Attitudes and Beliefs of Nurses and Nurse Assistants toward Patients with Sickle Cell Disease: A Mixed Methods Study.

BACKGROUND: Pain experienced among individuals with sickle cell disease (SCD) is the primary requirement for hospitalization. PURPOSE: This study examined the relationship of age, race, and years of experience among medical-surgical nurses and nursing assistants to their attitudes in caring for SCD patients and identified barriers that influence pain management care. DESIGN, SETTING, PARTICIPANTS: An explanatory sequential mixed-methods study design was used. Online survey data were collected among 56 participants and online interviews were conducted among three participants. METHODS: The General Perceptions of Sickle Cell Patients (GPSCP) Scale-17, composed of four subscales, assessed providers attitudes toward patients with SCD. Two subscales assessed providers' attitudes behaviors related to acute and chronic pain management. RESULTS: There was no relationship between age and years of experience to scores on four subscales. White/Caucasian study participants scored higher on the Red Flag Behaviors subscale, indicating that White/Caucasian participants had stronger beliefs concerning drug-seeking behaviors among SCD patients as compared to other ethnicities/races. Themes generated from the qualitative interview data analysis were: 1) reflections on one's own practice compared to others' practice; 2) communication as a barrier/facilitator to providing care; 3) lack of national guidelines; and 4) adjunct staff are critical to facilitating holistic care. CONCLUSIONS: Racial and ethnic differences exist among medical-surgical nurses and nursing assistants' attitudes. Poor communication and lack of national standards of care are barriers to providing high quality care. CLINICAL IMPLICATIONS: Culturally sensitive care, based on current practice guidelines, is needed for improved pain management care for patients with SCD.

Experiences of new nurses in the United States during the acute phase of the COVID-19 pandemic.

AIM: This qualitative descriptive study describes the experiences of new nurses during the acute phase of the COVID-19 pandemic in the United States. BACKGROUND: New nurses faced the dual challenge of transitioning to practice while working during a global pandemic. Although multiple studies have described nurses' experiences during the COVID-19 pandemic, research is warranted to understand new nurses' experiences during the acute phase of the pandemic. METHODS: Registered nurses (n = 46) with less than two years of work experience, who participated in the COVID-19 Study and Registry of Healthcare and Support Personnel (CHAMPS), participated in this study. Thematic analysis was used to examine their responses. The COREQ guidelines were used in reporting this study. RESULTS: Five themes were extracted: feelings of increasing isolation, feelings of intense fear, personal health concerns, shattered and disrupted expectations, and living in a constant dilemma. DISCUSSION: New nurses described their distress and profound sense of isolation which was compounded by their status as new employees and being shunned by others. There was intense fear for their safety and health. They viewed their limited nursing experience with only COVID-19 patients as detrimental to their careers and encountered complex dilemmas and were obligated to make problematic choices. CONCLUSIONS: New nurses revealed unrelenting psychological and physical distress during the pandemic. Identification and implementation of strategies to address their distress and alleviate its negative consequences were needed but not provided. IMPLICATIONS FOR NURSING POLICY: The development and implementation of policies to address the challenges new nurses encounter are needed. Action strategies to promote professional socialization and job retention are required.

An uncertain time: Clinical nurses' first impressions during the COVID-19 pandemic.

The COVID-19 pandemic overwhelmed the US healthcare system and healthcare providers. Nurses, who comprise one of the most affected groups because they are the largest group of healthcare providers, were in a unique position to speak about their perspectives. As a result of the COVID-19 pandemic, nurses have experienced ongoing physical and psychological challenges while displaying strength and perseverance during uncertain times. In this study, we explored the perceptions and experiences of nurses in clinical practice caring for patients diagnosed with COVID-19 during the pandemic. Researchers conducted a qualitative descriptive study with 20 clinical nurses most of whom were enrolled in a graduate program while working in healthcare settings. Semi-structured interviews conducted through Zoom occurred between August 2020 and December 2020. Thematic analysis was used to analyze the transcripts. Five themes emerged: navigating uncertainty, managing death and loss, acknowledging emotional responses, learning opportunities, and facing community undercurrents. Lack of clinical practice guidelines, and inconsistent access to personal protective equipment when providing care to patients with COVID-19 caused emotional strain for nurses and highlighted future learning opportunities. Providing support to dying patients was devastating to nurses. Concern about community misunderstandings of the pandemic created challenges. Evolving teamwork provided invaluable support to study participants. Nurses shared essential information for revising and creating clinical practice guidelines. Nursing interventions and strategies were used to produce humane and positive patient outcomes and provide a foundation for nurse-driven care in possible future pandemics.

