Ph.D. - Nursing

Permanent URI for this collectionhttps://hdl.handle.net/10125/2116

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IDENTIFICATION OF FALL RISK FACTORS AND DEVELOPMENT OF A FALLS PREDICTION MODEL FOR COMMUNITY-DWELLING OLDER ADULTS RECEIVING PUBLIC HEALTH NURSING SERVICES IN HAWAI`I
(University of Hawai'i at Manoa, 2023) Chock, Johnelle; Tse, Alice M.; Nursing
Nationally, one in four seniors fall each year, with the incidence of falls increasing with age. It is estimated that there are 26 fall-related injuries per day. For older adults 65 years and older, falls are the leading cause of hospitalizations, traumatic brain injury, and the leading cause of injury Emergency Department visits. The Centers for Disease Control and Prevention estimates that in 2030, 73 million older adults will live in the United States, leading to 52 million falls and 12 million fall-related injuries annually. Fall risk factors have been identified as intrinsic or extrinsic. The overall purpose of this study is to discover which fall risk factors (Missouri Alliance for Home Care Fall Risk Assessment Tool (MAHC-10), age, living arrangement, gender, number of medications, medication type, Charlson Comorbidity Index (CCI) score, and the Age-Adjusted Charlson Comorbidity Index (ACCI) score) provide the strongest indicators of falls among community-dwelling older adults in Hawaii. A fall prediction model was developed using the strongest fall indicators for community-dwelling older adults in Hawaii. This study utilized a secondary analysis of the Hawaii Department of Health Public Health Nursing Branch fall database. The sample size was 211 community-dwelling older adults 60 years and older living in Hawaii. Data was collected for the model and included the MAHC-10 score, age, living arrangement, gender, number of medications, medication type, the CCI score, and the ACCI score. A nonparametric two-sample Wilcoxon test, a nonparametric Pearson chi-square test, a Fisher’s exact test, a Cochran-Armitage test for trend, or a univariate logistic regression was performed on the independent variables. A receiver operating characteristic (ROC) curve, sensitivity, and specificity were completed for the screening tools. Multiple logistic regression was completed to develop a prediction model for falls among Hawaii community-dwelling older adults. The statistical modeling was performed using SPSS version 25. This study found that there were individual significant associations between community-dwelling older adult falls and the MAHC-10 total score of six or more, prior history of falls, environmental risk factors, CCI total score of two or more, the ACCI total score of six or more, depression, cancer, myocardial infarction (MI), peripheral vascular disease (PVD), and antispasmodic medication. This study also developed a parsimonious model with five variables and a c-statistic of 0.70 (95% CI= 0.61- 0.79). The variables that were included in the model were prior history of falls, MI or PVD, antispasmodic medication, depression, and environmental hazards. This study identified significant fall risk factors and developed a parsimonious model for this sample of community-dwelling older adults in Hawaii. This information could be used in the community to identify older adults at risk for falling and provide evidence-based fall prevention interventions in the future.
Healthcare Needs And Factors Related To Non-use/underutilization Of Veterans Healthcare Administration (VHA) Health Services Entitlements By Post 9/11 Women Veterans
(University of Hawaii at Manoa, 2023) Parsons, Teresa Ann; Tse, Alice; Nursing
Women are the fastest growing population in the Department of Veteran Affairs (VA), but only inrecent history. U.S. military shift to an All-Volunteer Force (AVF) in 1973 resulted in a dramatic spike in women serving in the military. During the transition from active military to Veteran status, Veterans are eligible to apply to the Department of Veterans Affairs (VA) for benefits, including healthcare. In 2020, the VA estimated that over two million Women Veterans (WV) were living. The VA estimates the percentage of WV will rise to over 18% of all Veterans by 2046. In a report to Congress in FY2020, 38.8% of eligible WV were enrolled in Veterans Health Administration (VHA) services, but only 22.4% used VHA services in the prior 12 months. It has been reported that many WV cite feeling unwelcome in VHA while others question the adequacy of gender-based services. The purpose of this study was to gain a better understanding of VHA health services use patterns and factors influencing non-use/underutilization by two current service era populations of WV. This study used a quantitative, secondary analysis of two WV cohorts: 158 Pre 9/11 and 124 Post 9/11 WV from the National Survey of Veterans 2010 (NSV 2010). The analysis included nonparametric tests for differences between groups for three outcome variables: enrollment for VHA care, use of primary care within the prior six months, and use of women’s healthcare within the prior twelve months. Binary logistic regressions were performed to determine the significance of predictor variables developed under the Behavioral Model of Health Services Use by Andersen. Findings: Percentages of non-enrolled in the Pre 9/11 and Post 9/11 WV groups were 53.15% and 45.97%, respectively. Within the prior year, 77.20% of Pre 9/11 WV used primary healthcare services and 65.60% used women’s healthcare services that were not in or paid for by the VHA. Similarly, 74.20% of Post 9/11 WV used primary healthcare services and 63.70% used women’s healthcare services that were not in or paid for by the VHA. An unanticipated finding was WV in the two service era groups who used outpatient care outside the VHA system in the prior six months, 35.66% Pre 9/11 and 41.30% Post 9/11 paid for healthcare services out-of-pocket. Directing research and programs to target WV who are not enrolled for VHA health services can guide VHA efforts to tailor outreach to improve access and use of entitled healthcare services within the VHA these WV have earned.
