PURPOSE The purpose of this study was to explore how primary care registered nurses address unmet social needs in patients. SPECIFIC AIMS Explore how RNs in a safety-net, primary care setting develop an awareness of and address patient's unmet social needs. Describe how information about unmet social needs are integrated into nursing assessment and intervention activities, and are shared with other members of the health care team. Describe the challenges primary care RNs face when addressing unmet social needs. FRAMEWORK Critical caring theory provided the framework for this study. DESIGN This study used a descriptive, qualitative design. Semi-structured interviews were conducted with seventeen nurses working in 11 different safety-net primary care clinics within a hospital-based system. RESULTS Three major themes emerged. Key findings included the importance of the nurse-patient relationship, the establishment of trust, and a caring, nonjudgmental approach to patients with unmet social needs. Nurses used knowledge of unmet needs to coordinate patient care, provide social support, and work collaboratively with care team members to refer patients to resources within the health care system and in the community. CONCLUSION Unmet social needs contribute to adverse health outcomes, and addressing social and medical needs is critical to eliminating health inequities and reducing health care costs. In this study, primary care nurses described relationships with patients that allowed for the sharing of sensitive information, leading the nurse to identify and address unmet social needs that could impact patient health.

Problem: Nurses are potentially exposed to hazardous drugs (HDs) in their practice. HD exposure is associated with adverse outcomes (reproductive problems, learning disabilities in offspring of nurses exposed during pregnancy, and cancer occurrence). Safe handling precautions (safety equipment and personal protective equipment, [PPE]) minimize exposure to HDs and decrease the potential for adverse outcomes. Despite existing OSHA recommendations, adherence to precautions is below recommendations. The purpose of this study was to examine relationships among factors affecting nurses’ use of HD safe handling precautions, to identify factors that promote or interfere with HD precaution use, and to determine nurse managers’ perspectives on use of safe handling precautions. This study used a conceptual model which proposes that both individual and organizational factors influence precaution use. Methods: A cross-sectional, correlational design was used. Nurses (N = 165; 46% response rate) from oncology centers across the US who reported handling chemotherapy completed a mailed survey. Instruments measured HD precaution use, knowledge, self efficacy, barriers, perceived risk, conflict of interest, interpersonal influences and workplace safety climate. Hierarchical regression was used. Twenty managers of nurses handling chemotherapy were interviewed. Results: Nurses were experienced in oncology (M = 15.8 ± 7.6) yrs, well-educated (62.5% ≥BSN), certified in oncology nursing (85%), worked in outpatient settings (69%), and on average treated 6.8 ± 5.2 patients per day. Chemotherapy exposure knowledge was high (M = 10.9, ± 1, 0-12 scale); as was self efficacy for using PPE (M = 20.8 ± 3, 7-24 scale), and perceived risk (M = 3.14 ± .6, 0-4 scale). Total precaution use during HD administration and disposal was low (M = 1.9, SD = 1.1, 0= never to 5 = 100%). Nurse characteristics did not predict HD precaution use. In the final model (R2 = .29, F (2, 155) = 24.6, p < .000), fewer patients per day, fewer barriers and better workplace safety climate were independent predictors of higher precaution use. Conclusions: Results emphasize the importance of organizational influence on nurses’ HD safe handling precaution use and suggest fostering a positive workplace safety climate and reducing barriers as interventions.

