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WIN Conference 2012

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Diana Lynn Woods, PhD, RN, ARNP-BC, Assistant Professor
Mary Lynn Brecht, PhD, Adjunct Research Professor
Maria Yefimova, BS, Doctoral Student

PURPOSE: This study purpose was to characterize complex patterns of BSD, and examine the association among different BSD patterns and cortisol profiles. This paper illustrates the application of two analytic approaches for examining patterns of behaviors over time: a) a non-parametric approach using THEMETM, a software that characterizes patterns, and b) a mixture model approach (group-based trajectory modeling) that identifies clusters of individuals following similar trajectories and characterizes these in terms of polynomial parameters. We illustrate the application of these approaches using BSD and cortisol profiles.

BACKGROUND: Commonly used methods for repeated measures typically estimate a pattern based on an average (magnitude or frequency) across participants for each observation point. This approach may not fully characterize many dimensions of behavioral symptoms of dementia (BSD) including within person variability and irregularity or clustering of behaviors. The limited ability to accurately detect and quantify complex BSD patterns has hampered the development and refinement of tailored interventions.

METHODS: Data from two studies reported elsewhere were pooled into a single data set for analysis (N = 99). A secondary analysis was completed using data from two groups of Nursing Home (NH) residents with complete cortisol profiles (N = 28, N = 27) using THEMETM. BSD and cortisol data were collected for four consecutive days. Participants were categorized into two groups within each site: normal cortisol profiles (G1) and abnormal cortisol profiles (G2). Random effects model was used to characterize BSD trajectories over time. THEMETM was used to identify within person behavior patterns and complexity.

RESULTS: There was a significant difference in total BSD between those with a normal cortisol profile (G1) compared to those with an abnormal cortisol profile (G 2) at Time 3 (12:00PM-1:59PM) within each site (p = 0.0456; p = 0.023) respectively. There was a significant difference in age, co-morbidities and anti-anxiety medication when G1 was compared with G2. THEMETM analysis showed a significant difference in BSD patterns (t = 1.94, p = 0.05) and complexity (t = 2.53, p = .014) when G1 was compared to G2. G1 exhibited more complex patterns of high intensity vocalization and restlessness than G2. Of those who exhibited 50-75% high intensity patterns, 80% in Site 1 had an abnormal cortisol rhythm, compared to 30% of those in Site 2. Group based trajectory methods showed no significantly different trajectories between groups.

CONCLUSIONS: Higher complexity and patterns differed significantly between G1 and G2. While
preliminary, results suggest that persons with higher variability of BSD exhibit complex patterns, in addition
to deregulated circadian rhythms indexed by abnormal cortisol rhythms. These findings highlight the
importance of using pattern analyses to identify complex behavioral manifestations and correspondence with
biological markers. THEME TM analysis was able to identify and characterize individual BSD patterns that
drove the overall trajectory of behavior. Pattern analysis merits further examination to investigate the
temporal clusters of BSD.



Janet Mentes, PhD, APRN, BC, FGSA, Associate Professor
Linda Phillips, PhD, RN, FAAN, FGSA, Professor
Mary Cadogan, DrPH, RN, GNP-BC, Adjunct Professor
Lynn Woods, PhD, RN, GNP-BC, Assistant Professor

PURPOSE: We describe the development and outcomes of the Nurses Caring for Older Adults Young Scholars Program, a mentorship program that identifies students early in their pre-licensure program, both bachelor's and master's entry programs, who are interested in care of older adults and offers them a 1-3 year mentorship program.

RATIONALE: Nursing care, specifically for the world's burgeoning older adult population, is an important component of access to and quality of health care. However, the current nursing education workforce is also aging, with an average age of 58 years and with the anticipated retirements of experienced educators; the profession of nursing is endangered. It is important to develop programs that will prepare the faculty necessary for educating future generations of nurses in the care of aging persons.

