In the United States nearly 1 million annual new and recurrent myocardial infarctions (MI) occur with 10% of patients hospitalized with MI having unrecognized ischemic symptoms. Inexperienced nurses are expected to accurately interpret cardiac symptom cues, possibly without ever having experienced care of patients with MI, yet have been shown to be less able to classify symptom cues and reach accurate conclusions than experienced nurses. The purpose of this study was to test an educational intervention using theories of pattern recognition to develop CT in MI and improve nursing students’ clinical decision-making and clinical judgment using high fidelity patient simulation. This study used a quasi-experimental three group pre-/post-test design and qualitative data to triangulate information on critical thinking, clinical decision-making, and clinical judgment in MI. A sample of junior baccalaureate in nursing students (N = 54) from a large metropolitan university were divided in pairs and randomized to one of two control groups. Data were collected with instruments which measured pattern recognition in MI, critical thinking in MI, and self-perception of clinical decision-making. In addition, diagnostic efficiency and accuracy were measured. Triangulation on clinical decision making with semi-structured interviews using ‘thinking aloud’ technique was conducted. Data were analyzed as qualitative data and compared among groups. Students who were given prototypes for MI using simulation significantly improved critical thinking as measured by pattern recognition in MI (t(3.153(2), p = .038) compared with the non-simulation control group. Qualitative findings showed that students receiving the experimental simulation with a non-MI scenario and feedback-based debriefing had greatest gains in clinical reasoning which included development of clinical decision-making using analytic hypothetico-deductive and Bayesian reasoning processes and learned avoidance of heuristics. Students receiving the experimental simulation learned to identify salient symptom cues, analyzed data more complexly, and reflected on their simulation experience in a way which students reported improved learning. Students who were given MI only simulation scenarios developed deleterious heuristics and showed fewer gains in clinical reasoning, though both simulation groups demonstrated greater critical thinking ability than the non-simulation control group. Findings support the use of simulation to improve clinical reasoning including pattern recognition and clinical decision-making, and emphasize the significance of simulation scenario construction and debriefing to achieving learning outcomes. The findings could be used to guide further research to improve critical thinking, clinical decision-making, and clinical judgment in nursing students using simulation. Funding for this study was provided by the American Association of Critical Care Nurses and Philips Medical Systems and a testing grant from Elsevier, Assessment.

Problem and significance: Adherence to health-promoting behaviors in a diabetes self-care regimen is essential for individuals with diabetes and can assist providers and individuals with diabetes management. The purpose of this research was to explore the relationship between personal factors (age, length of diabetes diagnosis, perceived health status, weight), perceived barriers to action (number of barrier days), interpersonal influences (social support), situational influences (depressive symptoms), and patient adherence to health-promoting behaviors (blood glucose monitoring, diet, and exercise) and health outcomes ( A1c and body mass index) in a diabetes self-care regimen. Methods: A descriptive correlational analysis was performed using baseline data from the National Health and Nutrition Examination Survey (NHANES) [2007-2008]. Constructs from the Health Promotion Model were used to predict health-promoting behaviors and health outcomes in diabetes self-management. The 713 participants with diabetes were primarily Black or Hispanic (57.5%), older ( M 62.2 years, SD 12.9), and married or living with a partner (56.2%). Approximately half of the participants were female (50.8%); 59% were obese. Results: The longer the time since diagnosis and the more barrier days experienced per month, the more frequently blood glucose monitoring was performed (R2 = .076, R2adj = .060, F (6, 363) = 4.875, p < .001). The greater the body weight, the more likely participants were to implement diet management behaviors (R2 = .097, R2adj = .081, F (7, 413) = 6.209, p < .001). The younger the age and the higher perceived health status, the more minutes per week were spent in exercise (R2 = .054, R2adj = .038, F (7, 412) = 3.307, p < .01). The older the age and the shorter time since diagnosis, the lower the A1c levels (R2 = .054, R2adj = .044, F (6, 568) = 5.391, p < .001). The younger the age, the more barrier days per month and the more diet management behaviors reported, the higher the BMI (R2 = .149, R2adj = .140, F (6, 581) = 16.764, p < .001). Findings indicate that treatment measures, not preventative, are being practiced, and that predictors of behaviors and outcomes are multifaceted and require further investigation.

