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2012 PhD Dissertations


Dr. Norma McNair - Dissertation Abstract,  successful defense was on May 21, 2012

Title of Dissertation: Baroreceptor Sensitivity in Patients with Traumatic Brain Injury
Committee members: Dr. Mary Woo (chair), Dr. Peggy Compton, Dr. Barbara Bates-Jensen and Dr. David Hovda
Background and Significance: Traumatic brain injury (TBI) affects 1.7 million Americans annually leading to significant morbidity and health care costs. An important cause of morbidity in TBI is secondary brain injury due to abnormal cerebrovascular autoregulation (CA).  Standard measures of CA are not amenable to use outside of the intensive care unit (ICU)  and patients continue to be at risk for secondary brain injury post- ICU. Baroreflex sensitivity (BRS) is a non-invasive assessment of autonomic tone that may be useful in evaluating CA. Evaluation of BRS and its relation to CA has not been examined in patients with TBI and predictors of CA are unknown.
Purpose:  The specific aims for this study were to 1) examine the association between BRS and CA in patients with TBI, 2) compare BRS and CA in TBI patients and age and gender matched healthy volunteers (HV) and 3) identify predictors of BRS and CA in TBI. Methods: This study used a two group comparative design with 52 subjects (26 with moderate to severe TBI; 26 HV). Measurement of variables: BRS was calculated as heart rate/mean arterial pressure; CA was calculated as cerebral blood flow velocity using transcranial Doppler; and cognition was assessed using the Galveston Orientation and Amnesia Test (GOAT)
Results: There was no significant correlation between BRS and CA, however, BRS had high specificity (77%) for normal CA. BRS was not significantly different between TBI and HV subjects, those with normal or abnormal CA nor was BRS an independent predictor of CA. Forty six percent of TBI subjects had abnormal CA after their TBI (mean = 59.58 ± 36.54 days) and 34.6% of HV had abnormal CA. Predictors of abnormal CA were male gender, ACE-Inhibitors and GOAT.
Implications: BRS can be used to identify normal CA.  The GOAT has potential for routine assessment of CA status in non-ICU areas.  Large proportions of TBI subjects long after a TBI event and HV had abnormal CA. Thus assessment of CA status is important in TBI subjects after ICU discharge and further research is needed on the impact of pre-existing CA abnormalities in HV.


Dr. Nancy Blake Dissertation abstract, successful defense was held on May 16, 2012

Title: The Relationship between the Nurses' Work Environment and Patient and Nurse Outcomes
Committee Members: (from left) Dr. Jack Needleman, Dr. Wendie Robbins, Blake, Dr. Linda Searle Leach, Chair, Dr. Nancy Pike

Purpose:  Medical errors cost the United States over $50 billion annually.  Healthy work environments (HWE) can reduce medical errors and decrease Registered Nurse (RN) turnover. Three of the variables that impact the work environments are communication, collaboration and leadership.  The Joint Commission stated that communication failures are the leading cause of harm to patients in hospitals today.  With an estimated shortage of 260,000 nurses identified in the year 2025, nurse leaders need to be creative and do what they can to improve the work environment.  The purpose of this research study was to determine the relationship between HWEs, patient outcomes and nurse turnover in the pediatric intensive care unit (PICU), specifically around communication, collaboration and leadership and risk adjusted patient mortality, risk adjusted length of stay, central line infections, ventilator associated pneumonia and nurse turnover in the PICU.  This type of study has never been done in the PICU. 
Methods:  Donabedian's model of Structure, Process and Outcomes was used as the conceptual framework. The study design was descriptive cross-sectional.  Nurses completed the Practice Environment Scale of the Nursing Work Index Revised (PES-NWIR), which is a 31 items instrument used the measure the practice environment, nurse outcomes and patient outcomes.  Participants also completed questions from the ICU Nurse-Physician Questionnaire regarding communication and a demographic questionnaire.  In addition to the nurses completing the questionnaire, data was obtained from the hospitals regarding nurse turnover, central line infections, ventilator associated pneumonia, risk adjusted length of stay and risk adjusted mortality as well as information about the unit's nursing and medical structure. Statistical analysis was done using SPSS 17.0.  Pearson correlations were conducted to examine the relationships of healthy work environments and the outcome measures.  Multiple regression, t-tests (two-tailed) and one way analysis of variance (ANOVA) were completed.  This significance level was set at .05 for this study.
Results: A sample of 415 RNs completed the survey from ten hospitals. RN's were mostly female (94%), Caucasian (95%), has a bachelor's degree (75 %), and 1-10 years as a PICU RN (70%). There was an inverse relationship between CLBSI and collaboration and communication (p<.01) but no association between communication, collaboration, or leadership and VAP. Risk adjusted mortality was inversely related to collaboration and communication (p<.05).    Risk adjusted LOS was inversely related to collaboration and communication (p<.05).  There was a statistically significant relationship between leadership and the outcome ITL (p<.05), but not any of the other predictor variables.
Conclusions: Communication and collaboration in the PICU between RNs and between RNs and MDs are vital for patient safety, preventing complications and increased risk of death and to reduce hospital costs at the unit level. Findings from this study also indicate that effective nursing leadership is important to PICU RNs and significantly influences their decisions about staying in their current job.


