Methods and Processes Used to Collect Pressure Injury Risk and Prevention Measures in the National Database of Nursing Quality Indicators® (NDNQI®).

BACKGROUND: Previous research found that reliability estimates for chart-extracted quality of care data vary. PURPOSE: The purpose was to examine methods and processes used to gather data on the National Database of Nursing Quality Indicators (NDNQI) pressure injury (PI) risk and prevention measures to identify factors that may influence their reliability. METHODS: Study participants (N = 120) from 36 hospitals completed a 35-item online survey. Included were the NDNQI PI Survey Team member with the most experience and/or skill in patient record review from each hospital (n = 36) and 84 other NDNQI PI Survey Team members. RESULTS: In general, participants followed NDNQI PI data collection guidelines. However, deviations were noted such as 60 (50%) participants collected PI data on units where they work, and 92 (76.7%) determined whether moisture management was performed by direct observation of patients rather than chart documentation. CONCLUSIONS: Findings provide insight on how to improve the reliability of hospital-acquired PI risk and prevention measures that includes clarification of the data collection guidelines.

Symptoms and Health-Related Quality of Life in Patients Receiving Cancer Therapy Matched to Genomic Profiles.

OBJECTIVES: To examine symptom occurrence and severity and overall health-related quality of life (HRQOL) in patients receiving cancer therapy guided by genomic profiling (matched therapy) and patients receiving nonmatched therapy. SAMPLE & SETTING: A retrospective and secondary analysis of data from 129 individuals with breast or gynecologic cancer receiving care at a regional outpatient cancer center. METHODS & VARIABLES: Descriptive statistics and multiple linear regression analyses were performed. Study variables included symptom occurrence and severity, HRQOL, and person- and health-/illness-related factors. Symptom occurrence and severity were measured by the Therapy-Related Symptom Checklist (TRSC), and HRQOL was measured by the HRQOL-Linear Analogue Self-Assessment. RESULTS: Individuals receiving matched therapy had lower mean TRSC scores compared to individuals receiving nonmatched therapy, but the difference was not statistically significant. HRQOL scores among individuals receiving matched therapy were not significantly higher than those receiving nonmatched therapy. Individuals with higher TRSC scores had significantly lower HRQOL. IMPLICATIONS FOR NURSING: The effects of matched therapy on an individual should be examined. Study findings are an initial step in understanding the symptom occurrence and severity and HRQOL.

Exploring the Relationship Between Nursing Specialty Certification and Surgical Site Infections.

OBJECTIVE: The aim of this study is to explore the relationship between nursing specialty certification and surgical site infections (SSIs) for colon (COLO) and abdominal hysterectomy (HYST) surgical procedures. BACKGROUND: SSI following COLO and HYST procedures is a preventable complication now included in the Centers for Medicare & Medicaid Services' Hospital Inpatient Quality Reporting Program. METHODS: Data from 69 hospitals, 346 units, and 6585 RNs participating in the National Database of Nursing Quality Indicators and SSI data on 22 188 patient COLO and HYST procedures from the National Healthcare Safety Network were examined in multivariate logistic regression analysis. RESULTS: Magnet® status was associated with lower SSI occurrence after adjusting for other variables. Higher American Society of Anesthesiologists scores, longer surgical procedure time, and wound class were associated with higher SSI occurrence. CONCLUSIONS: Future theory-based research should examine the association of nursing specialty certification with patient outcomes and investigate the effect of Magnet status on SSI.

Characteristics of the Nursing Practice Environment Associated With Lower Unit-Level RN Turnover.

OBJECTIVE: The aim of this study is to examine characteristics of the nursing practice environment associated with lower RN turnover. BACKGROUND: Identifying characteristics of the practice environment that contribute to lower RN turnover is important for meeting the national quality strategy priority of reducing healthcare costs. METHODS: Data from 1002 adult care units in 162 National Database of Nursing Quality Indicators participating hospitals were analyzed using multivariate linear regression. The Practice Environment Scale of the Nursing Work Index was used to measure practice environment characteristics. RN turnover was measured at the unit level. RESULTS: Nursing units with higher overall ratings of the nursing practice environment had lower rates of RN turnover. Units with higher RN perceived staffing and resource adequacy experienced significantly lower RN turnover. CONCLUSIONS: Unit managers and hospital administrators should consider RN perception of staffing and resource adequacy and the overall practice environment when developing targeted strategies for decreasing RN turnover.

