Dissertation under the direction of Professors Linda Norman and Ann Minnick Research Objective: The objective of this study was to establish a description of Nurse Residency Programs (NRPs) to identify if there is treatment fidelity across programs, a first step to enable a study that assesses the impact of NRPs on patient outcomes. Background: The increasing complexity of the healthcare environment and concern regarding newly licensed RNs ability to cope with the reality of care has resulted in the development of a variety of nurse residency program initiatives. Unknown is the extent to which various elements and components are implemented across programs. Unknown are which nurse-sensitive outcomes may be influenced by nursing residencies. Study Aims: 1) To describe NRPs across US community, public, and teaching hospitals and 2) To identify patient outcomes believed by critical care nurses to be influenced by nursing residencies. Methods: Aim 1: Program attributes were measured using a 24-item survey based on the Minnick and Roberts conceptual framework. The survey was sent to known NRP Directors or Chief Nursing Officers at 1,011 US hospitals identified in the 2010 American Hospital Association dataset. Two-hundred and three surveys were returned. Aim 2: Data were collected from three focus groups that included 19 critical care nurses from the Southeastern US region. Results: Aim 1: 9.4% of hospitals reported operating a NRP. NRP Models included: University HealthSystem Consortium (UHC, 22.1%), Facility-Based (FBM, 53.7%), and Other (24.2%). Small hospitals (< 250 beds) are not likely to support nursing residencies. Significant (p < .01) differences among and within program model types, in terms of career planning, project requirements and project type, and mentoring were noted. Aim 2: Critical care nurses identified outcomes for NRPs that were consistent with nurse-sensitive outcomes described in the health services literature. Conclusions: The extent of differences within and across program types indicates a lack of treatment fidelity needed to detect objectively the impact of NRPs on patient outcomes. The expansion of NRPs may be limited by the number of hospitals of a size able to support such programs. Efforts to identify patient outcomes likely to be influenced by NRP participants should be expanded beyond critical care.

Health related stigma (HRS) is a poorly understood phenomenon in patients with advanced lung cancer. Approximately 30% of patients with lung cancer, regardless of smoking status, report feeling stigmatized due to their diagnosis and this may influence outcomes in these patients. Stigma has been linked to poor outcomes in other populations like HIV/AIDS. This is a cross-sectional descriptive study of patients with advanced lung cancer (N=62) that examines associations between internal and external HRS with physical symptoms, psychological symptoms, social support, and quality of life (QOL). In this study, 66.1% reported a smoking history and 33.9% reported feeling there is a stigma associated with lung cancer. External HRS was significantly correlated with distress, support from a main caregiver, general social support, physical, emotional, spiritual, intellectual and overall QOL. Internal HRS was significantly correlated with general social support, physical, emotional, intellectual, and overall QOL. Physical symptoms, depression, and anxiety were not significantly associated with any social support or QOL. Distress, however, was associated with physical, emotional, spiritual, intellectual and overall QOL. Results indicate that external HRS may be more influential on outcomes in patients with advanced lung cancer than internal HRS. Further research is needed to clarify the role of stigma in patients with lung cancer.

Interruptions are multi-dimensional events that occur at varying frequencies and durations in different social contexts and task environments. Given that interruptions are believed to be pervasive in the nursing work environment and patient care requires a great amount of cognitive resources, it is important to describe nurses responses to interruptions in the direct care work environment. Of major concern is the potential link between interruption and errors. Until types of interruptions and responses are described, it is not possible to study this potential link. The purpose of this study was to examine nurses responses to and management of interruptions during patient care and to explore contextual factors that influence nurse decision-making when interrupted. The findings indicate that nurses are interrupted frequently during their work. Nurses acted immediately on 95% of interruptions with either a task switch (47.9%) or by multitasking (46.7%). Characteristics (task type, source, and initiation method), of the first interruption during a task were associated with the nurses responses. Likewise, characteristics of the interrupted task were associated with the nurses response to the first interruption. A large proportion (26%) of interruptions occurred during medication administration (a time when errors may result in the most harm to patients) when current evidence and protocols call for limiting interruptions. This finding may be clinically meaningful in development of practice interventions related to interruption handling strategies. Other findings regarding data collection strategies to study this phenomenon will guide future research.