APPROACH: The Young Scholars Program (YSP) focuses on helping the students to develop the requisite research, educational and professional skills with a focus on culturally competent "Gero smart" nursing skills to accelerate into a PhD program after completing their basic nursing coursework. Pre-licensure students are matched with faculty mentors during their participation in the program and are involved in a variety of mentored projects such as co-authorship of research or clinically focused publications, both podium and poster research presentations and participation as paid research assistants on faculty research grants. OUTCOMES/CHALLENGES: In the three years since its inception, we have mentored 9 students through the YSP; of these students 5 have been accepted into PhD programs and 2 have entered gerontological nursing practice. We currently have 3 YS in the first year of the program. Facilitators for a young scholar's solidifying an intention to pursue doctoral education include: participating in faculty mentor's research activities, attending the Gerontological Society of America scientific meeting with faulty mentors, attending monthly gerontological nursing interest group meetings, participating in quarterly film festivals focused on issues of older adults and receiving recognition at graduation for participation in the program. Barriers include: students concerns about lack of clinical experience in transitioning into the doctoral program on graduation, financial concerns, and difficulty committing to a specialty area so early in his/her academic career.

CONCLUSIONS: The Young Scholars program has been successful in encouraging pre-licensure students who have an identified interest in research to pursue doctoral studies after completing their basic nursing program. Of the students who act on their intention to enroll in doctoral studies, pre-licensure mentorship with active participation in their mentor's research activities appears to be the strongest factor in following through with application and enrolling in a doctoral program.



J. Kelly Graves, PhD, RN, Adjunct Assistant Professor
Eufemia Jacob, RN, PhD, Assistant Professor

PURPOSES/AIMS: The specific aims of this study will examine 1) depression, anxiety, and quality of life in children and adolescents Sickle Cell Disease (SCD).

RATIONALE/CONCEPTUAL BASIS/BACKGROUND: The chronic nature of (SCD) puts youth at risk for anxiety and depression as they face the challenge of painful exacerbations or crises which can be life threatening. There is evidence that depression in youth will occur again in adulthood, with more negative outcomes for those diagnosed in youth. By internalizing anxiety and depression, problems may occur in social development and adaptation. Further, depression and/or anxiety in a chronic medical illness like SCD, may lead to an increased morbidity and mortality. Studies suggest that children and adolescents with SCD may be at greater risk for adjustment problems, impaired psychosocial functioning and reduced quality of life. However, relatively little is known about how the co-morbid conditions of depression and anxiety impact the quality of life in youth with SCD.

METHODS: As part of the "Wireless Pain Intervention Program", participants completed a set of questionnaires that included the Revised Anxiety and Depression Scale (RCADS) and a quality of life scale (PedsQL). Participants met the following criteria for inclusion in the study: 1) diagnosis of SCD, 2) age 10 and 17 years, and 3) ability to read, write, and understand English or Spanish. Data collection occurred in community sites in Southern California as arranged by the Sickle Cell Disease Foundation of California.

RESULTS: Children (n=44; 58.7%; mean age 11.6 ± 1.1 years) and adolescents (n=31; 41.3%; mean age 14.9 ± 0.9 years) who participated were males (n=37; 49.3%) and females (n=38; 50.7%) and had Hgb SS (n=35; 46.7%), HgbSC, (n=23; 30.7%), and others/unknown (n=17; 22.6%). They had acute pain episodes requiring hospitalization from 0 to 3 times per year (n=35; 46.7%) to more than 3 times per year (n=40; 53.3%). Some participants were at risk for generalized anxiety (n=5; 6.7%), major depression (n=8; 10.7%), obsessive compulsion (n=7; (9.3%), panic disorder (n=9; 12.0%), social phobia (n=2; 2.7%), and separation anxiety (n=8; 10.7%). Their scores were greater than 65% on the corresponding RCADS subscales. No age
and gender differences were found in these scores.

IMPLICATIONS: Adolescents with SCD are at risk for anxiety, depression, and other associated psychosocial distress that may affect quality of life. While clinicians primarily focus on treatment of symptoms (pain, respiratory, abdominal symptoms, etc.) or disease (hydroxyurea, blood transfusions), little attention is made with assessment and management of psychosocial needs. Psychosocial assessment to screen, detect, and treat mental health distress is warranted. Future research is needed to examine interventions that will address not only the physical, but also the psychosocial needs (e.g. anxiety, depression) of children and adolescents with sickle cell disease.