Pressure Ulcer Risk and Prevention Practices in Pediatric Patients: A Secondary Analysis of Data from the National Database of Nursing Quality Indicators®.

Little is known about pressure ulcer prevention practice among pediatric patients. To describe the frequency of pressure ulcer risk assessment in pediatric patients and pressure ulcer prevention intervention use overall and by hospital unit type, a descriptive secondary analysis was performed of data submitted to the National Database for Nursing Quality Indicators® (NDNQI®) for at least 3 of the 4 quarters in 2012. Relevant data on pressure ulcer risk from 271 hospitals across the United States extracted from the NDNQI database included patient skin and pressure ulcer risk assessment on admission, time since the last pressure ulcer risk assessment, method used to assess pressure ulcer risk, and risk status. Extracted data on pressure ulcer prevention included skin assessment, pressure-redistribution surface use, routine repositioning, nutritional support, and moisture management. These data were organized by unit type and merged with data on hospital characteristics for the analysis. The sample included 39 984 patients ages 1 day to 18 years on 678 pediatric acute care units (general pediatrics, pediatric critical care units, neonatal intensive care units, pediatric step-down units, and pediatric rehabilitation units). Descriptive statistics were used to analyze study data. Most of the pediatric patients (33 644; 89.2%) were assessed for pressure ulcer risk within 24 hours of admission. The Braden Q Scale was frequently used to assess risk on general pediatrics units (75.4%), pediatric step-down units (85.5%), pediatric critical care units (81.3%), and pediatric rehabilitation units (56.1%). In the neonatal intensive care units, another scale or method was used more often (55% to 60%) to assess pressure ulcer risk. Of the 11 203 pediatric patients (39%) determined to be at risk for pressure ulcers, the majority (10 741, 95.8%) received some kind of pressure ulcer prevention intervention during the 24 hours preceding the NDNQI pressure ulcer survey. The frequency of prevention intervention use among those at risk ranged from 99.2% for skin assessment to 70.7% for redistribution surface use. Most pediatric patients are being assessed for pressure ulcer risk, but the implementation of interventions to prevent pressure ulcers among children needs to be improved. Future qualitative research should be conducted to determine how and when clinical judgment is used to assess pressure ulcer risk and the type of pressure-redistribution surfaces used among younger pediatric patients.

Pressure Injury Prevalence and the Rate of Hospital-Acquired Pressure Injury Among Pediatric Patients in Acute Care.

PURPOSE: The purpose of this study was to describe the prevalence and rate of hospital-acquired pressure injuries (HAPIs) in pediatric patients. DESIGN: Descriptive, secondary analysis of 2012 data on pressure injuries among pediatric patients from the National Database for Nursing Quality Indicators (NDNQI). SUBJECTS AND SETTING: The sample included 39,984 patients 1 day to 18 years old from 678 pediatric acute care units (general pediatrics, pediatric critical care, neonatal intensive care, pediatric step-down, and pediatric rehabilitation units) in 271 US hospitals that submitted pressure injury data to the NDNQI for at least 3 quarters during 2012. RESULTS: The pressure injury prevalence was 1.4% and the prevalence of HAPI was 1.1%. The rate of HAPI among males was 1.06%, and the rate among females was 1.14%. HAPI rates were highest among children ages 9 to 18 years (1.6%) and 5 to 8 years (1.4%) and lowest among patients 1 to 30 days of age (0.72%). By unit type, HAPIs were highest among patients in pediatric critical care units (3.7%) and pediatric rehabilitation units (4.6%) and lowest in general pediatrics units (0.57%). Most of the HAPIs were Stage 1 and Stage 2 (65.6%); 14.3% were deep tissue pressure injuries and 10.1% were unstageable pressure injuries. CONCLUSION: Acutely ill children develop pressure injuries, including HAPI. Study findings provide data on HAPI from a large sample of hospitalized children and by pediatric unit type for comparison purposes.

Relationship of Wound, Ostomy, and Continence Certified Nurses and Healthcare-Acquired Conditions in Acute Care Hospitals.