Awakening Nurse Managers’ Spirit Of Self-care Within
(University of Hawaii at Manoa, 2021) Ricossa, Katherine Ann; Tse, Alice; Nursing
BackgroundNurse Managers (NMs) are vulnerable to leaving the profession due to dissatisfaction from mounting on-the-job pressures and perhaps unknowingly lack the practices of loving-kindness and self-care, which may help build resilience. There is a gap in the literature where the practice of self-care has not been addressed on behalf of NMs. Purpose The purpose of this dissertation was to determine if there is a correlation between demographic characteristics as it relates caring practices among NMs with their perceptions of their immediate supervisors (caring leader) and to discover if there is a correlation between a caring for self and caring leaders. Study Methods This study was descriptive, exploratory, and quantitative. The convenience sample consists of directors, nurse managers and assistant nurse managers. The setting is an organization called the California Association of Nurse Leaders. An IRB was obtained by the University of Hawai’i at Mānoa. Demographic information was collected with two instruments that measured self-care and leadership. The Watson Caritas Self Rating® (WSCRS) and Watson Caritas Leader Rating® (WCSRS). WSCRS had a Cronbach Alpha of .89. WSCRS had a Cronbach Alpha of .82, Recruitment and survey questions were distributed electronically. The study period was May 19, 2021, to June 30, 2021. Data Analysis The sample size consisted of NMs (n = 23). Missing data revealed that bias existed with family composition. For both WCSRS and WCSR surveys, the least responded items were: helping and trusting relationships, and values, belief and faith. Cronbach alpha indicated good internal consistency. Using a regression model, findings indicate statistical significance (p < 0.05). Findings Family composition revealed bias, indicating those who live alone may have had more time to complete the survey. Results were examined separately and then combined to establish significance. The following independent variables were statistically significant when tested separately: advanced degree (masters’ and doctorate) and marital status (married or partnered). However, when these variables were combined only advanced nursing degree was significant. The caring leader and advanced degree in nursing remained significant when tested separately. When combined, the advanced degree in nursing was significant. Caring for self and caring leader had a positive correlation. Conclusion This study was considered a pilot due to the small sample size. Findings indicated that advanced degree in nursing (masters’ or doctorate) remained the most single predictor of caring for self throughout the study. A supervisor (caring leader) was correlated to the NMs’ ability for caring for self.
The Lived Experience Of Trigeminal Neuralgia Patients And Their Decision To Undergo Gamma Knife Stereotactic Radiosurgery Treatment For Pain Control
(University of Hawaii at Manoa, 2021) O'Neil, Maureen Margaret; Fontenot, Holly B.; Nursing
Significance: Trigeminal Neuralgia (TN) is described as intermittent excruciating facial pain, causing severe distress to those who experience it. When the pain is uncontrolled, Gamma Knife Stereotactic Radiosurgery is a treatment option that has significantly increased over the past two decades. This has also increased nurse/patient interactions with trigeminal neuralgia patients. While medical and physics studies are well documented, very little is known about the trigeminal neuralgia patient’s lived experience and coping mechanisms with this type of severe facial pain. Methods: Using the interpretative phenomenological methodology, this study explored the participants’ lived experiences. The study inquiry, “What was your experience of living with TN, and how did you come to decide on GKSR treatment?” consisted of in-depth interviews using open-ended questions. It explored the participants’ perception of their trigeminal neuralgia diagnosis including coping with this pain, the effect it had on family and work, and their healthcare interactions. Results: The interview encountered three main themes including how trigeminal neuralgia affected them personally, socially, and their interactions with the healthcare community. The impact of the interviews described their isolation, frustration with attempts to get pain relief, and most significantly, suicidal ideation. Conclusion: Their shared experiences provided an opportunity to better understand this diagnosis and the difficulties that patients may encounter. It also examined how nursing may contribute to improving patient well-being during the process of receiving Gamma Knife treatment. The potential for further education and research to continue to improve nursing care for the trigeminal neuralgia patient was also explored.
