The Impact of Behavioral Lifestyle Intervention on Inflammatory Cytokines in Older Adults Living With Type 2 Diabetes: A Feasibility Study.

OBJECTIVE: This study investigates the effects of a behavioral lifestyle intervention on inflammatory cytokines and frailty in older adults (≥ 65 years) with type 2 diabetes (T2D). METHOD: We conducted a single-arm, 6-month intervention supplemented with diet and activity self-monitoring technology. We assessed frailty using Fried criteria and quantified inflammatory cytokines (interleukin [IL]-2, IL-4, IL-6, IL-8, IL-10, granulocyte-macrophage colony-stimulating-factor [GM-CSF], interferon [IFN-γ], tumor necrosis factor [TNF-α]) using a multiplex assay. We used paired t-tests with significance at P < .05. We calculated the Spearman correlation and evaluated the relationship between frailty, BMI, and inflammatory cytokines. RESULTS: Eighteen participants completed the study (mean ± SD: 71.5 ± 5.3 years; BMI: 34 ± 6 kg/m2). At baseline, we had 4 frail, 13 pre-frail, and 1 non-frail participant. At 6 months, we observed the therapeutic effects of the intervention on frailty score, BMI, IL-2, IFN-y, and GM-CSF. DISCUSSION: The study highlights the importance of behavioral lifestyle intervention in improving inflammatory cytokines and frailty in older adults.

Innovation in Collaborative Online Learning Yields Sustainable Model for University-wide Interprofessional Education.

BACKGROUND: Growing health professional accreditation mandates and expectations for interprofessional education (IPE) have led to heightened interest amongst health professions educators and administrators in the creation and development of effective and sustainable IPE programming. IPE ACTIVITY: At the University of Texas Health Science Center at San Antonio, an institution-wide initiative called Linking Interprofessional Networks for Collaboration (LINC) was initiated to strengthen IPE knowledge and skills, increase IPE offerings, and integrate IPE into curricula. In 2020, stakeholders developed, implemented, and evaluated a university-wide IPE activity called the LINC Common IPE Experience, which includes three collaborative online learning modules that students complete synchronously using a videoconference platform without direct faculty facilitation. Mini-lectures, interprofessional discussions, and authentic case studies using innovative media facilitated meaningful engagement of 977 students from 26 different educational programs. DISCUSSION: Quantitative and qualitative results from evaluations demonstrated significant student engagement, increased awareness and understanding of teamwork, progress towards interprofessional competency development, and benefits related to professional development. The LINC Common IPE Experience provides a valuable example of a robust, high-impact foundational IPE activity that can serve as a sustainable model for university-wide IPE.

Perceptions and Use of Safe Sleep Baby Boxes at Hospital Discharge by New Mothers.

BACKGROUND: A large community hospital in South Texas began distributing safe sleep baby boxes to reduce sudden unexplained infant death (SUID) in 2017. PURPOSE: To describe safe sleep practices among new mothers who received a safe sleep baby box at hospital discharge. METHODS: An information sheet containing a link to an online survey was mailed to all women who received a safe sleep baby box prior to discharge from the hospital from January 2018 to January 2019. RESULTS: N = 84 women participated. Most reported using the safe sleep baby box only during nap time (n = 62, 88.6%). Only 70.2% of participants reported that baby always slept their back (n = 59). Most reported their baby did not use a pacifier (n = 62, 73.8%), and many reported they were not breastfeeding their baby (n = 38, 45.2%). CLINICAL IMPLICATIONS: Many women were not using the safe sleep baby box as intended and were not following many of the other safe sleep guidelines. Nurses should ask their patients about plans for infant safe sleep after discharge to provide individualized education or recommend specific resources to address the family's needs.

Application of the Flipped Classroom Approach in an Undergraduate Maternal-Newborn Nursing Course to Improve Clinical Reasoning.