Dr. Susan Stemmler Dissertation abstract, successful defense was held on May 7, 2012

Title: Methamphetamine-Using Mothers: Perceptions of Prepregnancy Sexual Risk, Recognizing Unintended Pregnancy And Engaging in the Pregnancy

Committee members: Dr. Adeline Nyamathi, Chair, Dr. Deborah Koniak-Griffin, Dr. Mary Sue Heilemann, Dr. Angela Hudson, Dr. Steven Shoptaw

Methamphetamine has become the drug of choice for a growing number of women in their childbearing years. Methamphetamine reduces inhibitions and increases libido, such that high-risk behaviors are conducted in association with methamphetamine use. Women who become pregnant while using methamphetamine are likely to be younger than the general population of pregnant mothers. They have more comorbid conditions and they delay entry into prenatal care services. The number of methamphetamine-involved births has increased as methamphetamine has become more available and affordable in urban settings.
This dissertation investigated prepregnancy and pregnancy experiences in a sample of 17 women, ten pregnant women and seven postpartum mothers who used meth during a portion of a recent pregnancy. Constructivist Grounded Theory fueled by Symbolic Interactionism was used for data collection and analysis of semi-structured interviews, observations, and field notes. The dissertation is comprised of three manuscripts that describe consecutive events in a transition that surrounded the participants' unintended pregnancies. The findings highlight their lives before pregnancy, learning they were pregnant, and becoming involved in the pregnancy. Three processes, Progressing to a meth-centered lifestyle, Reconciling Pregnancy, and Engaging in Pregnancy, depict the commonalities, variations, and conditions of the women's experiences.  Within the process of Progressing to a meth-centered lifestyle, initiation to methamphetamine occurred and progressed to regular, chronic use. The women's age and social development were linked in the women's recollections of their initial use of methamphetamine. Reconciling Pregnancy describes two intertwining events, pregnancy and being drug-free after arrest or entry into substance abuse treatment. This combination of occurrences established a foundation for the women to begin modifying their perceptions about being pregnant and about pursuing sobriety. The third process, Engaging in Pregnancy, conveys the women's participation in their pregnancy transition by taking care of themselves for the sake of the pregnancy and bonding with their unborn child. It describes the influences that assisted the women to strengthen their involvement in their pregnancies while preparing for a sober life as mothers.
The qualitative findings expand our understanding of women living a methamphetamine-centered lifestyle. Through their rich descriptions of events surrounding unintended pregnancy, we learned about the women's neglect of self and poor health-seeking practices. Their stories uncover needs for intervention in each of the three processes.


Dr. Keejeong Cheon's Dissertation Abstract, successful defense was held on May 2, 2012

Title of Dissertation: Psychological Well-Being of Mothers with Preterm Infants

Committee members: Dr. Nancy Pike, Chair, Dr. Deborah Koniak-Griffin, Dr. Adeline Nyamathi, Dr. Lillian Gelberg

