The Influence of Race and Gender on Nursing Care Decisions: A Pain Management Intervention.

BACKGROUND: Understanding whether a patient's race or gender and/or the nurse's race or gender influence how nurses form care decisions can contribute to exploration of methods that can positively affect disparate treatment. AIMS: This research examined how the variables of race and gender of both the nurse and the patient influence nurses' decision making about pain management. DESIGN: A randomized four-group post-test-only experimental design was used to examine the variables and variable interactions. SETTINGS: An investigator-developed case vignette tool hosted online was used to obtain data about nursing pain management decisions. The vignette intervention was developed to simulate four exact patient scenarios that differed only by patient race and gender. Participants/Subjects: A quota sample of 400 nurses was recruited using a self-selected face-to-face recruitment technique. METHODS: A four-way between-groups analysis of variance assessed whether the gender of the nurse, race of the nurse, gender of the patient, or race of the patient made any differences in the dose intensity of pain medications selected by the nurse sample. RESULTS: No significant interactions were noted between any combinations of the four independent variables. A significant main effect was noted in medication intensity for nurse gender (F [1,384] = 9.75, p = .002). CONCLUSIONS: Data trends suggested that gender stereotypes about how patients managed pain played a role in dose intensity decisions because female patients on average were given higher doses of pain medication than male patients were by all the nurses in the study. Further research is needed in this complex area of study.

Using Baseline Data to Predict Chronic PTSD 48-months After Mothers Report Intimate Partner Violence: Outcomes for Mothers and the Intergenerational Impact on Child Behavioral Functioning.

Worldwide one in three women report intimate partner violence. Many of these women report long term mental health problems, especially PTSD, which is associated with negative problem solving, isolation, somatization, depression, and anxiety. Children are impacted by their exposure to domestic violence and experience internal (i.e., depression, anxiety) and external (i.e., hostility, delinquency) behavioral clinical problems. To predict which women will experience chronic PTSD symptoms, a PTSD predictor tool was developed and applied to PTSD symptom scores four years after 300 mothers with children (age 18 months to 16 years) received assistance for the violence. At four years, 266 (89%) of the 300 mother child dyads were retained. Of those, 245 met inclusion criteria for this study and 53% had scores above the clinical threshold for PTSD. The predictor tool performed well. There was a significant association, χ2 (4) = 11.83, p = .019, Cramer's V = 0.229, between mothers predicted at low/some risk for chronic PTSD and scoring below the cut-off score for diagnostic PTSD symptoms at four years. Mothers predicted to be at extreme risk for chronic PTSD reported PTSD symptoms at or above the diagnostic level at 48 months. Children whose mothers had PTSD were at greater risk for Borderline/Clinical range behavioral problems compared to children whose mothers did not have PTSD. Relative risk values ranged from 2.07 (Externalizing) to 2.30 (Internalizing). When appropriate interventions are available, the PTSD predictor tool can assist with triage and guided referral of women at risk for chronic PTSD.

Journey to Becoming a Neonatal Nurse Practitioner: Making the Decision to Enter Graduate School.

BACKGROUND: Neonatal nurse practitioners (NNPs) play an important role in caring for premature and ill infants. Currently, there is a shortage of NNPs to fill open positions. Understanding how nurses decide to become NNPs will help practicing nurse practitioners, managers, and faculty encourage and support nurses in considering the NNP role as a career choice. PURPOSE: To describe how nurses decide to enter graduate school to become nurse practitioners. METHODS: A qualitative study using semistructured interviews to explore how 11 neonatal intensive care unit nurses decided to enter graduate school to become NNPs. RESULTS: Key elements of specialization, discovery, career decision, and readiness were identified. Conditions leading to choosing the NNP role include working in a neonatal intensive care unit and deciding to stay in the neonatal area, discovering the NNP role, deciding to become an NNP, and readiness to enter graduate school. Important aspects of readiness are developing professional self-confidence and managing home, work, and financial obligations and selecting the NNP program. IMPLICATIONS FOR PRACTICE: Neonatal nurse practitioners are both positive role models and mentors to nurses considering the role. Unit managers are obligated to provide nurses with opportunities to obtain leadership skills. Faculty of NNP programs must be aware of the impact NNP students and graduates have on choices of career and schools. IMPLICATIONS FOR RESEARCH: Exploring the decision to become an NNP in more geographically diverse populations will enhance understanding how neonatal intensive care unit nurses decide to become NNPs.