PURPOSE: The purpose of this study was to describe the (a) number and types of employed WOC certified nurses in acute care hospitals, (b) rates of hospital-acquired pressure injury (HAPI) and catheter-associated urinary tract infection (CAUTI), and (c) effectiveness of WOC certified nurses with respect to lowering HAPI and CAUTI occurrences. DESIGN: Retrospective analysis of data from National Database of Nursing Quality Indicators. SUBJECTS AND SETTINGS: The sample comprised 928 National Database of Nursing Quality Indicators (NDNQI) hospitals that participated in the 2012 NDNQI RN Survey (source of specialty certification data) and collected HAPI, CAUTI, and nurse staffing data during the years 2012 to 2013. METHODS: We analyzed years 2012 to 2013 data from the NDNQI. Descriptive statistics summarized the number and types of employed WOC certified nurses, the rate of HAPI and CAUTI, and HAPI risk assessment and prevention intervention rates. Chi-square analyses were used to compare the characteristics of hospitals that do and do not employ WOC certified nurses. Analysis-of-covariance models were used to test the association between WOC certified nurses and HAPI and CAUTI occurrences. RESULTS: Just more than one-third of the study hospitals (36.6%) employed WOC certified nurses. Certified continence care nurses (CCCNs) were employed in fewest number. Hospitals employing wound care specialty certified nurses (CWOCN, CWCN, and CWON) had lower HAPI rates and better pressure injury risk assessment and prevention practices. Stage 3 and 4 HAPI occurrences among hospitals employing CWOCNs, CWCNs, and CWONs (0.27%) were nearly half the rate of hospitals not employing these nurses (0.51%). There were no significant relationships between nurses with specialty certification in continence care (CWOCN, CCCN) or ostomy care (CWOCN, COCN) and CAUTI rates. CONCLUSIONS: CWOCNs, CWCNs, and CWONs are an important factor in achieving better HAPI outcomes in acute care settings. The role of CWOCNs, CCCNs, and COCNs in CAUTI prevention warrants further investigation.

Nurse staffing and patient outcomes: a longitudinal study on trend and seasonality.

BACKGROUND: Time trends and seasonal patterns have been observed in nurse staffing and nursing-sensitive patient outcomes in recent years. It is unknown whether these changes were associated. METHODS: Quarterly unit-level nursing data in 2004-2012 were extracted from the National Database of Nursing Quality Indicators® (NDNQI®). Units were divided into groups based on patterns of missing data. All variables were aggregated across units within these groups and analyses were conducted at the group level. Patient outcomes included rates of inpatient falls and hospital-acquired pressure ulcers. Staffing variables included total nursing hours per patient days (HPPD) and percent of nursing hours provided by registered nurses (RN skill-mix). Weighted linear mixed models were used to examine the associations between nurse staffing and patient outcomes at trend and seasonal levels. RESULTS: At trend level, both staffing variables were inversely associated with all outcomes (p < 0.001); at seasonal level, total HPPD was inversely associated (higher staffing related to lower event rate) with all outcomes (p < 0.001) while RN skill-mix was positively associated (higher staffing related to higher event rate) with fall rate (p < 0.001) and pressure ulcer rate (p = 0.03). It was found that total HPPD tended to be lower and RN skill-mix tended to be higher in Quarter 1 (January-March) when falls and pressure ulcers were more likely to happen. CONCLUSIONS: By aggregating data across units we were able to detect associations between nurse staffing and patient outcomes at both trend and seasonal levels. More rigorous research is needed to study the underlying mechanism of these associations.

A pressure ulcer and fall rate quality composite index for acute care units: A measure development study.

