Paper Session A1: Social Determinants of Health

Development of a Guide to Mothering After Prison

Margaret Oot Hayes, Regis College

Background: Mothers being released from prison are unaware of the numerous difficulties related to reunification with their children that they may be faced with upon release from prison. Some challenges related to reunification with children include: lack of trust from their children's caretakers and/or children, reluctance of the caretaker to relinquish the care back to the mothers, substance abuse, mental health problems; inadequate preparation to resume the parenting role, difficulty settling down to family life, difficulty making responsible decisions, custody battles, and family conflicts. In addition to these challenges, mothers being released from prison are oftentimes unaware of the resources available to assist them with this fragile transition.

Purpose: The purpose of this pilot study was to develop a guide to mothering after prison that will ease the transition in order to facilitate a more successful reunion.

Methods: A participatory action research design was used to interview incarcerated mothers and parenting experts at a minimum security facility in the Northeastern part of the United States. With IRB approval, the audio-recorded interviews were focused on identifying needs and resources for maternal reunification after incarceration, obstacles and facilitators for reunification, and shared experiences and advice. Thematic analysis was conducted using Colaizzi's method.

Results: A guidebook was developed that provides anticipatory guidance to mothers reuniting with their children after incarceration. The major themes with sub-themes that emerged were: Take Care of Self First (Maintain Sobriety; Establish Stable Environment; Improve Health); Slow Reunification (Ease Back Slowly into Children's Lives; Allow Children to Decide When to Reunite; Earn Trust); and Reach Out for Support (Support From Family, Friends, and Community; Learn How to Mother from Others).

Conclusions/Implications: The guidebook can provide mothers in prison with guidance and advice on how to mother after prison. Future research will involve interviewing the caregivers and children.

Racial & Ethnic Disparities in Predictors of Glycemia: A Moderated Mediation Analysis of Inflammation-Related Predictors of Diabetes in the NHANES 2007-2010

Sarah Nowlin, New York University [black down pointing small triangle] Charles Cleland, New York University [black down pointing small triangle] Niyati Parekh, New York University [black down pointing small triangle] Holly Hagan, New York University [black down pointing small triangle] Gail D'Eramo Melkus, New York University

Background/Purpose: Racial/ethnic minorities experience worse health outcomes in diabetes (T2D), cardiovascular disease, and obesity. The pathophysiological processes that underlie these chronic diseases can be traced back to inflammation, which can be present in those with diabetes, and higher among racial/ethnic minorities. Dietary intake can influence both inflammation and T2D outcomes. Although dietary intake patterns, inflammation, and T2D are associated, the contribution of these factors to racial/ethnic disparities in T2D is unclear. Therefore, the purpose of this paper is to identify associations between race/ethnicity and HbA1c among participants from NHANES 2007-2010, as mediated by diet quality, BMI, and inflammation and moderated by T2D status.

Theoretical Framework: The theoretical model guiding this study is based on two frameworks: the Biobehavioral Framework by Kang et al. (2010), which focuses on stress and inflammation, and the Conceptual Framework model for disparities in endocrine disorders by Golden et al. (2012).

Methods: The NHANES study is a continuous nationwide survey. Participants were included in this analysis if they had data from the interview and exam, were >= 20 years of age, identified race/ethnicity as either non-Hispanic White (NHW), non-Hispanic Black (NHB), Mexican American, or other Hispanic; and had complete dietary data from 24 hour recalls. The primary outcome variable for this secondary data analysis was HbA1c. Mediating variables included dietary scores (HEI), BMI, and CRP. T2D status was the moderating variable. Moderated mediation tests the hypothesis that the association between race/ethnicity and the three mediators, and the three mediators and HbA1c, are conditional on T2D status.

Results: This analysis included n=7,850 participants. The moderated mediation model accurately explained the variation in HbA1c measures in those without T2D, as mediated by HEI, BMI and CRP. However, significant variation in HbA1c remained after accounting for aforementioned mediators when contrasting NHW to NHB without T2D. The model was not a good fit for explaining racial/ethnic disparities in HbA1c in participants with T2D. A test of the index of moderated mediation was not significant for moderation of the effect of race/ethnicity on HbA1c by T2D status.

