Racial and Ethnic Variations in Mortality Rates for Patients Undergoing Maintenance Dialysis Treated in US Territories Compared with the US 50 States.

BACKGROUND AND OBJECTIVES: In the United States mortality rates for patients treated with dialysis differ by racial and/or ethnic (racial/ethnic) group. Mortality outcomes for patients undergoing maintenance dialysis in the United States territories may differ from patients in the United States 50 states. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study of using US Renal Data System data included 1,547,438 adults with no prior transplantation and first dialysis treatment between April 1, 1995 and September 28, 2012. Cox proportional hazards regression was used to calculate hazard ratios (HRs) of death for the territories versus 50 states for each racial/ethnic group using the whole cohort and covariate-matched samples. Covariates included demographics, year of dialysis initiation, cause of kidney failure, comorbid conditions, dialysis modality, and many others. RESULTS: Of 22,828 patients treated in the territories (American Samoa, Guam, Puerto Rico, Virgin Islands), 321 were white, 666 were black, 20,299 were Hispanic, and 1542 were Asian. Of 1,524,610 patients in the 50 states, 838,736 were white, 444,066 were black, 182,994 were Hispanic, and 58,814 were Asian. The crude mortality rate (deaths per 100 patient-years) was lower for whites in the territories than the 50 states (14 and 29, respectively), similar for blacks (18 and 17, respectively), higher for Hispanics (27 and 16, respectively), and higher for Asians (22 and 15). In matched analyses, greater risks of death remained for Hispanics (HR, 1.65; 95% confidence interval, 1.60 to 1.70; P<0.001) and Asians (HR, 2.01; 95% confidence interval, 1.78 to 2.27; P<0.001) living in the territories versus their matched 50 states counterparts. There were no significant differences in mortality among white or black patients in the territories versus the 50 states. CONCLUSIONS: Mortality rates for patients undergoing dialysis in the United States territories differ substantially by race/ethnicity compared with the 50 states. After matched analyses for comparable age and risk factors, mortality risk no longer differed for whites or blacks, but remained much greater for territory-dwelling Hispanics and Asians.

Regional Variations in the Interpretation of the End-Stage Renal Disease Thirty-Month Coordination Period: Potential Implications for Patient Care.

Chronic kidney disease is a non-communicable disease that is now well recognized as a major source of premature morbidity and mortality. In general, racial/ethnic minorities in the United States are more likely than non-minority groups to develop end-stage renal disease (ESRD), but paradoxically most have a lower mortality risk. Unlike most minorities, dialysis patients in Puerto Rico have a mortality risk nearly 50% higher than the national average. Multiple factors such as medical conditions, socioeconomic, environmental, and health system factors can influence health outcomes for patients with ESRD. We describe one potential health system factor that may contribute to this finding, a unique interpretation and implementation of the ESRD Medicare Secondary Payer provision in the Commonwealth of Puerto Rico. We conducted a search of regulatory documents and key stakeholder interviews to help envision the potential implications of these differences for dialysis facilities, health care providers, and patients with ESRD.

Assessing Learning Styles of Graduate Entry Nursing Students as a Classroom Research Activity: A quantitative research study.

BACKGROUND: A number of studies across different disciplines have investigated students' learning styles. Differences are known to exist between graduate and baccalaureate nursing students. However, few studies have investigated the learning styles of students in graduate entry nursing programs. . OBJECTIVES: Study objective was to describe graduate entry nursing students' learning styles. DESIGN/SETTING/PARTICIPANTS/METHODS: A descriptive design was used for this study. The Index of Learning Styles (ILS) was administered to 202 graduate entry nursing student volunteers at a southwestern university. Descriptive statistics, tests of association, reliability, and validity were performed. Graduate nursing students and faculty participated in data collection, analysis, and dissemination of the results. RESULTS: Predominant learning styles were: sensing - 82.7%, visual - 78.7%, sequential - 65.8%, and active - 59.9%. Inter-item reliabilities for the postulated subscales were: sensing/intuitive (α=0.70), visual/verbal (α=0.694), sequential/global (α=0.599), and active/reflective (α=0.572). Confirmatory factor analysis for results of validity were: χ2(896)=1110.25, p<0.001, CFI=0.779, TLI=0.766, WRMR=1.14, and RMSEA =0.034. CONCLUSIONS: Predominant learning styles described students as being concrete thinkers oriented toward facts (sensing); preferring pictures, diagrams, flow charts, demonstrations (visual); being linear thinkers (sequencing); and enjoying working in groups and trying things out (active),. The predominant learning styles suggest educators teach concepts through simulation, discussion, and application of knowledge. Multiple studies, including this one, provided similar psychometric results. Similar reliability and validity results for the ILS have been noted in previous studies and therefore provide sufficient evidence to use the ILS with graduate entry nursing students. This study provided faculty with numerous opportunities for actively engaging students in data collection, analysis, and dissemination of results.

