Age Suppresses the Association Between Traumatic Brain Injury Severity and Functional Outcomes: A Study Using the NIDILRR TBIMS Dataset.

OBJECTIVES: Recovery from traumatic brain injury (TBI) is extremely difficult to predict, with TBI severity usually demonstrating weak predictive validity for functional or other outcomes. A possible explanation may lie in the statistical phenomenon called suppression, according to which a third variable masks the true association between predictor and outcome, making it appear weaker than it actually is. Age at injury is a strong candidate as a suppressor because of its well-established main and moderating effects on TBI outcomes. We tested age at injury as a possible suppressor in the predictive chain of effects between TBI severity and functional disability, up to 10 years post-TBI. SETTING: Follow-up interviews were conducted during telephone interviews. PARTICIPANTS: We used data from the 2020 NDILRR Model Systems National Dataset for 4 successive follow-up interviews: year 1 (n = 10,734), year 2 (n = 9174), year 5 (n = 6,201), and year 10 (n = 3027). DESIGN: Successive cross-sectional multiple regression analyses. MAIN MEASURES: Injury severity was operationalized using a categorical variable representing duration of posttrauma amnesia. The Glasgow Outcomes Scale-Extended (GOS-E) operationally defined functioning. Sociodemographic characteristics having significant bivariate correlations with GOS-E were included. RESULTS: Entry of age at injury into the regression models significantly increases the association between TBI severity and functioning up to 10 years post-TBI. CONCLUSIONS: Age at injury is a suppressor variable, masking the true effect of injury severity on functional outcomes. Identifying the mediators of this suppression effect is an important direction for TBI rehabilitation research.

Predictors of the inability to achieve full oral feeding in postoperative infants with CHD.

OBJECTIVES: Poor oral feeding is a known contributor to growth challenges in neonates with complex CHD who require early surgery. Almost 60% of these infants do not achieve full oral feeding by hospital discharge. This study's objective was to identify predictors of the inability to achieve full oral feeding by discharge in neonates with complex CHD following surgical intervention with cardiopulmonary bypass. STUDY DESIGN: A retrospective analysis of a prospective study of 192 full-term neonates with complex CHD was performed. A stepwise selection logistic regression model was developed to predict oral feeding status at hospital discharge. Univariate subgroup analysis was performed with groups determined based on a CHD classification system. RESULTS: 58% of neonates (112/192) failed to achieve full oral feeding by hospital discharge. A logistic regression model identified duration of deep hypothermic circulatory arrest and reintubation as predictors of the inability to achieve full oral feeding. Among neonates who achieved full oral feeding by discharge (42%), only 7.5% did so after postoperative day 10. Brain maturation, brain injury, and preoperative oral feeding were not predictors of full postoperative oral feeding. CONCLUSIONS: Many infants with CHD fail to achieve full oral feeding by time of hospital discharge. Longer duration of deep hypothermic circulatory arrest and increased number of intubations were predictive of poor feeding after surgery. Prolonging hospitalisation solely to achieve full oral feeding after postoperative day ten is of limited utility; earlier discharge should be promoted to avoid negative impacts on neonatal neurodevelopment as unintended consequences of lengthy hospitalisations.

Looking back to move forward: Creating a blueprint for success for nurse scientists in the Veterans Health Administration.