Conclusions/Implications: Results from this analysis indicate that HEI, BMI, and CRP do not mediate the association between race/ethnicity and HbA1c in those with T2D. As previous research has indicated that the association between BMI and CRP could be moderated by sex, further research into the mechanisms behind these differences should be conducted, as hormonal influences may play a role in fat deposition and inflammation. The biobehavioral health disparities framework introduced in this paper may explain racial/ethnic health disparities in other T2D-related health outcomes such as renal failure and diabetic retinopathy. Further research into these health outcomes is warranted.

A Theory Based, Culturally Appropriate Intervention to Promote Mammography Screening Among Chinese American Women

Yiyuan Sun, Adelphi University [black down pointing small triangle] Anne Moyer, Stony Brook University [black down pointing small triangle] Catherine Messina, Stony Brook University

Background/Purpose: Chinese American women (CAW) experienced a faster increase in incidence rates, are more likely to be diagnosed with larger tumor size, and are less likely to be diagnosed at early stages of disease. These health disparities for CAW are largely due to lack of timely screening and early detection. The lower rate of mammography participation among CAW is associated with their unique decision styles and health beliefs.

Theoretical Framework: Prospect Theory, Health Belief Model and Transtheoretical Model were integrated to guide the intervention and outcome measures.

Methods: A two group, pre- and post-test experimental design was used to examine the effects of the intervention on stage of mammography adoption. 143 Eligible CAW, recruited from New York City metropolitan area, were randomly assigned to receive either a gain- or loss-framed brochure which presented equivalent information concerning risk for developing breast cancer in Chinese American women, the importance of early detection, facts about mammography and free/low cost mammography screening information. Measurements include demographics, decision balance, perceived risk and perceived seriousness of breast cancer, knowledge about and access to mammography screening, stage of mammography adoption at baseline and 2 month follow-up. Chi-square and t-tests were used to examine for group equivalences in baseline data; ANCOVA for repeated measure were conducted to test the effects of the intervention. Multiple linear regressions were used to identify predictors and mediators for stage of mammography adoption.

Results: Stage of adoption, perceived risk and perceived seriousness of breast cancer, knowledge about and access to mammography screening had significant improvement over time. Significant predictors for stage of mammography adoption include: having a mammography before, changes in decision balance, and changes in access to mammography screening, which account for 44% of the variance in stage of mammography adoption. Decision balance scores mediate the effect of message framing on stage of mammography adoption.

Conclusions/Implications: Results of this study informed health providers how Chinese American women's decision styles and mammography beliefs influence their screening behaviors and hold the promise of decreasing health disparities in this understudied, growing minority population. Findings from this study advanced nursing knowledge regarding the relationships among decision balance, message framing and mammography behavior.

Infection Related Socioeconomic Disparities in Home Health Care

Jingjing Shang, Columbia University

Background/Purpose: Eliminating health disparities is one of the top priorities of the U.S. Department of Health and Human Services. Home health care (HHC), the most rapidly growing health care sector in the United States, plays a significant role in post-acute care. Care delivered in the uncontrolled home environment and by family members who do not have formal training in infection control poses high risk for HHC patients, especially for those who are socioeconomically disadvantaged. The proposed study will characterize the socioeconomic disparities among patients in HHC setting.

Theoretical Framework: The study was guided by the Social Ecological Model that emphasizes that health outcomes result from not only personal attributes, but also the socioeconomic system.

Methods: This is a cross-sectional study using a 5% random sample of 2013 national Outcome and Assessment Information Set (OASIS) data linked with 2013 American Community Survey (ACS) from the census bureau by using HHC patient's residence zip code. Infection was identified in OASIS if the patient was hospitalized or received emergency care because of infections. SES was measured by income and education at the zip code level from ACS data. Risk-adjusted logistic regression models was used to estimate the effect of SES on infections.

Results: Of 153,559 HHC patients, 4,457 (2.91%) were hospitalized or received emergency care because of infections during their HHC staying, 21,297 (13.87%) lived in area with low income and low educational level. Adjusted for individual characteristics and medical condition, patients who lived in areas with low income and low educational level were significantly likely to develop infections that causing hospitalization or emergency care (OR = 1.19, 95% CI = 1.09, 1.29).