Study on the Effects of Individualized Learning Therapy on Cognitive Function and Behavioral and Psychological Symptoms of Dementia in the Institutionalized Older Adults.

BACKGROUND: The increasing number of elderly people affected by dementia in Taiwan has made dementia care a crucial issue of concern. This issue is particularly important in terms of the proper management of behavioral symptoms and improvement of the cognitive functions of those affected by this disease. PURPOSE: This study examined the effects of individualized learning therapy on cognition and neuropsychiatric symptoms among elderly people with dementia. METHODS: A quasi-experimental, pretest-posttest research design was adopted. We recruited elderly people with dementia at the only two institutions for elderly patients with dementia in Central Taiwan. These institutions were assigned randomly as the experimental or control group, with totals of 23 and 21 participants, respectively. The participants in the experimental group received individualized learning therapy for 30 minutes twice weekly for 3 months. The comparison group received usual care only. The cognitive function and neuropsychiatric symptoms of all participants were measured using the Mini-Mental Status Examination (MMSE) before the start of and immediately after the 12-week intervention and the Chinese version of the Neuropsychiatric Inventory (CNPI), which was administered once per week during the intervention. Independent t tests (or Mann-Whitney U tests), chi-square tests (or Fisher's exact tests), paired t test, and generalized estimating equations were used for data analysis. RESULTS: Participants in the experimental group had significantly higher MMSE scores (p < .01) and lower CNPI scores (p < .01) than their comparison group peers after the intervention. Furthermore, the neuropsychiatric symptoms in the experimental group such as hallucinations, bizarre behavior, depression, apathetic expression, irritability, and sleep disorder had significantly improved by the seventh week. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Individualized learning therapy may be an effective approach to improve cognitive function and reduce neuropsychiatric symptoms among older people with dementia. Therefore, future clinical application is warranted.

Improving Human Papillomavirus Vaccinations in Military Women.

The purpose of this evidence-based project was to provide patient education to increase human papillomavirus (HPV) vaccination rates in military women. Despite the availability of a vaccine, HPV continues to be the most common sexually transmitted infection in the United States. The goal of this program was to increase patient knowledge and HPV vaccination rates by providing education and a verbal recommendation for vaccination during regularly scheduled well-woman exams. The project resulted in a 65% increase in vaccination rates, raising the preprogram vaccination rate of 55% to a postintervention vaccine percentage of 91%. The results demonstrate the importance of patient education and provider recommendation in vaccine acceptance.

Relationship Between Age and Pre-End Stage Renal Disease Care in Elderly Patients Treated with Maintenance Hemodialysis.

Receipt of pre-end stage renal disease (ESRD) clinical care can improve outcomes for patients treated with maintenance hemodialysis (HD). This study addressed age-related variations in receipt of a composite of recommended care to include nephrologist and dietician care, and use of an arteriovenous fistula at first outpatient maintenance HD. Less than 2% of patients treated with maintenance HD received all three forms of pre-ESRD care, and 63.3% received none of the three elements of care. The mean number of pre-ESRD care elements received by the oldest group (80 years and older) did not differ from the youngest group (less than 55 years), but was less than the 55 to 66 and 67 to 79 years groups; adjusted ratios of 0.93 (0.92 to 0.94; p < 0.001) and 0.94 (0.92 to 0.95; p < 0.001), respectively. A major effort is needed to ensure comprehensive pre-ESRD care for all patients with advanced chronic kidney disease (CKD), especially for the youngest and oldest patient groups, who were less likely to receive recommended pre-ESRD care.

Pediatric Pain Management: An Evidence-Based Approach.