Maria Elena Ruiz, PhD, RN, FNP-BC, Assistant Adjunct Professor, Associate Director Chicano Studies Research Center
Carlos Contreras, BA student, UCLA Philosophy and Chicano Studies
Judy Popovic, MPH, RN, MS Student
Rebecca Glaser, MA student, UCLA Psych Education

PURPOSES/AIMS: The purpose of this community based research study was to explore the perception of older Latinos living in skid row on factors that may have contributed to their becoming homeless. Results provide a framework for intervention, policy and program development to support the largely isolated elderly Latinos, thus reducing further structural isolation and health risks.

RATIONALE/CONCEPTUAL BASIS/BACKGROUND: The graying of America has attracted increased media attention, as a growing number of individuals experience hunger, poverty and homelessness. In 2008, almost 44,000 seniors were homeless. Within the next ten years, this figure may rise to almost 59,000 (33% increase). By midcentury, the numbers may almost double, to 93,000. Yet, little is known about the fastest growing elderly population, or Latino elders, and associated risk factors for homelessness. Even less is known about Latinos aging in skid row Los Angeles. How can we reconcile that members from a traditionally familistic orientation end up living alone and often isolated, homeless, or at best in single room occupancy hotels?

METHODS: Utilizing a mixed quantitative and qualitative design, a bicultural and bilingual team of researchers recruited 20 older self-identified Latino men and women living in skid row. Participants completed a survey and participated in semi-structured audio taped oral interviews; gathering demographics and exploring issues on homelessness, health, social support, health access, and agency support.

RESULTS: Beyond the simple typology most identified in the literature (job and housing loss and medical/social issues), the findings are significant, as the stories reveal multiple pathways intercept; including job/housing loss, family and network dissolution, violence, medical/social issues, language and cultural isolation, legal status and today's sociopolitical climate.

IMPLICATIONS AND SIGNIFICANCE: The findings call into question the issue of homelessness for a diverse and aging population, and our healthcare system's ability to fully assess and to provide culturally comprehensive health care and services to a growing homeless population. For the discipline of nursing, the significance for nursing practice are that we will need to provide advanced training for assessing an individual's risk for homelessness, while we also prepare to take leadership roles in order to advance a multidisciplinary community partnerships that address the totally of an individual's health and environmental risks.



Eunice E. Lee, PhD, RN, Associate Professor
Karabi Nandy, PhD, Assistant Adjunct Professor, School of Nursing and Department of Biostatistics
Grigor Sukiassyan, PhD, Master's Student

PURPOSES/AIMS: To examine self-reported bias in mammography screening rates among Korean American (KA) women and compare beliefs between women of those for whom we were able to verify mammography uptakes and those for whom we could not verify uptakes.

RATIONALE/BACKGROUND: It is well known that women from ethnic minority groups tend to over-report mammography uptake, but actual mammography uptake rates compared to self-reports among KA women have not been reported in the literature. It would be necessary to explore whether any beliefs based on the Health Belief Model are related to verification rate.

METHODS: Mammography rates were verified among KA women who participated in our randomized clinical trial, Korean Immigrants & Mammography-Culture-specific Health Intervention (KIM-CHI) at 15-months post-baseline. All KA women who reported having had a mammography during the study period, in both intervention and control groups, were asked to sign a Health Insurance Portability and Accountability Act (HIPAA) notification which they mailed to us if they agreed that we could verify their mammography uptakes.

RESULTS: Out of 395 women who participated in the 15-months post-baseline data collection, 192 reported having a mammogram during the study period. Of those, 12 women refused to let us verify their mammography uptake and 22 women reported that they had had a mammogram in Korea, but it was not possible for us to verify those. Of the 158 women to whom we mailed HIPAA forms, 106 mailed back signed forms (67% return rate). Of those 106 women, we were able to verify 92 mammography uptakes with physicians or mammography facilities (87% verification rate). We did not find any differences in variables of sociodemographic and health beliefs between the two groups.