Parents' experiences using medical cannabis for their child.

BACKGROUND: Parents across the United States use medical cannabis for their children, often without professional guidance. These parents have become more expert on medical cannabis than most health professionals. PURPOSE: Using a case-study design, this study was conducted to describe the experience of parents using medical cannabis for relief of seizures in their child or dependent. METHODS: Data were subjected to qualitative content analysis for the identification of patterns and themes. FINDINGS: Analysis of all data revealed seven themes including "Discovery of Cannabis as a Medication," "Guidance on Dosing," "Costs and Benefits of Cannabis," "Distrust of the Pharmaceutical Industry," "Federal Interference," "God and Cannabis," and "Changing Societal Perceptions about Medical Cannabis." DISCUSSION: Themes revealed a complex, multifaceted experience. Many parents report benefit from medical cannabis, and are not hindered by the financial costs or uncertainties. Political and social influences have significant impact on the stigmatization and normalization of cannabis.

Challenges to Studying Illicit Drug Users.

PURPOSE: Throughout the world, illicit drug use continues to pose a significant risk to public health. The opioid crisis in North America, the diversion of the prescription drug tramadol throughout Africa, and the increasing supply of methamphetamines in East and South Asia all contribute to increasing risks to individual and societal health. Furthermore, the violation of human rights in efforts to enforce prohibitionist values poses significant threats to many individuals worldwide. With these evolving situations, it is imperative that researchers direct their attention to the various populations of illicit drug users. However, the inclusion of illicit drug users, often considered a vulnerable population, as participants in research studies presents several increased risks that must be addressed in study protocols. Researchers are required to provide "additional safeguards" to all study protocols involving illicit drug users, but there is often substantial variability and inconsistency in how these safeguards are applied. Additional safeguards can be timely, costly, and unduly burdensome for researchers, ethical review boards, and research participants. APPROACH: Through synthesis of the current literature, this article addresses the barriers to studying illicit drug users and the methods researchers can utilize to minimize risk. A case study is provided to illustrate the high level of scrutiny of study protocols involving the participation of illicit drug users and the effect of such scrutiny on recruitment of participants. The article concludes with a discussion of the effects of the current political climate on the recruitment of illicit drug users in research. CONCLUSIONS: Individuals who participate in criminal or illegal behaviors such as illicit drug use, prostitution, illegal entry into a country, and human trafficking are susceptible to multiple physical, mental, and social health risks, as well as criminal prosecution. The importance of research on the health of marginalized populations cannot be overstated. This work must continue, and at the same time, we must continue to protect these individuals to the best of our ability through diligent attention to sound research methods. CLINICAL RELEVANCE: The use of illicit drugs continues to pose a substantial threat to global health. Individuals who use illicit drugs are susceptible to multiple physical, mental, and social health risks, as well as criminal prosecution. It is imperative that researchers study these vulnerable populations in order to develop interventions to minimize individual and societal harm. There are several barriers to the study of illicit drug users that must be addressed through rigorous methodology and the addition of safeguards.

The Patient Experience of Waiting on the Deceased Donor Kidney Transplant List While Receiving Dialysis.

End stage renal disease (ESRD) is a global health problem, and the gold standard treatment is kidney transplantation. However, due to the global shortage of organs, many patients with ESRD rely on dialysis for survival while waiting several years for a kidney transplant. An integrative review of qualitative studies was conducted on the experience of patients with ESRD who require either peritoneal dialysis or hemodialysis while waiting for a deceased donor kidney transplant. Eight international studies were selected for review. Six themes were identified: 1) living in hope, 2) uncertainty, 3) mixed emotions, 4) coping with waiting, 5) restrictions on freedom, and 6) support network. Patients on dialysis and waiting for a kidney transplant have emotional, educational, and informational needs that need to be better understood and addressed by nurses and physicians.

Labor, delivery, and anesthesia experiences of women with physical disability.