BACKGROUND: Composite indices are single measures that combine the strengths of two or more individual measures and provide broader, easy-to-use measures for evaluation of provider performance and comparisons across units and hospitals to support quality improvement. OBJECTIVE: The study objective was to develop a unit-level inpatient composite nursing care quality performance index-the Pressure Ulcer and Fall Rate Quality Composite Index. DESIGN: Two-phase measure development study. SETTINGS: 5144 patient care units in 857 United States hospitals participating in the National Database of Nursing Quality Indictors® during the year 2013. METHODS: The Pressure Ulcer and Fall Rate Quality Composite Index was developed in two phases. In Phase 1 the formula was generated using a utility function and generalized penalty analysis. Experts with experience in healthcare quality measurement provided the point of indicator equivalence. In Phase 2 initial validity evidence was gathered based on hypothesized relationships between the Pressure Ulcer and Fall Rate Quality Composite Index and other variables using two-level (unit, hospital) hierarchical linear mixed modeling. RESULTS: The Pressure Ulcer and Fall Rate Quality Composite Index=100-PUR-FR, where PUR is pressure ulcer rate and FR is total fall rate. Higher scores indicate better quality. Bland-Altman plots demonstrated agreement between pairs of experts and provided evidence for inter-rater reliability of the formula. The validation process demonstrated that higher registered nurse skill mix, higher percent of registered nurses with a baccalaureate in nursing or higher degree, higher percent of registered nurses with national specialty certification, and lower percent of hours supplied by agency staff were significantly associated with higher Pressure Ulcer and Fall Rate Quality Composite Index scores. Higher percentages of unit patients at risk for a hospital-acquired pressure ulcer and higher unit rates of physical restraint use were not associated with higher Pressure Ulcer and Fall Rate Quality Composite Index scores. CONCLUSIONS: The Pressure Ulcer and Fall Rate Quality Composite Index is a step toward providing a more holistic perspective of unit level nursing quality than individual measures and may help nurses nursing administrators obtain a broader view of which patient care units are the higher and lower performers. Further study is needed to examine the usability of the Pressure Ulcer and Fall Rate Quality Composite Index.

Inter-Rater Agreement of Pressure Ulcer Risk and Prevention Measures in the National Database of Nursing Quality Indicators(®) (NDNQI).

In this descriptive multi-site study, we examined inter-rater agreement on 11 National Database of Nursing Quality Indicators(®) (NDNQI(®) ) pressure ulcer (PrU) risk and prevention measures. One hundred twenty raters at 36 hospitals captured data from 1,637 patient records. At each hospital, agreement between the most experienced rater and each other team rater was calculated for each measure. In the ratings studied, 528 patients were rated as "at risk" for PrU and, therefore, were included in calculations of agreement for the prevention measures. Prevalence-adjusted kappa (PAK) was used to interpret inter-rater agreement because prevalence of single responses was high. The PAK values for eight measures indicated "substantial" to "near perfect" agreement between most experienced and other team raters: Skin assessment on admission (.977, 95% CI [.966-.989]), PrU risk assessment on admission (.978, 95% CI [.964-.993]), Time since last risk assessment (.790, 95% CI [.729-.852]), Risk assessment method (.997, 95% CI [.991-1.0]), Risk status (.877, 95% CI [.838-.917]), Any prevention (.856, 95% CI [.76-.943]), Skin assessment (.956, 95% CI [.904-1.0]), and Pressure-redistribution surface use (.839, 95% CI [.763-.916]). For three intervention measures, PAK values fell below the recommended value of ≥.610: Routine repositioning (.577, 95% CI [.494-.661]), Nutritional support (.500, 95% CI [.418-.581]), and Moisture management (.556, 95% CI [.469-.643]). Areas of disagreement were identified. Findings provide support for the reliability of 8 of the 11 measures. Further clarification of data collection procedures is needed to improve reliability for the less reliable measures. © 2016 Wiley Periodicals, Inc.

Concurrent and lagged effects of registered nurse turnover and staffing on unit-acquired pressure ulcers.

OBJECTIVE: We examined the concurrent and lagged effects of registered nurse (RN) turnover on unit-acquired pressure ulcer rates and whether RN staffing mediated the effects. DATA SOURCES/SETTING: Quarterly unit-level data were obtained from the National Database of Nursing Quality Indicators for 2008 to 2010. A total of 10,935 unit-quarter observations (2,294 units, 465 hospitals) were analyzed. METHODS: This longitudinal study used multilevel regressions and tested time-lagged effects of study variables on outcomes. FINDINGS: The lagged effect of RN turnover on unit-acquired pressure ulcers was significant, while there was no concurrent effect. For every 10 percentage-point increase in RN turnover in a quarter, the odds of a patient having a pressure ulcer increased by 4 percent in the next quarter. Higher RN turnover in a quarter was associated with lower RN staffing in the current and subsequent quarters. Higher RN staffing was associated with lower pressure ulcer rates, but it did not mediate the relationship between turnover and pressure ulcers. CONCLUSIONS: We suggest that RN turnover is an important factor that affects pressure ulcer rates and RN staffing needed for high-quality patient care. Given the high RN turnover rates, hospital and nursing administrators should prepare for its negative effect on patient outcomes.