Numerous studies have shown that in comparison to adults, children do not receive analgesia (oligoanalgesia) and are not adequately treated for pain. Several organizations, including The Joint Commission and Institute of Medicine (IOM) have emphasized patients' rights to pain management and the need for initial assessment and ongoing evaluation. Nurses are responsible for assessing patients' pain and implementing appropriate pain management in the emergency department (ED). Evidence suggests that nurses' lack of knowledge about pain assessment in children contributes to inadequate pain management. Studies also show that the use of pain assessment tools appropriate to a child's age and cognitive development play a vital role in improving pain assessment documentation, prompting nurses to provide pain medication. The purpose of this quality improvement project was to improve nurses' assessment and management of children's pain in an emergency department. A total of 1,200 EMRs of pediatric patients ages 3 months to 6 years of age were reviewed before and after an educational intervention (600 before and 600 after the intervention). Pain education for ED nurses improved pain assessment and management among children.

Anxiety, Decision Conflict, and Health in Caregivers of Children with ADHD: A Survey.

The purpose of this study was to test a theoretical model to determine the effect of caregiver anxiety and decision conflict on the health of caregivers of children with ADHD. Cross-sectional analyses were conducted on data derived from caregivers (aged 24-70). Participants completed the Decision Conflict Scale, the Zung Anxiety Scale, the Duke Health Profile, and a demographic form. A path model that fit well indicated that anxiety and decision conflict had direct and indirect effects on the caregivers' health. Future study is needed to clarify factors contributing to uncertainty and to decrease emotional symptoms for caregivers, thus promoting their mental health.

Factors affecting perceptions of family function in caregivers of children with attention deficit hyperactivity disorders.

BACKGROUND: Attention deficit and hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. ADHD has been shown to persist into adulthood in 30%-70% of cases. The long-term and escalating nature of ADHD creates an increasing burden on families because of the influence of hyperactivity and impulsivity on academic achievement and social interaction. There is a lack of information on factors influencing function in the families of children with ADHD. PURPOSE: The purpose of this study was to test theoretically derived relationships among family demographic characteristics; family factors such as support, hardiness, and caregiver health; and family-functioning outcomes. METHODS: This study used a cross-sectional study and structural equation modeling approach. A self-report questionnaire collected information from 122 caregivers on demographics, income, employment, and marital status data as well as on personal health, family support, family hardiness, and family function statuses as determined, respectively, using the Duke Health Profile, Family APGAR score, Family Hardiness Index, and Family Assessment Device. RESULTS: Structural equation modeling provided a reasonable fit to the data using AMOS (χ = .249, df = 1, p = .613, minimum discrepancy C = .249), goodness-of-fit index (.999), adjusted goodness of fit index (.990), normed fit index (.999), comparative fit index (1.0), and root mean square error of approximation (.000). Results indicated a 55.6% probability of becoming the construct model, with family hardiness and family support directly affecting family function and caregiver health. Family support functioned as a mediator in the relationship between family hardiness and family function. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: The findings of this study help nurses improve professional assessments and interventions for families of children with ADHD by highlighting the importance of increased family support, promoting family hardiness, and promoting caregivers' health to improved family function.

Supporting cardiovascular risk reduction in overweight and obese hypertensive patients through DASH diet and lifestyle education by primary care nurse practitioners.

PURPOSE: To describe an intervention among overweight and obese hypertensive patients, encouraging Dietary Approaches to Stop Hypertension (DASH) diet and lifestyle changes, designed and led by a primary care nurse practitioner (NP). DATA SOURCES: A pre- and postintervention quasi-experimental time-series design was implemented over 2 months. Intervention included three group classes and two individual counseling telephone calls. Forty-five hypertensive patients enrolled, with a mean age of 55 years and mean initial BMI of 32. Twenty-six (58%) completed the program. Standard instruments (Rapid Eating Assessment for Patients [REAP] and Partners in Health [PIH] questionnaires) were used to evaluate diet and lifestyle factors before and after the program. CONCLUSIONS: Participants had statistically significant improvements in diet and lifestyle scores on both REAP and PIH questionnaires, as well as statistically significant weight loss (average 3.6 pounds lost) over the 2-month intervention period. IMPLICATIONS FOR PRACTICE: This NP-led primary care intervention on diet and lifestyle showed early success in improving the health of overweight and obese hypertensive patients. Investment in NP-led diet and lifestyle counseling should be considered among high-risk patients in the primary care setting.

Community engagement approach: developing a culturally appropriate intervention for Hispanic mother-child dyads.