Mixed Methods Exploration Of Health Literacy Among Former Soviet Union Immigrants
(University of Hawaii at Manoa, 2021) Kostareva, Uliana; Albright, Cheryl; Nursing
The purpose of this dissertation was to assess the health literacy in Russian-speakingimmigrants from the former Soviet Union (FSU) and identify factors relevant to their health literacy. Immigrants have been shown to have lower health literacy than native-born population and experience challenges navigating healthcare systems of their host countries, but little is known about health literacy of FSU immigrants. This dissertation aims to fill this knowledge gap. Among the world’s 272 million international migrants, more than 25 million are from FSU. Large diasporas of FSU immigrants reside in the United States (US), Germany, and Israel. As a three manuscripts approach, this dissertation examined healthcare system factors that may influence FSU immigrants’ health literacy across the US, Germany, Israel, and two FSU countries (manuscript 1), performed a multilingual literature review (manuscript 2), and conducted a mixed methods research study to assess the health literacy of FSU immigrants in the US (manuscript 3). As a scoping review with a broad search and a narrative commentary, manuscript 1 provided an overview of FSU immigrants’ sociodemographic data, historical background, migration context, and depicted a landscape of healthcare system factors relevant to health literacy, including departed countries (Russia and Kazakhstan) and receiving countries (US, Germany, Israel) within the Integrated Health Literacy Model framework. Manuscript 1 examined multiple distinct healthcare systems and described system-level factors that may influence individual health literacy. As an integrative review with a focused search, manuscript 2 synthesized any available research literature relevant to health literacy and health insurance literacy among FSU immigrants in four languages, identifying just seven articles. Only two articles measured health literacy of FSU immigrants, which was lower than the general population. Also, manuscript 2 provided a model and possible methodology for other multilingual literature searches. Manuscript 3 conducted quantitative analyses and found that 40% of a sample of FSU immigrants living across the US had inadequate or problematic levels of health literacy based on HLS-EU-Q12. Manuscript 3 discovered that social status, social support, and English proficiency were significantly associated with health literacy in this sample, while age, gender, and education were not. Qualitative analysis identified major themes of health insurance, access to health information, experience with health care, healthcare system differences, and health beliefs as relevant to the health literacy of respondents from their own perspectives. When studying health literacy of FSU immigrants, it is important to consider personal factors as well as healthcare system and organizational factors.
Exploring A Shared History Of Colonization, Historical Trauma And Links To Alcohol Use With Native Hawaiians Living In Rural Hawaii In The 21st Century
(University of Hawaii at Manoa, 2020) Greywolf, Cynthia Taylor; Casken, John; Nursing
Abstract American Indigenous populations, American Indians (AIs), and Alaska Natives (ANs) have experienced historically traumatic events over the past 500 years, and Native Hawaiians (NHs) over the last 240 years from contact with Europeans, and the subsequent colonization, and appropriation of traditional homelands. Colonization resulted in massive losses of people, and culture including loss of cultural knowledge, traditions, land, and identity. The proximal issues of racism, discrimination, oppression, and marginalization have compounded the problem leaving a long legacy of unresolved historical trauma and a complex form of chronic Post- Traumatic Stress Disorder (PTSD), and unresolved grief among individuals in the tribes and groups. Indigenous scholars have posited historical trauma as a prime cause of the current social pathology among AI/AN/NH populations through the inter-generational transmission of stress leading to high rates of suicides, homicides, domestic violence, child abuse, alcohol, and substance use, and mental health disparities. AI researchers have emphasized the need to study historical trauma in relation to specific sociocultural contexts. Research exploring the impact of colonization and historical trauma has been conducted with AIs and ANs demonstrating a link between historical trauma, and increased physical and mental health disparities, alcohol, and other substance use. Little is known about the behavioral risks of substance use that may have resulted from colonization and historical trauma in NHs. There are specific cultural and historical losses which are unique to NHs who are at a higher risk for poorer mental health outcomes, and alcohol and other substance use compared to other ethnic populations in Hawaii. NHs have a history, similar to AIs/ANs, which elevates the importance of exploring their lived experience, and perceptions of colonization, historical trauma and links to alcohol use in the 21st century.
Exploring Risk Perception In A Native Hawaiian Community On Oʻahu
(University of Hawaii at Manoa, 2019) Torris-Hedlund, Morgan Aiwohi; Qureshi, Kristine; Nursing
Purpose. Disasters pose a significant risk to the residents of Oʻahu. One of the most effective ways to save lives and reduce loss is preparedness. A vital element in understanding preparedness measures is determining if people see themselves at risk. Many factors influence risk perception, including age, gender, culture, and ethnicity. Owing to this understanding, Native Hawaiians may have a unique perception of risk. Paton’s social cognitive model was used to frame risk perception's role in exploring how Native Hawaiians living in the community of Papakōlea on Oʻahu view their risk from natural disasters. Methods. A qualitative study using photovoice was conducted, wherein participants chose photos to communicate their concerns for disaster risks. A collaborative thematic analysis was performed, and illuminated themes were paired with the participants’ images. Results. Sixteen (n=16) members of the community participated, ten women and six men organized into three age cohorts, 18-37, 38-57, and 58+. After reviewing 115 photos, participants selected nine to represent their concerns and identified five themes: natural conditions and processes, access in and out of the community, physical safety, threats beyond their control or understanding, and responsibility for family. Discussion. Participants saw erosion, overgrown vegetation, and flooding as risk factors. The upkeep of homes, roads, and property were also seen as threats. Participants worried that access in and out of the community might put them in danger during a disaster. Threats beyond the immediate community caused significant anxiety. The most critical concern to participants was their family and other community members.