Partner Abuse of Mothers Compromises Children's Behavioral Functioning Through Maternal Mental Health Dysfunction: Analysis of 300 Mother-Child Pairs.

Partner violence is associated with numerous negative consequences for victims, especially poor mental health. Children who are exposed to partner violence are more likely to have behavior problems. Nevertheless, research on the relationship between severity of abuse, maternal mental health functioning following partner violence, and child behavior problems is limited. We explored the direct and indirect effects on the child's behavioral functioning of severity of maternal abuse and maternal mental health functioning following abuse. A sample of 300 mothers was recruited when they sought assistance for abuse for the first time at shelters for abused women or at the district attorney's office. Severity of abuse, mothers' mental health functioning, and child behavioral functioning were measured by maternal self-report at entry into the study and 4 months later. In SEM analysis, at both entry and 4 months, severity of abuse had a direct effect on maternal mental health functioning, which in turn had a direct effect on child behavioral functioning. The path from severity of abuse to child behavioral functioning also was significant but became non- significant once maternal mental health functioning was added to the equation, indicating that the path from severity of abuse to child behavioral functioning was indirect and occurred as a result of the mother's mental health functioning, which remained directly linked to child behavioral problems. Intergenerational interventions are needed to address both maternal mental health and child behavioral functioning when a mother reports partner violence and is experiencing mental health problems.

Parenting in the Wake of Abuse: Exploring the Mediating Role of PTSD Symptoms on the Relationship Between Parenting and Child Functioning.

BACKGROUND: Children whose mothers report partner violence and symptoms of posttraumatic stress disorder (PTSD) are at risk for behavior dysfunctions. AIM: To examine the mediating effects of maternal PTSD symptoms on the relationship of parenting behaviors to child internalizing and externalizing behavior dysfunctions. FINDINGS: Maternal PTSD symptoms have a partial mediating effect on the relationship between inconsistent discipline and child internalizing and externalizing behaviors. Maternal PTSD symptoms have a fully mediating effect on the relationship between poor supervision and child internalizing behaviors. CONCLUSIONS: There is a need to identify women who report partner violence and are at high risk for PTSD and intervene early to prevent problematic parenting and resulting child behavior problems.

Modeling the intergenerational impact of partner abuse on maternal and child function at 24 months post outreach: Implications for practice and policy.

OBJECTIVE: Many women are exposed to partner violence during their lifetime which affects mental health and child development. This study revalidates an intergenerational model connecting partner violence to poor functioning for mothers and children using structural equation techniques. METHOD: A longitudinal design collected data on 300 mother-child pairs. Comparisons between the model, tested at study entry and again at 24 months, are reported. Maternal measures included childhood experiences of abuse, partner abuse, chronic pain, and mental health. The Child Behavior Checklist measured child function. RESULTS: Comparison of both models revealed that maternal chronic pain, maternal mental health, and child witnessing of mother's abuse remain strong predictors of child dysfunction. Maternal social support and self-efficacy are significant predictors of more positive maternal mental health with a conduit effect on child behavior. CONCLUSION: Intimate partner violence directly impacts the victim and also has a secondary impact on the children of abuse victims.

Predictors and outcomes of community agency use in abused mothers.

OBJECTIVE: To identify characteristics of abused mothers that predict use and difficulty of use of community agencies for intimate partner violence (IPV) and to describe the outcomes of community agency use. DESIGN AND SAMPLE: A prospective study design was used. Three hundred mothers who had experienced physical or sexual IPV and were seeking services for the first time at either a safe shelter for abused women or applying for a protection order. MEASURES: Data were collected and analyzed by the research team. Predictors were tested using binary logistic regression and outcomes were tested using a series of Mann-Whitney U nonparametric test of difference on change scores between baseline and 24-month scores. RESULTS: No individual predictors were statistically significant and/or meaningful for use or difficulty using community agencies. There were significant differences in change scores for severity of violence after women used counseling, the police, or legal services. There were also significant change scores for anxiety after women used legal services and social services. CONCLUSIONS: Abused women need individualized attention to assure that they can access the services they need to recover from IPV. Evidence-based practice is needed for community agencies to treat abused women to facilitate safety and health.

Maternal-child dyads of functioning: the intergenerational impact of violence against women on children.