Human milk is a biologically active fluid that provides immune protection for the developing infant. The levels of milk immune components vary among women over time post-delivery. Very little is known about the associations of maternal stressors with the levels of milk immune components, especially among populations with health disparities where little lactation research exists. Here in the U.S., African American (AA) women report lower breastfeeding rates and their infants experience higher mortality rates compared to other populations. Therefore the purpose of this study was to explore the relationships of maternal stress with milk immune components from AA mothers of healthy term infants. Maternal physical, psychological, and environmental stressors were measured using self-report and medical record data. Milk samples collected on Day 3, 9, and 14 post-delivery were analyzed for ten milk immune components (secretory immunoglobulin A, epidermal growth factor, interleukins -4,- 6,- 8,- 10, tumor necrosis factor-alpha, interferon gamma induced protein-10, macrophage inflammatory protein-1 alpha, monocyte chemotatic protein-1) and saliva collected on Day 9 post-delivery was analyzed for cortisol. There was at least one statistically significant correlation of a maternal stressor with 9 of the 10 milk immune components. Most associations were observed on Day 3 and Day 9 post-delivery. Of the twelve maternal stressors, there were two or more significant correlations with a milk immune component observed in five of the stressors. There were no significant correlations among maternal stressors with salivary cortisol, nor of cortisol with milk immune components. The shared variance among the significant relationships was frequently less than 10%; however, the directional changes in these immune components could potentially impact infant health. Therefore, further research is warranted to explore these relationships.

The precise cause of cancer cachexia is unknown. It is a syndrome associated with weight loss, lipolysis, muscle wasting, anorexia, chronic nausea and asthenia. Patients with head and neck cancer (HNC) are particularly vulnerable to developing cachexia. A current accepted hypothesis is that the tumor produces cytokines, which affects metabolism, cellular respiration and neurological processes leading to resultant cellular changes that promote muscle wasting and symptoms such as depression, anorexia, fatigue and pain. This dissertation focused on cytokines and their associations with red blood cells, albumin, weight loss, symptom development and musculoskeletal dysfunction in HNC patients over 12-months. Higher baseline levels of IL-6 was associated with greater weight loss. Increasing IL-10 from baseline and decreasing TGF-1β and IFN-γ levels from baseline were associated with weight loss. Several cytokines correlated with worsening symptom development over the study period. Worsening neck functionality was associated with several increasing cytokines over 6-months.

NURSING SCIENCE Depression and Vitamin D in Pregnancy Amy Rebekah Lamb Dissertation under the direction of Professor Melanie Lutenbacher Depression is a serious problem affecting 8-27% of all pregnant women. Current research suggests that pregnant women with low vitamin D levels are at increased risk for depression, however research in this area is limited and conflicting. Studies also indicate that many pregnant women have significantly low vitamin D levels despite taking prenatal vitamins. In light of rising rates of depression, growing concern over vitamin D deficiency in pregnancy, and conflicting evidence regarding the association between depression and vitamin D in pregnancy more work is needed to better understand the associations between vitamin D and depression. This descriptive longitudinal study explored the associations between levels of depressive symptoms and vitamin D in a sample of 125 pregnant women. Depressive symptoms were measured using the Edinburgh Postnatal Depression Screen (EPDS) in the first and third trimesters. Vitamin D levels were measured using 25OHD serum levels collected in the first trimester and at time of delivery. Low levels of vitamin D were associated with high depressive symptoms over time in this sample (r=-0.30, p=.005). Low vitamin D levels may be an important risk factor for increased depressive symptoms in pregnancy. Further studies examining underlying mechanisms and supplementation are needed.

Father involvement research has shown that fatherhood is important to the behavioral and physiological development of children. Children with involved fathers have lower rates of teenage delinquency and pregnancy, improved academic outcomes, and improvements in major health determinants. While there have been many studies of father involvement, there have been fewer studies focused on fathers and their infants and even fewer with hospitalized infants. Of those studies, the majority have been qualitative in design. This study is one of the first to examine factors which influence father involvement in the NICU using mixed methods. Fathers (N=80) at a 97-bed NICU in St. Petersburg, Florida were asked to complete a single survey which asked about the previous two weeks of their involvement with their hospitalized infants and factors which may have affected that involvement. Fathers who were more involved were younger and married or living with the mother. Fathers of multiples were more likely to perform kangaroo care and were more likely to be involved. Fathers who performed kangaroo care were likely to be more involved and confident. Bathing was more likely to be performed if the father had attended the delivery. Fathers who bathed their infants visited more and were more likely to be involved. Visitation declined with increasing age of the infant, number of children in the family, and length of time in Level II status. Content analysis of responses to open-ended questions showed that the majority of fathers felt that facilitators to their involvement included the healthcare teams encouragement and teaching, and increased knowledge about their infants. Barriers included employment, lack of access to their infants, nurses responses, lack of knowledge, other children, and hospital logistics.

