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2015 PhD Dissertations

Dr. Ariel Rankin's successful defense was held May 26, 2015


Title: Repurposing a Legacy: The Experiences of African American Women Receiving a Human Immunodeficiency Virus Diagnosis at the Age of 50 or Older

Committee Members: Drs. Donald E. Morisky, Adey Nyamathi (chair), Linda Phillips (on Facetime) Sally Maliski and Carol Pavlish

By the end of 2015, over half of all HIV/AIDS cases will be in adults aged 50 and older. One of the fastest growing older adult sub groups afflicted by the HIV epidemic is older African American women. At present, no studies have explored the unique experiences of older African American women who have received an HIV diagnosis at the age 50 and older.

A descriptive qualitative study employing constructivist grounded theory methodology was used to gain insights into the experience of African American women diagnosed with HIV at age 50 and older. In taking the constructivist approach, analysis stemmed from shared experiences and relationships with participants. Semi-structured interviews were conducted, audio-recorded and transcribed. A total of 16 interviews were used. Open-ended, non-leading questions and probes were developed from a literature review and community members' suggestions. Coding, mapping, analytic strategy usage, and memoing all assisted in creation of the grounded theory. 

The results of this study demonstrated how older African American women utilized various strategies to repurpose a legacy, after an HIV diagnosis. The strategies used by the women included re-evaluating perceptions of HIV risk, learning lessons from tumultuous times, and reconciling past and present events. The women's lack of HIV risk perceptions and their provider's failure to assess risky behaviors resulted in delayed HIV testing. After being tested, the women embarked on a journey to resolve newfound issues, and in the process, learned various life lessons. This process allowed the women to make meaning of their HIV diagnosis and set out on a path to self-discovery. The results of this study can shape forthcoming research on the HIV trajectory of older African American women living with HIV/AIDS and at risk for HIV/AIDS.

Dr. Lindsay William's successful defense was held May 18, 2015


Title: Women Veterans' Perceptions of Mental Health Outpatient Services

Committee Members: Huibrie Pieters, Vickie Mays, Carol Pavlish and Sally Maliski (chair)

Women Veterans are the largest growing population Veterans, yet have a significant mental health disparity, greater than both civilian women and Veteran men. This disparity continues in the mental health outpatient treatment options for women Veterans. Veteran Administration (VA) healthcare services may not be suited to their needs as women, and civilian services are not well suited to manage their needs as Veterans. Therefore, this dissertation study used constructivist Grounded Theory methods to explore the experiences of women Veterans when accessing mental health outpatient services, their decision-making process when make the choice to enter mental health service, and aspects of the experience that are important or meaningful to them.

Twelve women Veterans revealed meaningful, personal stories on their experiences of trauma and their use of mental health outpatient services. While addressing each of these factors, what emerged from the data was a broader Grounded Theory Process model of how women Veterans process trauma, and the categories of Trauma, Transitions, Identity and Structure. Women Veterans who participated in the study used mental health outpatient services to assist in reestablishing identity after trauma and to propel forward in their lives.This research provides key insight into how women Veterans make healthcare related choices and process traumatic events, like military sexual trauma (MST). This has implications for research, practice, and policy to improve the provision of care for women Veterans.

Dr. Michele Wargo-Sugleris' successful defense was held May 14, 2015


Title: Job Satisfaction, Work Environment, and Successful Aging: Determinants to Remain in Older Acute Care Nurses

Committee Members: Drs. Linda Searle Leach, Linda Phillips (chair), Wendie Robbins and Paul Torrens.

This study investigated the determinants of job satisfaction, work environment, and successful aging in association with retire among older registered nurses (RNs).  In addition, this study was designed to further understand what motivates nurses to remain employed in their current positions by investigating the relationship among these determinants and their predictive value in the retirement of older RNs.  Job satisfaction has long been correlated with retention of RNs and the work environment has more recently emerged as an important factor in retention of RNs. Positive work ability, perceived health and psychological work-related factors, including reward incentives, work environment, job autonomy, and job satisfaction are significantly associated with nurse intentions to continue working, instead of seeking alternative employment or retiring but these factors have not been studied among older RNs.  Successful aging has been influential in the retention of workers in the business arena.  The combination of these three concepts, job satisfaction, work environment, and successful aging, and how they relate to retirement is particularly significant in face of the current and continued nursing shortage in the United States and around the world.