Childhood obesity affects approximately 20% of U.S. preschool children. Early prevention is needed to reduce young children's risks for obesity, especially among Hispanic preschool children who have one of the highest rates of obesity. Vida Saludable was an early childhood obesity intervention designed to be culturally appropriate for low-income Hispanic mothers with preschool children to improve maternal physical activity and reduce children's sugar-sweetened beverage consumption. It was conducted at a large southwestern United States urban health center. Presented here are the methods and rationale employed to develop and culturally adapt Vida Saludable, followed by scoring and ranking of the intervention's cultural adaptations. An empowered community helped design the customized, culturally relevant program via a collaborative partnership between two academic research institutions, a community health center, and stakeholders. Improved health behaviors in the participants may be attributed in part to this community-engagement approach. The intervention's cultural adaptations were scored and received a high comprehensive rank. Postprogram evaluation of the intervention indicated participant satisfaction. The information presented provides investigators with guidelines, a template, and a scoring tool for developing, implementing, and evaluating culturally adapted interventions for ethnically diverse populations.

Relationship Between Age and Timely Placement of Vascular Access In Incident Patients on Hemodialysis.

BACKGROUND AND PURPOSE: Placement of an arteriovenous fistula (AV) prior to initiating hemodialysis can affect clinical outcomes for patients who subsequently initiate chronic hemodialysis treatments. Age-related variation in receipt of a functioning A TF prior to initiating hemodialysis is not well known. The purpose of this study was to examine age-related rates in use of AVF at the first outpatient hemodialysis treatment among U.S. incident patients on hemodialysis. FINDINGS: Among 526,145 patients identified, the use of AVF outpatient hemodialysis treatment was lower in the youngest (younger than 55 years) and oldest (80 years and older) vs. both 55 to 66-year and 67 to 79-year age groups. These findings persisted after adjusting for demographics, lifestyle behavior, employment and insurance status, physical/functional conditions, and co-morbid conditions. CONCLUSIONS: The presence of a functioning AVF at initial hemodialysis treatment varies by age. Modifying healthcare policy and/or expanding the role of nephrology nurses should be considered to address this issue.

Identifying critical thinking indicators and critical thinker attributes in nursing practice.

BACKGROUND: Critical thinking is an essential skill in the nursing process. Although several studies have evaluated the critical thinking skills of nurses, there is limited information related to the indicators of critical thinking or evaluation of critical thinking in the context of the nursing process. PURPOSE: This study investigated the potential indicators of critical thinking and the attributes of critical thinkers in clinical nursing practice. Knowledge of these indicators can aid the development of tools to assess nursing students' critical thinking skills. METHODS: The study was conducted between September 2009 and August 2010. In phase 1, a literature review and four focus groups were conducted to identify the indicators of critical thinking in the context of nursing and the attributes of critical thinkers. In phase 2, 30 nursing professionals participated in a modified Delphi research survey to establish consensus and the appropriateness of each indicator and attribute identified in phase 1. RESULTS: We identified 37 indicators of critical thinking and 10 attributes of critical thinkers. The indicators were categorized into five subscales within the context of the nursing process toreflect nursing clinical practice: assessment, 16 indicators of ability to apply professional knowledge and skills to analyze and interpret patient problems; diagnosis, five indicators of ability to propose preliminary suppositions; planning, five indicators of ability to develop problem-solving strategies; implementation, five indicators of ability to implement planning; and evaluation, six indicators of ability to self-assess and reflect. CONCLUSION/IMPLICATIONS FOR PRACTICE: The study operationalized critical thinking into a practical indicator suitable for nursing contexts in which critical thinking is required for clinical problem solving. Identified indicators and attributes can assist clinical instructors to evaluate student critical thought skills and development-related teaching strategies.

Determinants of physical activity in primary school students using the health belief model.

