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Research for Review

Monthly Update - 2023

Below is a listing of research articles and abstracts that may be useful as you care for patients, their families and yourself. The abstracts below are printed or adapted from the original articles published. They are to be used by nurses and staff for educational purposes only. They are not to be not to be reproduced or sold without the expressed permission of the Authors.

September 2023

Alcaraz, K. I., Wiedt, T. L., Daniels, E. C., Yabroff, K. R., Guerra, C. E., & Wender, R. C. (2019). Understanding and addressing social determinants to advance cancer health equity in the United States: A blueprint for practice, research, and policy. CA: A Cancer Journal for Clinicians, 70(1), 31–46.

Abstract: Although cancer mortality rates declined in the United States in recent decades, some populations experienced little benefit from advances in cancer prevention, early detection, treatment, and survivorship care. In fact, some cancer disparities between populations of low and high socioeconomic status widened during this period. Many potentially preventable cancer deaths continue to occur, and disadvantaged populations bear a disproportionate burden. Reducing the burden of cancer and eliminating cancer-related disparities will require more focused and coordinated action across multiple sectors and in partnership with communities. This article, part of the American Cancer Society's Cancer Control Blueprint series, introduces a framework for understanding and addressing social determinants to advance cancer health equity and presents actionable recommendations for practice, research, and policy. The article aims to accelerate progress toward eliminating disparities in cancer and achieving health equity.

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Black women have the highest death rate from breast cancer and a higher chance of developing breast cancer before the age of 40 than White women. Mammography screening is recommended for early detection which has led to decreased mortality and improved survival. Unfortunately, Black women are less likely to have breast cancer screenings. Environmental justice communities represent place-based structural disparity/racism leading to health inequality. Environmental justice specifically addresses situations where minority or low-income communities bear disproportionately poor human health outcomes and environmental risks. The purpose of this qualitative study was to gain a deep understanding of breast cancer screening disparity from multiple perspectives to enable collective solutions to barriers faced by Black women in an environmental justice community. Data were collected from 22 participants using a focus group approach from Black women with breast cancer (n= 5) and without it (n= 5), healthcare providers (n= 6), and community leaders (n= 6). An iterative and inductive thematic data analysis method was used to analyze data. The themes that emerged from the data included:(1) misconceptions and fear of mammograms;(2) breast cancer screening beyond mammograms; and (3) barriers beyond mammograms. These themes reflected personal, community, and policy barriers leading to breast cancer screening disparity. This study was an initial step to develop multi-level interventions targeting the personal, community, and policy barriers that are needed to advance breast cancer screening equity for Black women living in environmental justice communities.

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Nguyen-Truong, C. K. Y., Nguyen, K. Q. V., Nguyen, T. H., Le, T. V., Truong, A. M., & Rodela, K. (2018). Vietnamese American Women’s Beliefs and Perceptions About Breast Cancer and Breast Cancer Screening: A Community-Based Participatory Study. Journal of Transcultural Nursing, 29(6), 555–562.

Introduction: Although breast cancer (BC) rates are declining in White non-Hispanic American women, they are increasing among Vietnamese American women (VAW) at 1.2% (95% confidence interval [0.1, 2.2]) per year. BC screening rates (64%) are below the national rates (81.1%). This article explores VAW’s beliefs about BC and screening.

Method: Using community-based participatory qualitative descriptive methods, 40 VAW were recruited from Oregon, and four focus groups were conducted. A directed content analysis was used. Results: Main themes were as follows: deferred to a health care provider or relying on self-detection and symptoms; fear of BC versus fear of procedural pain; limited knowledge; motivation by observing others’ journey in BC death or survivorship; body image concern; “living carefree,” “good fortune—having good health”; and coverage for a mammogram expense means health care access.

Discussion: Tailored interventions should address mammogram knowledge, fear, erroneous information, body image, fate and luck, and promoting access.

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Liebermann, E. J., VanDevanter, N., Shirazian, T., Frías Gúzman, N., Niles, M., Healton, C., & Ompad, D. (2019). Barriers to Cervical Cancer Screening and Treatment in the Dominican Republic: Perspectives of Focus Group Participants in the Santo Domingo Area. Journal of Transcultural Nursing, 31(2), 121–127.

Introduction: Cervical cancer is the second leading cause of cancer death among women in the Dominican Republic, and high rates persist despite existing Pap smear screening programs. The purpose of this study was to explore Dominican women’s knowledge and attitudes regarding human papillomavirus (HPV) and cervical cancer, cervical cancer screening practices, and perceived barriers and facilitators to early detection of cervical cancer.