Exploring The Influence Of Diet Quality On Visceral Adiposity And Risk Of Mortality From Non-communicable Diseases Among Adults In The US
(University of Hawaii at Manoa, 2019) Panizza, Chloe; Boushey, Carol J.; Nutrition
High visceral adipose tissue (VAT), more so than subcutaneous adipose tissue, is associated with an increased risk of chronic disease and mortality. Following a higher quality diet is associated with lower VAT, and a reduced risk of death from all-causes, CVD, and cancer. This dissertation further explored the relationships between patterns of eating, VAT, and mortality through three distinct studies. Exploration of the Healthy Eating Index-2015 (HEI-2015) scores among the Multiethnic Cohort (MEC) examined the association between HEI-2015 scores and risk of all-cause and cause-specific mortality. A pilot study was conducted to determine the effects of intermittent energy restriction combined with a Mediterranean diet (IER+MED) compared to an active comparator, a euenergetic Dietary Approaches to Stop Hypertension (DASH) diet, on VAT reduction among East Asian American adults. Assessing the association between Healthy Eating Index-2010 (HEI-2010) scores, VAT and overall adiposity among a multiethnic adult population constituted the third study. These studies were completed using observational and interventional designs. For the HEI-2015 study, the primary analysis was a survival analysis among MEC participants followed over a 17-22 y period. The IER+MED study was a randomized study where participants followed the prescribed diets over 12 weeks. The HEI-2010 study was cross-sectional and used DXA-based VAT. Among the MEC sample, comparing those with the highest quality diets to those with the lowest quality, the reduction in risk of mortality from all-cause, CVD, and cancer was 21%, 24%, and 20%, respectively, for men and 21%, 25%, and 16%, respectively, for women. Those following the IER+MED had significantly larger reductions in DXA-derived VAT and total fat mass (−22.6 ± 3.6 cm2 and −3.3 ± 0.4 kg, respectively) vs. DASH (−10.7 ± 3.5 cm2 and −1.6 ± 0.4 kg) (p = 0.02 and p = 0.005). For the HEI-2010 study, BMI, percent body fat, total body fat, trunk fat, insulin, and HOMA-IR were inversely related to HEI-2010 scores (all p values < 0.004). Findings from this dissertation support following a healthy dietary pattern is associated with lower VAT, and a reduced risk of mortality from all-causes, CVD, and cancer. In particular, IER+MED, may help to lower VAT and improve liver function.
Power and Control in Medicine and Nursing – Could Intrinsic Gender Beliefs Impact Interprofessional Education in Pre-Professional Programs?
(University of Hawaii at Manoa, 2019) Delnat, Catherine Christine; Casken, John; Nursing
ABSTRACT Examination of the power dynamics at work in perpetuating health care hierarchy-related interprofessional collaboration barriers is needed to rationally develop strategies for teaching collaborative skills to health care providers. A mixed-methods study employing critical realist grounded theory examined the implicit beliefs, assumptions and power hierarchies related to gendered perceptions of the professions of nursing and medicine by students of those professions. Two focus groups of nursing students (n = 6 and n = 8) and one focus group of medical students (n = 6) and an online survey of both medical and nursing students utilizing the Interpersonal Hierarchy Expectation Scale (Mast, 2005a) (N = 73) provided the data. Focus group data revealed that both nursing and medical students had strongly gender-essentialized beliefs about the social categories of medicine and nursing with nursing as feminine and medicine as masculine. Students ascribed expectations of work performance based on gender with female physicians expected to be more successful in family-oriented roles (pediatrics) and male nurses expected to be more successful in ‘non-nurturing’ roles (surgery). Survey data revealed that both nursing and medical students had the same level of hierarchy expectations. Gendered stereotypes of nurses as communal and physicians as agentic can contribute to the maintenance of components of the health care hierarchy that lead to sub-optimal interprofessional collaborative practice. Understanding students’ essentialist beliefs about the social categories of nursing and medicine can inform effective interprofessional education curriculum development.
