<p>The Nurse-Family Partnership (NFP) is a targeted, nurse home visitation program for young, low-income, first time mothers. While the effectiveness of the NFP has been established in the context of the US, and is currently being evaluated in the Canadian public health care system, little has been done to document how work of this nature influences or impacts public health nurses (PHNs), an essential component of this program delivery model, on both professional and personal levels. This qualitative interpretive descriptive study explored PHNs’ experiences of long-term home visiting a targeted population of young, vulnerable mothers in a Canadian NFP program. The study was conducted in two phases beginning with a secondary analysis of five focus groups conducted with public health nurses (N = 6) who delivered the NFP intervention as part of the feasibility and acceptability pilot in Hamilton, Ontario. This was followed by further exploration of identified themes and a practice, problem and needs analysis through individual, semi-structured interviews with the original focus group participants and all PHNs who have since delivered the NFP (N =10). Relationships formed with clients, the NFP program and support of NFP colleagues were rewarding factors while workload and workplace factors were significant contributors to stress. The study findings have implications for the identification of strategies to minimize staff turnover, PHN burnout, secondary traumatic stress and compassion fatigue, and improve program delivery.</p> / Master of Science in Nursing (MSN)

The median prevalence of smoking among women of childbearing age in the United States is 22.4%. Of women who identify themselves as smokers in the three months prior to conception, 55% quit during pregnancy; however, 40% of those who quit relapse and return to smoking within six months after delivery. Smoking has been identified as an important means of stress management among smokers in general, and though limited to the perinatal period, pregnancy-specific stress adds to a woman’s typical day-to-day stress burden. Little data exists as to the effect of SHS exposure on smoking status during pregnancy and the impact of SHS exposure on the maternal perception of stress is unknown. Due to limited evidence, a critical need exists to examine the relationships of perceived maternal stress, SHS exposure, and perinatal smoking status in order to better understand perinatal smoking behaviors. The purposes of this dissertation were to: 1) evaluate the literature examining the relationship between the variables of maternal stress, SHS exposure, and perinatal smoking status; 2) determine the reliability and validity of the Everyday Stressors Index (ESI) use in pregnant women; and 3) to investigate the impacts of maternal perception of everyday stress, and SHS exposure on perinatal smoking status. Evidence obtained from the critical review of the literature supported an association between psychosocial stress and smoking during pregnancy or postpartum. Little information regarding the role of SHS exposure on perinatal smoking status was discovered. Psychometric testing of the ESI demonstrated strong internal consistency reliability, and factor analysis yielded three factors capturing three important domains of everyday stress. SHS exposure emerged as the most significant predictor of smoking status. Persistent smokers/relapsers had the highest ESI scores, followed by quitters, and then nonsmokers. While ESI means decreased in all smoking status groups from the first to the third trimester, the magnitude of decrease was not predictive. A significant interaction effect of SHS exposure in the home and decrease in ESI score occurred in the quit group only with quitters 1.14 times more likely to experience a decrease in ESI score compared to smokers/relapsers.

The purpose of this dissertation is to explore potential barriers nurses experience in providing effective pain management for preterm and critically ill infants in neonatal intensive care units (NICUs). The specific aims of the study conducted are to examine (a) NICU caregivers’ knowledge about pain, (b) scales used to evaluate pain in infants, (c) NICU nurses’ documented pain practices, and (d) bias in treating pain of certain types of infants. This dissertation is comprised of three manuscripts. The first manuscript is an integrated review of the literature describing caregiver knowledge, barriers, and bias in the management of pain in neonates. The second manuscript is a systematic review of multidimensional pain scales developed for use in preterm and critically ill infants. The final manuscript reports a descriptive exploratory study designed to examine nurses’ knowledge of pain, knowledge of intensity and appropriate management of procedural pain, bias in treating pain of certain types of infants, and documented pain management practices. Over the past 25 years, caregiver knowledge of pain in preterm and critically ill infants has advanced from beliefs that neonates do not feel pain, to the knowledge that preterm infants experience more pain than term infants, older children, and adults. Nine multidimensional pain scales with varying levels of reliability and validity have been developed, yet a gold standard for pain assessment in preterm and critically ill neonates has not emerged. In this study, baccalaureate prepared nurses (BSN) and nurses with higher total years of nursing experience had better knowledge of pain in this population than associate degree nurses (ADN). However, pain management was inconsistent, resulting in pain that was untreated as often as 80% of the time. Nurses reported that physician practice was the primary obstacle to providing effective pain management. Additional concerns included knowledge deficits of nurses and physicians, lack of communication and teamwork, and rushed care. Nurses reported biases in managing pain and were less likely to invest time and energy treating the pain of infants experiencing neonatal abstinence syndrome.