Method: Six focus groups (N = 64) were conducted in Spanish in urban, suburban, and rural locations, in private and public school settings, community and workplace settings, in or near Santo Domingo, as part of a larger study on barriers and facilitators to HPV vaccine implementation. Audio recordings were transcribed verbatim and translated from Spanish to English. Qualitative data analysis used inductive and deductive approaches.

Results: Knowledge regarding HPV and cervical cancer varied across groups, but all agreed there was significant stigma and fear regarding HPV. Most women reported having Pap screening at least yearly. Follow-up of abnormal Pap testing was less consistent, with cost and uncertainty about provider recommendations identified as barriers. Discussion: Broader examination of provider-level and health system barriers and facilitators to cervical cancer prevention in the Dominican Republic is essential, in order to inform interventions to improve the effectiveness of cervical cancer screening and treatment programs and reduce preventable deaths.

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July 2023

Wang, X., Carcel, C., Woodward, M., & Schutte, A. E. (2022). Blood pressure and stroke: a review of sex-and ethnic/racial-specific attributes to the epidemiology, pathophysiology, and management of raised blood pressure. Stroke, 53(4), 1114-1133.

Abstract: Raised blood pressure (BP) is the leading cause of death and disability worldwide, and its particular strongassociation with stroke is well established. Although systolic BP increases with age in both sexes, raised BP is more prevalent in males in early adulthood, overtaken by females at middle age, consistently across all ethnicities/races. However, there are clear regional differences on when females overtake males. Higher BP among males is observed until the seventh decade of life in high-income countries, compared with almost 3 decades earlier in low- and middle-income countries. Females and males tend to have different cardiovascular disease risk profiles, and many lifestyles also influence BP and cardiovascular disease in a sex-specific manner. Although no hypertension guidelines distinguish between sexes in BP thresholds to define or treat hypertension, observational evidence suggests that in terms of stroke risk, females would benefit from lower BP thresholds to the magnitude of 10 to 20 mm Hg. More randomized evidence is needed to determine if females have greater cardiovascular benefits from lowering BP and whether optimal BP is lower in females. Since 1990, the number of people with hypertension worldwide has doubled, with most of the increase occurring in low- and-middle-income countries where the greatest population growth was also seen. Sub-Saharan Africa, Oceania, and South Asia have the lowest detection, treatment, and control rates. High BP has a more significant effect on the burden of stroke among Black and Asian individuals than Whites, possibly attributable to differences in lifestyle, socioeconomic status, and health system resources. Although pharmacological therapy is recommended differently in local guidelines, recommendations on lifestyle modification are often very similar (salt restriction, increased potassium intake, reducing weight and alcohol, smoking cessation). This overall enhanced understanding of the sex- and ethnic/racial-specific attributes to BP motivates further scientific discovery to develop more effective prevention and treatment strategies to prevent stroke in high-risk populations.

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Park, B., Budzynska, K., Almasri, N., Islam, S., Alyas, F., Carolan, R. L., ... & Lamerato, L. (2020). Tight versus standard blood pressure control on the incidence of myocardial infarction and stroke: an observational retrospective cohort study in the general ambulatory setting. BMC family practice, 21(1), 1-8.

Background: The 2017 American College of Cardiology and American Heart Association guideline defined hypertension as blood pressure (BP) = 130/80 mmHg compared to the traditional definition of =140/90 mmHg. This change raised much controversy. We conducted this study to compare the impact of tight (TBPC) versus standard BP control (SBPC) on the incidence of myocardial infarction (MI) and stroke.

Methods: We retrospectively identified all hypertensive patients in an ambulatory setting based on the diagnostic code for 1 year at our institution who were classified by the range of BP across 3 years into 2 groups of TBPC (< 130 mmHg) and SBPC (130–139 mmHg). We compared the incidence of new MI and stroke between the 2 groups across a 2-year follow-up. Multivariate analysis was done to identify independent predictors for the incidence of new MI and stroke.

Results: Of 5640 study patients, the TBPC group showed significantly less incidence of stroke compared to the SBPC group (1.5% vs. 2.7%, P < 0.010). No differences were found in MI incidence between the 2 groups (0.6% vs. 0.8%, P = 0.476). Multivariate analysis showed that increased age independently increased the incidence of both MI (OR 1.518, 95% CI 1.038–2.219) and stroke (OR 1.876, 95% CI 1.474–2.387), and TBPC independently decreased the incidence of stroke (OR 0.583, 95% CI 0.374–0.910) but not of MI.

Conclusions: Our observational study suggests that TBPC may be beneficial in less stroke incidence compared to SBPC but it didn’t seem to affect the incidence of MI. Our study is limited by its retrospective design with potential confounders.

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Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., ... & Wright, J. T. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127-e248.

