Leadership Behaviors of Frontline Nurse Managers: A Mixed-Methods Research Study Identifying Essential Areas for Social Support.

OBJECTIVE: This study examined how frontline nurse managers (FLNMs) perceive and experience formal and informal social support and how personal factors and social support relate to their transformational leadership (TL) behaviors. BACKGROUND: Ineffective leadership by FLNMs is associated with costly outcomes. Evidence suggests that leadership development is a function of personal and social factors; however, a better understanding of this process is needed. METHODS: A convergent mixed-methods design was used. The quantitative strand included a cross-sectional survey in a sample of FLNMs. The qualitative strand used a semistructured interview and a descriptive qualitative approach with a subset of this sample. RESULTS: Formal and informal social support is positively related to the TL behaviors of FLNMs as evidenced by the convergent data. The influence of family members in the work-related decisions of FLNMs has been underreported in the literature and is an area for consideration in supporting retention and desired leadership behaviors. CONCLUSION: The findings of this study imply a need for organizations to establish systems that endorse the growth of FLNMS, create opportunities for career advancement, and integrate members of the FLNMs' personal support systems into recognition initiatives.

Life-space mobility in dementia patients and family caregivers: A dyadic approach.

BACKGROUND AND OBJECTIVE: Given that most dementia care is provided at home by family caregivers, caregivers' health and outdoor activities may influence persons with dementia (PWDs)' mobility. At the same time, PWDs' functional deterioration and mobility changes might affect mobility behaviours in their caregivers. The aims of this pilot study were to examine the relationship of PWD's life-space mobility (LSM) with their caregiver's LSM and to investigate the role of caregiver and PWD characteristics in determining the level of LSM in both PWDs and caregivers. DESIGN AND METHOD: A cross-sectional survey was conducted with 26 caregivers providing dementia care at home. Caregivers were used as proxy for assessing sociodemographic, clinical and physical function in PWDs. Caregivers' sociodemographic characteristics, LSM, social support, depressive symptoms, caregiving burden and preparedness for caregiving were measured. RESULTS: The level of LSM in caregivers was correlated with the PWD's LSM level. Caregivers who perceived high levels of social support and readiness for caregiving tended to report high levels of LSM. PWDs' age and independence in instrumental activities of daily living were correlated with caregivers' LSM. CONCLUSIONS: The study findings suggest that the caregiver's LSM influenced and was affected by the PWD's LSM. This underscores the need for additional research that examines the role of caregivers' psychosocial and physical health on PWDs' mobility and the context of dementia care and its influences on how dementia care dyads decide and participate in mobility behaviours. IMPLICATIONS FOR PRACTICE: The findings of this pilot study will be helpful in identifying a target for interventions designed to delay the onset of mobility disability and maintain and improve social participation in PWDs. To minimise the effects of mobility limitations in PWDs, it is critical to examine their mobility issues from multilevel perspectives, including their caregiver's LSM levels and characteristics that have implications for both research and clinical practice.

Adolescents and Young Adults with Cancer Using a Symptom Heuristics App: Provider Perceptions and Actions.

Purpose: This study examined health care providers' perceptions of the usefulness and ease of use of a symptom heuristics app delivered via a tablet computer as a resource for understanding symptom experiences of adolescents and young adults (AYAs) with cancer. AYAs' app-generated symptom reports were compared with providers' documentation of AYAs' symptoms. Methods: This multisite study included responses from 86 AYAs 15-29 years of age who completed the Computerized Symptom Capture Tool (C-SCAT) before two scheduled visits for chemotherapy. After each visit, their providers completed a survey addressing their perspective of: (1) the usefulness of data provided by the C-SCAT to understand the AYAs' symptom experience, and (2) the nature of the discussion of symptoms with the AYA. An electronic health record review compared symptoms that AYAs identified by using the C-SCAT with providers' documentation of symptoms. Results: One hundred forty-four complete surveys were returned after 162 visits. Fifty percent (n = 72) of responses reported that the C-SCAT helped identify the patient's symptoms, and 53% (n = 76) reported that it helped identify the patient's priority symptoms. Providers also reported higher patient engagement and more focused discussions regarding symptoms. They reported that use of the C-SCAT facilitated the development of symptom management plans. Priority symptoms were documented more frequently than nonpriority symptoms (54% vs. 32.7%; p < 0.01) as was a plan for managing priority symptoms (33.7% vs. 17.9%; p < 0.01). Conclusion: Use of the C-SCAT enhanced providers' understanding of AYAs' symptom experiences. Further research is needed to demonstrate the effectiveness of the C-SCAT as a resource to improve symptom management among AYAs with cancer.