BACKGROUND: Although many women with physical disabilities report poor quality reproductive health care, little research has addressed labor, delivery, and anesthesia experiences of these women. This study was conducted to explore these experiences in women with significant mobility disabilities. METHODS: A qualitative descriptive study was conducted with 22 women from the United States who had delivered newborns within the prior 10 years. All had significant mobility disabilities. Two-hour, in-depth telephone interviews were conducted using a semistructured, open-ended interview protocol, which addressed many topics, including labor, delivery, and anesthesia experiences. We recruited most participants through social networks, interviewing women from 17 states. Conventional content analysis, facilitated by NVivo software, was used to identify major themes. RESULTS: The mean age of women was 34.8 ± 5.3 years. Most women were white, college educated, and used wheeled mobility aids. Four key themes emerged from participants' narratives of laboring and giving birth with a disability. These included women's preferences for type of delivery, clinicians and some women expected no labor pain, fears prompting active advocacy, and positive experiences. As participants discussed their experiences with anesthesia, four additional themes were identified: importance of consultation with the anesthesia team, decisions about epidural/spinal vs general anesthesia, failed epidural with repeated efforts, and fear of injury related to anesthesia. CONCLUSIONS: The responses of women in this study suggest that there is need to make intrapartum care better for women with physical disabilities and to improve their experiences with labor, birth, and obstetric anesthesia care.

Perceptions of Smartphone User-Centered Mobile Health Tracking Apps Across Various Chronic Illness Populations: An Integrative Review.

PURPOSE: This integrative review presents a synthesis of the current qualitative research addressing the motivating factors, usability, and experiences of mobile health tracking applications (apps) across various chronic disease populations. DESIGN: Integrative review of the literature. METHODS: Databases used to conduct this integrative review included: PubMed Plus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Google Scholar, Science Direct, and EBSCO megafile. The following search terms were used in all five databases: smartphone apps, apps, mHealth, eHealth, mobile health apps, health tracking apps, user-centered apps, wireless technology, engagement, qualitative, and usability. FINDINGS: The initial literature review yielded 689 results. Once inclusion and exclusion criteria were employed, 11 studies met the criteria set forth for this review. The reviewed studies provided insight into users' perceptions, experiences, and motivations to incorporate smartphone mobile health apps into their daily lives when living with chronic illnesses. CONCLUSIONS: This review indicates the growing interest in user-centered mobile health tracking apps, but with little understanding of motivating factors that foster sustained app use. Mobile health tracking apps targeted to users with chronic conditions need to have a high level of usability in order to motivate users to sustain engagement with their mobile health tracking app. CLINICAL RELEVANCE: User-centered mobile health tracking app technology is being used with increasing frequency to potentially provide individualized support to chronic illness populations.

Nursing Doctoral Faculty Perceptions Related to the Effect of Increasing Enrollments on Productivity.

Nursing faculty teaching in research and clinical doctoral programs participated in a national survey study to examine the impact of expanded doctoral enrollments on the doctoral faculty's scholarly productivity. They were invited to respond to an open-ended question soliciting information not already addressed in the survey. Results of the analysis are reported here. Findings corroborated the review of literature and results of the survey and focus groups that provided the basis for the survey's development. Current workloads may be unsustainable, jeopardizing the profession's response to Institute of Medicine recommendations.

Perceptions of academic administrators of the effect of involvement in doctoral programs on faculty members' research and work-life balance.

BACKGROUND: Support for research strongly predicts doctoral program faculty members' research productivity. Although academic administrators affect such support, their views of faculty members' use of support are unknown. PURPOSE: We examined academic administrators' perceptions of institutional support and their perceptions of the effects of teaching doctoral students on faculty members' scholarship productivity and work-life balance. METHODS: An online survey was completed by a random sample of 180 deans/directors of schools of nursing and doctoral programs directors. Data were analyzed with descriptive statistics, chi-square analysis, and analysis of variance. DISCUSSION: Deans and doctoral program directors viewed the level of productivity of program faculty as high to moderately high and unchanged since faculty started teaching doctoral students. Deans perceived better administrative research supports, productivity, and work-life balance of doctoral program faculty than did program directors. CONCLUSION: Findings indicate the need for greater administrative support for scholarship and mentoring given the changes in the composition of doctoral program faculty.