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines (guidelines) with recommendations to improve cardiovascular health. In 2014, the ACC and AHA, in partnership with several other professional societies, initiated a guideline on the prevention, detection, evaluation, and management of high blood pressure (BP) in adults. Under the management of the ACC/ AHA Task Force, a Prevention Subcommittee was appointed to help guide development of the suite of guidelines on prevention of cardiovascular disease (CVD). These guidelines, which are based on systematic methods to evaluate and classify evidence, provide a cornerstone for quality cardiovascular care. Guidelines are official policy of the ACC and AHA.

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June 2023

Dionne-Odom, J. N., Azuero, A., Taylor, R. A., Wells, R. D., Hendricks, B. A., Bechthold, A. C., ... & Rosenberg, A. R. (2021). Resilience, preparedness, and distress among family caregivers of patients with advanced cancer. Supportive Care in Cancer, 29(11), 6913-6920. DOI: 10.1007/s00520-021-06265-y

Objective: Resilience has been proposed as a primary factor in how many family caregivers of patients with advanced cancer are able to resist psychological strain and perform effectively in the role while bearing a high load of caregiving tasks. To evaluate this hypothesis, we examined whether self-perceived resilience is associated with distress (anxiety and depressive symptoms), caregiver preparedness, and readiness for surrogate decision-making among a racially diverse sample of family caregivers of patients with newly diagnosed advanced cancer.

Methods: Secondary analysis of baseline data from two small-scale, pilot clinical trials that both recruited family caregivers of patients with newly diagnosed advanced cancer. Using multivariable linear regression, we analyzed relationships of resilience as a predictor of mood, caregiving preparedness, and readiness for surrogate decision-making, controlling for sociodemographics.

Results: Caregiver participants (N = 112) were mean 56 years of age and mostly female (76%), the patient’s spouse/partner (52%), and White (56%) or African-American/Black (43%). After controlling for demographics, standardized results indicated that higher resilience was relevantly associated with higher caregiver preparedness (beta = .46, p < .001), higher readiness for surrogate decision-making (beta = .20, p < .05) and lower anxiety (beta = - .19, p < .05), and depressive symptoms (beta = - .20, p < .05).

Conclusions: These results suggest that resilience may be critical to caregivers’ abilities to manage stress, be effective sources of support to patients, and feel ready to make future medical decisions on behalf of patients. Future work should explore and clinicians should consider whether resilience can be enhanced in cancer caregivers to optimize their well-being and ability to perform in the caregiving and surrogate decision-making roles.

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Kent, E. E., Rowland, J. H., Northouse, L., Litzelman, K., Chou, W. Y. S., Shelburne, N., ... & Huss, K. (2016). Caring for caregivers and patients: research and clinical priorities for informal cancer caregiving. Cancer, 122(13), 1987-1995. DOI: 10.1002/cncr.29939

Informal/family caregivers are a fundamental source of care for cancer patients in the United States, yet the population of caregivers and their tasks, psychosocial needs, and health outcomes are not well understood. Changes in the nature of cancer care and its delivery, along with the growing population of survivors and their caregivers, warrant increased attention to the roles and demands of caregiving. This article reviews current evidence presented at a 2-day meeting examining the state of the science of informal cancer caregiving that was convened by the National Cancer Institute and the National Institute of Nursing Research. The meeting sought to define who is an informal cancer caregiver, summarize the state of the science in informal cancer caregiving, and describe both the kinds of interventions developed to address caregiving challenges and the various outcomes used to evaluate their impact.

This article offers recommendations for moving science forward in 4 areas: 1) improving the estimation of the prevalence and burden of informal cancer caregiving; 2) advancing the development of interventions designed to improve outcomes for cancer patients, caregivers, and patient caregiver dyads; 3) generating and testing strategies for integrating caregivers into formal health care settings; and 4) promoting the use of technology to support informal cancer caregivers.

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Travers, J. L., Rosa, W. E., Shenoy, S., Bergh, M., & Fabius, C. D. (2022). Characterizing caregiving supportive services use by caregiving relationship status. Journal of the American Geriatrics Society. https://doi.org/10.1111/jgs.18213

Background: Informal caregivers of older adults experience a high degree of psychosocial burden and strain. These emotional experiences often stem from stressful tasks associated with caregiving. Caregiving supportive services that provide assistance for stressful tasks are instrumental in alleviating caregiving burden and strain. Research is limited on what types of supportive services caregivers are utilizing by relationship status and their source of information regarding these services. We sought to characterize caregiving supportive services use by caregiver relationship status.