AIM: The purpose of this manuscript is to report the findings of a qualitative content analysis of interviews with VA Nurse Scientists about work life experiences, barriers, and facilitators across the enterprise. BACKGROUND: The VA enterprise is widely variable in terms of size, services, research activity, and budget. For this reason, the roles of nurses with a research-focused doctorate are also quite diverse. METHODS: We purposively sampled 18 PhD prepared Nurse Scientists based on a variety geographic locations, titles, and years in the field and who conduct research. We conducted semi-structured interviews over the virtual platform, WebEx. Interviews, averaging 1 h in length, were conducted between April and May 2021. We analyzed interviews using deductive and inductive content analysis. RESULTS: We found five key factors affecting VA Nurse Scientists. Each factor emerged as an important issue influencing whether Nurse Scientists reported being successful, supported, and productive in their research. These include having: 1) mentorship, 2) supportive leadership 3) available resources, 4) respect and understanding from clinical and research colleagues who understand a Nurse Scientist's role in research, and 5) a career pathway. CONCLUSIONS: VA Nurse Scientists are leaders and innovators who generate evidence to improve health outcomes and promote equity in health and health care of Veterans, their families, and caregivers. Results from this project suggest that many Nurse Scientists need additional mentorship, resources, and networks to advance their development, increase their funding success, and maximize the impact of their role, ultimately enhancing care of Veterans and their families.

Building Family Interventions for Scalability and Impact.

Family nursing researchers are charged with addressing the conceptual and methodological underpinnings of family research when developing family-focused interventions. Step-by-step guidance is needed that integrates current science of intervention development with family science and helps researchers progress from foundational work to experimental work with policy integration. The purpose of this manuscript is to provide pragmatic, evidence-based guidance for advancing family intervention research from foundational work through efficacy testing. Guidance regarding the development of family interventions is presented using the first three of Sidani's five-stage method: (a) foundational work to understand the problem targeted for change; (b) intervention development and assessment of acceptability and feasibility; and (c) efficacy testing. Each stage of family intervention development is described in terms of process, design considerations, and policy and practice implications. Examples are included to emphasize the family lens. This manuscript provides guidance to family scientists for intervention development and implementation to advance family nursing science and inform policy.

Oral feeding dysfunction in post-operative infants with CHDs: a scoping review.

Post-operative oral feeding difficulties in neonates and infants with CHD is common. While pre-operative oral feeding may be normal, oral feeding challenges manifest in the post-operative period without a clearly defined aetiology. The objective of this scoping review was to examine post-operative oral feeding in full-term neonates and infants with a CHD. Electronic databases query (1 January 1975-31 May 2021), hand-search of the reference lists of included studies, contact with experts, and review of relevant conferences were performed to identify quantitative studies evaluating post-operative oral feeding in full-term neonates and infants with a CHD. Associations with additional quantitative variables in these studies were also examined. Twenty-five studies met inclusion criteria. Eighty per cent were cohort studies that utilised retrospective chart review from a single institution. The primary variable of interest in all studies was oral feeding status upon discharge from neonatal hospitalisation. The most common risk factors evaluated with poor feeding at time of discharge were birth weight (36% of included studies), gestational age (44%), duration of post-operative intubation (48%), cardiac diagnosis (40%), and presence of genetic syndrome or chromosomal anomaly (36%). The most common health-related outcomes evaluated were length of hospital stay (40%) and length of ICU stay (16%). Only the health-related outcomes of length of hospital stay and length of ICU stay were consistently significantly associated with poor post-operative oral feeding across studies in this review. A clear aetiology of poor post-operative oral feeding remains unknown.

Social Determinants of Health in the Lives of Urban-Dwelling, Pregnant Puerto Rican Women and Families: Nursing Implications From a Secondary Narrative Analysis.

Urban-dwelling childbearing Puerto Rican women and families on the U.S. mainland face a myriad of social determinants that affect pregnancy and overall health outcomes. Historically, Puerto Ricans have poorest pregnancy outcomes of all Hispanic women. Acknowledgment of the cyclic, structural barriers faced by this patient population is essential to providing wholistic care. Here, we discuss family nursing implications derived from narrative analysis of a parent study that investigated ecological systems affecting 21 pregnant Puerto Rican women residing in an impoverished and crime-ridden neighborhood in Philadelphia. Content analysis of interviews revealed interwoven social determinants of health embedded in participant narratives. Furthermore, we present case vignettes based on integration of participant interviews that encapsulate the everyday experiences of these women and their families and provide clinicians with guidance and strategies for interacting with and advocating for this population.