Tutkimuksen tarkoituksena oli kuvailla, millaisia omaiskokemuksia ja selviytymisen strategioita päihteidenkäyttäjien perheenjäsenillä on. Laadullinen aineisto kerättiin haastattelemalla perheenjäseniä (n=10). He olivat 33–67-vuotiaita (keski-ikä 53 vuotta) naisia. Aineisto analysoitiin induktiivisella sisällönanalyysillä. Perheenjäsenillä oli kokemusasiantuntijuutta. Tulokset kuvattiin heidän narratiiviensa kautta. Perheenjäsenet olivat kohdanneet raskaita asioita: alkoholia, huumeita ja sekakäyttöä perheissään. Ensin päihdesairaus näyttäytyi heille outona ilmiönä, joka aiheutti elämänkriisin. Se heikensi perheen sosiaalisia suhteita. Perheenjäsenet yrittivät salata päihdesairautta, samaan aikaan tuntien väsymystä ja vihan tunnetta. He eivät saaneet tukea päihteidenkäyttäjiltä haastaviksi kokemissaan elämänvaiheissa, esimerkiksi sairastuessaan itse tai lapsen sairastaessa. Siitä seurasi surun ja pettymyksen tunteita. Perheenjäsenten narratiivit piirtyivät kolmella tasolla: oman elämänhistorian peilaamisena, itseanalysointina ja symbolisina kerronnan keinoina. Perheenjäsenten alettua nähdä itsensä apua tarvitsevina, he päättivät lopettaa salaamisen ja ryhtyivät puhumaan tunteistaan. He pyrkivät irrottautumaan käyttäjän päihderiippuvuudesta ja alkoivat ymmärtää sen sairausluonteen. Oma ansio- tai vapaaehtoistyö oli tärkeää, kuten myös harrastukset ja itsehoito. Perheenjäsenet hyödynsivät vertaistukea ja kuvasivat sitä uuden elämän alkamiseksi. Samaistuminen muiden kerrontoihin ja kokemuksiin tarkoitti mahdollisuutta oppimiseen. Perheenjäsenet käyttivät myös hengellisiä selviytymisen strategioita. He kertoivat Al-Anon-ohjelmaan kuuluvasta hengellisyydestä, esimerkiksi tyyneysrukouksesta. Perheenjäsenet ajattelivat elämän olevan merkityksellistä ja luottivat henkiseen kasvuun. He pyrkivät suhtautumaan optimistisesti tulevaisuuteensa. He toivoivat, että elämässä on mahdollista kokea parempia vaiheita tai että elämä jatkuisi ennallaan, ei huonompana. Tulokset osoittavat, että perheenjäsenten voimaantuminen on prosessi, joka lähtee liikkeelle itsestä. Haasteelliset elämänjaksot voivat pitkällä tähtäimellä tuoda myös positiivisia muutoksia. Perheenjäsenten hyvinvoinnin tutkiminen ja edistäminen nousevat tärkeiksi asioiksi. / The purpose of this study was to describe experiences of family members who have been affected by their close relatives’ substance abuse. In addition, an other dimension of the study was to describe family members’ coping strategies. The qualitative data was collected by interviewing family members (n = 10). They were 33–67 year-old (mean age 53) women. The data was analyzed by inductive content analysis. Family members had expertise by experience. The results were described by using their narratives. Hard sights met their eyes: alcohol, drugs and mixed substance use in their families. At first they described substance abuse as a strange phenomenon that caused a crisis. It impaired the mutual social relations in the family. Family members tried to hide substance abuse, feeling tiredness and anger at the same time. They didn’t get support from substance abusers in challenging episodes, for instance their own or child’s illness. Resulting in feelings of sadness and disappointment. Family members’ narratives etched on three levels: reflecting their own life history, self-analysis and symbolic ways of narration. After admitting their own helplessness family members decided to stop concealment and started on speaking about their feelings. They tried to cut loose from the relative’s substance abuse and began to see it as an illness. Their own employment or voluntary work was an important factor in coping, as well as hobbies and self-care of their own. Family members utilized peer support and described it as a new lease of life. It enabled learning, when they could identify on others’ narratives and experiences. Religious coping strategies were also used. They told that Al-Anon’s recovery program included some religious aspects like serenity pleading. Family members thought their own lives important and devoted to spiritual growth. They tried to be positive about their future. They hoped that life would afford an opportunity to see better episodes or at least it will continue as before, not worse than expected. The results prove that empowerment of family members is a process that starts off the person itself. Challenging episodes can also bring about positive changes, in the long run. It is important to inspect and promote family members’ welfare.