Nutritional Risk in the Cancer Patient 65 and Older Undergoing Systemic Treatment Via Phase I Clinical Trials
(University of Hawaii at Manoa, 2019) Williams, Anna C.; Ceria-Ulep, Clementina; Nursing
Abstract One of the greatest risk factors for contracting cancer is aging. By the year 2030 the number of new cancer cases will balloon to 2.3 million per year. Malnutrition is a common problem identified in cancer patients and is recognized as an important component of adverse outcomes, including increased morbidity and mortality and decreased quality of life (QOL). Nutritional risk is not consistently assessed in the older adult cancer patient population. The purpose of this study was to identify variables related to nutritional risk in the cancer patient 65 years and older receiving systemic treatments via Phase I clinical trials. The study described the relationship between nutritional risk and the four domains of QOL (physical, social, emotional, and functional). This study was guided conceptually by an adapted version of the City of Hope QOL model, focusing on the four key domains of QOL. The instrument chosen to measure QOL was the FACT-G (Version 4), created by Cella, et al. (1993), is a cancer specific version of the FACIT (Functional Assessment of Chronic Illness Therapy) Measurement System. It contains a 27-item compilation of general questions divided into the four QOL domains. A sample of 73 patients, with a mean age of 71, were successfully accrued for this study from an NCI RO1 aimed at integrating supportive care for cancer patients on Phase I clinical trials using the MNA-SF instrument to assess for nutritional risk. The population was predominantly Caucasian and overall well-educated. Most of the patients were Protestant and were married or partnered, living with a spouse or child. Most were retired with an annual income of $50,000 or greater. The participants were almost equally divided by male and female. Study findings revealed that the strongest correlation with nutritional risk was BMI status (r = .47, p < .0001). Multiple regression analysis demonstrated that the factors associated with nutritional risk included BMI, previous chemotherapy and physical subscale of the FACT-G QOL instrument. Additional descriptive data reinforced the importance of nursing assessment and intervention to support nutritional status. Nutrition impacts all dimensions of QOL and will be even more important in an aging population. Nursing research can contribute greatly to advancing this area of practice.
Experiences and perceptions of first-time mothers who conceived with assisted reproductive technology and subsequently had infants who were admitted to the neonatal intensive care unit
(University of Hawaii at Manoa, 2019) Oshiro, Kiyomi; Shannon, Maureen; Nursing
Background: The evolution of modern reproductive technology and the use of assisted reproductive technology (ART) have increased dramatically worldwide, making pregnancy possible for many infertile couples. However, since ART was established and the prevalence of the utilization of ART treatment to achieve conception has increased and become more complex, one of the most important consequences has been premature births. As a result, an increasing number of women who have successfully conceived after undergoing ART give birth to preterm infants, and these infants, in all likelihood, require admission to and some length of stay in the neonatal intensive care unit (NICU) for special care after birth. Nevertheless, no study has focused on mothers who conceived as a result of ART treatments/procedures and who, subsequently, had infants that required admission to the NICU. The purpose of this study was to explore the experiences, perceptions, and coping strategies of mothers who underwent ART and gave birth to infants who required admission to the NICU. Method: A qualitative descriptive approach was used to explore the emic experiences, perceptions, and coping processes of ART first-time mothers when their infants were admitted to the NICU. This study employed open-ended questions to explore and interpret meaningful themes. The interview data were transcribed and analyzed using an iterative process in order to identify common themes. Findings: Nine women meeting the inclusion criteria were recruited and enrolled in the study. Data analysis revealed four themes that reflected common perceptions and experiences of the participants. The participants in this study provided some new information about these mothers’ unique experiences and perceptions, as well as some similarities with the experiences of non-ART mothers whose infants had NICU stays. Many of the mothers indicated that undergoing ART was a really traumatic experience, and, for a few, having an infant in the NICU was a less traumatic experience because the ART treatment had created more intense feelings of distress. Some of the mothers stated that the exposure to the technology and procedures (e.g., injections) that were a part of their ART treatments helped their adjustment to having their infants in the NICU. Other mothers indicated that watching their infants experience injections and invasive procedures, or have routine equipment used to assess their well-being (e.g., monitors), was more uncomfortable and upsetting due to their ART experiences. The new finding indicated that, for mothers who required ART treatment and had viable births but whose infants needed special care in the NICU, their experiences of stress and ways of coping focused on adapting to a new unfamiliar environment while transitioning to motherhood.