Biobehavioral Framework of Symptom and Health Outcomes of Uncertainty and Psychological Stress in Parkinson Disease.

Parkinson disease (PD) is a debilitating, progressive neurodegenerative disorder characterized by complex motor and nonmotor symptoms that fluctuate in onset, severity, level of disability, and responsiveness to treatment. The unpredictable nature of PD and the inability to halt or slow disease progression may result in uncertainty and psychological stress. Uncertainty and psychological stress have important implications for symptom and health outcomes in PD. Uncertainty and psychological stress have been shown to worsen symptoms, functional capacity, and quality of life in chronic illnesses; however, the causal mechanisms have yet to be elucidated. We propose a biobehavioral framework for examining uncertainty and psychological stress in PD. The framework considers factors that may contribute to uncertainty and neuroendocrine-immune mechanisms of uncertainty and psychological stress that may influence symptom and health outcomes in PD, for the ultimate purpose of improving symptom and disease progression, functional capacity, and quality of life.

Randomized sham controlled trial of cranial microcurrent stimulation for symptoms of depression, anxiety, pain, fatigue and sleep disturbances in women receiving chemotherapy for early-stage breast cancer.

PURPOSE: Women with breast cancer may experience symptoms of depression, anxiety, pain, fatigue and sleep disturbances during chemotherapy. However, there are few modalities that address multiple, commonly occurring symptoms that may occur in individuals receiving cancer treatment. Cranial electrical stimulation (CES) is a treatment that is FDA cleared for depression, anxiety and insomnia. CES is applied via electrodes placed on the ear that deliver pulsed, low amplitude electrical current to the head. METHODS: This phase III randomized, sham-controlled study aimed to examine the effects of cranial microcurrent stimulation on symptoms of depression, anxiety, pain, fatigue, and sleep disturbances in women receiving chemotherapy for early-stage breast cancer. Patients were randomly assigned to either an actual or sham device and used the device daily for 1 h. The study was registered at clinicaltrials.gov, NCT00902330. RESULTS: The sample included N = 167 women with early-stage breast cancer. Symptom severity of depression, anxiety, and fatigue and sleep disturbances were generally mild to moderate. Levels of pain were low. Anxiety was highest prior to the initial chemotherapy and decreased over time. The primary outcome assessment (symptoms of depression, anxiety, fatigue, pain, sleep disturbances) revealed no statistically significant differences between the two groups, actual CES vs. sham. CONCLUSION: In this study, women receiving chemotherapy for breast cancer experienced multiple symptoms in the mild to moderate range. Although there is no evidence for the routine use of CES during the chemotherapy period for symptom management in women with breast cancer, further symptom management modalities should be evaluated to mitigate symptoms of depression, anxiety, fatigue, pain and sleep disturbances over the course of chemotherapy.

Symptoms, Cytokines, and Quality of Life in Patients Diagnosed with Chronic Graft-Versus-Host Disease Following Allogeneic Hematopoietic Stem Cell Transplantation.