Overweight and obese women who lose weight prior to pregnancy have fewer pregnancy complications than those who do not (Forsum, Brantsaeter, Olafsdottir, Olsen, & Thorsdottir, 2013; Schummers, Hutcheon, Bodnar, Lieverman, & Himes, 2015). Research findings suggest there are missed opportunities to provide diet and physical activity counseling during preventive care visits. Providers cite a lack of time and resources as barriers (Morgan et al., 2006; Yamamoto et al., 2014). This was a two-group, randomized, pilot-study of 19 overweight or obese women in Central Georgia. Participants completed surveys related to their perception of risk for obesity-related pregnancy complications, readiness to change nutrition and physical activity behaviors, nutrition and physical activity self-efficacy, actual physical activity, and dietary history at baseline, after completion of the study, and at follow-up. Those in the intervention group participated in one face-to-face meeting, reviewed eight online education modules, and received weekly booster messages. The control group participated in a similar protocol; however, information was limited to general women’s health topics. Nineteen women (intervention = 11, control = 8) completed all instruments related to primary outcomes—perception of risk, readiness to change, and self-efficacy. The average age of participants was 28.7 years (SD = 6.35). The average body mass index was 36.54 kg/m2 (SD = 5.52). Women were predominately Caucasian (68.4%) and married (52.6%) with children (57.9%). Most had a college degree (42.1%) or higher (15.8%), and a yearly income between $25,000 and $75,000 (42.1%). Evaluation of completion data, resources, and intervention management indicated that the intervention may be feasible during preventative care visits. Participant responses to exit interview questions demonstrated the intervention may be acceptable for women of childbearing age. Effect sizes ranged from small (ƞp2= .00, p = .88) to large (ƞp2= .27, p = .08) indicating the intervention may be effective in an adequately powered sample. Future research should focus on the further development and implementation of programs that assist with pre-conception weight loss. Providing women with information regarding the complications associated with being overweight and obese, as well as the information or tools necessary to reduce weight prior to pregnancy, may be instrumental for improving short and long-term pregnancy outcomes for both mothers and their offspring.

Diabetes is a chronic, complex illness with a risk for acute and long-term complications. The aim of this quality improvement project on prevention of type 2 diabetes was to increase self-management behaviors in patients at high risk of type 2 diabetes, decrease the financial burden of type 2 diabetes, and decrease the incidence of complications that can occur from type 2 diabetes. The primary outcome of this project was each participant reporting at least one lifestyle modification that would be helpful in preventing type 2 diabetes after attending two group education sessions. A pretest posttest design was used for this project. Three completed the initial questionnaires, and two attended the educational sessions and completed the posttest questionnaires. Of the total number of participants, one reported a decrease in hot/cold cereal, regular soda, sugar or honey in coffee/tea, other potatoes, tomato sauces, chocolate, doughnuts, and cookies, cake, pies, brownies. Two participants reported a decrease in fruit juice, fried potatoes, and pizza. One participant had an increase in physical activity while the other participant had no change in physical activity. The landmark Diabetes Prevention Program (DPP) Trial demonstrated that counseling on a healthy diet and moderate physical activity reduced the incidence of type 2 diabetes. The two participants in this project reported they made some helpful changes in diet after two education sessions. It is vital to the success of a prevention program to convey the significance of preventing a chronic disease such as type 2 diabetes

Abstract Traumatic Brain Injury (TBI) is a global epidemic (Schwarzbold et al., 2008). According to Brey (2006), a brain injury occurs every 21 second in the United States, which results in 1.5 million head injuries annually. The purpose of this project was to educate psychiatric personnel regarding the needs of the TBI population and to measure learning and retention. This is a quality improvement project that utilized a pretest and posttest design with an educational intervention. The intervention was administered electronically via Microsoft PowerPoint. Results were measured with the Wilcoxon Signed Rank Test. A total of 17 participants completed the pretest and posttest, and 11 completed the second posttest; the second posttest administered six weeks after the initial posttest. The results show that knowledge increased from pretest to posttest, (p < 0.05), however, retention of the material did not occur per test results, (p ≥ 0.05). There is no other research to compare to these results. Therefore, more research and educational intervention are needed to educate psychiatric personnel regarding the needs of the TBI patient.