BACKGROUND: Thailand is a middle-income country in which two-thirds of children demonstrate an insufficient level of physical activity. Physical inactivity is a major risk factor for obesity and many other health-related consequences in children. Thus, it is important to understand how primary school children perceive things in their daily life as determinants of physical activity. The purpose of this study was to investigate the impact of cues, perceived benefits, and perceived barriers on the level of physical activity among primary school students. METHODS: A cross-sectional study was conducted in Phitsanulok Province, Thailand, in 2011. Multistage sampling selected a total of 123 primary school students. The Physical Activity Questionnaire for Older Children and the Cues, Perceived Benefits, and Barriers to Physical Activity Questionnaire were used to assess the student levels of physical activity, as well as the perceived benefits, barriers, and cues to action. The association between these factors and the level of physical activity was determined by correlation statistics and confirmed by robust regression. Multivariate analysis of variance compared health belief model determinants: perceived benefits, perceived barriers, and cues to action on physical activity between male and female students. Self-administered questionnaires were validated and tested in a pilot study. RESULTS: The level of activity among primary school children was significantly influenced by perceived barriers, such as fear of strangers when playing outdoors, bad weather, and too much homework. However, activity was not influenced by cues to action or perceived benefits. Perceived benefits, barriers, and cues to physical activity did not differ by gender. CONCLUSION: A safe environment and fewer barriers, such as amount of homework, could enhance physical activity in primary school children.

Literature review: patients' and health care providers' perceptions of stressors in critical care units.

The purpose of this article was to provide a historical review and analysis of the research literature focusing on patients', nurses', and health care providers' perceptions of stressors in the critical care setting. A narrative historical literature review method was used. The inclusion criteria include English-language studies of stressors as perceived by patients and health care providers from 1984 to 2011. Several studies investigated perceptions of stressors using the Environmental Stressors Questionnaire and the findings did not show any significant changes of stress perception over time since 1989 until the present. There is a need to further investigate stress perceptions in the health care setting using a mixed qualitative and quantitative approach to provide a more precise description of stressors and stress perceptions in the critical care setting.

Cross-cultural research: challenge and competence.

Increasing globalization, population diversity and health disparities among non-dominant cultures necessitate cross-cultural research. Research with other cultures is fraught with challenges that must be addressed by the competent cross-cultural researcher. Areas for consideration include choice of research foci, ethical concerns, cultural adaptation of research measurements and interventions, participant recruitment and retention, strategies for data collection and analysis, dissemination of findings and perspectives of time. Approaches to dealing with these challenges are addressed, with an emphasis on community-based participatory research.

Preventing intensive care unit delirium: a patient-centered approach to reducing sleep disruption.

Delirium in the intensive care unit is a disorder with multifactorial causes and is associated with poor outcomes. Sleep-wake disturbance is a common experience for patients with delirium. Care processes that disrupt sleep can lead to sleep deprivation, contributing to delirium. Patient-centered care is a concept that considers what is best for each individual. How can clinicians use a patient-centered approach to alter processes to decrease patient disruptions and improve sleep and rest? Could timing of blood draws and soothing music work to promote sleep?

The Patient Protection and Affordable Care Act of 2010 (PL 111-148): an analysis of maternal-child health home visitation.

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act, setting in motion a historic and, for many, a long-awaited radical change to the current American health care system. Section 2951 of the PPACA addresses provision and funding of maternal, infant, and early childhood home visiting programs. The purpose of this article is to acquaint the reader with the legislative odyssey of home visitation services to at-risk prenatal and postpartum women and children as delineated in the PPACA and to discuss the nursing practice and research implications of this landmark legislation. Few question the need for more rigorous methodology in all phases of home visitation research. Public health nursing may provide the comprehensive approach to evaluating effective home visitation programs.

Cultural Adaptation for Ethnic Diversity: A Review of Obesity Interventions for Preschool Children.

Obesity disproportionately affects U.S. ethnic minority preschool children, placing them at risk for obesity related co-morbidities and premature death. Effective culturally appropriate interventions are needed to improve health behaviors and reduce obesity in young high-risk minority children, while their behaviors are still developing. All known obesity intervention studies (e.g., diet and physical activity) since 2000 targeting U.S. ethnic minority preschool children were reviewed. Five electronic databases and eight published literature reviews were used to identify the studies. Intervention studies without identified ethnic minority participants were excluded. Ten obesity interventions studies met the review criteria. Published cultural adaptation guidelines were used to develop a mechanism to analyze, score, and rank the intervention adaptations. Cultural adaptations varied widely in rigor, depth, and breadth. Results indicated a relative absence of appropriately adapted obesity interventions for ethnic minority groups, suggesting a need for more rigorous cultural adaptation guidelines when designing obesity interventions for diverse ethnicities. Culturally appropriate adaptations appeared to enhance intervention relevance, effectiveness, and feasibility. The purpose of this literature review was to evaluate 1) the type and extent of cultural adaptations strategies applied to the interventions, and 2) how these adaptations related to the study outcomes.