Conclusions/Implications: Our findings suggest there is a health disparity related to infection control in home care setting. Undeserved population living in areas with low income and low education level are at high risk of developing infections. Further development of relevant health policy is in great need to eliminate health disparities in the home healthcare settings.

Breast Cancer Survivorship in Urban Hispanic Women

Carolee Polek, University of Delaware [black down pointing small triangle] Thomas Hardie, Universityof Pennsylvania [black down pointing small triangle] Janet Deatrick, University of Pennsylvania

Background: There are 15.5 million American cancer survivors with a prediction of 20 million in 10 years. The most common survivors are women treated for breast cancer (BC) and these women struggle with the challenges of medical, psychosocial and functional impairments survivorship brings. Challenges exist regardless of race, but some of these are faced by women from minority groups long before the diagnosis of BC and can be amplified in their intensity during survivorship, potentially shortening survival and decreasing quality of life. Studies have concluded non-medical variables related to the domains of poverty, neighborhood, and treatment resources influences outcomes.

Purpose: The purpose of this study was to examine domains of poverty, neighborhood and treatment resources in urban minority BC survivors.

Methods: A focus group was conducted using a series of linked vignettes addressing services, coping, neighborhood, ongoing survivorship and late effects. Participants included 13 female Hispanic breast cancer survivors treated at an urban cancer center. Ages ranged from 43 to 77 in a variety of cancer stages and varied from time of diagnoses. Transcripts were analyzed using both inductive and deductive content analytic approaches which resulted in a list of coding categories, categories, and then themes.

Results: Three themes transcended area of nativity. The primary theme surrounded language barriers during every facet of treatment. Transportation challenges was a theme throughout the discussion. Lastly, psychosocial support was a concern for both the individual and family.

Conclusions/Implications: Projections estimate women from minority groups will comprise > 50% of women in 2050 making it essential we address gaps in our clinical recognition of the survivorship needs to develop effective interventional strategies. There are potential challenges unique to these urban minority women that need to be addressed so they can receive the services to improve their quality of life.

Paper Session A2: Nursing Education: Innovative Teaching Strategies

The Effect of Formative Capstone Simulation Scenarios on Baccalaureate Nursing Students' Anxiety and Self-Confidence Related to Initial Clinical Practicum

Jennifer Ross, Villanova University [black down pointing small triangle] Hannah Carney, Kent Hospital

Background/Purpose: Clinical practicum is an anxiety-producing experience for nursing students. Evidence suggests that simulation decreases anxiety; however, there are no published studies available exploring the effect of pre-clinical simulations with standardized patients (SPs) on nursing student anxiety related to initial clinical practicum. The purpose of this study was to: determine the effect of formative capstone simulation scenarios on sophomore baccalaureate nursing students' anxiety related to initial clinical practicum, and anxiety and self-confidence related to clinical decision making prior to initial clinical practicum.

Theoretical Framework: Kolb's Experiential Learning Theory provided theoretical support for this study.

Methods: A one-group, pretest/posttest quantitative research design was used for this study. Sophomore baccalaureate nursing students (n=95) enrolled in an Essentials of Nursing Practice laboratory course participated in the study. Formative capstone simulation scenarios with SPs were implemented into the course as a culmination of the first two years of the nursing curriculum prior to initial clinical experience. The Spielberger State-Trait Anxiety Inventory (STAI) State Form Y and Nursing Anxiety and Self-Confidence with Clinical Decision Making Scale (NASC-CDM) were used to assess students' anxiety and self-confidence immediately before and immediately following the formative capstone simulation scenarios. Paired T-tests were used to compare anxiety related to initial clinical practicum, and anxiety and self-confidence related to clinical decision making, before and after formative capstone simulation scenarios.

Results: State anxiety and anxiety related to clinical decision making were significantly lower following formative capstone simulation scenarios (p < 0.001), and self-confidence related to clinical decision making was significantly higher following formative capstone simulation scenarios (p < 0.001).