The purpose of this dissertation was to explore the determinants of Pap screening completion among sub-Saharan African immigrant women. Cervical cancer is a public health problem globally. The risk of invasive cervical cancer remains high among sub- Saharan African immigrant women in the US despite being a preventable cancer. Early detection through Pap screening is crucial for prevention, treatment and prognosis. The specific aims of this dissertation were to 1) examine Pap screening practices among African immigrant women and to identify gaps to guide future research; 2) explore barriers and motivators that influence Pap screening decisions among African immigrant women; and 3) explore African immigrant men’s knowledge of Pap screening and attitudes about supporting their wives/female partners to utilize Pap screening, and 4) explore predictors of Pap screening use among sub-Saharan African immigrant women, Specific aim one was addressed by a review and synthesis of literature focused on Pap screening among African immigrant women. Common factors influencing Pap screening completion included immigration status, health care interactions, knowledge deficiency, religiosity, and certain personal characteristics. Specific aim two was addressed by the conduct of a qualitative descriptive study of barriers and motivators contributing to Pap screening decisions in 22 African immigrant women. Women experienced different barriers including low knowledge of screening, cultural beliefs, fear and communication issues. Addressing knowledge gaps and other barriers related to Pap screening may improve Pap screening participation in this group. Specific aim three was addressed by a qualitative descriptive study of men’s attitudes and beliefs regarding Pap screening and support for their wives for Pap screening participation. African immigrant men demonstrated suboptimal knowledge and awareness of cervical cancer screening. Most men had a lack of knowledge regarding HPV and its link with cervical cancer. Despite knowledge deficiency men showed significant interest in supporting their wife/female partners. Specific aim four was addressed by conducting an analysis of cross sectional data collected from 108 sub-Saharan African women. Predictors of Pap screening completion was determined using logistic regression while controlling for age and education. Pap screening awareness and provider’s recommendations were independent predictors of Pap screening. Given the unequitable burden of cervical cancer experienced by this population, the findings from this dissertation point to the need for a multilevel targeted health interventions directed toward African immigrant population are needed to increase the rates of Pap screening among African immigrant women. Prevention efforts should focus on individual level factors and develop culturally relevant strategies that will effectively provide educational outreach interventions and alleviate barriers to Pap screening. Engaging spousal support and addressing social norms related to spouses/partners’ roles that may influence partaking in cervical cancer screening is important among African immigrant women. Cervical cancer is preventable; Pap screening will lead to early detection of cervical cancer in female African immigrants.

Purpose: The purpose of this study is to describe the relationship between health literacy, preparedness for discharge, adherence to discharge instructions and difficulty coping after discharge among emergency department patients. Specific Aims: The Aims of this study were to: (1) describe the variability of health literacy of adult patients in an academic tertiary Emergency Department; (2) describe the relationship between health literacy, care transition, and perceived readiness for discharge on the patient’s adherence to discharge instructions and (3) explore whether health literacy, perceived preparation for discharge and care transition, predicts difficulty coping after discharge. Framework: Dr. Meleis’s Transitions Theory was used as a framework. Design: This is a prospective cohort study of adults treated and discharged from the ED. Results: Eighty five percent of the subjects completed the study (n = 132). Subjects satisfied with transition care (P = .025) and who felt more prepared for discharge (P = .035) had less difficulty coping. Subjects more satisfied with care transition were more likely to adhere to medication instructions (P = .029). The higher the satisfaction with discharge preparation, the less likely the subjects were to go to their follow-up appointment (P = 0.051). No associations were found with health literacy. Conclusion: Satisfaction with care transition during the discharge process and feeling well-prepared are related to less difficulty coping after discharge. Nurses have an opportunity to intervene and enhance the discharge experience. This may contribute to more positive outcomes after being seen in an emergency department.

More than 85% of American adults do not consume recommended amounts of fruits or vegetables. Preterm birth and hypertensive disorders of pregnancy are common adverse conditions affecting pregnancy and are leading causes of maternal and fetal morbidity and mortality. Preterm birth affects nearly 10% of all births in the United States and is on the rise, as are hypertensive disorders, which have increased by 25% over the last two decades. Pregnancy is a state of controlled inflammation, and dysregulation has been linked to preterm birth and other adverse gestational outcomes. A healthy diet is recommended in pregnancy, but little is known about the effect fruit and vegetable intake on perinatal outcomes. Omega-3 (n-3) fatty acids are essential dietary components and are known to affect inflammatory state, but little is known about how they affect inflammation in pregnancy. As current evidence is lacking, further research is needed to investigate the relationships between maternal nutrition in pregnancy, inflammation and birth outcomes. The purposes of this dissertation were to: 1) to review and evaluate the current evidence on the relationship between n-3 fatty acids and inflammation in pregnancy; 2) to evaluate the current state of the science on the impact of maternal dietary consumption of fruits and vegetables on preterm birth, gestational diabetes, preeclampsia, small for gestational age, gestational weight gain and measures of inflammation or oxidative stress in pregnancy; and 3) to examine relationships between maternal dietary intake of fruits and vegetables, cytokine expression in early and mid-pregnancy, preterm birth and gestational hypertension. A critical review of literature examining the relationship between inflammation and n-3 intake during pregnancy found that multiple inflammatory cytokines in maternal and fetal tissues were lower in women who received n-3 supplements. A second review of literature review supported an inverse relationship between fruit and vegetables and risk of preeclampsia and suboptimal fetal growth. The available evidence was insufficient to establish relationships between fruit and vegetable intake and gestational diabetes, preterm birth or inflammation. A study evaluating the relationships between maternal fruit and vegetable intake, inflammation and birth outcomes was conducted. This study provided evidence supporting a relationship between first and second trimester cytokine expression and maternal dietary intake of fruits and vegetables. Those who met recommended vegetable intake in the first trimester had higher first trimester serum CRP, IL1-α, IL-6 and TNF-α and lower first trimester cervicovaginal IL-6 levels. Those who met recommendations for first trimester fruit intake had 56% lower risk for preterm birth. Those who met second trimester vegetable intake recommendations had more than twice the risk of developing gestational hypertension. The results of this dissertation provide support for the beneficial effects of omega-3 fatty acids and fruit and vegetable intake in pregnancy. Maternal intake of these dietary components may promote optimal immune status during pregnancy. Supplementation of maternal omega-3 fatty acids may help regulate inflammation via the anti-inflammatory effects their bioactive eicosanoids exert. Fruit and vegetables have antioxidant and anti-inflammatory effects that may also help balance the inflammatory state during pregnancy. These dietary components may help promote favorable immune status during pregnancy and reduce risk of adverse perinatal outcomes such as poor fetal growth, hypertensive disorders of pregnancy and preterm birth.