Application of knowledge is shown to improve student comprehension, but with dwindling hands-on clinical opportunities in nursing programs, active learning strategies need to be incorporated into classroom learning. Nursing faculty in an undergraduate nursing program transitioned from a lecture format to a flipped classroom format, thereby incorporating active learning. Quantitative and qualitative data on student performance were collected over three semesters. The Assessment Technologies Institute (ATI) maternal-newborn content mastery exam, used as the final examination for the course, was used to assess student academic performance. End-of-course student feedback was collected from the Campuslabs IDEA Student Rating of Instruction (SRI) evaluation to assess students' perceptions of their ability to understand and apply knowledge, as well as perceptions of the flipped classroom format in general. The ATI exam scores for the course did not change significantly, but the SRI showed a statistically significant increase in the percentage of students who felt they gained a "deeper understanding" and could "apply the knowledge and skills." Although students resisted the flipped classroom format change initially, subsequent cohorts came to accept the change. Implications for educators are that although student dissatisfaction increased initially, the inclusion of the flipped classroom format within a course improved students' confidence in their ability to perform.

Systemic inequities and depressive symptomology in Hispanic mothers: A path analysis model.

BACKGROUND: Hispanic mothers are one of the largest groups to give birth. They also experience high rates of morbidity and mortality; however, there is limited data related to their health inequities. PURPOSE: The purpose of this study was to evaluate systemic inequities associated with discrimination using the Reproductive Justice Framework to observe factors that influenced depressive symptomology in Hispanic women. METHODS: A path analysis was conducted to evaluate systemic inequities that influenced postpartum depression using the public database, Listening to Mothers III (LMIII). The sub-sample consisted of n = 406 Hispanic mothers. Data was initially collected between the years 2011 and 2013. RESULTS: Hispanic mothers were more likely to experience occurrences of perceived discrimination while seeking perinatal healthcare. These occurrences of discrimination led to lower trust in their healthcare providers, lower satisfaction with care, more instances of unwanted medical procedures, the need to feel to hold back comments about their health which ultimately resulted in higher rates of self-reported postpartum depression. The model fit indices supported the model's plausibility (χ2 /df ratio = 3.16, Comparative Fit Index = 0.91, Root Mean Square Error of Approximation = 0.06). CONCLUSIONS: This data supported our hypothesis that the pathway of discriminatory barriers Hispanic mothers experience during pregnancy influence postpartum depression.

Improving the Safety, Effectiveness, and Efficiency of Clinical Alarm Systems: Simulation-Based Usability Testing of Physiologic Monitors.

BACKGROUND: Clinical alarm system safety is a national patient safety goal in the United States. Physiologic monitors are associated with the highest number of device alarms and alarm-related deaths. However, research involving nurses' use of physiologic monitors is rare. Hence, the identification of critical usability issues for monitors, especially those related to patient safety, is a nursing imperative. OBJECTIVE: This study examined nurses' usability of physiologic monitors in intensive care units with respect to the effectiveness and efficiency of monitor use. METHODS: In total, 30 nurses from 4 adult intensive care units completed 40 tasks in a simulation environment. The tasks were common monitoring tasks that were crucial for appropriate monitoring and safe alarm management across four categories of competencies: admitting, transferring, and discharging patients using the monitors (7 tasks); managing measurements and monitor settings (23 tasks); performing electrocardiogram (ECG) analysis (7 tasks); and troubleshooting alarm conditions (3 tasks). The nurse-monitor interaction was video-recorded. The principal investigator and two expert intensive care units nurse educators identified, classified, and validated task success (effectiveness) and the time of task completion (efficiency). RESULTS: Among the 40 tasks, only 2 (5%) were successfully completed by all the nurses. At least 1-27 (3%-90%) nurses abandoned or did not correctly perform 38 tasks. The task with the shortest completion time was "take monitor out of standby" (mean 0:02, SD 0:01 min:s), whereas the task "record a 25 mm/s ECG strip of any of the ECG leads" had the longest completion time (mean 1:14, SD 0:32 min:s). The total time to complete 37 navigation-related tasks ranged from a minimum of 3 min 57 s to a maximum of 32 min 42 s. Regression analysis showed that it took 6 s per click or step to successfully complete a task. To understand the nurses' thought processes during monitor navigation, the authors analyzed the paths of the 2 tasks with the lowest successful completion rates, where only 13% (4/30) of the nurses correctly completed these 2 tasks. Although 30% (9/30) of the nurses accessed the correct screen first for task 1 and task 2, they could not find their way easily from there to successfully complete the 2 tasks. CONCLUSIONS: Usability testing of physiologic monitors revealed major ineffectiveness and inefficiencies in the current nurse-monitor interactions. The results indicate the potential for safety and productivity issues in completing routine tasks. Training on monitor use should include critical monitoring functions that are necessary for safe, effective, efficient, and appropriate monitoring to include knowledge of the shortest navigation path. It is imperative that vendors' future monitor designs mimic clinicians' thought processes for successful, safe, and efficient monitor navigation.