Tutkimuksen tarkoituksena oli kehittää, esitestata ja pilotoida asiakkaan osallisuuden mittari. Rakennetun mittarin avulla voidaan arvioida potilaiden osallistumista omaan hoitoonsa päiväsairaalassa tai vastaavaa hoitoa tuottavassa hoitoyksikössä sekä hoidon toteutuksen, vuorovaikutuksen, saadun informaation, yksilöllisyyden ja potilaan oman osallistumisen yhteyttä hoitoon osallistumiseen. Mittarin esitestauksen tavoitteena oli tuottaa Pohjois-Pohjanmaan sairaanhoitopiirin käyttöön mittari. Mittarin avulla voidaan jatkossa tuottaa tietoa, jolla voidaan edistää potilaiden osallistumista omaan hoitoonsa sosiaali- ja terveydenhuollossa. Mittarin rakentaminen noudatti mittarin kehittämisen vaiheita, jotka olivat operationalisoiminen, käsitteellistäminen ja esitestaus. Tutkimuksen operationalisointi vaiheessa mittariin valittiin teemat. Osallistuva asiakas hankkeen laadullisen osahankkeen tulosten mukaan potilaan osallistumiseen voi vaikuttaa hoidon toteutus, potilaan ja hoitohenkilökunnan välinen vuorovaikutus, riittävä hoitoa koskeva informaatio, hoidon yksilöllisyys ja potilaan oma osallistuminen. Nämä teemat nostettiin mittarin rakenteeksi mittarin kehittämisvaiheessa, sillä aikaisemmat tutkimustulokset tukivat rakenteeseen nostettuja teemoja. Esitestestausvaiheessa asiantuntijapaneeli (n=20) arvioi mittarin sisällönvaliditeetin ja tuloksen mukaan mittarin luotettavuusindeksi S-CVI/Ave oli 0,94. Mittarin pilot-aineisto (n=300) kerättiin Pohjois-Pohjanmaan sairaanhoitopiirissä 2.11.2017‒5.12.2017 välisenä aikana. Aineisto analysoitiin käyttäen eksploratiivista faktorianalyysiä. Eksploratiivisen faktorianalyysin mukaan muodostui 6 faktoria, jotka selittivät 69 % muuttujien variansseista. Varimax rotatoitujen faktoreiden korrelaatiot olivat 0,40‒0,89 välillä. Aineiston analysoinnin tuloksena muodostettiin hoidon toteutuksen, vuorovaikutuksen, informaation, yksilöllisyyden sekä potilaan oman osallistumisen summamuuttujat ja löydettiin summamuuttujien avulla yhteys osallisuuden käsitteeseen pilot-testaus aineistosta. Pilot-aineiston tulosten mukaan potilaiden ilmoittama käyntikerta oli yhteydessä hoitoon osallistumiseen hoidon toteutuksen, informaation ja vuorovaikutuksen käsitteiden osalta. Käyntisyyllä oli yhteys potilaan osallistumiseen informaation käsitteen osalta. / The aim of this research was to develop and pilot-test patients participation instrument. Patients participation instrument can be used to evaluate patient’s own participation in care in medical day care unit or similar units and care implementation, interaction, received information and patient individuality connection to patient participation. Pilot-test goal was to develop an instrument which can be used to generate information that can be used to further patient participation in their own care in social- and healthcare services. Instrument development followed instrument development phases, which were operationalizing the concept, conceptualization, and pilot testing. In the first phase of operationalization instrument dimensions were decided. In a project of patient participation was a qualitative study which results indicate that care implementation, interaction, received information, patient individuality and patient’s own participation in care could be factors that influence patient’s participation. These dimensions made instruments structure in development phase of the instrument, because earlier research results support these factors. Instrument content validity was evaluated by clinical and patient judges (n=20). In result this instrument S-CVI/Ave was 0.94. Pilot sample (n=300) was collected in Northern Ostrobothnia university hospital in medical day care center 2.11.2017‒5.12.2017. Pilot sample was analyzed by using exploratory factor analysis. Exploratory factor analysis resulted 6 factors which explained 69% of the total variances. Varimax rotated factors correlations were between 0.40‒0.89. Analysis continued by constructing care implementation, interaction, received information, patient individuality and patient’s own participation sum variables. After that it was possible to find connection between sum variable and patient participation in pilot sample. Pilot sample results that patient’s number of hospital visits was connected to the patient participation in care implementation, interaction and received information. The reason of hospital visit was connected to received information.