Breastfeeding is the gold standard of infant feeding and its benefits extend beyond the mother and child. Multiple organizations recommend exclusive breastfeeding for the first six months of an infant’s life. Exclusive breastfeeding rates nationally and in the state of Kentucky fall below the Healthy People 2020 goals. A mother’s intention to breastfeed has been shown to impact actual breastfeeding behavior. The current state of the measurement of intention was explored through a literature review. A majority of the measures were single item scales. The reliability and validity of the scales should be further tested in diverse populations. The purposes of this dissertation were to: a) explore the role of breastfeeding intention on duration of exclusive breastfeeding, and b) determine the common modifiable factors among women who breastfeed exclusively for at least four months. English speaking mothers 18 years of age and older were asked to participate if they had delivered a healthy infant in the last 72 hours and if they intended to feed their baby some amount of breast milk (n = 84). Mothers were followed for 16 weeks or until they weaned their infant, whichever came first. Social support, breastfeeding self-efficacy and breastfeeding intention were measured at baseline. Breastfeeding support and breastfeeding self-efficacy were measured at four and 16 weeks. Results indicated that mothers with stronger intention to breastfeed were more likely to breastfeed exclusively for a longer period of time. Mothers who breastfed their infant exclusively for 16 weeks were asked to participate in one of two focus group meetings (n = 15). The following five themes emerged from the data: 1) knowledge, 2) peer experience, 3) support, 4) perseverance, and 5) the public.

Northern Arizona women of childbearing age are at disproportionately higher risk for poverty and persistent health disparities in maternal risk factors and maternal child health outcomes. Preconception care is a lifespan and population-based approach to providing health promotion activities to women of childbearing age to improve the health of women, their families, and communities. The county's Reproductive Health Program offers comprehensive reproductive and preconception healthcare to underserved women and men throughout the county without regard for ability to pay, serving as a critical safety net for this vulnerable population. A formative evaluation was performed using the CDC's Framework for Program Evaluation in Public Health and retrospective chart review to assess program implementation. In 2010, 1,561 patients received care over 2,575 visits; the majority of patients (69.4%) were women of childbearing age (females 15-44). Most patients (92.9%) were ≤ 150% FPL, and uninsured (77.8%). Program patients were racially/ethnically diverse, with nearly half identifying themselves as White (48.8%), followed by Hispanic (35.3%), and American Indian/Alaskan Native (11.6%). Program reach was limited. Comprehensive medical and social risk assessment and health promotion activities were consistent with evidence-based recommendations. More than 3,400 STI and pap screenings were performed, with identification of 178 abnormal results at the primary program site. One hundred forty-five females had a positive pregnancy test at the primary program site, one-third (33.1%) to teens. For women of childbearing age not trying to become pregnant (98%), a range of family planning methods were provided, which most commonly included oral contraception (36.9%), followed by condoms (15.4%), and Depo-Provera injection (12.6%). More than 10% of low-income females 15-44 received referrals for further medical care not provided with program. Logistic regression analysis revealed program visits associated with a decreased risk of unplanned pregnancy, though this was not significant (OR 0.87, 95% CI 0.59-1.29, p>0.05). In conclusion, this program provided evidence-based preconception care to underserved women of childbearing age, though reach was limited. Additional studies are recommended to explore patient needs and barriers to improve reach and tailor services. Development of a community advisory council is recommended to guide program activities.