Nursing diagnoses of impaired memory and chronic confusion for older adults: diagnostic content validation.

OBJECTIVE: To validate the defining characteristics of the nursing diagnoses, impaired memory and chronic confusion for older adults, by testing diagnostic concept definitions among expert nurses. METHODS: We used a Diagnostic content validation using an online survey of expert clinical nurses. RESULTS: 195 expert nurses performed the diagnostic validations. Findings provided validity of impaired memory with 11 major defining characteristics and chronic confusion, with 11 major and one minor defining characteristics. In both diagnoses, content validity index was 0.85. Factor analysis provided four and five supported factors for impaired memory and chronic confusion, respectively. CONCLUSION: The study provided evidence of validity of the two diagnoses and made them clearer. Using these updated nursing diagnoses, nurses have the potential to improve accuracy and quality of care for elderly patients, contributing to more accurate nursing gerontological care.

Nursing diagnoses of impaired memory and chronic confusion for older adults: diagnostic content validation / Diagnósticos de enfermagem memória prejudicada e confusão crônica para idosos: validação de conteúdo diagnóstico / Diagnósticos de enfermería memoria deteriorada y confusión crónica en adultos mayores: validación del contenido diagnóstico

ABSTRACT Objective: To validate the defining characteristics of the nursing diagnoses, impaired memory and chronic confusion for older adults, by testing diagnostic concept definitions among expert nurses. Methods: We used a Diagnostic content validation using an online survey of expert clinical nurses. Results: 195 expert nurses performed the diagnostic validations. Findings provided validity of impaired memory with 11 major defining characteristics and chronic confusion, with 11 major and one minor defining characteristics. In both diagnoses, content validity index was 0.85. Factor analysis provided four and five supported factors for impaired memory and chronic confusion, respectively. Conclusion: The study provided evidence of validity of the two diagnoses and made them clearer. Using these updated nursing diagnoses, nurses have the potential to improve accuracy and quality of care for elderly patients, contributing to more accurate nursing gerontological care.

RESUMO Objetivo: Validar as características definidoras dos diagnósticos de enfermagem memória prejudicada e confusão crônica para idosos, testando as definições dos diagnósticos entre enfermeiros especialistas. Método: Validação de conteúdo diagnóstico utilizando um questionário online para enfermeiros clínicos especialistas. Resultados: 195 enfermeiras especialistas realizaram as validações diagnósticas. Os resultados demonstraram a validade de memória prejudicada com 11 características definidoras principais, e confusão crônica com 11 características definidoras principais e uma secundária. Em ambos os diagnósticos, o índice de validade de conteúdo foi de 0,85. A análise fatorial forneceu quatro para memória prejudicada e cinco fatores para confusão crônica. Conclusão: O estudo forneceu evidências de validade dos dois diagnósticos, tornando-os mais claros. Por meio do uso desses diagnósticos de enfermagem atualizados, os enfermeiros podem melhorar a precisão e a qualidade do atendimento a pacientes idosos, contribuindo para um cuidado gerontológico de enfermagem mais preciso.

RESUMEN Objetivo: Validar las características que definen los diagnósticos de enfermería memoria deteriorada y confusión crónica en adultos mayores, testeando las definiciones de los diagnósticos entre enfermeros especialistas. Método: Se trata de una validación del contenido diagnóstico realizado mediante un cuestionario en línea para enfermeros clínicos especialistas. Resultados: Las validaciones de diagnóstico las llevaron a cabo 195 enfermeras especialistas. Los resultados demostraron la validez del deterioro de la memoria con 11 características principales definidoras y la confusión crónica, con 11 principales definidoras y una secundaria. En ambos diagnósticos, la tasa de validez del contenido fue de 0,85. El análisis factorial proporcionó cuatro factores para el deterioro de la memoria y cinco para la confusión crónica. Conclusión: El estudio trajo evidencias de la validez de los dos diagnósticos y los dejó más claros. Al valerse de estos diagnósticos actualizados, los enfermeros pueden mejorar la precisión y la calidad de la atención de los pacientes adultos mayores y contribuir aún más con el cuidado gerontológico de enfermería.