Methods: We analyzed cross-sectional data from the 2015 National Study of Caregiving limited to caregivers of older adults =65 years of age. Caregiver relationship status (i.e., spouse, child, other relative/non-relative) was the independent variable. Type of supportive service and source of information about supportive services were the dependent variables. Bivariate analyses were performed to examine the association with caregiver relationship status and associations between use of caregiving supportive services and caregiver and care recipient characteristics. Among service users, we measured associations between caregiver relationship status, type of supportive services used, and source of information about supportive services.

Results: Our sample consisted of 1871 informal caregivers, 30.7% reported using supportive services. By caregiver relationship status, children had the greatest use of supportive services compared to spouses and other relatives/non-relatives (46.5% vs. 27.6% vs. 25.9%, p = <0.01, respectively). Among users of services, there were no differences in type of services used. Spouses primarily received their information about services from a medical provider or social worker (73.8%, p = <0.001). Conclusion: Our findings highlight the need to ensure that other caregiving groups, such as spouses and other relatives/non-relatives, have access to important supportive services such as financial support. Medical providers and/or social workers should be leveraged and equipped to provide this information and refer to services accordingly.

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May 2023

Erickson, J. I., & Pappas, S. (2020). The value of nursing research. JONA: The Journal of Nursing Administration, 50(5), 243-244.

Innovations in patient care, nursing, and the practice environment are hallmarks of organizations receiving American Nurses Credentialing Center (ANCC) Magnet Recognition®. In this month's “Magnet® Perspectives” column, the chair and vice-chair of ANCC's Commission on Magnet Recognition examine the growing importance of nursing research on patient care and outcomes and the role of Magnet hospitals as research pacesetters for the nursing profession. The authors discuss the critical difference between research and evidence-based practice, why both are important, and how organizations can develop the structures and processes to inspire and advance a robust culture of clinical inquiry.

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Hudson, M. L. (2020). Transformational Leadership-An Integrated Evidence Review

For chief nurse executives to survive in contemporary healthcare organizations must cultivate nurse leaders who are poised to produce nurse job satisfaction and subsequently, patient outcomes, including quality and patient safety. The article describes an integrated evidence review of the relationship between transformational leadership and nurse job satisfaction. The author identifies implications for practice and further research.

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Aim: This integrative review aims to explore how nursing leadership influences evidence-based practice in contemporary health care settings.

Background: Although managers and environmental ward culture have long been identified as being among the main barriers to evidence-based practice, there is little overall conceptualization and understanding of the specific role of nurse leaders in directly influencing and supporting this.

Evaluation: The team carried out an integrative literature review (n = 28) utilizing PubMed, CINAHL and the Cochrane Library (2006-2016).

Key issues: The key role of leadership, the methodology used, and understanding and addressing barriers to or facilitators of the implementation of evidence-based practice emerged as key issues.

Conclusion: Nurse managers have a particular influential role on the implementation of evidence-based practice in terms of providing a supportive culture and environment. For this they need to have an underlying knowledge but also to be aware of and address barriers to implementation, and understand the key role of nurse managers in creating and supporting the optimum environment.

Implications for nursing management: Nurse managers need to facilitate and enhance nurses' use of evidence-based practice. Both managers and nurses need to have the necessary academic preparation, support and resources required for practicing using an evidence base.

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April 2023

Pusey-Reid, E., Gona, C. M., Lussier-Duynstee, P., & Gall, G. (2022). Microaggressions: Black students' experiences-A qualitative study. Journal of Professional Nursing, 40, 73-78.

Background: Studies in other disciplines have shown that Black college students experience microaggressions on campus. This affects campus learning climates, posing a risk to students' success.

Purpose: The purpose of this secondary analysis is to describe Black nursing students' experiences with microaggression at a predominantly white institution.

Methods: In this secondary analysis of a descriptive qualitative study, principles of thematic analysis were used to code, categorize, and synthesize interview data from 16 nursing alumni participants specifically to examine microaggression.

Results: The thematic analysis of the data revealed microaggressive behaviors experienced by Black nursing students. Three salient themes emerged: microaggressions among peers, from faculty members to students, and in the clinical setting.

Conclusion: This study offers critical insights into the microaggressions that Black students experience. These microaggressions interfere with students' learning and highlight the need for academic institutions to take measures to dismantle these behaviors. These findings can illuminate to faculty and students the roles they play in perpetuating racism and subjecting students of color to detrimental psychological distress.

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Pusey-Reid, E., Quinn, L., Samost, M. E., & Reidy, P. A. (2023). Skin Assessment in Patients with Dark Skin Tone. AJN, American Journal of Nursing, 123(3), 36-43.