Disparities in medication adherence (MA) associated with African American (AA) adults may be related to a dynamic interplay between personal factors, behavioral capability, and environmental factors. The purpose of the study was to examine this relationship in AA adults with metabolic syndrome (MetS). A cross-sectional, correlational analysis was conducted from baseline data from a larger intervention study. Constructs from the Social Cognitive Theory were used to predict MA. The sample of 91 AA adults with MetS was primarily middle-aged (age range 45-70 years old; M 53, SD 6.3), female (79%), relatively well-educated, and married. Despite being on antihypertensive medications, 53% of the participants presented with uncontrolled high blood pressure (≥130/90 mmHg). Although the vast majority (95%) of the sample displayed adequate health literacy (HL), 30% of the sample was non-adherent to their medication regimen. A positive significant relationship was found between age and MA [χ2 (1, n = 90) = 6.71, p = .01)]. Stress [χ2 (1, n = 90) = 6.28, p = .012)] and social support (SS) [χ2 (1, n = 90) = 4.10, p = .04)] were the only significant relationships among environmental factors, barriers and hypertension MA. Highly stressed AA adults were significantly more likely to be non-adherent or had a 15% reduction in the odds of hypertension MA. Similarly, adults with a low income were 5.8 times more likely to be non-adherent (OR 5.828, 95% CI, 1.014-33.493, p= .0482), while those with low SS had a 9% reduction in the odds of MA; SS trended toward significance (OR.914. 95% CI .823-1.016, p =.09). With increasing age, AA adults were more likely to be non-adherent (OR 1.12, 95% CI 1.028-1.220, p =.0096). Most of the participants reported a high degree of autonomy, satisfaction with their health care climate, and the availability of SS. Although increasing age, adequate SS, high stress, and adequate HL appeared to influence MA in AA adults with MetS, the research questions were only partially answered. Further investigation of the relationships and potential mediating pathways between personal characteristics, environmental factors, behavioral capability and hypertension MA in AA adults with MetS is needed.

Little is known about how the decision for elective cesarean section comes about in the clinical environment. A prospective longitudinal study based on the Health Belief Model was conducted about first time mothers’ decision making processes and their health beliefs which led to their satisfaction with their decision about their mode of delivery. A convenience sample of 144 nulliparous women with singleton pregnancies and no medical indications requiring a cesarean delivery were recruited using internet based informational notices and with flyers. Women (n = 127) planning a vaginal delivery (VDMR) represented 88.2% of the sample and women (n = 17) requesting a cesarean delivery (CDMR) represented 11.8% of the sample. Data were collected during the third trimester and six weeks after the delivery using an internet-based questionnaire. Data were analyzed using t-tests and multiple linear regression to predict the effect of maternal health beliefs, maternal childbirth self efficacy, partner support, acceptance of the maternal role, and request group (VDMR vs. CDMR) on the dependent variables of maternal perception of the delivery and maternal satisfaction with her decision for the mode of delivery. Compared to women with VDMR, women with CDMR were significantly older, less educated, perceived more risk of emergent cesarean and less ability to deliver vaginally. Hypothesis testing indicated that the overall regression model did not significantly predict maternal perception of the delivery. The model accounted for a significant amount (15.1 %) of the variance in maternal satisfaction with the decision for mode of delivery. Acceptance of the maternal role and maternal request group significantly contributed to the model indicating that women with higher acceptance of the maternal role and women with CDMR had poorer satisfaction with their decision for the mode of delivery. The findings showed that factors influencing maternal perceptions of the delivery and satisfaction with the mode of delivery are different. Health beliefs had less relevance for perception of the delivery. It is possible that experiences that occur within the context of the delivery are more salient for maternal perception. Women with higher acceptance of the maternal role and who request a cesarean delivery are at risk for less satisfaction with their delivery decision and more decisional conflict and thus may need more support during decision-making processes and after delivery. Future research should examine the long-term impact of dissatisfaction with delivery decision on maternal outcomes.

The population of medically fragile adolescents has grown in recent decades because of the sequelae of prematurity, injuries, and chronic or terminal illnesses. Medically fragile adolescents who require respiratory assistance are part of this unique population with challenges in their daily lives, yet as nurses, we know little about their experiences and the best approaches to use in caring for them. The purpose of this study was to explore the experiences of medically fragile adolescents who require respiratory assistance. Interpretive phenomenology was used to describe and interpret the experience of 11 medically fragile adolescents who required respiratory assistance. The adolescents ranged in age from 13 to 18 years of age and required respiratory assistances of tracheostomies, ventilator support, and Bi-level positive airway pressure (BiPap). Audiotaped semi-structured interviews were conducted with the adolescents. Data analysis was completed using the steps delineated by Diekelmann and Allen (1989). Six themes and one pattern were identified from the interviews with the adolescents. The major themes were “Get to know me”, “Allow me to be myself”, “Being there for me”, “No matter what, technology helps”, “I am an independent person”, and “The only one I know of”. This study explored medically fragile adolescents who required a specific technology, respiratory assistance, within a distinct developmental stage. These adolescents have a clear view of who they are as a person. They want nurses to view them as a person, not just a patient. The adolescents felt that friends were there for them when they needed support. This was in contrast to those that they did not consider friends who were judgmental. Technology had meanings that encompassed enhanced daily living and existing as a part of their day, not their whole day. The adolescents viewed themselves as an independent person and were actively engaging in activities and strategies to achieve their goals of independence. This study contributes to nursing knowledge by helping nurses to understand what these adolescents experience in their daily lives and aiding nurses in providing better care for these adolescents. Recommendations for nursing practice, education, and research were identified in this study.