PURPOSE/OBJECTIVES: To describe associations among symptoms, cytokines, and quality of life (QOL) of patients with chronic graft-versus-host disease (cGVHD). DESIGN: Prospective, cross-sectional, cohort. SETTING: The bone marrow transplantation unit at a National Cancer Institute-designated cancer center in Virginia.
 SAMPLE: 24 adults diagnosed with cGVHD. METHODS: Data were collected for demographic factors, symptoms, and QOL from medical record and validated questionnaires. Serum was analyzed for cytokine levels. MAIN RESEARCH VARIABLES: cGVHD, symptoms, cytokines, C-reactive protein, and QOL.
 FINDINGS: Participants reported multiple, concurrent symptoms. Cytokine levels were higher in participants with symptoms versus those without symptoms. Cytokine interleukin-6 correlated with lack of energy and dry mouth. Negative correlations were noted between QOL and symptoms. CONCLUSIONS: Findings demonstrated multiple concurrent symptoms present in this sample and significant relationships among symptoms, cytokines, and QOL. IMPLICATIONS FOR NURSING: cGVHD is a serious condition affecting QOL in many individuals after bone marrow transplantation for many different cancers. Results from this pilot study indicate that patients experience multiple symptoms, including sexual dysfunction, that adversely affect QOL. Better understanding of the interrelated symptoms of cGVHD and the biomarkers associated with these symptoms may lead to targeted symptom management interventions.

Preintubation application of oral chlorhexidine does not provide additional benefit in prevention of early-onset ventilator-associated pneumonia.

BACKGROUND: Daily application of oral chlorhexidine gluconate (CHX) following intubation to reduce the risk of ventilator-associated pneumonia (VAP) is now the standard of care in many ICUs. This randomized clinical trial evaluated the benefit of adding a preintubation CHX dose to the known benefit of postintubation CHX to reduce the risk of early-onset VAP. A secondary aim was to test the effect of a preintubation oral application of CHX on early endotracheal tube (ETT) colonization. METHODS: Subjects (N = 314) were recruited from two teaching hospitals and were randomly assigned to oral application of 5 mL CHX 0.12% solution before intubation (intervention group, n = 157), or to a control group (n = 157) who received no CHX before intubation. All subjects received CHX bid after intubation. Groups were compared using a repeated-measures model with Clinical Pulmonary Infection Score (CPIS) as the response variable. In a planned subset of subjects, ETTs were cultured at extubation. RESULTS: Application of a preintubation dose of CHX did not provide benefit over the intervention period beyond that afforded by daily oral CHX following intubation. ETT colonization at extubation was < 20% in both groups (no statistically significant difference). Mean CPIS remained below 6 (VAP threshold score) in both groups. CONCLUSIONS: Although it is feasible to deliver CHX prior to intubation (including emergent or urgent intubation), the results suggest that preintubation CHX may be inconsequential when the ventilator bundle, including daily oral CHX, is in place. During the preintubation period, providers should focus their attention on other critical activities. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00893763; URL: www.clinicaltrials.gov.

Randomized, prospective, clinical evaluation of prosthodontic modalities for mandibular implant overdenture treatment.