Revealing the Invisible Emotion Work of Caregivers: A Photovoice Exploration of Informal Care Provided by Family Caregivers for Post-9/11 Veterans With Traumatic Brain Injuries.

OBJECTIVE: Describe the different forms of emotion work performed by family caregivers of veterans living with a traumatic brain injury (TBI). DESIGN: Collaborators were provided cameras to take photographs illustrating their experiences as family caregivers. The meaning behind caregiver photographs was solicited using photoelicitation interviews and coded. SETTING: Homes of veterans or other informal settings in 2 regions of the United States served by the Southeast Louisiana Veterans Health Care System and the Veterans Affairs Portland Health Care System. PARTICIPANTS: Twenty-six family caregivers of post-9/11 era veterans with TBI. RESULTS: Caregivers described performing different types of intangible, and largely invisible, work centered on emotion management. Emotion work primarily involved creating a new normal, keeping things calm, and suppressing their own emotional experiences to "put on a brave face." Although having derived a sense of satisfaction and identity from their role, caregivers acknowledged that emotion work was challenging and sometimes stressful. The Photovoice method allowed caregivers to express through metaphor experiences that otherwise would have been hard to articulate and share with others. CONCLUSION: Findings signal a need for healthcare systems and providers to acknowledge emotion work as a potential source of stress and to provide multifaceted support for veterans and family caregivers.

Undergraduate Nursing Students and Management of Interruptions: Preparation of Students for Future Workplace Realities.

AIM: The aim of this study was to investigate interruption management strategies and associative cues used by nursing students when interrupted during simulated medication administration. BACKGROUND: Interruptions occur with high frequency in health care settings and are associated with increased medication errors and decreased task efficiency. The Altmann and Trafton memory for goals model, a cognitive-science model, proposes use of associative cues during an interruption to mitigate these negative effects. METHOD: A mixed-methods, two-site study explored associative cues and other management strategies that nursing students used when interrupted during simulated medication administration. Data were collected via direct observation and semistructured interviews. RESULTS: Students primarily multitasked (66.7 percent) during the interruption. Few students (5.5 percent) used associative cues. Students voiced the need for education and practice on how to manage interruptions. CONCLUSION: Evidence-based strategies are required to prepare nursing students for workplace interruptions. Use of associative cues during interruptions warrants further investigation.

The additional burden of PTSD on functioning and depression in veterans with traumatic brain injury.

BACKGROUND: Many United States veterans and active military with a history of traumatic brain injury (TBI) also experience challenges from comorbid posttraumatic stress disorder (PTSD), yet the additional burden of PTSD is not clear. PURPOSE: To address this knowledge gap, this study examined the relationship of PTSD to cognitive, social, and physical functioning and depressive symptoms in veterans recently diagnosed with TBI. METHODS: Veterans were recruited from a VA rehabilitation clinic. The Patient Competency Rating Scale and Center for Epidemiologic Studies Depression Scale measured functioning and depression, respectively. Chart review captured PTSD diagnosis. FINDINGS: In the sample of 83 veterans, 65% had a current PTSD diagnosis. After controlling for sociodemographic variables and TBI severity, PTSD was a significant predictor of lower cognitive, social, and physical functioning and higher depressive symptomatology. DISCUSSION: Clinicians should incorporate PTSD assessment in their work with veterans with TBI. Integrated behavioral health and rehabilitation interventions that provide strategies for veterans to manage TBI symptoms and PTSD are critical.

Patients' and caregivers' perspectives in determining discharge readiness from home health.

There are no national, empirically derived clinical decision support tools to assist the interprofessional home health team in determining readiness for discharge from skilled home health. Eliciting patient and family caregiver perspectives around readiness for home health discharge is integral to developing tools that address their needs in this decision-making process. The purpose of this study was to describe the factors home health patients and their family caregivers perceive as critical when determining readiness for discharge from services. A qualitative descriptive study was conducted among skilled home health recipients and their family caregivers who were either recently discharged or recertified for additional care from two different Medicare-certified skilled home health agencies. Nine themes emerged: self-care ability, functional status, status of condition(s) and symptoms, presence of a caregiver, support for the caregiver, connection to community resources/support, safety needs of the home environment addressed, adherence to the prescribed regimen, and care coordination.