Pressure ulcers and prevention among acute care hospitals in the United States.

BACKGROUND: Most pressure ulcers can be prevented with evidence-based practice. Many studies describe the implementation of a pressure ulcer prevention program but few report the effect on outcomes across acute care facilities. METHODS: Data on hospital-acquired pressure ulcers and prevention from the National Database of Nursing Quality Indicators 2010 Pressure Ulcer Surveys were linked to hospital characteristics and nurse staffing measures within the data set. The sample consisted of 1,419 hospitals from across the United States and 710,626 patients who had been surveyed for pressure ulcers in adult critical care, step-down, medical, surgical, and medical/surgical units. Hierarchical logistic regression analysis was performed to identify study variables associated with hospital-acquired pressure ulcers among patients at risk for these ulcers. RESULTS: The rate of hospital-acquired pressure ulcers was 3.6% across all surveyed patients and 7.9% among those at risk. Patients who received a skin and pressure ulcer risk assessment on admission were less likely to develop a pressure ulcer. Additional study variables associated with lower hospital-acquired pressure ulcer rates included a recent reassessment of pressure ulcer risk, higher Braden Scale scores, a recent skin assessment, routine repositioning, and Magnet or Magnet-applicant designation. Variables associated with a higher likelihood of hospital-acquired pressure ulcers included nutritional support, moisture management, larger hospital size, and academic medical center status. CONCLUSIONS: Results provide empirical support for pressure ulcer prevention guideline recommendations on skin assessment, pressure ulcer risk assessment, and routine repositioning, but the 7.9% rate of hospital-acquired pressure ulcers among at-risk patients suggests room for improvement in pressure ulcer prevention practice.

Relationship between major depression and insulin resistance: does it vary by gender or race/ethnicity among young adults aged 20-39 years?

BACKGROUND: To examine the relationship between major depression and insulin resistance by gender and race/ethnicity among young adults without diabetes mellitus. METHODS: Secondary analyses of cross-sectional data from the National Health and Nutrition Examination Survey 1999-2008 were performed (n = 2265). Major depression was measured by the Composite International Diagnostic Interview and the Patient Health Questionnaire 9. Insulin resistance was measured by the homeostasis model assessment of insulin resistance. Multivariate logistic regression analyses adjusted for risk factors of insulin resistance were conducted. RESULTS: There was a significant negative association between major depression and insulin resistance among men. For women, no significant association was found. There was no significant interaction between race/ethnicity and major depression on insulin resistance (Wald χ(2) = 4.2927, P = 0.2315). Body mass index (BMI) and waist circumference (WC) were significantly associated with insulin resistance among both men (odds ratio [OR] 1.255, 95% confidence interval [CI] 1.195-1.318 for BMI; OR 1.095, 95% CI 1.076-1.115 for WC) and women (OR 1.220, 95% CI 1.182-1.260 for BMI; OR 1.084, 95% CI 1.064-1.105 for WC). CONCLUSIONS: There are gender differences in the relationship between major depression and insulin resistance among adults aged 20-39 years. No evidence was found to support the role of race/ethnicity in this relationship. Health care professionals should be aware of risk factors for insulin resistance and develop interventions to help prevent the progression of insulin resistance to type 2 diabetes mellitus.

Unit-level time trends and seasonality in the rate of hospital-acquired pressure ulcers in US acute care hospitals.

This is a longitudinal study of the trend and seasonality in unit-level hospital-acquired pressure ulcer (HAPU) rates from 2004 to 2011, for 5447 acute care nursing units in 733 US hospitals. Unit-level HAPU rates decreased significantly during 2004-2007 (OR = 0.91, 95% CI [0.90, 0.91]) and the decreasing trend was much stronger during 2008-2011 (OR = 0.84 [0.83, 0.85]). Seasonal variations in HAPU rates were strong and consistent during 2004-2008, with the highest HAPU rate in Quarter 1 (Jan-Mar) and the lowest rate in Quarter 3 (Jul-Sep). During 2009-2011, the magnitude of this seasonality was greatly reduced, and only HAPU rate in Quarter 1 remained significantly higher than HAPU rates in other quarters.