PURPOSE: The purpose of this qualitative descriptive study was to describe critical care nurses’ experiences of moral challenges, moral distress, and moral resilience during the COVID-19 pandemic. The specific aims of this study were to: 1. Describe the moral challenges experienced by ICU nurses. 2. Describe moral resilience in terms of integrity, buoyancy, moral efficacy, self-regulation, and self-stewardship among ICU nurses (from Rushton’s framework). 3. Explore the relationship between moral distress and moral resilience to advance the concept of moral resilience in the face of the COVID-19 pandemic. FRAMEWORK: This study was undergirded by an adaptation of Rushton’s conceptual framework of moral concepts. DESIGN: A qualitative descriptive design was used. Participants were recruited between January to May 2021, and a semi-structured interview guide was utilized to interview participants. RESULTS: 17 participants were interviewed for the study. Participants described the four themes of moral challenges: death and dying, pain and suffering, being alone, and being helpless and not in control. Moral resilience was described as: integrity, buoyancy, moral efficacy, self-regulation, self-stewardship, and self-perception. The relationship between moral distress and moral resilience was described as iterative and fluid. CONCLUSION: The findings of the study provided a new domain of moral resilience called self-perception and a revised adaptation of the conceptual framework for moral resilience.

Communication with healthcare providers (HCP’s) at the end-of-life (EOL) is a crucial process that can make a difference in the quality of the EOL experience for patients and their families. Targeting EOL communication interventions between patients, their families, and HCP’s is better informed from an understanding of what family members perceive as good and bad communication. The purpose of this study was to explore experiences related to communication with HCP’s in central Massachusetts during EOL care. Data from the parent study (n = 373) included responses from an open ended question at the end of the survey. The larger, qualitative descriptive study, from the parent study, (n = 218 ) that examined the open ended question revealed communication as the overarching theme. A secondary analysis of this open ended survey data using qualitative content analysis was used to describe next of kin’s perspectives of communication with HCP’s during the decedents’ end-of-life experience (n = 171). Family members (children = 38.4% and spouse = 22.0%) comprised the majority of the sample. Decedents were mostly 80 or older (47.6%), died in an acute care setting of mostly cancer (33.0 %) and cardiovascular disease (32.3%). Accessing information, emerged as the overarching theme. Continuum of information, healthcare provider sensitivity, having the answers and raising awarenesswere revealed as subthemes. The majority of respondents reported good aspects versus bad aspects of communication at the EOL. The framework for a good death (Emanuel & Emanuel (1998) under-girded the study but was not supported as it relates to these findings. The framework was useful in capturing the multidimensional process that each patient and their family could experience during the EOL process. The findings from this study provide insight for HCP’s about which aspects of communication are helpful at the EOL. Continuing education of the health care team on these identified helpful communication aspects will provide better access for patients and families for a quality EOL experience.