IMPLICATIONS: Even though we had an 87% verification rate among KA women who returned the HIPAA form, we speculate that the 33% who did not return signed HIPAA forms over-reported their mammography uptake. Verifying mammography uptakes from an ethnically minority group such KA women, who tend to not have regular physicians or places for health care, was challenging. Suggestions for future studies will be discussed.



Carolyn E. Ziminski, RN, BSN, Doctoral Candidate
Mary P. Cadogan, DrPH, RN, Professor, Adjunct Series
Linda R. Phillips, PhD, RN, Professor

BACKGROUND: Emergency Departments (ED) are a frequent source of care for older adults who often present with complex, specialized and time consuming care needs. Older adults seen in the ED are at greater risk for repeat visits, functional decline, increased complications and death. Randomized clinical trials providing a transitional model of care for older adults in the ED have proved ineffective at reducing subsequent service use. This suggests while there is an understanding of the challenges and poor outcomes for the care of older adults in the ED there is not a sufficient understanding of the origins of these problems.

PURPOSE: The purpose of this qualitative descriptive study is to expand on previous analysis on the care of older adults in the ED, and describe from the perspective of ED health professionals factors that influence the way in which they provide care to older adults.

SAMPLE: Nurses who spoke English and had worked in the ED of a large urban hospital in Los Angeles for at least 6 months were eligible to participate. The final sample included nurses with a range of ED experience from 1-33 years as well as physicians and ancillary staff, and included representatives from all three shifts.

METHODS: A qualitative, descriptive methodology was used. After receiving IRB approval, nine focus groups) were conducted with nurses physicians and ancillary staff employed at a large urban ED. A semistructured interview guide consisting of open ended questions was used to elicit experiences of providing care to older adults in the ED. Focus group data were analyzed using constant comparative analysis.

RESULTS: Staff described contextual factors which affect their care delivery to older adults. Tensions in care for older adults emerged from five areas: system constraints, perceived expectations, knowledge, image of role as an ED professional and the ED model of care. These areas contributed to a clash with the geriatric model of care creating tensions in the ED care environment of older adults. For example, staff described how older adults often had needs which they felt fell outside the specific role functions for the ED professional such as toileting and preventative turning. These five contextual factors created barriers to providing comprehensive geriatric care in the ED.

IMPLICATIONS: The intersection of increased demand of ED services by older adults versus the tensions in the ED care environment of older adults creates a perfect storm for which poor outcomes can occur raising issues of quality, safety and use of resources. Interventions aimed at improving care of older adults in the ED need to be a system-wide approach targeting direct care staff, ED leadership and hospital administrators.



Norma D. McNair, RN, MSN, CNRN, Doctoral Candidate

BACKGROUND/AIMS: Cerebral Autoregulation (CA) is abnormal in patients with Traumatic Brain Injury (TBI) and leads to secondary brain injury. Such secondary injury can be induced by common nursing procedures, such as sitting and ambulation. Standard measures of CA are not amenable to routine clinical use. Baroreceptor Sensitivity (BRS) is a non-invasive measure of autonomic tone and shares some of the same neurological pathways as CA. Thus, BRS may be a useful clinical marker for CA in patients with TBI. The relationship of CA and BRS in patients with TBI is unclear. The specific aim of this research was to evaluate BRS and CA in a group of patients with moderate to severe TBI.

METHODS: CA (cerebral artery blood flow velocity measured in the left middle cerebral artery using transcranial Doppler) and BRS were examined in 26 TBI subjects (age 37.04+14.51 years; 18 males) 30 seconds prior to (baseline) and 30 seconds after a postural challenge. CA and BRS were classified as normal or abnormal per published norms. Statistical analyses consisted of t-tests, Pearson's correlations and chisquare with significance set at p < 0.05. Sensitivity and specificity of BRS to detect abnormal CA were also evaluated.