Background: There is a scarcity of nursing literature, studies, and educational materials on the assessment and early recognition of both common and serious integumentary and general health issues in people with dark skin tones. Nurses must be exposed to such learning resources to be adequately prepared to care for patients with diverse skin tones and to help reduce health disparities and promote health equity. This article provides faculty, nursing students, and clinicians with basic information about the assessment of dark skin tone and calls for action in academia and professional practice to ensure nurses and nursing students can effectively perform skin assessments in all patients.

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Gona, C. M., Pusey-Reid, E., Reidy, P. A., Truong, K. A., & Tagliareni, M. E. (2023). Justice, Equity, and Inclusion in a School of Nursing: A Quality Improvement Program. Journal of Nursing Education, 62(1), 20-27.

Background: Despite the increased racial and ethnic diversity in the general population of the United States, the nursing workforce remains mostly White. Schools of nursing (SON) have increased recruitment and enrollment; however, students who represent racial and ethnic minori¬tized groups experience microaggressions, injustice, and social exclusion. This quality improvement program sought to equip faculty with skills to create a just and inclusive SON. The program was guided by the Institute for Health¬care’s Model for Improvement.

Method: Five workshops were developed and implemented during two semesters. Workshops were led and moderated by a diversity, equity, and inclusion consultant.

Results: After the workshops, participants committed to create an inclusive environment, intervene when microaggressions occurred, implement curricular changes, and recognize themselves as members of a privileged group. Postworkshop discussions and re¬flections led to new initiatives in the SON.

Conclusion: This faculty development program demonstrates programs to enhance justice, equity, and inclusion can be implemented successfully within SON.

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March 2023

Stringer, M., Ohnishi, B. R., Ferrarello, D., Lazzeri, J., Giordano, N. A., & Polomano, R. C. (2022). Subject Matter Expert Nurses in Safe Sleep Program Implementation. MCN: The American Journal of Maternal/Child Nursing, 47(6), 337-344.

Background: Pennsylvania’s sudden unexpected infant death rates rank among the highest nationally. A nursing team developed, implemented, evaluated, and disseminated an evidence-based quality improvement (QI) program at birthing hospitals in Pennsylvania to address this issue. To facilitate implementation, clinical nurses were educated as Subject Matter Experts (SMEs) to empower them to transform and sustain outcomes-driven QI for infant safe sleep Nursing practice.

Methods: This descriptive study examined outcomes from 268 nurses who received comprehensive education on infant safe sleep and the SME role. Likert-type scale surveys measured knowledge gained and progress made in practice following education. A programmatic dashboard tracked program implementation. Descriptive statistics were used to report findings.

Intervention: SME nurses (N = 268) completed two interactive learning modules addressing safe sleep guidelines and teaching strategies and attended a workshop to acquire skills for program implementation. Key competencies included data collection and dissemination, policy development, and communication techniques.

Results: Immediate post-education surveys completed by SMEs indicated that over 98% of respondents strongly agreed or agreed they were able to effectively demonstrate communication strategies, identify SME role components, provide environment surveillance, and demonstrate best practices in infant safe sleep. To allow time for assimilation of the SME role, a survey was initiated at 6 months to capture progress made. Seventy-eight SMEs responded to the survey and reported exceptional or substantial progress in 10 areas for SME responsibilities.

Conclusion: The use of the SME role for program implementation led to highly favorable SME-reported outcomes in leading a hospital-based QI program.

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Capper, B., Damato, E. G., Gutin-Barsman, S., Dowling, D., Newberry, D. M., & Parker, L. (2022). Mothers' Decision Making Concerning Safe Sleep for Preterm Infants: What Are the Influencing Factors?. Advances in Neonatal Care, 22(5), 444-455.

Background: Parental decisions regarding infant sleep practices vary widely, resulting in a lack of adherence to the American Academy of Pediatrics safe sleep recommendations (SSR) and, consequently, an increased risk of sudden infant death syndrome (SIDS). Preterm infants are among those at the highest risk for SIDS, yet few studies focus on parental decision-making surrounding sleep practices for preterm infants.

Purpose: The purpose of this study was to identify factors influencing decisions concerning infant sleep practices of mothers of preterm infants.

Methods: This study used a mixed-methods design. Recruitment was through social media messaging by 2 parent support organizations. An online survey was used to assess factors influencing mothers’ decisions regarding sleep practices for preterm infants.

Findings/Results: Survey participants (n = 98) were from across the United States. Mothers of preterm infants (mean gestational age at birth = 29.42 weeks) most often reported positioning infants on their back to sleep (92.3%) and a low (15.4%) use of a pacifier at sleep time. Three themes emerged for the decisions made: adherence to SSR; nonadherence to SSR; and infant-guided decisions. Regardless of the decision, mothers indicated that anxiety over the infant’s well-being resulted in a need for sleep practices that facilitated close monitoring of the infant.