Systematic Review of Disparities in Kidney Transplantation Prior to Implementation of the Kidney Allocation System and Directions for Research.

Major changes were made to the U.S. kidney allocation system (KAS) on December 4, 2014, in the effort to address disparities in kidney transplantation (KT) and achieve equity in organ allocation. Research is necessary to examine whether KAS achieved its goal; first, a firm understanding of the disparities that existed prior to implementation of KAS is needed. This systematic review examined the literature on disparities in access to deceased donor KT (DDKT) after listing in the pre-KAS era and discussed mechanisms to explain these disparities. Thirty-two articles were included. Racial, gender, age, socioeconomic, physiologic, geographic, and health care system disparities existed in the pre-KAS era. Findings of this review will inform the agenda for future disparities research in the post-KAS era.

Increasing nursing research capacity: The roles and contributions of nurse scientists within healthcare systems in the Greater Philadelphia region.

PhD prepared nurse scientists within healthcare systems are uniquely positioned to advance nursing science through research and evidence-based practice (EBP) initiatives due to their ability to closely collaborate with nurses and other healthcare professionals in the clinical setting. The purpose of this paper is threefold: 1) to describe the roles and contributions of Nurse Scientists, from their perspectives, in four different health care systems in the Greater Philadelphia area, three of which are Magnet® designated hospitals; 2) to highlight organizational approaches to increase nursing research and EBP capacity; and 3) to explore strategies that Nurse Scientists used to overcome barriers to build nursing research capacity. Nurse Scientists employed in these healthcare systems share many of the same essential roles and contributions focused on developing nursing research and EBP initiatives through education and mentorship of clinical nurses, conduct and oversight of independent research, and dissemination activities. With supportive executive nurse leadership, the Nurse Scientists within each healthcare system employed different strategies to overcome barriers in building nursing research and EBP capacity. Nurse scientists within healthcare settings have potentially powerful positions to generate and apply new knowledge to guide nursing practice and improve outcomes.

Factors Related to International Travel for Transplantation Among U.S.-Listed Kidney Transplant Candidates.

Factors related to travel for transplantation were examined using data from the Scientific Registry for Transplant Recipients. Candidates who traveled abroad for a kidney transplant had higher odds of being male, Asian or Hispanic, college-educated, employed, privately insured, and a non-U.S. citizen/non-U.S. resident. Candidates with a body mass index greater than 30, a calculated panel reactive antibody (cPRA) greater than 80%, and a history of more than two years of hemodialysis or peritoneal dialysis had lower odds of traveling abroad for a kidney transplant. Geographically, candidates listed in the northeastern region of the United States (New York and Western Vermont) had the highest odds of traveling abroad for a kidney transplant. Findings of this study can be used to guide practice and education with transplant candidates, and to direct further investigation in this understudied but growing area of transplantation.

Beyond anger: emotion regulation and social connectedness in veterans with traumatic brain injury.

PRIMARY OBJECTIVE: Patients with traumatic brain injury (TBI) often present with emotion dysregulation. Most TBI rehabilitation has addressed this impairment primarily in relation to anger, irritability and aggressiveness. Yet, emotion regulation (ER) may have broader ramifications for psychological well-being. The present study examined ER's association to several aspects of social connectedness. RESEARCH DESIGN: Cross-sectional study Methods and procedures: 83 veterans with TBI who were outpatients at a VA medical rehabilitation service were interviewed in their homes. A 5-item ER subscale, drawn from the Patient Competency Rating Scale, was subjected to psychometric analysis and examined as a predictor of five social connectedness measures: community reintegration (CR), interpersonal functioning, quality of relationship with key family members and social role limitations due to physical problems and due to emotional problems. Sociodemographic, military and medical information was also collected. MAIN OUTCOMES AND RESULTS: The ER subscale showed good psychometric properties. ER contributed significantly to CR, interpersonal functioning and limitations in social roles. This underscores ER's role in social connectedness among veterans with TBI. CONCLUSIONS: Impairments in ER should be regarded as a risk factor for poor interpersonal outcomes, a target for mental health treatment and a focus for interventions aimed at improving psychological well-being in TBI.