Violence against women is a global epidemic with potential consequences of injury, illness, and death. Children exposed to the violence may also be impacted with functional impairments. Little is known of the inter-generational impact of violence experienced by the mother from an intimate partner on functioning of her children. No dyad analysis was found in the literature. To examine the inter-generational impact of violence against women on the behavioral functioning of children, 300 mothers reporting intimate partner abuse and one randomly chosen child, age 18 months to 16 years of age; were evaluated for borderline and clinical diagnostic levels of problem behaviors. Linear, Logistic, and Ordinal regression models were applied. Mothers' problem behavior scores were significantly related to children's problem behavior scores (internalizing r = 0.611, externalizing r = 0.494, total problems r = 0.662, all ps < 0.001). Mothers who reported clinical and borderline clinical internalized problems (i.e., depression, anxiety) were 7 times more likely to have children with the same problems and mothers with borderline clinical and clinical external problems (i.e., aggression, hostility) were 4.5 times more likely to have children with the same external problems. These dyadic analyses provide evidence of a direct relationship of maternal functioning on child behavioral functioning. Intervention strategies to decrease internalizing maternal behavioral problems, such as depression, anxiety, and post traumatic stress disorder, and/or externalizing problems, such as hostility and aggression, can be expected to have a pass through, secondary impact on the behavioral functioning of children. Awareness of the relationship between intimate partner violence against mothers and child behavioral function can support interventions that decrease the distress experienced by mothers and their children, interrupt intergenerational transmission of abusive behaviors, and promote better maternal child functioning.

Physical and sexual intimate partner violence, women's health and children's behavioural functioning: entry analysis of a seven-year prospective study.

AIMS AND OBJECTIVES: To increase knowledge of physical and sexual intimate partner violence against women, its impact on women's health and children's behavioural functioning. BACKGROUND: Physical assault and sexual assault frequently co-occur. Women who experience both physical and sexual violence are at risk of poorer health outcomes than women who experience only physical violence. The behavioural functioning of children of women who experience partner violence may be adversely affected. DESIGN: Cross-sectional, using baseline data from a seven-year prospective study. METHODS: Data related to severity of abuse (both physical and sexual) and the outcome measures of maternal (n = 300) mental health measures, risk of lethality, chronic pain and child (n = 300) behavioural functioning were analysed. RESULTS: Higher physical abuse scores were significantly correlated with higher sexual abuse scores, and higher levels of physical abuse were associated with higher maternal anxiety and higher child externalisation scores. Higher levels of sexual abuse were associated with higher maternal somatisation and post-traumatic stress disorder symptoms and higher child internalisation scores and total problems. CONCLUSIONS: These initial findings suggest that children have behavioural functioning and coping that is closely related to their mothers' functioning, which is based on the type of abuse experienced by the mothers. As we gain a greater understanding of these issues, we will be better able to develop effective policies and therapeutic interventions to help abused women and their children. RELEVANCE TO CLINICAL PRACTICE: Findings for the mental health functioning of women participating in this study add to the overwhelming evidence for the importance of screening for partner violence when women present for health care and for the need for effective assistance services for women who have or are currently experiencing partner violence. They also support emerging research that indicates the great need to provide effective services for the children of abused women.

Light for nurses' work in the 21st century: a review of lighting, human vision limitations, and medication administration.

A literature review was conducted to determine the state of the science related to medication errors and light. The limited literature is discussed in relationship to human vision and light needs. Little systematic action has been taken to increase nurses' awareness of the connection between lighting and potential medication errors. Implications for nursing practice and research about light conditions are provided. Interventions from other industries may aid nursing in making decisions about light conditions.

Women's functioning following an intervention for partner violence: new knowledge for clinical practice from a 7-year study.

Intimate partner violence affects one in three women worldwide, with women who experience violence almost twice as likely to experience poor mental health, especially depression, compared with women who are not abused. To learn the impact of interventions of safe shelter and justice services on improved mental health and behavior functioning, 300 abused women are interviewed every 4 months in a 7-year prospective study. For this paper, abuse, mental health and resiliency status of these women, 1 year after accessing services for the first time, are reported. Measures of mental health (depression, anxiety, post-traumatic stress disorder (PTSD), somatization), and adult behavioral functioning are reported. At 4 months following a shelter stay or justice services, a large effect size was measured for improvement in all mental health measures; however, improvement was the lowest for PTSD. All mental health measures plateaued at 4 months with minimum further improvement at 12 months. Both internal behavioral dysfunctions (withdrawal and somatic complaints) were worse with increased depressive symptoms, as were external behavioral dysfunctions (aggressive and rule-breaking behaviors). A concerning 39.2% of the women had clinical PTSD scores at 12 months following receipt of safe shelter or justice services, compared with a much lower percentage of women with clinical depression (14.2%), clinical somatization (9.4%), and clinical anxiety (13.5%). Depression was a significant positive predictor of internal and external behavioral dysfunctions, indicating that women who had higher levels of depression tended to report more internal dysfunctions (withdrawal, anxiety, somatization) and more external behaviors (aggression and rule-breaking).