Maternal Characteristics, Pregnancy Complications, and Adverse Birth Outcomes Among Women With Disabilities.

OBJECTIVES: The objective of this study is to describe the maternal characteristics, pregnancy complications, and birth outcomes among a representative sample of Rhode Island women with disabilities who recently gave birth. METHODS: Data from the 2002-2011 Rhode Island Pregnancy Risk Assessment Monitoring System survey were analyzed. RESULTS: Approximately 7% of women in Rhode Island reported a disability. Women with disabilities reported significant disparities in their health care utilization, health behaviors, and health status before and during pregnancy and during the postpartum period. Compared with nondisabled women, they were significantly more likely to report stressful life events and medical complications during their most recent pregnancy, were less likely to receive prenatal care in the first trimester, and more likely to have preterm births (13.4%; 95% CI, 11.6-15.6 compared with 8.9%; 95% CI, 8.5-9.3 for women without disabilities) and low-birth-weight babies (10.3%; 95% CI, 9.4-11.2 compared with 6.8%; 95% CI, 6.8-6.9). There was no difference in the rates of cesarean section between women with and without disabilities. CONCLUSIONS: These findings support the need for clinicians providing care to pregnant women with disabilities to be aware of the increased risk for medical problems during pregnancy and factors that increase the risk for poor infant outcomes.

Effects of disability on pregnancy experiences among women with impaired mobility.

OBJECTIVE: Little is known about how functional impairments might affect the pregnancies of women with mobility disability. We aimed to explore complications that arise during pregnancy that are specifically related to physical functional impairments of women with significant mobility disabilities. DESIGN: Qualitative descriptive analysis. SETTING: Telephone interviews with women from 17 USA states. SAMPLE: 22 women with significant mobility difficulties who had delivered babies within the prior 10 years; most participants were recruited through social networks. METHODS: We conducted 2-h, in-depth telephone interviews using a semi-structured, open-ended interview protocol. We used NVIVO software to sort interview transcript texts for conventional content analyses. MAIN OUTCOME MEASURES: Functional impairment-related complications during pregnancy. RESULTS: The women's mean (standard deviation) age was 34.8 (5.3) years. Most were white, well-educated, and higher income; eight women had spinal cord injuries, four cerebral palsy, and 10 had other conditions; 18 used wheeled mobility aids; and 14 had cesarean deliveries (eight elective). Impairment-related complications during pregnancy included: falls; urinary tract and bladder problems; wheelchair fit and stability problems that reduced mobility and compromised safety; significant shortness of breath, sometimes requiring respiratory support; increased spasticity; bowel management difficulties; and skin integrity problems (this was rare, but many women greatly increased skin monitoring during pregnancy to prevent pressure ulcers). CONCLUSIONS: In addition to other pregnancy-associated health risks, women with mobility disabilities appear to experience problems relating to their functional impairments. Pre-conception planning and in-depth discussions during early pregnancy could potentially assist women with mobility disabilities to anticipate and address these difficulties.

Health risk factors and mental health among US women with and without chronic physical disabilities by whether women are currently pregnant.

Growing numbers of reproductive-age US women with chronic physical disabilities (CPD) raise questions about their pregnancy experiences. Little is known about the health risks of women with versus without CPD by current pregnancy status. We analyzed cross-sectional, nationally-representative National Health Interview Survey data from 2006 to 2011, which includes 47,629 civilian, noninstitutionalized women ages 18-49. NHIS asks about specified movement difficulties, current pregnancy, and various health and health risk indicators, including tobacco use and body mass index (BMI). We used responses from eight movement difficulty and other questions to identify women with mobility difficulties caused by chronic physical health conditions. Across all women regardless of CPD, women reporting current pregnancy are significantly less likely to currently smoke tobacco and report certain mental health problems. Among currently pregnant women only, women with CPD are more likely to smoke cigarettes every day (12.2 %) versus 6.3 % for pregnant women without CPD (p ≤ 0.001). Among currently pregnant women, 17.7 % of women with CPD have BMIs in the non-overweight range, compared with 40.1 % of women without CPD (p ≤ 0.0001). Currently pregnant women with CPD are significantly more likely to report having any mental health problems, 66.6 % compared with 29.7 % among women without CPD (p ≤ 0.0001). For all women, currently pregnant women appear to have fewer health risks and mental health concerns than nonpregnant women. Among pregnant women, women with CPD have higher rates than other women of health risk factors that could affect maternal and infant outcomes.