As nurses age there is a suggested difference between older and younger nurses' ability to work and this difference could affect decisions made to remain on the job.  Common stereotypes specific to older workers may lead to an overall disinterest about retaining older workers by human resource personnel and possible discrimination when hiring, workplace education and layoffs of older nurses.  One clear priority towards older nurses is to redress employer attitudes on the subject of older workers and their ability to work.  This research sought to find ways that change rather than entrench seemingly inappropriate stereotypes of older workers.  Understanding older RN's decisions on retirement in terms of the multi-faceted topics of job satisfaction, work environment, and successful aging contributes to the development of strategies important to the decision to stay or delay retirement of older nurses for human resource departments.

Dr. Angela Halpin's successful defense was held April 29, 2015

Communication and Message Framing Effects on Pneumonia Readmission Reduction

Background: As the eighth leading cause of death in the United States, pneumonia (PN) is relevant to the health of the elderly and the young.  According to the Centers for Medicare & Medicaid (CMS), which evaluate mortality and readmissions within 30 days of admission, the prevalence of PN readmissions is 17.5% - 19.5%.  Accountability for readmission is part of the Affordable Care Act's Hospital Readmissions Reduction Program (RRP), which levies penalty costs for readmissions. RRPs influence patients with pneumonia, accounting for over 1.1M discharges and comprising 18.5% of all readmissions.
Since pneumonia is one of the targets of the RRP, this research proposes that purposeful communication using framing effects can motivate patients to make decisions with providers for care post discharge and can prevent readmissions. Communication strategies (CS), such as framing effects, are known to facilitate decision-making about health care choices.  Framing effects as a method of reducing readmission have not been examined in the medical condition of pneumonia.  The process of making decisions for pneumonia care post discharge requires testing.
Specific Aims:
1. To compare the communication strategies (intervention) of framing effects (positive or negative messages) on the readmission outcome at 30 days post discharge. 
2. To assess the extent pneumonia readmissions decrease at 30 days post discharge when communication strategies (CS) include the patient or family in decisions about transitions.
3. To determine the impact of agreement between patients and HCPs on recommendations for post hospital care.
4. To examine the potential confounding effects on the relationship between framing effects and readmission rates of age, pneumonia severity index (PSI), and the number of diagnoses. 
Design and Data Analysis:
This is a double-blind randomized control trial (RCT) with parallel assignment of pneumonia patients to one of three arms.  The three arms are comparable in diagnoses and demographics.  The independent variable (IV) is the communication strategy (framing effects), and the dependent variable (DV) is the readmission.  PN patients (N = 156), as participants of the interdisciplinary team (IT), participate in communication about their transition from hospital to home.  Both IV and DV are nominal. 
     Analysis of data includes both parametric and nonparametric statistical test. Independent variable predictors are analysed using logistic regression. Covariates include age, gender, ethnicity, education, life style, and pneumonia severity index.  Each covariate is ranked as high or low risk and assessed as a predictor for readmission. For intervention arms A, B, and C, an odds ratio evaluated the expected national readmission rate and the study's predictions of readmission reduction rate.
     To ensure significant size of the study population, an effect size was calculated using G power.  The sample randomized each group (N = 156); three participants were excluded resulting in: Intervention A: positive framing, n = 44, Intervention B: negative framing, n = 65, and control group, n = 44.  Groups are compared on readmission rates.
Conclusion:  The findings suggest that framing effects messages could be used to aid in the reduction of pneumonia readmission rates in hospital settings.  The decision-making strategy incorporates education and understanding of risk by the patient, so the healthcare team can encourage and improve readmission outcomes.

Dr. Cynthia Albarran's abstract, successful defense was held on February 26, 2015

Title: Expanding Perspectives and Gaining Leverage: How Migrant Farmworker Women Navigate HIV Risk in Their Close, Long-Term Relationships 
Committee Members: (from left) Drs. Adey Nyamamthi, Deborah Koniak-Griffin, MarySue Heileman and Cyndi Albaran from the School of Nursing; Dr. Maylei Blackwell from Chicana/o Studies