Background: A preterm infant's admission to the Neonatal Intensive Care Unit (NICU) is associated with maternal stress. However, the impact of hospitalization on coping and psychological well-being (PWB) is poorly understood. 
Specific Aims: Examine the impact of maternal stress, type of coping strategies, perceived social/nursing support, and maternal/infant characteristics on the PWB of mothers with preterm infants in the NICU from admission to 2 weeks.
Methods: Mothers recruited from three NICUs in Los Angeles. PWB was measured using the Brief Symptom Inventory, Patient Health Questionnaire 9, and General Well-Being Schedule. Other outcomes measured included maternal stress, coping strategies, and social/nursing support. Data were analyzed with multiple linear regression.
Results: One hundred mothers who participated were primarily over 30 (55%), Hispanic (62%), low income (67%), and living with spouse or partner (74%). Infants were 32 weeks (± 3.3) gestation with birth weight 1848g (± 730).  Maternal stress accounted for 43% of the variance for anxiety and 22% for depression. Hispanic mothers had more severe depressive symptoms than non-Hispanic mothers. Perceived social support predicted PWB while nursing support did not. Emotion-focused coping was used more at admission (p < .001), and problem-focused coping more at two weeks (p < .001). Infant characteristics (gestational age, infant morbidity score, hospital discharge < 2 weeks) and maternal characteristics (race/ethnicity, language, education, marital status, income, employment status, pregnancy complications, breastfeeding) were predictors of PWB.
Conclusions: Maternal PWB is adversely influenced by preterm infant's NICU admission, however, improved by 2 weeks. Problem-focused coping strategies were used by 2 weeks and can provide a bench-mark for teaching readiness.  Depression screening may be useful in identifying mothers at risk. Future research to assess PWB past 2 weeks is needed.


Dr. Eileen Fry-Bowers Dissertation abstract, successful defense was held on May 2, 2012

Picture (left to right): Dr. Aurelia Macabasco-O'Connell, Dr. Sally Maliski, Dr. Eileen Fry-Bowers, Dr. Mary Ann Lewis, and Dr. M. Robin DiMatteo
Title: The Impact of Maternal Health Literacy on Structures, Interpersonal Processes and Outcomes of Ambulatory Care for Low-Income Latino Children
Committee members: Dr. Sally Maliski, Chair, Dr. Mary Ann Lewis, Dr. Aurelia Macabasco-O'Connell and Dr. Robin DiMatteo from UC Riverside
Objective.  Child health outcomes depend on a parent's ability to read, communicate, analyze, and use health information to participate in their child's care. Low maternal health literacy (HL) may disrupt access to pediatric health care, impede informed parent decision-making, and exacerbate pediatric health disparities.  This dissertation explores relationships between maternal (HL), maternal self-efficacy (SE) in communication, interpersonal interactions with health care providers (HCPs), and maternal perception of quality of pediatric ambulatory care.
Methods.  A cross-sectional, correlational study of low-income Latina mothers (n = 124) of children 3 months to 4 years examined relationships between socio demographic characteristics, maternal HL (Newest Vital Sign), social support (Family Support Scale), self-efficacy in communications with providers (Perceived Efficacy in Patient-Physician Interactions), interpersonal interactions with HCPs (Interpersonal Processes of Care in Diverse Populations Survey) and maternal perception of quality of pediatric ambulatory care (Promoting Healthy Development Survey).
Results.  Data revealed maternal HL to be a complex construct associated with multiple socio-demographic characteristics including social support, cultural and linguistic factors.  Although maternal HL and self-efficacy (SE) were not significantly related, important relationships between maternal SE and informal support, and maternal SE and the communication subscale, "elicits concerns," were identified.  Overall, maternal HL was related t the successful transmission of anticipatory guidance, the delivery of family centered care and the helpfulness of information provided, but it contributed far less to the quality variables than anticipated. Conversely, maternal-HCP interpersonal processes were substantially related to maternal perception of quality of pediatric ambulatory care. Moreover, effective interpersonal processes between these mothers and their child's HCP significantly predicted each mother's perception of the quality of pediatric ambulatory health care received. 
Conclusions. Maternal HL may be a more dynamic concept than previously understood.  This study reveals the substantial role that interpersonal processes play in the mother-HCP exchange.  "Speaking with clarity," "explaining results fully" and "working with a parent" to determine a child's plan of care is most predictive of whether a mother feels that her child is receiving quality ambulatory care services. Clarifying the relationships between these variables is an important step towards understanding how these factors impact maternal interaction with the health care system and influence pediatric health disparities.