Despite advances in obstetric care, hypertensive disorders continue to complicate pregnancies at a high rate. Worldwide, hypertensive disorders affect up to 10% of pregnancies. The United States has seen a 25% increase in the incidence of hypertensive disorders over the last two decades (American College of Obstetricians and Gynecologists, 2017). These complications constitute one of the greatest causes of maternal and perinatal morbidity and mortality with an estimated 50,000 to 60,000 deaths per year across the world (American College of Obstetricians and Gynecologists, 2017). Although the etiology of hypertensive disorders remains unclear, there may be an association with both maternal biological and psychological distress in the development of the disorder. Although both distress and biomarkers have been identified in association with a hypertensive disorder, little data exist examining the components of distress and the alterations in biomarkers in women developing these disorders. Due to the limited evidence, a critical need exists to examine the relationship of perceived maternal distress and biomarker measures in the development of a hypertensive disorder during pregnancy in order to better understand this phenomenon. The purposes of this dissertation were to: 1) understand the experience of having a hypertensive disorder during pregnancy; 2) to investigate the association of perceived stress and changes in immune response via biomarker measures in women who develop a hypertensive disorder during pregnancy; 3) to review, summarize, and evaluate the literature examining the relationship between perceived maternal distress (stress, anxiety, and depression) and the development of a hypertensive disorder; and 4) to investigate the association of perceived distress in the development of a hypertensive disorder during pregnancy. Data obtained from a qualitative study of women with a hypertensive disorder during pregnancy placed on bed rest reported several stressors associated with the experience. These stressors related to differing and often conflicting management plans by different providers and not feeling providers heard their concerns. The evidence supports these women experience stress during this pregnancy complication. Analysis of data obtained at each trimester of pregnancy did identify differences in biomarker levels based on perceived stress and women with a hypertensive disorder and those without a hypertensive disorder. Evidence from a systematic review of literature supporting maternal distress in the development of a hypertensive disorder was mixed. However, few studies existed and of those reviewed, most lacked rigor. Analysis of data obtained early and late in pregnancy did not indicate a relationship between psychological distress and the development of a hypertensive disorder in pregnancy. Women with a higher BMI were 12% more likely to develop a hypertensive disorder. The factors associated with the development of a hypertensive disorder are complex. Maternal perceived stress and inflammatory responses differ between women with a hypertensive disorder and those without a hypertensive disorder in pregnancy; however maternal distress did not differ between groups. Body mass index was associated with the development of hypertension in pregnancy. Clinicians need to include assessment of maternal BMI as a modifiable risk factor in the development of a hypertensive disorder during pregnancy. In addition, although psychological distress was not associated with the development of a hypertensive disorder, women still suffer with components of distress. Clinicians could identify and support women experiencing distress thereby promoting a healthier pregnancy.

The purpose of this research was to identify the values influencing the nurse's perception and choice of behavior in a hypothetical clinical situation. The theoretical framework was Rokeach's (1973) Theory on the Nature of Human Values and Value Systems. A descriptive study using a mailed survey was conducted on a random sample of 331 members of the National Association of Neonatal Nurses. Data on individual nurses' values, perception of information and behavioral choices were collected with an investigator developed questionnaire, consisting of a values scale (alpha =.82) and an information scale and choice alternatives related to three hypothetical vignettes: a low birthweight infant (alpha =.75), an infant with trisomy-13 (alpha =.70) and a chronically ill infant (alpha =.68). Results of this study indicate that (1) nurses identified a hierarchy of values related to their practice; "doing right" (x = 6.1), beneficence (x = 5.4), and justice (x = 4.8), (2) information related to the infant was consistently most important; however, in uncertain situations, rules or external protocols had an increased influence on the behavioral choice process, (3) the behavioral choice option with the greatest agreement was different for each situation, and a consistently negative association between the options within each vignette indicates that nurses have clearly defined choice preferences, (4) model testing revealed a consistent relationship among the variable of justice and protocol, doing right and infant characteristics, and infant characteristics and the choice options across the three vignettes (p <.05). The major findings include the identification of the value dimension, "doing right" and a lack of congruence between the values the nurse identifies as important and the actions the individual implements in practice. The phenomenon of "doing right" is a combination of items originally hypothesized to measure nurse autonomy, family autonomy and beneficence. The convergence of these items results in an unique dimension that represents the nurse's internally directed motivation or sense of duty to the infant/family unit. The lack of congruence between the identified values and the behaviors implemented in practice represents the sense of frustration and feeling of powerlessness experienced by nurses (n = 97) as they balance the role of professional and the role of employee.

Although a relationship has been found in some studies between paternal attachment and female sexual behavior, knowledge of this relationship in African Americans has been limited. The purpose of this research was to determine if there was a relationship between father-daughter attachment, parent teen sexual risk communication and early sexual activity, condom use, history of sexually transmitted infection, global/sexual self-esteem and teen pregnancy in African-American females. An anonymous consent and survey was administered online to N=113 African American college women (age 18-21) attending a southeastern university. Measurements included the Parent Attachment Questionnaire (Father), Rosenberg’s Self-Esteem, Sexual Self-Esteem Inventory (short scale), the PTSRC and a sexual history. Findings of high levels of father attachment were found in this mostly middle class sample but neither attachment nor parent teen sexual risk communication was related to age of vaginal/oral initiation, condom use or sexually transmitted infections. However, attachment was predictive of global self-esteem. In addition, those with a high level of attachment were 1.0 times more likely to also have a positive pregnancy test history when maternal support for the father–daughter relationship was low. No relationship was found between sexual self-esteem and paternal attachment or between sexual self-esteem and condom use. Paternal monitoring was associated with older ages of vaginal initiation. Conclusion: Higher paternal attachment coupled with paternal monitoring may facilitate global self-esteem and be a protective factor against early sexual initiation (vaginal). Fathers are in need of education as to how to stay connected with daughters and to engage in direct and indirect sexual risk communication. Nevertheless, prevention strategies utilizing fathers could be effective in delaying onset of sexual activity. This document was originally created in Microsoft Word 2000 and later modified in Microsoft Word 2007 (compatibility mode). SPSS 17.0 statistical software was used for analysis and N-Query 6.0 was utilized for power analysis.