Abstract:     Women around the world are at risk for HIV when they are in close, long-term relationships with a male partner who is unfaithful, abusive, and/or uses alcohol or illicit drugs.  HIV risk is particularly high among couples that migrate across international borders and experience extended periods of separation. In the US, HIV incidence among farmworker communities is as high as 15 times that of the general population. This study used Constructivist Grounded Theory methodology to explore migrant women's perceptions of and experiences with partner-related HIV risk among a community sample of migrant farmworkers in southern California.  Twenty women with a history of a close, long-term risky relationship participated in one or two in-depth interviews in Spanish.  Interviews were transcribed, translated into English and coded.  After initial coding, focused coding identified the most significant areas of interest and categories were formed.  Theoretical sampling helped to fill the gaps and detail how participants navigated and responded to risk in their relationships.  A Community Advisory Board comprised of stakeholders and farmworker women from the target community offered advice regarding research design, assisted in referring individuals for possible recruitment, and provided insight into preliminary data interpretations and developing categories.

     Results are presented in a theory grounded in women's words, consisting of two simultaneous, overlapping processes.  The first is a process of expanding perspective. While explaining their perceptions of partner risk, women repeatedly used metaphors of eyesight and "seeing" risk over a fluid five-phase process that included being blinded by vulnerabilities, making the discovery, weighing priorities, adopting a risk perspective, and assessing the consequences.  While expanding their views of what HIV risk meant to them, women were also simultaneously and actively pushing back against the actions of their abusive, unfaithful, and/or addicted long-term male partners.  In this second process of gaining leverage, participants did not feel that they had overcome the danger of their risky relationships.  Instead, they felt they were gaining leverage over risk in small but important ways through the use of three specific categories of action: fighting the bad (pushing back against a partner's actions using their own resources), finding the good (navigating complex outside resources while avoiding additional harm), and fortifying the self (helping themselves emotionally and physically get through risky relationships with the goal of "moving forward").

     Future interventions should focus on the ways in which migrant women cognitively, socially and emotional navigate their perceptions of risky relationships, as well as the ways in which they are already taking action to gain leverage.  In this way, healthcare providers can capitalize on women's strengths and plan culturally appropriate public health programs to reduce HIV in migrant communities.

Dr. Linda Kim's successful defense was held June 18, 2014

Title:  The Effects of Simulation-based TeamSTEPPS Interprofessional Communication and Teamwork Training on Patient and Provider Outcomes 

Committee Members: Drs. Linda Searle Leach, Courtney Lyder, Donna McNeese-Smith, Jack Needleman

Abstract: Background: Recent research studies that have applied interprofessional TeamSTEPPS program reported improvements in communication and teamwork between healthcare providers, as well as their perceptions of patient safety culture. Nevertheless, literature on impacts on both provider and patient outcomes remains limited, especially as it relates to the impact of interprofessional simulation-based TeamSTEPPS program in the medical/ surgical setting.

Purpose: To evaluate the effects of simulation-based TeamSTEPPS interdisciplinary communication and teamwork training on provider outcomes (perceptions of communication, teamwork, and patient safety culture) and patient safety outcomes (patient falls and hospital acquired pressure ulcers). A secondary purpose was to investigate associations between provider characteristics (age, gender, ethnicity, primary language, English proficiency, educational level, country of pre-licensure nursing/ MD education, years of U.S. work experience) and provider outcomes.

Methods: A quasi-experimental, pretest-posttest repeated measures study design was used for this pilot study. The study was carried out on two medical/ surgical units in two comparable hospitals located in Los Angeles County and involved a final convenience sample of 61 nurse and physician participants. Repeated measures multivariate analysis of variance (MANOVA) was used to evaluate the differences between and within- sample groups and effects over time. Multiple regression analysis was performed to identify provider characteristics associated with significant variances in the communication, teamwork, and patient safety culture perception scores.

Results: For the first part of the study, positive trends were noted in patient and provider outcomes following the TeamSTEPPS study; however, the results were not statistically significant. In the second part of the study, nurse characteristics including race/ culture, gender, age, years of practice in the U.S., years of employment in the current unit, primary language, and English proficiency had significant effects on nurse perceptions of communication and teamwork.

Conclusion: On-going research identifying effective interventions and strategies to improve interprofessional communication, teamwork, and a culture of patient safety will continue to be of great importance as the U.S. faces the growth of a population with increased chronic conditions, requiring the provision of a mix of services over time and across settings. Lessons learned from this pilot study may facilitate future implementation of a stronger simulation-based TeamSTEPPS training at this and other healthcare organizations, as a strategy to improve provider and patient outcomes.

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