Changes in Patient-Reported Outcome Measures With a Technology-Supported Behavioral Lifestyle Intervention Among Patients With Type 2 Diabetes: Pilot Randomized Controlled Clinical Trial.

BACKGROUND: In the United States, more than one-third of the adult population is obese, and approximately 25.2% of those aged ≥65 years have type 2 diabetes (T2D), which is the seventh leading cause of death. It is important to measure patient-reported outcomes and monitor progress or challenges over time when managing T2D to understand patients' perception of health and quantify the impact of disease processes or intervention effects. The evaluation of patient-reported outcome measures (PROMs) is especially important among patients with multiple chronic conditions in which clinical measures do not provide a complete picture of health. OBJECTIVE: This study examined the feasibility of collecting Patient-Reported Outcome Measurement Information System (PROMIS) measures, and preliminarily evaluated changes in PROMIS scores and compared the scores with standard scores of the general US population. The parent study is a pilot randomized controlled clinical trial testing three different modes (mobile health [mHealth], paper diary, and control) of self-monitoring in a behavioral lifestyle intervention among overweight or obese patients with T2D. METHODS: Patients with comorbid overweight or obesity and a diagnosis of T2D for at least 6 months were recruited from a diabetes education program. Participants were randomized to the following three groups: mHealth, paper diary, and control (standard of care) groups. Paper diary and mHealth experimental groups received additional behavioral lifestyle intervention education sessions, as well as tools to self-monitor weight, physical activity, diet, and blood glucose. All participants completed PROMIS-57 and PROMIS-Global Health (GH) version 1.0 questionnaires during visits at baseline, 3 months, and 6 months. The PROMIS-57 includes the following seven domains: anxiety, depression, fatigue, pain interference, physical function, satisfaction with participation in social roles, and sleep disturbance. The PROMIS-GH is composed of the following two domains: global mental health and global physical health. RESULTS: A total of 26 patients (mHealth, 11; paper diary, 9; control, 6) were included in our analysis. The study sample was predominantly African American (68%) and female (57%), with a mean age of 54.7 years and a mean BMI of 37.5 kg/m2. All patients completed the PROMIS-57 and PROMIS-GH questionnaires, and we compared the mean scores of the three groups to investigate potential differences. No relevant differences were noted across the groups. However, positive trends were noted in both intervention (mHealth and paper diary) groups in the middle (month 3) and end (month 6) of the study. CONCLUSIONS: Our pilot study provides evidence for the feasibility of using PROMIS questionnaires to record important components of T2D-related symptoms among overweight or obese individuals. The results from our study support the use of PROMIS questionnaires to provide clinicians and researchers with a benchmark for assessing the overall need for symptom management and determining the success or challenges of an intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT02858648; https://clinicaltrials.gov/ct2/show/NCT02858648.

Sampling Methods.

Knowledge of sampling methods is essential to design quality research. Critical questions are provided to help researchers choose a sampling method. This article reviews probability and non-probability sampling methods, lists and defines specific sampling techniques, and provides pros and cons for consideration. In addition, issues related to sampling methods are described to highlight potential problems.

Nurse Competence on Physiologic Monitors Use: Toward Eliminating Alarm Fatigue in Intensive Care Units.

BACKGROUND: Studies on nurse competence on alarm management are a few and tend to be focused on limited skills. In response to Phase II of implementing the National Patient Safety Goal on clinical alarm systems safety, this study assessed nurses' perceived competence on physiologic monitors use in intensive care units (ICUs) and developed and validated a tool for this purpose. METHODS: This descriptive study took place in a Magnet hospital in a Southwestern state of the U.S. A Nurse Competence on Philips Physiologic Monitors Use Survey was created and went through validation by 13 expert ICU nurses. The survey included 5 subscales with 59 rated items and two open-ended questions. Items on the first 4 subscales reflect most common tasks nurses perform using physiologic monitors. Items on the fifth subscale (advanced functions) reflect rarely used skills and were included to understand the scope of utilizing advanced physiologic monitors' features. Thirty nurses from 4 adult ICUs were invited to respond to the survey. RESULTS: Thirty nurses (100%) responded to the survey. The majority of nurses were from Neuro (47%) and Surgical Trauma (37%) ICUs. The data supported the high reliability and construct validity of the survey. At least one (3%) to 8 nurses (27%) reported lack of confidence on each item on the survey. On the first four subscales, 3% - 40% of the nurses reported they had never heard of or used 27 features/functions on the monitors. No relationships were found between subscales' scores and demographic characteristics (p > .05). Nurses asked for training on navigating the central-station monitor and troubleshooting alarms, and the use of unit-specific super users to tailor training to users' needs. CONCLUSION: This is the first study to create and test a list of competencies for physiologic monitors use. Rigorous, periodic and individualized training is essential for safe and appropriate use of physiologic monitors and to decrease alarm fatigue. Training should be comprehensive to include all necessary skills and should not assume proficiency on basic skills. Special attention should be focused on managing technical alarms. Increasing the number of super users is a recommended strategy for individualized and unit-specific training. There is a need for a usability testing of complex IT-equipped medical devices, such as physiologic monitors, for effective, efficient and safe navigation of the monitors.