Implications for Practice and Research: The findings of this study indicate the need for understanding the underlying anxiety preventing mothers from adhering to SSR despite knowing them, along with tailoring infant sleep messaging and education to improve the safety of sleep practices for preterm infants. Research is needed to examine decision-making in more diverse populations.

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Middlemiss, W., Brownstein, N. C., Nelson, S. P., Manchiraju, S., Leddy, M., Steliotes, N., & Grzywacz, J. G. (2021). Crafting effective messages to enhance safe infant sleep. Journal of the American Association of Nurse Practitioners, 33(6), 441-450.

Background: Health care professionals are continually challenged by the need to provide health information in a waythat successfully changes health practices. Research has documented this as a concern in relation to safe infant sleep health campaigns. Often, caregivers’ knowledge of recommended practices is not associated with a change in infant sleep choices.

Purpose: Health campaigns, including most safe infant sleep efforts, often share specific risk factors and steps for avoiding risk, that is, in a verbatim format. Research has shown that caregivers’ behavior may be more likely to change when presented with messages based on their general understanding of risk, that is, gist-based format. This research examines caregivers’ responses as related to verbatim- and gist-based safe sleep information.

Methods: Five hundred forty-one caregivers of infants were shown 12 images depicting infants in safe or unsafe sleep spaces. Images varied across three commercially available spaces, infant race, and presence/absence of one policybased risk factor.

Results: Differences in caregivers’ discernment of safe and unsafe sleep images paralleled reported differences in knowledge of safe sleep recommendations. Discernment of safe/unsafe images was greater for White than Black caregivers, as well as for females in comparison with male caregivers. Gist-based considerations, such as familiarity with the sleeper depicted or infant race, were also associated with caregivers’ discernment of safe/unsafe images.

Implications for practice: Attending to both gist- and verbatim-based knowledge regarding safe infant sleep campaign information may help to effectively facilitate caregivers’ ability to always create safe sleep spaces for their infants.

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February 2023

Douthard, R. A., Martin, I. K., Chapple-McGruder, T., Langer, A., & hang, S. (2021). US maternal mortality within a global context: Historical trends, current state, and future directions. Journal of Women's Health, 30(2), 168-177.

In the United States, despite significant investment and the efforts of multiple maternal health stakeholders, maternal mortality (MM) has reemerged since 1987 and MM disparity has persisted since 1935. This article provides a review of the U.S. MM trajectory throughout its history up to its current state. From this longitudinal perspective, MM trends and themes are evaluated within a global context in an effort to understand the problems and contributing factors. This article describes domestic and worldwide strategies recommended by maternal health stakeholders to reduce MM.

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Ahn, R., Gonzalez, G. P., Anderson, B., Vladutiu, C. J., Fowler, E. R., & Manning, L. (2020). Initiatives to reduce maternal mortality and severe maternal morbidity in the United States: a narrative review. Annals of Internal Medicine, 173(11_Supplement), S3-S10.

Maternal mortality and severe maternal morbidity are critical health issues in the United States, with unacceptably high rates and racial, ethnic, and geographic disparities. Various factors contribute to these adverse maternal health outcomes, ranging from patient-level to health system–level factors. Furthermore, a majority of pregnancy-related deaths are preventable. This review briefly describes the epidemiology of maternal mortality and severe maternal morbidity in the United States and discusses selected initiatives to reduce maternal mortality and severe maternal morbidity in the areas of data and surveillance; clinical workforce training and patient education; telehealth; comprehensive models and strategies; and clinical guidelines, protocols, and bundles. Related Health Resources and Services Administration initiatives are also described.

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Guglielminotti, J., Samari, G., Friedman, A. M., Lee, A., Landau, R., & Li, G. (2022). Nurse workforce diversity and reduced risk of severe adverse maternal outcomes. American Journal of Obstetrics & Gynecology MFM, 4(5), 100689.

Background: Racial and ethnic diversification of the physician and nurse workforce is recommended as a leverage point to address the impact of structural racism in maternal care, but empirical evidence supporting this recommendation is currently lacking.

Objective: This study aimed to assess the association between state-level registered nurse workforce racial and ethnic diversity and severe adverse maternal outcomes during childbirth.

Study Design: This population-based cross-sectional study analyzed 2017 US birth certificate data. Severe adverse maternal outcomes included eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Proportions of minoritized racial and ethnic registered nurses in each state were abstracted from the American Community Survey (5-year estimate, 2013–2017). This proportion was categorized into 3 terciles, with the first tercile corresponding to the lowest proportion and the third tercile corresponding to the highest proportion. Crude and adjusted odds ratios and 95% confidence intervals of severe adverse maternal outcomes associated with terciles of the state proportion of minoritized racial and ethnic nurses were estimated using logistic regression models.