Respectful Maternity Care in Santa Cruz County, California
(University of Hawaii at Manoa, 2019) Stein, Cindy Aliza; Shannon, Maureen; Nursing
Abstract Background: In the global setting, despite access to lifesaving care in facilities that serve women during childbirth, many women delay or avoid using these services, as evidenced by vast amounts of literature on the topic. This has even proven true when controlled for variables that serve as obstacles to obtaining the care that they need. Global stakeholders have acknowledged the presence of disrespect and abuse (D&A) by staff within health facilities as a deterrent to women seeking lifesaving maternity services; the association between how respectfully a woman is treated during childbearing with how likely she is to utilize maternity services in the future. The movement to eliminate D&A in the maternity setting has resulted in the development of Respectful Maternity Care (RMC) as a model to combat this issue. However, a standardized definition of what respect means to childbearing women has never been established, making implementation of RMC universal standards and interventions difficult. This study was aimed at beginning to define what women consider respectful care to be so that minimum standards can be applied with an eye towards training staff, creating regulations that encourage or require RMC, or other potential interventions aimed at better serving women during childbirth. Method and Findings: A qualitative descriptive study design was used in order to hear detailed accounts of women’s experiences and perceptions about respect. This emic approach allowed for an analysis of the experiences of participants while an iterative process was used to analyze the data resulting in codes, categories and themes via content analysis. Using semi structured interviews that explored themes in respectful maternity care through the lens of ten women who had recently given birth in Santa Cruz County, California. Recruitment stopped once saturation was achieved. Five themes emerged from the analysis: 1) Needs Were Met In a Timely Manner; 2) Care is Patient Centered; 3) Overall Feelings of Kindness; 4) Caregivers Are Experts; and 5) The Environment is Safe. The working definition of respect that can be derived from this study and its resulting themes is, “Respect in the maternity setting is a multivariate concept based on women feeling well cared for by health workers based on their attitudes and actions: attentiveness, a high level of knowledge, kindness, a focus on patient preference, and providing a safe environment to put women at ease.” Limitations: Due to the homogenous nature of the study sample, saturation was reached at ten, a small sample size. Descriptions may be limited in that they are not generalizable to other populations. Also, contributing factors such as experiences during the prenatal period were not discussed in interviews. Conclusions: The results of this small study indicated that women experiencing childbirth consider respectful care to involve attitudes and behaviors of maternity staff that encompass treating the women with kindness, providing care that is based on current evidence to ensure their and their infants’ safety, being attentive to their needs in a timely manner, and including them in conversations about plans of care while considering their desires reflecting a patient-centered approach to care. Keywords: maternal mortality, maternal death, facility-based maternity care, barriers to obstetric care, maternal morbidity, maternal near-misses, disrespectful maternity care, respectful maternity care, burnout, midwife burnout, compassion fatigue, human rights and birth, three delay, three-delays model.
The Essential Structure of the Lived Experience of College Students who are Family Members of Veterans with PTSD who Served in the Iraqi-Afghanistan Armed Conflicts
(University of Hawaii at Manoa, 2019) Neves, Abbie Joan; Casken, John; Nursing
ABSTRACT Background: Post traumatic stress disorder (PTSD) has become widely known as one of the ‘signature injuries’ of the Iraqi-Afghanistan armed conflicts. The indirect experiencing of trauma from a close family member’s PTSD is conceptualized in the literature as secondary, vicarious, or intergenerational trauma. Intergenerational trauma is a significant problem which is likely to continue given the current U.S. involvement and state of unrest in countries such as Iraq, Afghanistan, and Syria. This problem has become more apparent as an increasing number of family members/dependents are using veteran’s administration education benefits to return to college due to military force shaping with little to no specific supportive services in place. Purpose: To gain insight into the lived experience of college students who were family members of veterans with PTSD who served in the Iraqi-Afghanistan armed conflicts. Methodology: A transcendental phenomenological design was used. Participants/co-researchers were selected via purposive non-probability sampling using a snowball technique. Data was collected via semi-structured interviews. The transcribed interviews were analyzed using Moustakas’ (1994) Modified Van Kaam method of phenomenological reduction. Findings: After identifying horizons and invariant constituents (unchanging horizons, four core themes were identified; powerlessness, silence, apprehensiveness, and loss, all of which were tested through application validation. Individual textural and structural descriptions were synthesized into a composite textural-structural description of the true essence and meaning of the experience of the phenomenon that represented the group as a whole. Recommendations: Further research, practice, and policy changes are recommended to develop supportive services for college students who are family members of veterans with PTSD. Keywords: intergenerational trauma, secondary trauma, vicarious trauma, college students, family members, dependents, PTSD, veterans, Iraqi-Afghanistan, war, armed conflicts.
A Qualitative Study Using Phenomenology: Investigation of the Lived Experience of Second Degree Master's Entry Nurses as they Transition in their Advanced Practice Role
(University of Hawaii at Manoa, 2018-08) Farr, Shirley M.; Nursing
Significance: Transition to advanced practice can be a challenge for students who are successful clinical bedside nurses. Second-career master’s entry students experience several transitions within their nursing educational process. Investigating the process that they go through the first 2 years after completing their graduate education and becoming Advanced Practice Registered Nurses (APRNs) was valuable in understanding the consequences/outcomes of their transition as it relates to role performance, clinical competence/judgment, professional competence, and satisfaction. Transition occurs throughout the stages in life. Transition is as an evolving process related to multiple situations in life experiences. Purpose: The purpose of this study was to investigate the lived experience of the second career masters’ entry nurse as he or she transitions in the APRN role as a Nurse Practitioner (NP). Method: The study design was qualitative, exploratory, and involved in-depth focus group interviews using a phenomenological method of inquiry. The sample was purposeful, with recruitment from Azusa Pacific University’s second-career Entry-Level Master’s program. The selected participants have graduated from their nursing program and have been working as NPs in an outpatient clinical setting from 1 to 24 months. Results: Seven main themes emerged from the focus group discussions: feeling overwhelmed, gaining confidence, being humble, being a life-long learner/educator, weaving previous degree and life experience, recognizing gaps and challenges in APRN education, and practicing in a familiar environment to ease the transition. Conclusions and Implications: Participants were able to transition to their NP role within the first 12 months. Implications for further research include the need to compare different entry-level master’s nursing programs that have an NP focus, examine traditional Master of Science NPs, and expand the timeframe to 3 to 5 years in practice.