Assessing and addressing moral distress and ethical climate Part II: neonatal and pediatric perspectives.

Moral distress remains a pervasive and, at times, contested concept in nursing and other health care disciplines. Ethical climate, the conditions and practices in which ethical situations are identified, discussed, and decided, has been shown to exacerbate or ameliorate perceptions of moral distress. The purpose of this mixed-methods study was to explore perceptions of moral distress, moral residue, and ethical climate among registered nurses working in an academic medical center. Two versions of the Moral Distress Scale in addition to the Hospital Ethical Climate Survey were used, and participants were invited to respond to 2 open-ended questions. Part I reported the findings among nurses working in adult acute and critical care units. Part II presents the results from nurses working in pediatric/neonatal units. Significant differences in findings between the 2 groups are discussed. Subsequent interventions developed are also presented.

Assessing and addressing moral distress and ethical climate, part 1.

BACKGROUND: There is minimal research exploring moral distress and its relationship to ethical climate among nurses working in acute care settings. OBJECTIVES: Objectives of the study were to explore moral distress, moral residue, and perception of ethical climate among registered nurses working in an academic medical center and develop interventions to address study findings. METHOD: A mixed-methods design was used. Two versions of Corley and colleagues' Moral Distress Scale, adult and pediatric/neonatal, were used in addition to Olson's Hospital Ethical Climate Survey. Participants were invited to respond to 2 open-ended questions. This article reports the results for those nurses working in adult acute and critical care units. RESULTS: The sample (N = 225) was predominantly female (80%); half held a bachelor of science in nursing or higher, were aged 30 to 49 years, and staff nurses (77.3%). The mean item score for moral distress intensity ranged from 3.79 (SD, 2.21) to 2.14 (SD, 2.42) with mean item score frequency ranging from 2.86 (SD, 1.88) to 0.23 (SD, 0.93). The mean score for total Hospital Ethical Climate Survey was 94.39 (SD, 18.3) ranging from 23 to 130. Qualitative comments described bullying, lateral violence, and retribution. DISCUSSION: Inadequate staffing and perceived incompetent coworkers were the most distressing items. Almost 22% left a previous position because of moral distress and perceived the current climate to be less ethical compared with other participants. Findings may potentially impact nurse retention and recruitment and negatively affect the quality and safety of patient care. Interventions developed focus on the individual nurse, including ethics education and coping skills, intraprofessional/interprofessional approaches, and administrative/policy strategies.

Existential neuroscience: effects of mortality salience on the neurocognitive processing of attractive opposite-sex faces.

Being reminded of the inherently finite nature of human existence has been demonstrated to elicit strivings for sexual reproduction and the formation and maintenance of intimate relationships. Recently, it has been proposed that the perception of potential mating partners is influenced by mortality salience. Using functional magnetic resonance imaging, we investigated the neurocognitive processing of attractive opposite-sex faces after priming with death-related words for heterosexual men and women. Significant modulations of behavioral and neural responses were found when participants were requested to decide whether they would like to meet the presented person. Men were more in favor of meeting attractive women after being primed with death-related words compared to a no-prime condition. Increased neural activation could be found under mortality salience in the left anterior insula and the adjacent lateral prefrontal cortex (lPFC) for both men and women. As previously suggested, we believe that the lPFC activation reflects an approach-motivated defense mechanism to overcome concerns that are induced by being reminded of death and dying. Our results provide insight on a neurocognitive level that approach motivation in general, and mating motivation in particular is modulated by mortality salience.