Women smokers with heart disease (HD) are at increased risk for negative health effects. At the time of invasive cardiovascular (CV) interventions is a critical opportunity to make lifestyle changes to reduce future CV interventions. The purposes of this study guided by the Health Belief Model were to determine which factors predict smoking cessation (SC) in women following an invasive CV procedure and to explore assistance received with SC. A correlational, prospective design was used. Data were collected from women smokers at the time of an invasive CV intervention and three months later. Instruments measured commitment to stop smoking, perceived threat of HD and future interventions, cessation self efficacy, barriers to SC, benefits of SC, cues to action, and motivation. Analyses included Chi-square, t-tests, and multiple, hierarchical, and logistic regression. On average women (N = 76) were middle-aged (M = 55.9 ± 8.0 yrs), smoked M = 15.3 ± 9.8 daily cigarettes and smoked for M = 33.6 ± 10.2 years. At baseline, fewer perceived barriers to SC, high cessation self-efficacy, and being more autonomously motivated to quit smoking explained 67 % of variance in commitment to stop smoking, F (6, 67) = 19.37, p < .001. At 3 months, only 8 (n = 54) women had quit smoking. Women smoked fewer daily cigarettes (M = 10.6 ± SD = 8.5) at 3 months compared to time of procedure (M = 15.3 ± 9.8), t(51) = 3.43, p < .01. Higher baseline cessation self-efficacy and lower HD threat were predictors of SC at three months, X2 (4, N=54) = 18.67, p = .001. At the three month follow up, the most common barrier to SC was anxiety (24%) and cigarette cravings (24%). While women were highly committed and confident they could quit, they reported receiving little help from their health care provider (HCP) other than simple advice to quit smoking. Most women undergoing an invasive CV procedure were unable to quit smoking even with a high desire to do so. Referrals for assistance from HCP to decrease anxiety and nicotine dependence and to address ongoing challenges to SC are needed.

Obesity is associated with higher death rates from breast and gynecological cancers. African American women(AAW) are more likely to be diagnosed with these cancers at later stages and have lower survival rates than Caucasian women. African American women are also disproportionately affected by obesity. Studies suggest that the healthcare experiences of obese women (primarily stigmatization), may contribute to their decisions to utilize healthcare services. However, these studies have largely comprised Caucasian women; there remains a paucity of studies addressing this issue in AAW. The purpose of this study was to explore the healthcare experiences of obese AAW and their utilization of preventive healthcare services. Interpretive phenomenology, based on the work of Maxx van Manen, was used to describe and interpret the healthcare experiences of 15 obese AAW living in communities in Georgia. The women ranged in age from 23 to 62, with body mass index ranging from 35-55. The majority of the sample (83%) had adequate health insurance. This was a well educated sample with 87% having college degrees or some college education. Individual, audio-taped interviews were used to collect data. Data were analyzed using interpretive phenomenological methods, with analysis and collection occurring concurrently. Data were analyzed as a whole then line by line to identify themes across transcripts. Two patterns and five themes were identified. Patterns were: They're not listening and Good or bad, it's my decision. Themes were: Attributing all problems to weight; They say lose weight but give us no tools; Stigmatization; Cancel my appointment please: I won't be back, and Empowerment. The women recalled a pleothra of negative encounters with providers that they termed "demeaning" and "nastiness for no reason." Many women reacted by delaying or avoiding healthcare, some not returning for preventive health screens for many years. The significant association between obesity and mortality from cervical and breast cancers necessitates timely preventive screens by obese women. The results of this study can help to inform practice, education, and research. Recommendations for all three areas were deleneated in the study.