Linking RN workgroup job satisfaction to pressure ulcers among older adults on acute care hospital units.

We examined the relationship between registered nurse (RN) workgroup job satisfaction and hospital-acquired pressure ulcers (HAPUs) among older adults on six types of acute care units. Random-intercept logistic regression analyses were performed using 2009 unit-level data from the National Database of Nursing Quality Indicators® (NDNQI®) and the NDNQI RN Survey. Overall, RN workgroup job satisfaction was negatively associated with HAPU rates, although the relationship varied by unit type. RN workgroup satisfaction was significantly associated with HAPU rates on critical care, medical, and rehabilitation units. No significant association was found on step-down, surgical, and medical-surgical units. Findings provide evidence that higher RN workgroup job satisfaction is related to lower HAPU rates among older adult patients in acute care hospitals.

Outcome and assessment information set data that predict pressure ulcer development in older adult home health patients.

OBJECTIVES: To identify risk factors for pressure ulcer (PrU) development in older adult home health patients from admission Outcome and Assessment Information Set (OASIS) data. DESIGN: Retrospective cohort study. SETTING: A convenience sample of 5 home healthcare agencies from across the United States. PARTICIPANTS: The cohort sample included 5395 nonhospice patients 60 years or older who were admitted for intermittent skilled home healthcare between September 30, 2007, and January 30, 2009. MAIN MEASURES: OASIS data on age, sex, race/ethnicity, diagnoses, caregiving, mental health status, clinical status, and functional status relevant to PrU risk were extracted from the electronic medical record of eligible patients in participating agencies. Patient OASIS data were followed forward chronologically from admission to new PrU development or discharge. MAIN RESULTS: The 3323 females (61.6%) and 2072 males (38.4%) ranged from age 60 to 103 years (mean, 78.2 [SD, 8.6] years). The cumulative incidence of PrUs was 1.3% (n = 71 patients). Multiple logistic regression analyses revealed that bowel incontinence, needing assistance with grooming, dependence in ability to dress the upper body, dependence in ability to dress the lower body, dependence in toileting, inability to transfer, being chairfast or bedfast, and the presence of a PrU on admission were positively associated with new PrU development. Among patients who were PrU-free on admission, bowel incontinence and inability to transfer best predicted PrU development. CONCLUSION: Results suggest that OASIS data can be used to identify patients who are at risk for PrUs with potential for use nationwide.

The reliability of the National Database of Nursing Quality Indicators pressure ulcer indicator: a triangulation approach.

A triangulation approach was used to examine the reliability of the National Database of Nursing Quality Indicators pressure ulcer indicator that included direct observation of these wounds in hospitalized patients and web-based testing with and without accompanying wound descriptions. Overall κ coefficients for pressure ulcer identification, staging, and origin indicate moderate to near perfect reliability and suggest that web-based testing can estimate the reliability of pressure ulcer staging from direct observation. Nurse certification in wound care and wound descriptors improved reliability levels.

Adapting pressure ulcer prevention for use in home health care.

PURPOSE: Clinical practice guidelines on pressure ulcer (PU)prevention have been written primarily for inpatient settings,but we currently lack data as to how these guidelines have been adapted for use in home health care. The purpose of this study was to delineate interventions and activities used to prevent PU in home health care. DESIGN: Focus group study using text analysis. SUBJECTS: A focus group was conducted with 9 certified wound care nurses who practiced in home health care at least 50% of the time. Most of the participants had 10 or more years of home health experience and 5 or more years of wound care experience. METHODS: The single 75-minute focus group was convened by teleconference and audiotaped. A semistructured moderator's guide was used to lead the discussion. Transcribed data were analyzed using standard text analysis. Preliminary results were distributed to focus group participants for review, comment, or clarification, and refined as needed. RESULTS: Certified wound care nurse participants used an array of interventions, including those recommended by clinical practice guidelines, to prevent PU in home health patients.However, specific activities differed from those performed in hospitals and nursing homes. Interventions unique to homehealth care included (1) assessment of patients' economic and insured status to determine implementation options, (2) assessment of caregiving resources and caregivers' ability to manage PU prevention, and (3) collaboration with community resources and health care vendors to obtain needed prevention materials and supplies. CONCLUSION: Findings provide insight into guideline adaptation in home health care and suggest that PU prevention in the homehealth care setting is more complex than that in hospitals and nursing homes and requires significant skills in communication and collaboration.