A Caregiver's Decision-Making Process in Remaining Engaged in a Lead Follow-Up Program with a Child with an Elevated Blood Lead Level
(University of Hawaii at Manoa, 2018-08) Dinsey-Read, Kimberley A.; Nursing
Oral Mucosal Microcirculation in the Context of Endotracheal Tube-Related Pressure Ulcer Development
(University of Hawaii at Manoa, 2018-08) Chun, Nicolle M.; Nursing
Critically ill patients commonly require multiple medical devices such as cardiac monitors, ventilators, non-invasive positive pressure ventilators, nasal gastric tubes (NG), orogastric tubes (OG), and urinary tract catheters. Nurses are challenged to prevent hospital acquired pressure ulcers (HAPUs) because many of these devices can cause ulcers on bony prominences and mucosa. The literature indicates that medical device-related pressure ulcers (MDRPUs) associated with endotracheal tube (ETT) were the most frequent (Coyer, F., Stotts, N. & Blackman, V., 2014; Hanonu & Karadag, 2016), with highest rates of MDRPUs were observed among Medical Intensive Care Unit (MICU) patients (Hanonu & Karadag, 2016). The purpose of this study was to explore the effects of ETT pressure and ETT repositioning frequency on oral mucosa microcirculation among intubated patients to guide clinicians in the prediction and prevention of oral mucosa pressure ulcers (OMPrU). A single-site, prospective, descriptive, observational study was conducted with a convenient sample of six patients who were enrolled between January 7, 2016 and June 30, 2016. Age, vital signs (including body temperature, heart rate (HR), mean arterial pressure (MAP)) , Sequential Organ Failure Assessment (SOFA) score, usage of anticoagulant, usage of pressor, total capillary density (TCD), functional capillary density (FCD), the percentage of perfused and non-perfused capillary loops (PPC) and microvascular flow index (MFI) were measured to address three research questions: What microcirculation changes of upper lip oral mucosa occur from ETT pressure every two hours upon ETT repositioning during the first eight hours of intubation using the ETT holder, AnchorFast?; What relationships exist between participants’ vital signs and oral mucosal microcirculation?; What relationship exists between participants’ age, SOFA score, and Braden Scale for Predicting Pressure Sore Risk (BSPPSR) and final 8-hour vital signs and final 8-hour oral mucosal microcirculation? This study provides additional evidence to support current practice of ETT repositioning every 4 hours. Future research on oral mucosa microcirculation in context of ETT-related pressure ulcer prevention should address the relationship of oral mucosa microcirculation including other variables such as patients’ underlying medical diagnoses, BSPPSR subscale, choice of sedation medication, gender, and angle of ETT.
Adaptation of the AADE7 Self-Care Behaviors Framework to Racial/Ethnic Populations with Diabetes and Perceived Health, Self-Care, Healthy Coping, and Depression.
(University of Hawaii at Manoa, 2018-08) Ching, Julaine M. M. L.; Nursing
Background: Racial/ethnic populations including Black/African-Americans, Asians, Hispanics, and American Indians are at risk for diabetes at rates disproportionately higher than non-Hispanic Whites. In previous studies, persons with diabetes have been shown to have increased rates of depression. In contrast, healthy coping and self-care behaviors improved perceived health among persons with diabetes. Purpose: The purpose of the study was to explore if race/ethnicity of persons with diabetes was associated with perceived health independent of self-care, healthy coping, and depression, and to further examine the racial/ethnic differences of persons with diabetes in the strengths of the associations of self-care, healthy coping, and depression with perceived health. Method: Secondary data analysis was performed using the National Health Interview Survey (NHIS) from 2010 to 2014 on 12,671 persons with diabetes aged 18-79 who responded to the question on perceived health. Variables pertaining to race/ethnicity, perceived health, self-care, healthy coping, and depression were analyzed using descriptive analyses and multivariable logistic regression. Results: There were significant relationships in perceived health of race/ethnicity among persons with diabetes independent of self-care, healthy coping, and depression, but these distinctions were eliminated when interactions between race/ethnicity, self-care, healthy coping, and depression included demographic and co-morbidity factors (p < .05). Race/ethnicity does not strengthen the relationship between self-care, healthy coping, depression, and perceived health. Self-care, healthy coping, and depression have a significant independent relationship with perceived health. Implications: This study indicates the need to consider in addition to race/ethnicity, self-care, healthy coping, and depression, covariates (demographics and co-morbidities) to provide a more comprehensive view of the person living with diabetes. In future studies, it is important to utilize refined statistical measurement tools and methods to address the concept of perceived health among persons with diabetes. Furthermore, there is a need to develop an AADE7 instrument incorporating self-care, healthy coping, depression, and perceived health.