Background: Due to the profound and life-changing aspects of giving birth and to each woman’s individualized birthing experience, it is important to understand the myriad of factors that contribute to a positive childbirth experience. The aims of this study were to: (1) identify factors related to a positive childbirth experience; (2) to examine relationships among women’s perceptions and personal evaluations of their childbirth experience, stress associated with labor pain, support from the nursing staff, initial contact with the baby following birth, support from partners, education, age, and obstetric history; and (3) to identify predictors of a positive childbirth experience. Method: A cross-sectional correlational study was conducted using a sample of 122 new mothers recruited over a 3-month period. Data were collected using self-report questionnaires. The three questionnaires used in this study consisted of: (a) the Questionnaire Measuring Attitude About Labor and Delivery Experience (QMAALD 29 items); (b) the Questionnaire Measuring Stress Associated with Labor Pain [SLPS (version 2)]; and (c) Personal Information Questionnaire (Demographic data). The Cronbach’s alpha coefficient for the 29 item QMAALD in this study was .82 and the Cronbach’s alpha coefficient of the SLPS (version 2) in this study was .89. The SPSS statistical software version 16.0 for Windows was used for data analysis. Results: Participants reported a low degree of stress associated with labor pain and a moderate amount of support received from the nursing staff. They reported holding and touching their baby immediately after birth. A positive childbirth experience was inversely related to stress associated with labor pain. The reduction of stress due to support received from the nursing staff was found to be positively related to a positive childbirth. Education was related to a positive childbirth experience; but not a significant predictor of a positive childbirth experience. Maternal age, initial contact with the baby following birth, number of labor and delivery experiences, duration of labor, interventions during labor, attendance at prenatal classes, and support from a partner did not relate to a positive childbirth experience. The regression analysis results indicated that the stress associated with labor pain, the reduction of stress due to the support received from the nursing staff, and attendance at prenatal classes were significant predictors of a positive childbirth experience. Conclusion: Stress associated with labor pain and the reduction of stress due to support received from the nursing staff were key factors contributing to a positive childbirth experience. Further research is needed to better understand the factors influencing women’s positive perceptions of the childbirth experience.

This study addresses the question, "What is the lived experience of Southeast Asian immigrant women who live in the United States related to domestic violence, including the relationships with their partners, their knowledge of domestic violence, and the existence of domestic violence in the Asian community?" Fourteen Thai women engaged in semistructured interviews during which they were asked to describe their experience. This study chose the phenomenological approach, using content analysis that identified six major themes representing essential aspects of the experience, as described by the participants: (a) Knowledge about Domestic Violence and Sources of Information, (b) The experience of Domestic Violence, (c) The existence of Domestic Violence among Thai Women, (d) Factors Considered to be Violence-protective, (e) Life as a Thai Wife, and (f) Ability to Perform Duties as a Woman. Ten of the participants had not experienced domestic violence by their husbands; two had been abused in previous marriages; one was currently being abused by her husband; and one had abused her husband early in their marriage. The women defined domestic violence as abusive actions identified by physical, verbal, emotional, psychological, and sexual abuse, including assault and threatening behavior. The women's knowledge of domestic violence was based on personal experience, witnessing abusive behavior in other relationships, or reports in mainstream media sources. The study's findings confirm the existence of domestic violence in the Thai community. The participants identified the husband's infidelity as the main cause, followed by family background creating a generational chain of abusive behavior. Protective factors that prevent domestic violence are the husband's supportive characteristics, the wife's financial independence, and confidence in the U.S. legal system. Although the majority of the study participants did not experience domestic violence, they encountered various constraints, such as feelings of frustration and helplessness, attributed to the challenges of immigrant women adapting to a new society and culture. Despite limitations involving recruitment, this study expands the knowledge of domestic violence among Thai immigrant women, providing valuable insight for healthcare professionals interested in improving culturally sensitive resources for these women. The study's findings also provide important evidence that suggests the need for further research to examine domestic violence among Southeast Asian immigrant women living in the United States.