Dr. Hae Sook Kim's Dissertation Abstract, successful defense was held on April 30, 2012

Picture (from left to right): Dr. Lynn Woods, Dr. Hae Sook Kim, Dr. Janet Mentes, Dr. Linda Phillips, Dr. Jennifer Lynn Martin, and Dr. Ailee Moon.
Title of Dissertation: The Relationship between Direct-Care Staff's Competence in Social Interaction and Behavioral Symptoms in Korean-American Nursing Home Residents with Dementia
Committee members: Dr. Lynn Woods, Chair, Dr. Janet Mentes, Dr. Linda Phillips, Dr. Ailee Moon, Dr. Jennifer Martin
The purpose of this study was to explore and describe the relationship between the social interaction competence of non-Korean direct-care staff members and Korean American older adults exhibiting behavioral symptoms of dementia (BSDs) who reside in nursing homes. A pilot study was completed to evaluate the feasibility, usability, content validity, and inter-rater reliability of two social interaction-coding schemas, developed by the principal investigator. In general, there was a negative trend between direct-care staff's dementia competence in social interaction and BSDs interacting with cultural competence in social interaction. These results suggest that both dementia competent and culturally competent social interaction influence BSDs. The results provide a foundation that may lead to the development of culturally appropriate and supportive interventions for ethnic minority older adults, as a starting point to improve dementia care for ethnic minority nursing home residents. Implications and recommendations for further studies are presented.


Dr. Mary Baron Nelson's Dissertation abstract, successful defense was held on April 24, 2012

Title of Dissertation: Widespread Mean Diffusivity Increases in Children with Brain Tumors after Chemotherapy Treatment

Committee members:  Dr. Peggy Compton, Chair, Dr. Paul Macey, Dr. Ron Harper, Dr. Eufemia Jacob,  and Dr. Sunita Patel

Two-thirds of children diagnosed with brain tumors achieve long-term survival, and increasingly, children younger than 5-6 years at diagnosis are treated with high-dose chemotherapy protocols, delaying or foregoing cranial radiation. Intrathecal chemotherapy is associated with white matter loss, with systemic administration of certain agents also damaging healthy brain tissue. However, effects of systemic chemotherapy on the brain in children with tumors are unclear. The objective of the study was to compare structural neural integrity with magnetic resonance imaging procedures in children with brain tumors (n = 7, mean age 8.3 years), treated with chemotherapy a mean of 5.4 years earlier, to age- and gender-matched healthy controls (n = 9, mean age 9.3 years). Magnetic resonance imaging data were collected using a diffusion tensor imaging protocol to evaluate tissue integrity throughout the brain. Voxel-based morphometry was used to determine differences between groups. Mean diffusivity and fractional anisotropy maps were obtained from normalized, smoothed images, and the two groups were compared using analysis of covariance, with age and gender as covariates. Higher mean diffusivity values emerged in patients over controls (p< 0.05, corrected for multiple comparisons), and were especially apparent in the central thalamus, internal and external capsules, putamen, globus pallidus and pons. No significant differences emerged in fractional anisotropy values between groups. The patient group had lower brain-to-CSF ratio (p = .03), assessed with volumetric analyses. Significantly higher mean diffusivity, indicating long-term damage possibly to glia more than to neurons, appeared in multiple areas in patients 5 years after treatment with chemotherapy.


Dr. David Ajeigbe's Dissertation abstract, successful defense was held on March 22, 2012.

Title of dissertation: Nurse-Physician Teamwork in the Emergency Department

Committee members: Dr. Donna McNeese-Smith, Chair, Dr. Linda Searle Leach, Dr. Linda Phillips, Dr. Paul Torrens from Public Health.

Aims: Descriptive study to examine the differences between nursing staff and their perception of nurse-physician teamwork in emergency department (ED) settings.  The exploratory aim of the study was to examine staff perception of job satisfaction, work environment, autonomy, and control over practice.  Design: The design included both an interventional and control group.  The intervention group was comprised of four EDs that participated in teamwork training and operationalized teamwork principles in their respective EDs. The control group of four EDs did not participate in the training. Survey questionnaires were used for data collection. Setting and Participants: Staff from four interventional and four control group EDs throughout California participated in the study. There were 191 participants fin the interventional Group EDs and 307 in the control group EDs. Main Outcome Measures: Differences between staff who worked in the interventional group EDs and staff who worked  in the control group EDs on perception of teamwork, job satisfaction, work environment, autonomy, and control over practice were measured via questionnaires. Results: The staff who worked  in the interventional group EDs showed significantly higher differences compared to staff who worked in the control group EDs on staff perception of teamwork (p = 0.006), job satisfaction (p < 0.0001), work environment (p = 0.0006), autonomy (p < 0.0001), and control over practice (p < 0.0001). Conclusion: Active practice of teamwork between the nurses and physicians in the EDs appeared to be associated with improved job satisfaction, and perception of work environment, autonomy, and control over practice of both nurses and physicians in the interventional group over those who worked in the control group EDs.

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