Major depressive disorder and insulin resistance in nondiabetic young adults in the United States: the National Health and Nutrition Examination Survey, 1999-2002.

OBJECTIVE: The association between depression and insulin resistance has been evaluated in previous studies with conflicting results. This study aimed to explore the relationship between major depressive disorder (MDD) and insulin resistance among nondiabetic young adult men and women in the United States. METHOD: Analyses of cross-sectional data from the National Health and Nutrition Examination Survey (NHANES), 1999-2002, were conducted. The nationally representative sample consisted of 279 men and 358 women aged 20-39 years. MDD was determined by the WHO Composite International Diagnostic Interview (CIDI). Insulin resistance was measured by the homeostasis model assessment for insulin resistance. RESULTS: Of 637 subjects, 16 men and 18 women had MDD (weighted percentage = 6.6%, SE = 1.2). Using logistic regression, no significant association was found between MDD and insulin resistance among the nondiabetic young adults in bivariate analysis (ß = -0.01, OR = 0.99, 95% CI = [0.38, 2.57], p = .98). A significant interaction effect between gender and MDD was observed. For men, MDD was negatively associated with insulin resistance after adjusting for age, race/ethnicity, waist circumference, smoking status, systolic blood pressure and triglyceride level (ß = -2.12, OR = 0.12, 95% CI = [0.02, 0.62], p = .01). No significant association between MDD and insulin resistance among women was found (ß = 0.61, OR = 1.84, 95% CI = [0.47, 7.14], p = .38). CONCLUSIONS: Overall findings suggest there is no significant association between MDD and insulin resistance among nondiabetic young adults aged 20-39 years. However, gender differences in this relationship were noted.

Reliability, validity and factor structure of the Appraisal of Self-Care Agency Scale-Revised (ASAS-R).

RATIONALE, AIMS AND OBJECTIVES: Self-care agency is a fundamental concept in nursing and health care research. Having self-care agency enhances an individual's health-promoting behaviours and/or specific capabilities for chronic disease self-management. The purpose of this study was to continue the development and psychometric testing of the Appraisal of Self-Care Agency - Revised (ASAS-R). METHODS: A cross-sectional methodological design was used to examine the reliability, validity and factor structure of the ASAS-R among individuals from the general population. The sample consisted of 629 adults who were randomly selected to conduct an exploratory factor analysis (EFA; n=240) and a confirmatory factor analysis (CFA; n=389) of the scale. A demographic questionnaire, the ASAS-R and the Health-Promoting Lifestyle Profile (HPLP-II) were the measures used to collect the data. RESULTS: The final 15-item three-factor ASAS-R had an overall Cronbach's alpha (α) of 0.89. The three factors extracted, rotated and scored in this study were labelled: having power for self-care, developing power for self-care and lacking power for self-care. All inter-items and item-to-total correlations met recommended criteria of r=0.30 to r=0.70, except for one of the items that had an item-to-total correlation of 0.71, slightly exceeding the maximum recommended item-to-total correlation. The three factors had Cronbach's alphas of 0.86, 0.83 and 0.79, respectively. The three factors together explained 61.7% of the scale items variance. Each item of the scale had a strong factor loading ranging from 0.52 to 0.81. All measures of model fit exceeded the recommended criteria, indicating that the 15-item ASAS-R had a very good fit (χ(2) /d.f.=1.97, GFI=0.94, AGFI=0.92, CFI=0.96, TLI=0.95, RMSEA=0.05, RMR=0.05 and the PCLOSE=0.48). CONCLUSIONS: The 15-item three-factor ASAS-R is a short, reliable and valid instrument to measure self-care agency among individuals from the general population, but further psychometric evaluation is needed among individuals with chronic diseases, especially those with diabetes mellitus.