RESULTS: Of the 3,668,813 birth certificates studied, 29,174 recorded severe adverse maternal outcomes (79.5 per 10,000; 95% confidence interval, 78.6–80.4). The mean state proportion of minoritized racial and ethnic nurses was 22.1%, ranging from 3.3% in Maine to 68.2% in Hawaii. For White mothers, the incidence of severe adverse outcomes was 85.3 per 10,000 for those who gave births in states in the first tercile of the proportion of minoritized racial and ethnic nurses and 53.9 per 10,000 for those who gave birth in states in the third tercile (risk difference, -31.4 per 10,000; 95% confidence interval, -34.4 to -28.5). It corresponds to a 37% decreased risk of severe adverse maternal outcomes associated with giving birth in a state in the third tercile (crude odds ratio, 0.63; 95% confidence interval, 0.60–0.66). A decreased risk of severe adverse maternal outcomes was observed for Black mothers (crude odds ratio, 0.65; 95% confidence interval, 0.61–0.70), Hispanic mothers (crude odds ratio, 0.51; 95% confidence interval, 0.48–0.54), and Asian and Pacific Islander mothers (crude odds ratio, 0.65; 95% confidence interval, 0.58–0.72) but not for Native American mothers (crude odds ratio, 0.89; 95% confidence interval, 0.72–1.09) or mothers with >1 race (crude odds ratio, 1.44; 95% confidence interval, 0.72–1.09). After adjustment for patients and hospital characteristics, giving birth in states in the third tercile was associated with a reduced risk of severe adverse outcomes as follows: 32% for White mothers (adjusted odds ratio, 0.68; 95% confidence interval, 0.59–0.77), 20% for Black mothers (adjusted odds ratio, 0.80; 95% confidence interval, 0.65–0.99), 31% for Hispanic mothers (adjusted odds ratio, 0.69; 95% confidence interval, 0.58–0.82), and 50% for Asian and Pacific Islander mothers (adjusted odds ratio, 0.50; 95% confidence interval, 0.38–0.65). The associations of the proportion of minoritized racial and ethnic nurses with the risk of severe adverse maternal outcomes were not statistically significant for Native American mothers and more than 1 race mothers. Results were similar when blood transfusion was excluded from the outcome measure.

Conclusion: A diverse state registered nurse workforce was associated with a reduced risk of severe adverse maternal outcomes during childbirth.

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January 2023

Jacobs JM, Post K, Massad K, et al. A telehealth intervention for symptom management, distress, and adherence to adjuvant endocrine therapy: A randomized controlled trial. Cancer. 2022;128(19):3541-3551. doi:10.1002/cncr.34409

Background: Patients taking adjuvant endocrine therapy (AET) after breast cancer face adherence challenges and symptom-related distress. We conducted a randomized trial to evaluate the feasibility, acceptability, and preliminary efficacy of a telehealth intervention (Symptom-Targeted Randomized Intervention for Distress and Adherence to Adjuvant Endocrine Therapy [STRIDE]) for patients taking AET.

Methods: From October 2019 to June 2021, 100 patients reporting difficulty with AET were randomly assigned to either STRIDE or a medication monitoring (MedMon) control group. STRIDE included six weekly small-group videoconferencing sessions and two individual calls. We defined feasibility as having >50% of eligible patients enroll, >70% complete the 12-week assessment, and > 70% of STRIDE patients complete =4/6 sessions. We monitored adherence with the Medication Event Monitoring System Caps (MEMS Caps). At baseline and 12- and 24-weeks after baseline, patients self-reported adherence (Medication Adherence Report Scale), AET satisfaction (Cancer Therapy Satisfaction Questionnaire), symptom distress (Breast Cancer Prevention Trial-Symptom Checklist), self-management of symptoms (Self-efficacy for Symptom Management-AET), coping (Measure of Current Status), quality of life (QOL; Functional Assessment of Cancer Therapy-Breast), and mood (Hospital Anxiety and Depression Scale). We used linear mixed effects models to assess the effect of STRIDE on longitudinal outcomes.

Results: We enrolled 70.9% (100/141) of eligible patients; 92% completed the 12-week assessment, and 86% completed =4/6 STRIDE sessions. Compared with MedMon, STRIDE patients reported less symptom distress (B[difference] = -1.91; 95% CI, -3.29 to -0.52; p = .007) and better self-management of AET symptoms, coping, QOL, and mood. We did not observe significant differences in AET satisfaction or adherence.

Conclusions: STRIDE is feasible and acceptable, showing promise for improving outcomes in patients taking AET after breast cancer.