Exploration of Factors Related to Depressive Symptomatology in Family Members of Military Veterans With Traumatic Brain Injury.

Traumatic brain injury (TBI) is a family affair, affecting those with the injury and their families. Psychological distress, often measured as depression or depressive symptoms, is highly prevalent among family members. Predictors of depression in family members of civilians with TBI have been examined, but predictors of depression in family members of military veterans have received very little research attention and are poorly understood. To address the knowledge gap, this study explored factors related to depressive symptoms in family members of veterans in the United States, using an ecological framework. Baseline data from 83 family members were used. Family members with higher caregiver burden, presence of a veteran with posttraumatic stress disorder (PTSD), and greater financial difficulty experienced significantly more depressive symptoms. Findings suggest that efforts to support family members and decrease their depression should aim to reduce caregiver burden and financial difficulty, and help family members cope with veteran PTSD and TBI. Family-focused interventions are needed.

Quality of relationship between veterans with traumatic brain injury and their family members.

OBJECTIVES: The quality of the relationship between patients with many illnesses and their family members has been shown to affect the well-being of both. Yet, relationship quality has not been studied in traumatic brain injury (TBI), and giving and receiving aspects have not been distinguished. The present study of veterans with TBI examined associations between relationship quality and caregiver burden, satisfaction with caregiving, and veterans' competence in interpersonal functioning, rated by veterans and family members. METHOD: In this cross-sectional study, 83 veterans and their family members were interviewed at home. Measures of quality of relationship, veterans' interpersonal competence and sociodemographics were collected for both, caregiver burden and satisfaction for family members only. RESULTS: As predicted, veteran-rated Qrel/Giving was associated with family-rated Qrel/Receiving, and veteran-rated Qrel/Receiving with family-rated Qrel/Giving. Lower caregiver burden and higher caregiving satisfaction were associated with higher Qrel/Receiving scores but not with Qrel/Giving scores. Veterans' interpersonal competence was associated with total Qrel as rated by either veterans or family members. CONCLUSIONS: Relationship quality should be included in family research in TBI, and giving and receiving aspects should be differentiated. Findings suggest that lower caregiver burden and greater satisfaction should be more achievable by increasing caregivers' sense of benefits received from the relationship.

Efficacy and acceptability of a home-based, family-inclusive intervention for veterans with TBI: A randomized controlled trial.

OBJECTIVE: Traumatic brain injury (TBI) often undermines community re-integration, impairs functioning and produces other symptoms. This study tested an innovative programme for veterans with TBI, the Veterans' In-home Programme (VIP), delivered in veterans' homes, involving a family member and targeting the environment (social and physical) to promote community re-integration, mitigate difficulty with the most troubling TBI symptoms and facilitate daily functioning. SETTING: Interviews and intervention sessions were conducted in homes or by telephone. PARTICIPANTS: Eighty-one veterans with TBI at a VA polytrauma programme and a key family member. DESIGN: This was a 2-group randomized controlled trial. Control-group participants received usual-care enhanced by two attention-control telephone calls. Follow-up interviews occurred up to 4 months after baseline interview. MAIN MEASURES: VIP's efficacy was evaluated using measures of community re-integration, target outcomes reflecting veterans' self-identified problems and self-rated functional competence. RESULTS: At follow-up, VIP participants had significantly higher community re-integration scores and less difficulty managing targeted outcomes, compared to controls. Self-rated functional competence did not differ between groups. In addition, VIP's acceptability was high. CONCLUSION: A home-based, family-inclusive service for veterans with TBI shows promise for improving meaningful outcomes and warrants further research and clinical application.