RESULTS: There were significant differences between CA at baseline and post position (baseline: 53.53 ± 10.13; post: 50.40 ± 10.87, p = 0.005) However, there was no significant difference in BRS between these time points (baseline: 13.62 ± 3.57; post: 13.73 ± 2.92, p = 0.86). CA was abnormal in 6 subjects and BRS was abnormal in 6 subjects, but both CA and BRS were abnormal in only one subject. Ability of BRS to identify abnormal CA (sensitivity) was low (true abnormal CA = 1; 5%) but its ability to classify normal CA (specificity) was high (true normal BRS and CA = 19; 76%).

IMPLICATIONS: BRS can identify normal CA and may be a useful clinical method to evaluate nursing procedure readiness, such as position changes, ambulation, or Trendelenberg position. Thus BRS may have clinical utility to assess the presence of normal CA and decrease the risk of secondary brain injury in TBI patients.



Lynn V. Doering, DNSc, FAAN, Professor, Rebecca Cross, PhD, NP, Assistant Professor, CSU Fullerton, School of Nursing

BACKGROUND: Inflammatory markers (C-reactive protein [CRP]); interleukin [IL]-6) have been shown to predict adverse outcomes in patients with CAD and are also positively associated with depression. While both CRP and IL-6 are increased immediately after cardiac surgery and decrease in the perioperative period, little is known about the later course of inflammatory markers.

OBJECTIVE: To describe the course of inflammation over the first 3 postoperative months in depressed cardiac surgery patients involved in a RCT of Cognitive Behavioral Therapy (CBT).

METHODS: We enrolled 808 cardiac surgery patients from five hospitals. They were screened for depressive symptoms with the Beck Depression Inventory (BDI) in the hospital and one month later and interviewed using the Structured Clinical Interview for DSM-IV (SCID-I); those who met criteria for clinical depression (n=62; 26% female, age 63 ± 9.7 years) were randomized to CBT (n=32) or UC (n=30). CBT patients received 8 weeks of nurse-guided therapy. UC patients received usual postop care plus biweekly phone calls to maintain contact. After 8 weeks, clinical depression in both groups was re-evaluated. Serum samples were collected during the SCID-I and after 8 weeks in both groups and biweekly during therapy in the CBT group. Samples were analyzed in a core laboratory by ELISA for high-sensitivity CRP and IL-6. Using general linear modeling and controlling for the time from surgery, we conducted repeated measures analysis to compare the change over time in inflammatory markers.

RESULTS: CRP and IL-6 decreased significantly in both groups during the first 3 months after surgery. However, the change over time did not differ between treatment groups.

CONCLUSIONS: This study is the first to provide evidence that reductions in inflammation continue for up to three months after cardiac surgery in depressed patients. Further study is needed to evaluate the relationship of decreased inflammation to CAD progression and treatment.



Angela L. Hudson, PhD, FNP, Assistant Professor

PURPOSE: The purpose of this study was to describe how and where do foster youth receive comprehensive HIV prevention and pregnancy prevention information.

RATIONALE/CONCEPTUAL BASIS/BACKGROUND: Although Adolescents living in foster care must see a primary health care provider every six months, adolescent foster youth continue to have high prevalence of unplanned pregnancy and are at risk for sexually transmitted infections. We used the Comprehensive Health Seeking and Coping Paradigm as a theoretical framework in order to understand foster youths' intentions to seek risk reduction information.

METHOD: A qualitative approach, using Grounded Theory, was the method of inquiry. Nineteen emancipated former foster youth participated in individual interviews.

RESULTS: Many adolescents in foster care did not want to broach the subject of sexual activity with their primary health care provider, especially if the foster parent was in the exam room. Participants reported receiving the most comprehensive HIV prevention and pregnancy prevention information in school-based sex education programs or within their group home setting from community volunteers. Three categories emerged from narrative data: Discomfort Visiting and Disclosing; Receiving and Not Receiving the Bare Essentials; and Learning Prevention from Community Others.

IMPLICATIONS: Primary care providers are missing opportunities to provide comprehensive risk reduction and prevention information to youth living in foster care. Schools and other community health agencies are uniquely positioned to offer health promotion and risk reduction education programs to this vulnerable population.

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