Ethnographic Study of Nutrition and Diet as it Relates to the Health and Well-Being of Native Hawaiian Kūpuna (Elders)
(University of Hawaii at Manoa, 2018-05) Wong, Kamomilani A.; Nursing
Background: Though Native Hawaiian kūpuna are faced with multiple social and health disparities, some are thriving into their later years of life. There is a gap in the literature regarding Native Hawaiian kūpuna who are 65 years and older and their nutrition and diet as it relates to their health and well-being. Purpose: The purpose of this study was to explore nutrition and diet as it relates to the health and well-being of Native Hawaiian kūpuna in Hawai‘i from a cultural context. Sample: Sample included 21 self-reported Native Hawaiian kūpuna, between 65 to 88 years of age, comprised of 13 females and eight males. They were all community-dwelling residents of the State of Hawai‘i. Setting: Two sites on the island of Oʻahu were the Papakōlea Community Park and Center and a church in Waimānalo. The third site was a church on the island of Hawaiʻi in Waimea. Method: The methodology used was a focused ethnographic approach. Data was collected via observations, field notes, and face-to-face interviews. Data analysis included descriptive statistics and thematic analysis. Results: Coding and thematic analysis led to six categories: (a) healthy person, (b) good health, (c) daily routine, (d) food choices/preferences, (e) Native Hawaiian cultural values, traditions, and practices, and (f) key to living well. Implications for future research to address the health and well-being of Native Hawaiian kūpuna include: (a) exploration of the perception of kūpuna regarding nutrition, diet, health, and well-being through their lifespan and (b) testing intervention programs in nutrition and diet within a Hawaiian cultural context.
Community Reintegration of the Severely Wounded Veteran: A Mixed Methods Study
(University of Hawaii at Manoa, 2018-05) Murray, Sarah J.; Nursing
Introduction: Combat missions in the Middle East have resulted in many United States’ (U.S.) casualties. Approximately 52,000 have been wounded in action, 5,851 have been killed in action, and—after evacuation—1000 more have died. Improvised explosive devices have caused the majority of injuries affecting multiple body systems—10% of which included burn injuries. Over 90% of the wounded have survived, resulting in large numbers of disabled veterans unable to return to military service. Instead, these veterans return to a civilian community that may not be prepared to meet their needs or help them reach the long-term final goal of community reintegration. Methods: Using a mixed-methods approach, we asked veterans with combat burns the question, "What was your experience reintegrating into the civilian community?" In addition, the Community Reintegration of Injured Service Members tool was administered to measure the current level of reintegration. Qualitative and quantitative analyses were performed to determine saturation and confirm results. Results: Six veterans with combat burns identified two major themes concerning reintegration: supportive communities and future-oriented thinking. Supportive communities are veteran specific; provide long-term burn/injury care; are financially beneficial; and support hobbies, education, and work opportunities. Future-oriented thinking involves the experience of a turning point in recovery, desire to serve others, new meaning in life, and posttraumatic growth. The Community Reintegration of Injured Service Members tool was highly reliable (151 items; alpha = 0.97). Conclusions: Community reintegration is both a process and an outcome that can be measured with both extrinsic and intrinsic factors. Despite limitations, veterans with burn injuries identified high levels of satisfaction with their level of reintegration according to the survey tool.
Complementary and Alternative Medicine use by Native Hawaiians and Part-Hawaiians with Type 2 Diabetes: A Feasibility Study
(University of Hawaii at Manoa, 2017-12) Suapaia, Mahealani E. L. A. A.; Nursing
In Hawai'i, type 2 diabetes is prevalent among Native Hawaiians and thus is a burden to their well-being, since there is an increased risk for health complications such as cardiovascular disease, kidney disease, and neuropathy. The terms “Native or Part Hawaiian” in this study refers to individuals who self identified one as their racial category. Individuals with type 2 diabetes should implement recommended daily self-management strategies to promote better health outcomes and possibly delay associated complications. The concept of self-management is found in chronic illness and Native Hawaiian health literature. The literature reveals that complementary and alternative medicine (CAM) serves to improve well-being through culturally accepted health and lifestyle practices. This study scrutinizes the process of recruiting and interviewing Native Hawaiians and Part Hawaiians with type 2 diabetes complication of diabetic peripheral neuropathy (DPN) and explores reasons these individuals use complementary and alternative medicine. A quantitative research method is conducted using two survey instruments: the CAM use survey and the SF-36 survey to assess reasons for CAM use, perceived general health, and bodily pain. A descriptive statistical analysis is performed to identify frequency data in a sample of 21 Native Hawaiians with DPN. The frequency data reveal factors that contribute to the use of CAM for diabetic peripheral neuropathy self-management, such as education, income, marital status, and religious beliefs. Knowledge and assessment of complementary and alternative medicine use may assist health care professionals in treating and caring for Native Hawaiians and Part Hawaiians with type 2 diabetes. Keywords: Native Hawaiian, type 2 diabetes, diabetic peripheral neuropathy, CAM

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