Afghanistan and Iraq war veterans' health care needs and their underuse of health care resources: implications for psychiatric-mental health nurses.

U.S. Veterans who have served in the Afghanistan and Iraq wars have combat-related medical and mental health issues, notably posttraumatic stress disorder and traumatic brain injury, but underuse health care resources. To better understand their health care needs, resource use, and facilitators and barriers to seeking health care, a literature review was conducted. The results suggest high prevalence of mental and medical health issues and disproportionate use of quantitative research design that lacked approaches to understanding the psychosocial, cultural, and contextual factors that affect help-seeking by Veterans. Strategies to increase the likelihood that Veterans will seek needed health care, gaps in the literature, and the need for further research are discussed.

Resident strategies for making a life in a nursing home: a qualitative study.

AIM: To identify strategies that older adults use to adapt to live in long-term care. BACKGROUND: The use of long-term care services has risen and this trend is expected to continue as the population reaches old age. Moving into a long-term care setting has been documented internationally as an overwhelming life change for many older adults. It has been observed that residents adjust differently over time, but the basis for these differences needs further exploration. DESIGN: A qualitative design using grounded theory method was employed. METHODS: A total of in-depth interviews were conducted in October 2008-February 2009 with a sample of 21 participants. Participants ranged in age from 65-93 years, 81% women and 19% men; mainly Caucasian with one African American and one Hispanic. Length of stay ranged from 3 days to over 9 years living in long-term care so that all stages of adjustment were included in the study. Ground theory method was used to analyse the data. FINDINGS: The results of this study yielded 21 facilitative strategies. The core category identified was personal resiliency, which served as the underpinning for the strategies used by the participants. Strategies were identified in making the decision to move into long-term care and in day-to-day living. CONCLUSION: Understanding the strategies that facilitate residents to make a successful transition to long-term care life will assist nurses to intervene in ways that are supportive. The strategies identified in this study may be used to develop interventions for residents that are having difficulty living in long-term care. Further exploration of how resiliency has an impact on strategies used by residents is clinically relevant, but further research is needed.

The association of pain severity and pain interference levels with abuse experiences and mental health symptoms among 300 mothers: baseline data analysis for a 7-year prospective study.

Women who experience interpersonal violence are at increased risk for anxiety, depression, posttraumatic stress symptoms, and chronic pain and other physical disorders. Although the effects of mental health disorders on women's functioning and well-being are well established, less is known about the effects of pain. We examined participants' (n = 300 mothers) experiences of pain severity and pain interference. Higher levels of pain severity and pain interference were significantly associated with anxiety, PTSD, and depression symptoms. Mental health symptoms compounded by pain, may leave abused women less able to access resources or practice safety behaviors to protect themselves and their children.

An integrative review of expert nursing practice.

PURPOSE: To review relevant literature on expert practice in nursing to assess common characteristics across the breadth of nursing specialties and work settings. ORGANIZING CONSTRUCT: An integrative literature search was conducted with inclusion criteria: (a) primary studies of how clinical staff nurses develop and demonstrate expert practice; (b) subjects from variety of specialties, employment settings, and countries of origin; and (c) studies of clinical staff nurses and not nurses in advanced practice roles. METHODS: Literature published between 1996 and 2009 was reviewed using MEDLINE and the Cumulative Index of Nursing and Allied Health Literature (CINAHL) using the key words "nursing,""expert," and "practice." FINDINGS: The characteristics of expert practice as explicated across a variety of specialty areas of practice and international settings included the following: knowing the patient, intuitive knowledge, reflective practice, risk taking, and skilled know-how. Involvement and engagement of the expert nurse with her or his patients underpin these characteristics. Themes were illustrated in a star model of nursing expert practice surrounded by support and grounded in emotional involvement. CONCLUSIONS: Expert practice develops as nurses gain experience in a specialized practice setting, reflect on and learn from their experience, and develop meaningful relationships with their patients, families, and colleagues. CLINICAL RELEVANCE: The findings provide an understanding of expert nursing practice that can serve as a foundation for efforts to transfer knowledge from expert nurses to less expert nurses in all practice settings to reduce the expertise gap that is now widening.