Development and psychometric testing of the Nursing Research Self-Efficacy Scale (NURSES).

BACKGROUND AND PURPOSE: The Nursing Research Self-Efficacy Scale (NURSES) was designed to measure individual nurses' degree of research self-efficacy and their perceptions regarding their unit's collective support of research use. Development for the NURSES instrument spanned a 4-year period, which included initial development, revisions, and psychometric evaluations. METHOD: The NURSES is a 38-item Likert-scale instrument developed through ongoing instrument validation that included content validation and exploratory and confirmatory analysis. The 5 subscales include obtaining science-based knowledge resources, critically reading and evaluating quantitative research literature, critically reading and evaluating qualitative research literature, understanding and applying theory, and collective research efficacy. RESULTS: Over a 4-year period, approximately 1000 practicing nurses from multiple hospitals responded to the instrument. Exploratory and confirmatory factor analyses supported the existence of four subscales for research self-efficacy and one subscale for collective research efficacy. Reliability for the subscales was excellent, ranging from .94 to .97. CONCLUSIONS: Hospitals may wish to use the NURSES instrument as an orientation tool, or to examine relationships between research efficacy and nurses' professional development. Health care facilities on a Magnet journey might also use the NURSES instrument to assess their nursing staff as they pursue evidence-based practice and conduct research.

Hierarchical regression and structural equation modeling: two useful analyses for life course research.

This article reviews the life course perspective and considers various life course hypotheses such as trajectories, transitions, critical periods, sequencing, duration, and cumulative effects. Hierarchical regression and structural equation modeling are suggested as analyses to use in life course research. Secondary analysis was performed on the Early Head Start Research and Evaluation Study, 1996-2010, to illustrate their strengths and challenges. Models investigated the influence of mother and infant characteristics and of parent-child dysfunction at 14 and 24 months to children's cognitive outcomes at 36 months. Findings were interpreted and discussed in the context of life course hypotheses.

Improving glycemic control with the adjunct use of a data management software program.

BACKGROUND: Published studies have supported the implementation of tight glucose control (TGC) programs to improve patient outcomes and reduce mortality rates. However, measuring a program's efficiency is challenging, because of a lack of systems that capture data, allow access to data, and support analysis and interpretation in a near prospective time frame. We hypothesized that providing clinicians access to real-time blood glucose (BG) results reports could improve the efficacy of our TGC program. METHODS: We performed a retrospective review of BG data during a 12-month period in a surgical trauma intensive care unit at a level I trauma center. A unit-specific insulin algorithm was used throughout the study. We compared BG values before and after the implementation of a data management software program that allowed clinicians access to real-time BG results reports. Reports were run daily and weekly to monitor the unit's TGC program. RESULTS: A total of 70 616 BG values from 1044 patients were analyzed. An overall decrease was observed in the BG level mean, from 121 mg/dL to 112 mg/dL (P < .001), as well as a decrease in the aggregated mean across patients, from 132 mg/dL to 119 mg/dL (P < .001), after implementation of the software. The percentage of values within the target range of 80 to 110 mg/dL increased from 38.9% to 50.4% (P < .001). The percentage of BG values less than 70 increased from 2.7% to 3.4% (P < .001). However, the percentage of severe hypoglyce-mic episodes (≤ 40 mg/dL) remained unchanged. CONCLUSIONS: Access to real-time aggregated BG data reports through the use of a data management software program improved the efficacy of our TGC program.

Complementary therapy used by Hispanic women during treatment for breast cancer.

The purposes of this study are to assess Hispanic women's use of complementary interventions during breast cancer treatment and delineate the association between the most burdensome side effects and the most frequently used complementary and alternative medicine (CAM). The researchers examined both descriptive statistics and correlational relationships between side effects and CAM. Data were collected from a convenience sample (N = 125). The mean age was 54, the educational average was less than 10 years, and the median income level was less than $20,000 per year. CAM was positively correlated with family income. Prayer was used by 93% of the women, humor was used by 83%, and 65% used exercise. The most frequent side effect of hair loss (70%) was the most bothersome side effect. The most burdensome and unmanageable side effects were bowel problems and nausea. Nurses play a key role in offering affordable, culturally appropriate symptom management interventions.