Ph.D. - Nursing
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Item 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(2023) Chock, Johnelle; Tse, Alice M.; NursingItem 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; NursingWomen 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.Item Awakening Nurse Managers’ Spirit Of Self-care Within(University of Hawaii at Manoa, 2021) Ricossa, Katherine Ann; Tse, Alice; NursingBackgroundNurse 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.Item 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.; NursingSignificance: 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.Item Mixed Methods Exploration Of Health Literacy Among Former Soviet Union Immigrants(University of Hawaii at Manoa, 2021) Kostareva, Uliana; Albright, Cheryl; NursingThe 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.Item 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; NursingAbstract 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.Item Exploring Risk Perception In A Native Hawaiian Community On Oʻahu(University of Hawaii at Manoa, 2019) Torris-Hedlund, Morgan Aiwohi; Qureshi, Kristine; NursingPurpose. 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.Item 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.; NutritionHigh 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.Item 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; NursingABSTRACT 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.Item 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; NursingAbstract 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.