In Healthy People 2010, mental health is listed as a major public health concern as evidenced by an alarming increase in the number of individuals who suffer from mental disorders. Mental disorders are a treatable public health condition. However, health disparities in the treatment of mental disorders are evident. The purpose of this study was to examine factors that affected health outcomes of persons with mental disorders. Two specific aims were addressed: Aim 1: to examine the relationships of population characteristics (predisposing factors and enabling resources), health behaviors (health services use and health practice); and health outcomes (physical health status and mental health status); Aim 2: to determine the differences in the usual source of care and health outcomes between individuals with self-reported mental disorders and individuals without mental disorders. This study was a secondary analysis of existing data collected from 2006 Medical Expenditure Panel Survey Household Component Consolidated file. A sample of U.S. civilian non-institutionalized adults (N=622) was grouped according to three self-reported health conditions: mental disorders (MD), physical illnesses (PI) and co-morbid mental disorders and physical illnesses (CM). This sample was predominantly male, White non-Hispanic and married; had a high school diploma, middle to high income, and private insurance; and preferred office-based clinics as the usual source of care, F(2,29)=5.94, p = .007. No statistically significant differences between groups in usual source of care (p=.069) and physical health status (p=.490) but there was a significant difference in mental health status (p=.001). Participants with CM had a poorer mental health status than those with PI and MD, F (2,619) =21.8, p= .000. The mental health status of individuals with PI was significantly better than that of participants with MD. Awareness of disparities in the usual source of care, health services use, and health outcomes among individuals with mental health conditions is imperative if barriers to care are to be eliminated. Innovative interventions pertinent to decreasing barriers to accessing health care and improving the health outcomes among individuals with MD must be tested. Advocating for mental health care policies that reduce health care services disparities among individuals with self-reported MD must be encouraged.

Significance: Morbidity and mortality related to CVD among women in the U.S. and most developed countries surpasses that of all cancers combined (AHA, 2008). Yet, CVD in women remains understudied, yielding low awareness among women and healthcare providers. The purpose of this study was to examine whether the relationship between health beliefs related to perceived cardiovascular disease (CVD) severity and health promoting behaviors were different in women with high self perception of CVD susceptibility versus women with low self perception of CVD susceptibility. Methods: This study used a descriptive, correlational design. A convenience sample (N = 220) included female registered nurses (RNs), 23-66 years old (M = 48; SD = 9.7), mostly white (N = 143; 65%), who had worked in nursing an average of 21 years (SD = 11.3) and reported their job as stressful/very stressful (N = 129; 59%). Nurses were recruited from five acute care hospital systems in a large southeastern city. Data were collected using standard questionnaires that measured perceived CVD severity and susceptibility, social support, depression, stress, exercise and nutrition. Participants completed data collection via an online survey method. Results: Data were analyzed using MANCOVA. For every standardized unit increase in perceived severity of CVD, participants had a 1.26 (95% CI: 0.02, 2.50) unit reduction in their healthy food choice score (lower scores = healthier food choices), and a 0.12 increase in their physical activity score (higher scores = more physical activity) (90% CI: 0.01, 0.23) unit. For every standardized unit increase in perceived CVD susceptibility there was an increase in the healthy food choice score by 2.37 (95% CI: 1.09, 3.65) units, and a reduction in the physical activity score by 0.27 (95% CI: 0.12, 0.41) unit. Greater age (p = 0.01) and greater depression (p = 0.001) were statistically significant predictors of lower physical activity. CVD susceptibility did not moderate the effect of CVD severity on nutrition or physical activity. Conclusions: Higher perceived CVD severity was associated with increased likelihood for healthy food choices and physical activity. In contrast, higher perceived CVD susceptibility was associated with decreased likelihood for healthy food choices and physical activity. More research is needed to understand how susceptibility beliefs around CVD are formed in women and how to better engage women in risk reduction behavior.

Children with psychologically vulnerable caregivers may be at risk for being labeled as having behavior problems when typical behaviors are viewed by their caregivers as problematic. Research examining the accuracy of the caregivers’ perceptions of children’s behaviors is limited. The purpose of this study was to use the Resiliency Model of Family Stress, Adjustment, and Adaptation to explore family and female caregiver factors associated with appraisals of children’s behaviors, the extent to which these appraisals may be distorted and children’s level of risk of having behavioral problems. A cross-sectional, correlational design was used. Data were collected from female caregivers of preschoolers. Reliable and valid instruments measured family factors, demographic characteristics, comfort in parenting, appraisal of behaviors, daily stress, parenting stress, depressive symptoms, social support, ratings of children’s behaviors, and distortion in the ratings. Analyses included ANOVA, ANCOVA, Chi-square, simultaneous and hierarchical linear regressions. Results indicated that family typology was not associated with the female caregivers’ appraisals of children’s behaviors or distortion of caregivers’ ratings of behaviors; however, it was associated with risk of having children with behavioral problems. In the simultaneous regressions models, greater discomfort with parenting and greater perceived daily stress were associated with more negative appraisals of children’s behaviors by the female caregivers and Caucasian race and higher distortion in behavioral ratings were associated with higher risk of behavioral problems in children. Social support did not buffer the effects of caregiver depression on appraisals of children’s behaviors or level of risk of children having behavioral problems.