Tämän tutkimuksen tarkoituksena oli kuvata kotona muistisairasta puolisoaan hoitavien ja hoitaneiden miesomaisten kokemuksia saamastaan tuesta sekä tuen tarpeesta. Tutkimus toteutettiin laadullisena tutkimuksena. Tiedonantajat rekrytoitiin tutkimukseen kahden muistiyhdistyksen kautta. Yhdistysten työntekijät valitsivat harkinnanvaraisella otannalla kymmenen tiedonantajaa (n=10) miesomaisten joukosta. Tiedonkeruu tapahtui vapaamuotoisten kirjoitelmien ja kirjoitelmia täydentävien haastatteluiden avulla keväällä ja kesällä 2017. Aineisto analysoitiin induktiivisella sisällönanalyysillä. Miesomaisten kokemuksista muodostui kolme luokkaa, jotka kuvasivat tutkittavaa ilmiötä: yhdessä eläminen arjessa, miesomaisten saama tuki ja miesomaisten tuen tarve. Tutkimustulosten mukaan yhdessä eläminen kuvattiin yhteiselon vaikeuksina sekä positiivisina kokemuksina. Yhdessä tekeminen ja osallistuminen nousivat tutkimuksesta esille. Tietoa muistisairauksista ja niiden etenemisestä oli saatavilla esitteiden ja luentojen muodossa. Vertaistuki, läheisiltä ja ystäviltä saatu tuki sekä yhdistysten järjestämät tilaisuudet koettiin tärkeänä sosiaalisena tukena. Muistiyhdistyksen merkitys tiedon antajana ja tilaisuuksien järjestäjänä korostui. Liikunta koettiin tärkeäksi toimintakyvyn ja voimavarojen ylläpitämisessä. Kotitöistä selvittiin itsenäisesti tai puolison kanssa yhdessä. Miesomaiset kaipasivat uutta ja ajantasaista tietoa muistisairauksista sekä käytösoireista. He toivoivat tukea ja ohjausta erilaisten lomakkeiden täyttämisiin sekä neuvoja tukien hakemisiin. Tietoa teknologiasta ja käyttäjäkokemusta erilaisista laitteista kaivattiin myös lisää. Muistisairauden edetessä tarvittaisiin apua kotitöihin sekä tukea miesomaisten jaksamiseen. Tutkimus on tuonut lisää uutta tietoa sekä ymmärrystä muistisairasta puolisoaan hoitavien miesomaisten saamasta tuesta ja tuen tarpeista. Tuloksia voidaan hyödyntää kehitettäessä miesomaisille tarkoitettuja tukimuotoja. Tukimuotojen kehittämisessä tulisi kiinnittää huomiota eri palvelujen tarjoajien yhteistyöhön, jolla varmistetaan tiedon siirtyminen ja kokonaisvaltainen tukeminen. / The purpose of this study was to describe how male caregivers experience received support and the need for it. The research was carried out as a qualitative study. The informants were recruited through two memory associations. The associations’ employees opted for a discretionary sampling altogether ten informants (n=10) among the male caregivers. The data collection was carried out in the spring and summer of 2017 with free-form writings and thematic interviews. The material was analysed using an inductive content analysis. The experiences of male relatives consisted of three concepts that illustrate the phenomenon was being studied: Living together in everyday life, support received by male caregivers and the need for support. According to the research results, the effects of memory disease on everyday life appear as difficulties and as positive experiences. Togetherness and participation emerged from the research. Information on memory disorders and their progress was available in brochures and lectures. Peer support, support from family and friends, and events organized by organizations and associations were seen as an important social support. The importance of the memory association as a provider of information and organizer of events was emphasized. Physical exercise was considered to be important in maintaining functional capacity and resources. Home chores were solved independently or with the spouse. Male caregivers needed new and updated information on memory disorders. The male caregivers hoped for support and guidance on filling in various forms and advice on how to apply for support. More information about technology and user experience on various devices were needed. As the memory disease proceeds help would be needed in home chores as well as in supporting male caregivers’ wellbeing. The research has brought new knowledge and understanding of the support received by male caregivers and the needs for support. The results can be used to develop new forms of support for male caregivers. In the development of support models attention should be paid to the cooperation of various service providers to ensure the transfer of information and comprehensive support.