey, and data of hospital structural characteristics from the American Hospital Association Annual Survey were used to perform a secondary-data analysis. Multivariable logistic regression and zero-truncated negative binomial regression models were estimated to determine the association between hospital nursing resources and patient outcomes. Staffing, education, and the work environment were associated with lower odds of mortality and failure-to-rescue for all surgical patients, and an outcomes advantage was found for patients with longer surgical times when they were in hospitals with low patient-to-nurse ratios, higher proportions of bachelor-prepared nurses, richer skill mix, and good work environments. Additionally, a good work environment was associated with substantially lower odds of mortality and failure-to-rescue for patients with the most prolonged surgical times.Publication A MIXED METHODS INVESTIGATION OF ATTITUDES AND SELF-CARE IN INDIVIDUALS WITH TYPE-1 DIABETES MELLITUS AND IMPAIRED AWARENESS OF HYPOGLYCEMIA(2023) Matus, Austin, MichaelBackground: Self-care of individuals with type 1 diabetes (T1D) may play a significant role in development and treatment of impaired awareness of hypoglycemia (IAH). This dissertation aimed to identify and define characteristics of self-care clusters in adults with T1D, explore the interrelationships between attitudes, self-care, and IAH within clusters qualitatively, and integrate findings to develop a typology. Methods: Adults (n=200, 27% Black, 61% female) with T1D (mean(SD) age: 39(15) years, T1D duration: 22(14) years) reported personal, clinical and social determinants of health, glycemic attitudes and self-care (Self-Care of Diabetes Inventory; 3 self-care scales: maintenance, monitoring, management; 1 confidence scale; scored 0-100; scores ≥ 70 are adequate). Cluster analysis via Ward’s method was performed with self-care domains as criteria. Semi-structured qualitative interviews were performed and analyzed via directed content analysis. An integrated results matrix was employed to develop a typology of self-care in T1D. Results: A typology of three self-care types was found: Expert (n= 70, 70% White, 20% IAH, insulin pump use: 63%, mean(SD) age: 45 (17) years, T1D: 25 (16) years), Inconsistent (n= 112, 75% White, 30.4% IAH, Insulin Pump use: 75%, mean(SD) age: 37 (14) years, T1D: 21 (13) years), and Novice (n= 18, 39% White, 27.8% IAH, Insulin pump use: 44%, mean(SD) age: 27 (7) years, T1D: 16 (8) years. Expert was characterized by adequate self-care across domains (Mean (SD) maintenance: 84.9 (8.8), monitoring: 85.0 (8.8), management: 72.5 (10.0). Inconsistent was characterized by adequate maintenance (78.6 (8.9), and inadequate monitoring (65.6 (9.77)) and management (56.8 (10.1)). Novice was characterized by inadequate self-care across domains (maintenance: 51.9 (7.7), monitoring: 56.9 (12.9), management: 44.5 (6.3)). Types differed across age (p<.001), race (p<.01), insulin pump use (p<.05), Self-Care Maintenance (p<.001), Monitoring (p<.001), and Management (p<.001). No differences were found in IAH or T1D duration. Conclusions: This self-care typology may explain in-part heterogeneity in T1D outcomes such as IAH. Therefore, understanding a patient’s self-care type may offer a more individualized approach for more effective treatment of IAH.Publication An Examination of Factors Related to Depression, Anxiety, and Polypharmacy in Persons with Heart Failure(2023) Nolan, Amy, EAdults with heart failure (HF) suffer from a high prevalence of depressive and anxiety symptoms, and therapies available to treat these symptoms have varying effectiveness. Data on the factors contributing to this needs-services gap (i.e., complexity) remain limited. This dissertation aimed to examine factors related to this complexity in adults with HF and specifically focuses on 1) psychological resilience and its association with depressive symptoms, 2) inflammation and its association with depressive and anxiety symptoms, and 3) the association between depressive and anxiety symptoms and polypharmacy, measured using a daily drug count. For the first manuscript of this dissertation, the study aims were achieved using the methods of a systematic review. The two remaining manuscripts are data-based, leveraging data from an existing repository of HF datasets collected between 2001 and 2009. The findings of the systematic review (Chapter 2) suggest that psychological resilience is negatively associated with depressive symptoms in adults with cardiac disease (n=10 of 13 studies). Using logistic regression (Chapter 3), inflammation measured by standardized c-reactive protein was found to be associated with increased odds of worsened depressive symptoms over three months (OR=1.75, p=0.042) in adults with HF (n=120). The final data-based manuscript (Chapter 4) used multivariable linear regression to examine the association between depressive and anxiety symptoms and polypharmacy (measured using a daily drug count) in adults with HF (n=299). However, anxiety was found to have no