Prevalence and risk factors for postpartum depression symptoms among women with disabilities.

The adverse consequences of postpartum depression on the health of the mother and her child are well documented. However, there is little information on postpartum depression among mothers with disabilities. This study examines the patterns of depression and depressive symptoms before, during and after pregnancy and the association between depression before and during pregnancy and postpartum depression symptomatology (PPD) among women with and without disabilities. Data from the 2009-2011 Rhode Island Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed in 2013. Almost 30% (28.9%; 95% CI 22.8-35.8) of mothers with disabilities reported often or always feeling down, depressed or sad after childbirth compared to 10% of those without disabilities (95% CI 8.9-11.3). Compared to other women in the study, women with disabilities had a greater likelihood for PPD symptoms (RR 1.6, 95% CI 1.1-2.2) after accounting for sociodemographics, maternal characteristics related to PPD, and depression before and during pregnancy. Adjusting for other covariates, self-reported prenatal diagnosis of depression was not associated with symptoms of PPD and depression during pregnancy was marginally associated with PPD symptomatology for women with disabilities. Women with disabilities are at a greater risk of experiencing symptoms of postpartum depression than other women. Screening for PPD among new mothers with disabilities and timely referral of those with PPD diagnosis are vital to the health of mothers with disabilities and their children.

A profile of U.S. nursing faculty in research- and practice-focused doctoral education.

PURPOSE: This study, which is part of a larger project, was conducted to profile the nursing faculty in the United States teaching in PhD and DNP programs. DESIGN: This is a descriptive study. A sample of 554 nursing faculty who teach in PhD and DNP programs was recruited by email solicitation to represent all geographic regions of the United States. Data were collected from November 2013 through January 2014 using an online survey instrument. METHODS: The instrument was developed based on results of review of the literature and of focus groups of doctoral faculty (faculty teaching in doctoral programs) to ascertain characteristics of faculty teaching in doctoral programs and of the schools in which they teach. Frequencies and descriptive statistics are reported. FINDINGS: Growth in DNP programs has outpaced growth in PhD programs, and DNP graduates have moved into doctoral education in greater numbers than PhD graduates. DNP faculty report less prior experience and current productivity scholarship than faculty in PhD programs only or both types of programs. CONCLUSIONS: Strategies are needed to ensure that doctoral programs are staffed by faculty who are prepared for doctoral education and the development of nursing science. CLINICAL RELEVANCE: The Institute of Medicine has recommended doubling the number of doctorally prepared nurses in the United States by 2020 to ensure that sufficient numbers of faculty are available to prepare the nursing labor force that is needed for delivery of healthcare services. Nurse scientists are needed to contribute to improvement in patient care quality and safety, and practice leaders are needed to facilitate the translation of research into safe, high-quality, and cost-effective care. The landscape of doctoral education in nursing is rapidly changing.

Persons with Disability: Their Experiences as Standardized Patients in an Undergraduate Nursing Program.

This descriptive qualitative study examined experiences of standardized patients with disabilities (SPWDs) in an undergraduate nursing program through focus group and telephone interviews. Content analysis identified five themes: 1) desire to improve care for others, 2) opportunity to be productive again, 3) joy in seeing students learn, 4) desire for more feedback on performance, and 5) importance of having SPWDs assess accessibility of the facility. SPWDs participated to improve sensitivity of students to disability and appreciated having a voice in educating future nurses. They requested more feedback on their performance and identified accessibility issues in the state-of-the-art nursing school building.

Work-life balance of nursing faculty in research- and practice-focused doctoral programs.

OBJECTIVES: The growing shortage of nursing faculty and the need for faculty to teach doctoral students to address the shortage call for examination of factors that may contribute to the shortage, including those that are potentially modifiable, including work-life balance.This descriptive study examined work-life balance of a national sample of nursing faculty teaching in research-focused and practice-focused doctoral programs. METHODS: Data were collected through an online survey of 554 doctoral program faculty members to identify their perceptions of work-life balance and predictors of work-life balance. RESULTS: Work-life balance scores indicated better work-life balance than expected. Factors associated with good work-life balance included higher academic rank, having tenure, older age, years in education, current faculty position, and no involvement in clinical practice. Current faculty position was the best predictor of work-life balance. CONCLUSIONS: Although work-life balance was viewed positively by study participants, efforts are needed to strengthen factors related to positive work/life in view of the increasing workload of doctoral faculty as the numbers of doctoral students increase and the number of seasoned faculty decrease with anticipated waves of retirements.