STATEMENT OF PROBLEM: Mandibular implant overdentures provide improved treatment outcome than conventional denture therapy, but there is controversy as to which overdenture treatment is the best choice. PURPOSE: This study evaluated 3 different mandibular implant overdenture treatments with respect to prosthesis retention and stability, tissue response, patient satisfaction and preference, and complications to determine treatment outcomes. MATERIAL AND METHODS: In a prospective, randomized clinical trial, using a crossover design, 30 subjects (mean age, 58.9; 63% male) received 4 implants in the anterior mandible. For each subject, 3 different overdenture attachment types were fabricated and/or fitted to the implants. These included a 4-implant bar attachment fitted to all 4 implants, a 2-implant bar attachment, and 2 independent ball attachments. Subjects were randomly assigned to 1 of 6 possible treatment sequences and received all 3 attachment types each for approximately 1 year. Data were collected at baseline, and at 6 and 12 months for treatment types. Denture retention and stability and parameters of soft tissue response were recorded. Complications were documented and questionnaires were used to identify subject masticatory ability, denture complaints, and preferences. Data were analyzed to determine statistical equivalence among the 3 different treatments using the Schuirmann's two one-sided test (TOST) procedure, and the Wilcoxon-Mann-Whitney TOST procedure (α=.05). RESULTS: Force gauge prosthesis retention measurements showed that the 3 treatment types were not statistically equivalent, with the 4-implant bar demonstrating the greatest retention. Criterion-based retention scores were statistically equivalent for all treatments. Both the force gauge and criterion-based prosthesis stability measurements were statistically equivalent among all 3 treatment types. Analysis of all other multiple criterion-based scoring systems indicated the majority of these variables demonstrated equivalence. Where equivalence was not identified, the most favorable responses were typically found with the O-ring treatment, and the least favorable with the 4-implant bar treatment. From the small percentage of treatment visits demonstrating minor complications, no single treatment presented with greater complications than the others. For the treatment preference among subjects, 52% selected the independent ball attachment, 32% the 4-implant bar, and 16% the 2-implant bar (P=.10). CONCLUSIONS: The 2-implant independent treatment used in this study provided equivalent or more favorable treatment outcomes for most measured parameters relative to the more complex and costly 2- and 4-implant bar attachments. The 4-implant bar treatment provided greater prosthesis retention than the other treatment types in this study, but after experience with all systems, subjects were more satisfied with and preferred the independent implant treatment.

The role of biobehavioral, environmental, and social forces on oral health disparities in frail and functionally dependent nursing home elders.

The purpose of this article is to review the literature on and discuss how interactions between bio-behavioral aging, nursing home environments, and social forces shaping current health care policies have contributed to oral health disparities in frail and functionally dependent elders who reside in nursing homes. Emerging empirical evidence suggests links between poor oral health with dental plaque deposition and systemic disease, such as nursing home-acquired pneumonia. The majority of nursing home residents lack either the functional ability or the mental capacity to perform their own mouth care and therefore must rely on others to perform mouth care for them. Certified nursing assistants (CNAs), who provide the majority of care activities, were unsure how to provide care to residents who engaged in care-resistive behaviors. The nurses who supervise the CNAs have limited knowledge regarding the provision of mouth care in general, and they specifically lack knowledge regarding the provision of mouth care to elders exhibiting care-resistant behavior. Elders in nursing homes have limited options when paying for dental care; Medicare does not generally cover routine dental care. Medicaid coverage varies widely between individual states; even when coverage exists, low Medicaid reimbursements discourage dentists from accepting Medicaid patients. The strategies needed to reduce these oral health disparities are complicated but not unrealistic. Investigators willing to embrace this cause will have no shortage of opportunities to test methods to improve the delivery of oral care as well as to monitor and reassess these methods.

Lifestyle and quality of life in long-term cardiac transplant recipients.

BACKGROUND: The purposes of this study were to describe long-term (>1 year) cardiac transplant recipients' perceptions of barriers to health-promoting behaviors; ability to manage their health, health-promoting lifestyle, health status and quality of life (QOL); and determine predictors of QOL. METHODS: Data were collected from 93 recipients who completed a self-report questionnaire incorporating: (1). patient characteristics; (2). barriers to health promotion, perceived health competence and health-promoting lifestyle; (3). perceived health status; and (4). QOL. All instruments used had acceptable reliability and validity. Objective measures of health status were retrieved from medical records. Data were analyzed using descriptive and comparative statistics, measures of association and multiple regression. RESULTS: Recipients were uncertain about their ability to manage their health; felt that barriers sometimes interfered with engaging in health-promoting behaviors; and often included health-promoting behaviors in their lifestyle. They rated their health as good and were moderately satisfied with life. Predictors of better perceptions of QOL included less education, longer time since transplant, ischemic etiology of heart failure, fewer barriers, higher perceived health competence and a health-promoting lifestyle (R(2) = 0.51; F = 14.77; p = 0.001). CONCLUSIONS: The present results provide information regarding factors that contribute to perceptions of quality of life after cardiac transplantation, have implications for identifying patients at risk for poor QOL, and sensitize clinicians to the need for ongoing patient education.