significant association with polypharmacy (p>0.05), while depression, social support, left ventricular ejection fraction, race, biological sex, and multimorbidity were significantly associated (all ps<0.05). The findings of this dissertation support the development of mechanism-based interventions to address depressive and anxiety symptoms in HF. The results also support previous findings of race- and sex-based disparities in polypharmacy.Publication EXAMINING THE CHARACTERISTICS THAT SUPPORT NURSES’ INNOVATIVE BEHAVIORS(2023) Leary, MarionStatement of the Problem: Nurses engaging in innovative behaviors, such as human-centered design (HCD) and design thinking (DT), are vital to health systems providing high-quality care. Identifying and classifying the individual and organizational characteristics that contribute to nursing innovativeness is essential.Methods: This is a 3-paper dissertation where the results of Paper 1 informed the research process for Papers 2 and 3. Paper 1 was an integrated review of the literature relating to the use of HCD and DT by healthcare providers in practice. Paper 2 measured the innovativeness of nurses who engaged in innovative behaviors. Psychometric testing and an exploratory factor analysis (EFA) was performed. Paper 3 used the data from Paper 2 to examine the concordance of our results with the Diffusion of Innovation adopter categories. A Latent Class Analysis (LCA) was performed to create a new typology of nurses engaging in innovative behaviors. Results: There are inconsistencies among the healthcare providers who use HCD and DT in their clinical practice, especially with nurses. Individual and organizational characteristics were identified which contribute to a nurse’s innovativeness including increased participation in, and offering of, innovation events. There are individual and organizational correlates of innovative behavior that specifically contribute to four factors of innovativeness: Risk Aversion, Willingness to Try New Things, Creativity and Originality, and Being Challenged. Our sample of nurses is slightly different than the normal distribution of the Diffusion of Innovation theory adopter categories, having more early adopters. We determined four LCA classes and their associated factors: Non-innovator, Uncreative, Optimal Innovator, and Wary Innovator. Conclusions: For nurses to be innovative in their practice, individual and organizational characteristics must be present. Participation and exposure to innovative behaviors, such as HCD and DT, increases a nurse’s innovativeness and is associated with greater innovativeness and self-perception as an innovator.Publication Perinatal Mental Health in Female Service Members and Veterans(2023) Clason, CaitlinPerinatal Mood and Anxiety Disorders (PMAD) are associated with adverse pregnancy outcomes, impaired maternal-infant bonding, and an increase of risky behaviors during pregnancy (e.g., substance use, avoiding prenatal care). Female service members and veterans (FSMAVs), defined as women who are currently or who have previously served in the U.S. Armed Forces, suffer from significantly higher rates of PMAD when compared to the civilian population. FSMAVs have a greater risk than civilian women to have Posttraumatic Stress Disorder (PTSD) or moral injury, both of which are predictors for PMAD. They are also more likely to manifest their symptoms in what is considered an atypical manner for their gender. At this time, the most widely used perinatal mental health screening tool, the Edinburgh Postnatal Depression Scale (EPDS), has not been validated in this population, nor do screening guidelines recommend screening FSMAVs for PTSD, moral injury or PMAD beyond depression and anxiety symptoms. In this context, exploring how FSMAVs describe their experiences with pregnancy and perinatal mental health will help inform whether the current screening tools and guidelines are adequate to appropriately identify those who would benefit from mental health interventions. This dissertation research: 1) assesses the perinatal health risks associated with military service (Chapter 2); 2) investigates correlations between common screening tools used to assess perinatal patients and explore service-related variables (e.g. rank, branch of service) and their relationships to test scores (Chapter 3); 3) explores the language used by FSMAVs to describe their pregnancy and perinatal mental health experiences and where these descriptions converge with or diverge from the EPDS (Chapter 4). In Chapter 3, a convergent mixed method (Quan + QUAL) that utilizes an observational, retrospective cohort for the quantitative thread and semi-structured interviews with thematic analysis for the qualitative thread is proposed to assess the aforementioned research goals. Results from this study will a) inform future research in an underdeveloped area of study; b) provide additional evidence for modifying screening guidelines and c) suggest modifying screening guidelines to include additional baseline assessments for the perinatal FSMAV population.