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Nipp RD, Gaufberg E, Vyas C, Azoba C, Qian CL, Jaggers J, Weekes CD, Allen JN, Roeland EJ, Parikh AR, Miller L, Wo JY, Smith MH, Brown PMC, Shulman E, Fernandez-Del Castillo C, Kimmelman AC, Ting D, Hong TS, Greer JA, Ryan DP, Temel JS, El-Jawahri A. Supportive Oncology Care at Home Intervention for Patients With Pancreatic Cancer. JCO Oncol Pract. 2022 Oct;18(10):e1587-e1593. doi: 10.1200/OP.22.00088. Epub 2022 Jul 13. PMID: 35830625.

Purpose: We sought to determine the feasibility of delivering a Supportive Oncology Care at Home intervention among patients with pancreatic cancer.

Methods: We prospectively enrolled patients with pancreatic cancer from a parent trial of neoadjuvant fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFIRINOX). The intervention entailed (1) remote monitoring of patient-reported symptoms, vital signs, and body weight; (2) a hospital-at-home care model; and (3) structured communication with the oncology team. We defined the intervention as feasible if = 60% of patients enrolled in the study and = 60% completed the daily assessments within the first 2-weeks of enrollment. We determined rates of treatment delays, urgent clinic visits, emergency department visits, and hospitalizations among those who did (n = 20) and did not (n = 24) receive Supportive Oncology Care at Home from the parent trial.

Results: From January 2019 to September 2020, we enrolled 80.8% (21/26) of potentially eligible patients. One patient became ineligible following consent because of moving out of state, resulting in 20 participants (median age = 67 years). In the first 2 weeks of enrollment, 65.0% of participants completed all daily assessments. Overall, patients reported 96.1% of daily symptoms, 96.1% of daily vital signs, and 92.5% of weekly body weights. Patients receiving the intervention had lower rates of treatment delays (55.0% v 75.0%), urgent clinic visits (10.0% v 25.0%), and emergency department visits/hospitalizations (45.0% v 62.5%) compared with those not receiving the intervention from the same parent trial.>

Conclusion: Findings demonstrate the feasibility and acceptability of a Supportive Oncology Care at Home intervention. Future work will investigate the efficacy of this intervention for decreasing health care use and improving patient outcomes.

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Greer JA, Moy B, El-Jawahri A, Jackson VA, Kamdar M, Jacobsen J, Lindvall C, Shin JA, Rinaldi S, Carlson HA, Sousa A, Gallagher ER, Li Z, Moran S, Ruddy M, Anand MV, Carp JE, Temel JS. Randomized Trial of a Palliative Care Intervention to Improve End-of-Life Care Discussions in Patients With Metastatic Breast Cancer. J Natl Compr Canc Netw. 2022 Feb;20(2):136-143. doi: 10.6004/jnccn.2021.7040. PMID: 35130492; PMCID: PMC8830600.

Background: Studies show that early, integrated palliative care (PC) improves quality of life (QoL) and end-of-life (EoL) care for patients with poor-prognosis cancers. However, the optimal strategy for delivering PC for those with advanced cancers who have longer disease trajectories, such as metastatic breast cancer (MBC), remains unknown. We tested the effect of a PC intervention on the documentation of EoL care discussions, patient-reported outcomes, and hospice utilization in this population.

Patients and methods: Patients with MBC and clinical indicators of poor prognosis (n=120) were randomly assigned to receive an outpatient PC intervention (n=61) or usual care (n=59) between May 2, 2016, and December 26, 2018, at an academic cancer center. The intervention entailed 5 structured PC visits focusing on symptom management, coping, prognostic awareness, decision-making, and EoL planning. The primary outcome was documentation of EoL care discussions in the electronic health record (EHR). Secondary outcomes included patient-report of discussions with clinicians about EoL care, QoL, and mood symptoms at 6, 12, 18, and 24 weeks after baseline and hospice utilization.

Results: The rate of EoL care discussions documented in the EHR was higher among intervention patients versus those receiving usual care (67.2% vs 40.7%; P=.006), including a higher completion rate of a Medical Orders for Life-Sustaining Treatment form (39.3% vs 13.6%; P=.002). Intervention patients were also more likely to report discussing their EoL care wishes with their doctor (odds ratio [OR], 3.10; 95% CI, 1.21-7.94; P=.019) and to receive hospice services (OR, 4.03; 95% CI, 1.10-14.73; P=.035) compared with usual care patients. Study groups did not differ in patient-reported QoL or mood symptoms.

Conclusions: This PC intervention significantly improved rates of discussion and documentation regarding EoL care and delivery of hospice services among patients with MBC, demonstrating that PC can be tailored to address the supportive care needs of patients with longer disease trajectories.

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