An innovative, multidisciplinary strategy to improve retention of nursing students from disadvantaged backgrounds.

Nursing students from disadvantaged backgrounds must overcome many barriers in order to succeed. This article will focus on how a multidisciplinary team helped 76 percent of these high-risk students persist in their nursing programs by addressing some of these barriers. Three baccalaureate nursing schools in the Texas Medical Center embarked on a three-year retention program designed to enhance the success of students identified by federal criteria as being at risk. Multidisciplinary teams led various activities, including a study skills component, which included preparing for lectures, taking notes, critical thinking, and test-taking strategies. Also addressed were written and oral communication skills, medical terminology, critical thinking, career coaching, and socialization activities. Collaboration among faculty and students at the three schools was key to the success of the program.

Establishing Concurrent Validity for a Brief PTSD Screen Among Women in a Domestic Violence Shelter.

There is a particular need for valid scales to screen for posttraumatic stress disorder (PTSD) among women who seek safe shelter from intimate partner violence. Screening to identify women who are at risk for PTSD can lead to early intervention that reduces the risk for PTSD-related outcomes such as poor decision making, inconsistent parenting, and behavior dysfunction among their children. The gold standard for diagnosing PTSD is the Clinician-Administered PTSD Scale for Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) (CAPS-5). A seven-item PTSD screen has been used for in this population and has a well-established cutoff score but has not been validated against the DSM-5 diagnostic criteria for PTSD. The study purpose was to establish concurrent validity for a seven-item screen for PTSD with the CAPS-5. Participants were 75 women, 18 years or older, who were residents of a 120-bed shelter in the southern United States. They spoke English or Spanish. They reported intimate partner physical or sexual violence within 4 months of their entry into the study. Following informed consent, data were collected in individual interviews, conducted in either English or Spanish. In addition to demographic data, the seven-item PTSD screen and the CAPS-5 were administered. A receiver operating characteristic (ROC) curve analysis was conducted to assess the concurrent validity of the seven-item PTSD screen with the CAPS-5. The seven-item PTSD screen results were significantly correlated with the CAPS-5 results in this sample (area under the curve [AUC] = .640, z = 2.670, p = .008). Sensitivity was 96.2, and observed specificity was 31.8. The seven-item PTSD screen demonstrates excellent sensitivity (e.g., 96% of true PTSD cases) and acceptable specificity (32% of non-PTSD cases) and can be used to quickly and accurately identify individuals for diagnostic assessment and intervention.

ICU nurses' experiences in providing terminal care.

At least 1 in 5 Americans die while using intensive care service-a number that is expected to increase as society ages. Many of these deaths involve withholding or withdrawing life-sustaining therapies. In these situations, the role of intensive care nurses shifts from providing aggressive care to end-of-life care. While hospice and palliative care nurses typically receive specialized support to cope with death and dying, intensive care nurses usually do not receive this support. Understanding the experiences of intensive care nurses in providing care at the end of life is an important first step to improving terminal care in the intensive care unit (ICU). This phenomenological research study explores the experiences of intensive care nurses who provide terminal care in the ICU. The sample consisted of 18 registered nurses delivering terminal care in an ICU that participated in individual interviews and focus groups. Colaizzi's steps for data analysis were used to identify themes within the context of nursing. Three major themes consisted of (1) barriers to optimal care, (2) internal conflict, and (3) coping. Providing terminal care creates significant personal and professional struggles among ICU nurses.

Exploring violence against women and adverse health outcomes in middle age to promote women's health.

A history of intimate partner violence (IPV) is linked to cardiovascular disorders among women. Static autonomic nervous system (ANS) imbalance may result from chronic stress associated with exposure to IPV. Autonomic nervous system imbalance is associated with an excessive proinflammatory response that may increase the risk for inflammatory diseases, including atherosclerosis. To better understand the process from IPV to poorer health outcomes in women diagnosed with acute coronary syndrome (ACS) we developed and tested a biobehavioral model of the psychological and biological pathway from IPV to chronic illness. We hypothesized that among women hospitalized for ACS, those who reported sexual abuse, with or without physical abuse, would have greater alterations in their serum levels of neuroendocrine markers, proinflammatory cytokines, and cell adhesion molecules and a chemotactic cytokine, at time of hospitalization for ACS, and 3 and 6 months later, than do women with physical abuse only. Participants were 45 women, primarily African American, admitted to a county hospital with a diagnosis of ACS. We evaluated 11 biomarkers and found a moderate group effect size for vascular cell adhesion molecule-1. All others had a small effect size.