Cognitive, Affective, and Behavioral Dimensions of the Lower Urinary Tract Symptom Experience in Men With Parkinson's Disease.

OBJECTIVE: Lower urinary tract symptoms (LUTS) in persons with Parkinson's disease (PD) have received little research attention. To address this gap in our knowledge, we examined the LUTS experience in men with PD, guided by The Theory of Unpleasant Symptoms. METHODS: A qualitative design was used to explore the LUTS experience in this population. Participants were recruited from a Veterans' Affairs PD Center. Maximum variation sampling was used to select diverse participants for audiotaped open-ended interviews. Additional data sources included field notes collected during interviews and observation of a PD support group. The template organizing analytic approach was used to code transcribed interviews and field notes. RESULTS: Cognitive, affective, and behavioral dimensions of the LUTS experience were identified. Participants attributed LUTS to aging, medications, and effects of motor symptoms on their ability to respond to the urge to void. There was little awareness of the neurologic contributions of PD to LUTS, and most viewed LUTS as "something that you have to put up with." Negative effects of LUTS on self-identity were noted, which jeopardized relationships, intimacy, participation in social activities, and travel. Affective responses to LUTS, particularly embarrassment, had a profound impact on quality of life. Behavioral strategies to manage LUTS focused on "being prepared to go when you need to go" and consisted mostly of trial-and-error efforts. CONCLUSION: Misconceptions about LUTS among men with PD may result in underreporting, missed opportunities for professional assistance, and diminished health-related quality of life. Future research should focus on developing and testing nursing interventions to address cognitive, affective, and behavioral aspects of the LUTS experience in men with PD.

Exploration of Individual and Family Factors Related to Community Reintegration in Veterans With Traumatic Brain Injury.

BACKGROUND: Community reintegration (CR) poses a major problem for military veterans who have experienced a traumatic brain injury (TBI). Factors contributing to CR after TBI are poorly understood. OBJECTIVE: To address the gap in knowledge, an ecological framework was used to explore individual and family factors related to CR. DESIGN: Baseline data from an intervention study with 83 veterans with primarily mild to moderate TBI were analyzed. Instruments measured CR, depressive symptoms, physical health, quality of the relationship with the family member, and sociodemographics. Posttraumatic stress disorder and TBI characteristics were determined through record review. RESULTS: Five variables that exhibited significant bivariate relationships with CR (veteran rating of quality of relationship, physical functioning, bodily pain, posttraumatic stress disorder diagnosis, and depressive symptoms) were entered into hierarchical regression analysis. In the final analysis, the five variables together accounted for 35% of the variance, but only depression was a significant predictor of CR, with more depressed veterans exhibiting lower CR. CONCLUSIONS: Efforts to support CR of Veterans with TBI should carefully assess and target depression, a modifiable factor.

Depressed Affect and Dimensions of Religiosity in Family Caregivers of Individuals with Dementia.

Religiosity and mood have long been recognized as associated, but some patterns of associations suggest complex relationships. Using a multidimensional measure of religiosity, we explored the possibility that dimensions of religiosity may have (1) different strengths of association and (2) directions of association with depressed mood. We measured five dimensions of religiosity in 1227 family caregivers of persons with dementia, testing associations of each dimension to caregivers' depressive symptoms. In zero-order associations, higher scores on each religiosity dimension were associated with lower depression. Yet in hierarchical multiple regressions models, adjusting for other religiosity dimensions, different dimensions showed either no independent association, an independent association, or an inverse association with depressed mood. Frequency of prayer reversed directions of association-showing higher depression in caregivers who prayed more. Findings underscore the complex and sometimes bidirectional association between depressed mood and religiosity and argue for recognition of distinct dimensions of religiosity.