Conditions causing disability and current pregnancy among US women with chronic physical disabilities.

BACKGROUND: Growing numbers of reproductive-age US women with chronic physical disabilities (CPD) are becoming pregnant. Little is known about the health conditions causing their CPD. OBJECTIVES: To identify health conditions causing CPD among reproductive-age women and specifically among currently pregnant women. RESEARCH DESIGN: Cross-sectional, nationally representative National Health Interview Survey data from 2006 to 2011. SUBJECTS: A total of 6043 civilian, noninstitutionalized women aged 18-49 with CPD. MEASURES: National Health Interview Survey asks about various movement difficulties and their underlying causes and about current pregnancy. We used responses from 8 movement difficulty and other questions to identify women with mobility difficulties caused by chronic physical health conditions. RESULTS: Among women with CPD, 2.0% report current pregnancy, with pregnancy rates falling monotonically as CPD severity rises. Regardless of pregnancy, 20.8% report 2 causes for their CPD, and 12.7% report 3+ causes; the most common causes are arthritis, back or neck problems, and other musculoskeletal conditions. Compared with nonpregnant women, currently pregnant women report fewer causal conditions: 15.8% report 2 causes and 8.0% 3+ causes; back or neck problems are reported most frequently, followed by musculoskeletal problems and arthritis. Multivariable logistic regression analyses predicting current pregnancy controlling for age category and individual common causes of CPD found that no cause was significantly associated with higher or lower adjusted odds of pregnancy. CONCLUSION: Almost one quarter of currently pregnant women with CPD report more than one cause for their disability. Further research will needed to examine how obstetrical needs vary for depending on the cause of a pregnant woman's disability.

Challenges to research productivity of doctoral program nursing faculty.

The Institute of Medicine, responding to a national health care crisis and related nursing labor force concerns, has called for an increase in the proportion of registered nurses with baccalaureate or higher degrees to 80% and a doubling of the number of nurses with doctorates by 2020. Simultaneously, large numbers of senior faculty are starting to retire, whereas the movement of doctorally prepared nurses into academia is insufficient to replace them. Issues associated with the efforts of nursing programs to increase their capacity to respond to the Institute of Medicine's recommendations, particularly the effect on scholarly productivity among nursing faculty in doctoral programs, are examined in this article. Creative strategies for promoting scholarly productivity among doctoral program faculty are identified.

Utilization of traditional healing practices from Mexico by U. S. women of Mexican origin: A systematic review.

Hispanics are 18.7 % of the U.S. population, and people of Mexican origin are 61.4 % of that Hispanic community. National health surveys indicate that utilization of traditional medicine among Hispanics is low compared to non-Hispanic Whites. However, many researchers have described their use in Hispanic populations as commonplace. OBJECTIVE: This review analyzed studies about traditional healing practices from Mexico (THPM) used by women of Mexican origin in the U.S. for a greater understanding of traditional health practices within U.S. communities of Mexican origin. DATA SOURCES: Journal databases were searched for studies between January 1, 1990 and December 31, 2020. STUDY SELECTION: The Whittemore and Knafl and Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) methods were used to analyze the studies. DATA EXTRACTION: Seven themes emerged: A) foundations, B) medical pluralism, C) non-disclosure and patient satisfaction, D) remedies and rituals, E) healers, F) affinity, and G) what clinicians need to know. Four subthemes were identified: G1) cultural sensitivity, G2) communication skills, G3) leveraging the influence of THPM, and G4) scientific inquiry. DATA SYNTHESIS: U.S. women of Mexican origin reported continued use of THPM for health promotion, influenced by their understanding of health and illness, community ties, and personal experiences. Study authors recommended strategies for improving patient-provider communication and understanding patients' use of traditional health and healing practices. CONCLUSION: Further explorations of THPM are needed to build awareness of culturally-tied health beliefs and behaviors that improve medical care experiences and quality for Hispanics of Mexican origin.