Conclusions/Implications: Formative capstone simulation scenarios that integrate the nursing process, safety, patient-centered care, professional values, health assessment, psychomotor skills, clinical reasoning, and therapeutic communication with SPs are an effective method to decrease anxiety and increase self-confidence in novice nursing students prior to entry into initial clinical practicum. Further research is needed to enhance the generalizability of these findings.

The Impact of Instituting in a Fundamental Nursing Course the Pedagogy of Process-Oriented Guided-Inquiry Learning (POGIL)

Maureen Roller, Adelphi University [black down pointing small triangle] Susan Zori, Adelphi University

Background/Purpose: Process oriented guided-inquiry learning (POGIL) pedagogy uses small groups of students to complete problem based activities and has been used in other disciplines as a useful teaching strategy to improve grades and satisfaction. The purpose of this study was to compare class final grades, Assessment Technologies Institute, LLC (ATi) national standardized exam scores, demographic data, and satisfaction of nursing students who are taking fundamentals nursing classes in which POGIL group case scenarios were used with students in classes compared with classes of students who do not use POGIL as a teaching strategy.

Theoretical Framework: Piaget's theory of constructivism undergirded this study. It recognizes that students learn concepts best by actively engaging in the learning process with the teacher as a facilitator and not as a traditional lecturer. It encourages students' participation in learning as a critical thinker. The POGIL pedagogy incorporates these principles.

Methods: The study design was quantitative descriptive. A convenience sample of undergraduate fundamental course students participated with N=63 in the POGIL group and N=75 in the group in which POGIL was not used. The setting was a mid-size, private university in the northeastern United States. Demographic variables were analyzed using descriptive statistics. The final course grade scores and scores on ATi of the two groups were compared using a paired sample t-test. The survey data completed by the students in the both groups were analyzed using t- tests.

Results: The experimental group had higher final course grades (p=0.046), better understanding of the course material (p=. 005), and greater satisfaction with grades (p=. 008).

Conclusions/Implications: Using POGIL improved grades and satisfaction in fundamentals courses. Exploring POGIL as a teaching strategy is in alignment with goals to promote evidence-based teaching and contributes to nursing education science. A priority in nursing education is to enhance the development of analytical critical thinking and teamwork and both can be learned through the use of POGIL methodology.

Impact of Flipped Classroom on Accelerated Bachelor of Science in Nursing Students' Achievement and Satisfaction

Majeda El-Banna, The George Washington University [black down pointing small triangle] Malinda Whitlow, The George Washington University [black down pointing small triangle] Angela McNelis, The George Washington University

Theoretical Framework: Active learning is based on a constructivism theory in which learners replace their existing knowledge with deeper and higher levels of understanding through interaction with a skilled teacher.

Background: Pre-licensure students have difficulty with pharmacology courses and content. Built on principles of active learning, flipped classroom interventions have resulted in higher exams scores compared to traditional approaches. Studies, however, have not included learners in Accelerated Bachelor of Science in Nursing (ABSN) programs.

Purpose: To examine the differences between a 3-week flipped classroom approach and traditional classroom approach on students' tests scores and satisfaction of teaching.

Methods: In this crossover repeated measure design, 76 ABSN students enrolled in two sections of Pharmacology course received either 3-weeks of flipped classroom or traditional classroom during Period 1, then switched modalities during Period 2. Quantitative data collected pre/post quizzes and test scores measuring knowledge and a questionnaire assessing satisfaction of teaching. Qualitative data collected through focus groups. Descriptive statistics, Wilcoxon rank sum test, stepwise linear regression mixed model, and thematic analysis were conducted.

Results: A significant difference was found on pre-quiz scores between flipped (M=60.49) and traditional (M=53.78), p=0.003; however, the post-quiz scores were not significantly different. There were no significant differences in test scores. Regression showed that teaching modality, period of intervention, and carry over effect did not predict test scores. Over half of the students in the flipped classroom reported they didn't prepare before coming to the class. Students indicated they were more satisfied with traditional teaching. Qualitative data revealed mixed perceptions and experiences about the flipped classroom.

Conclusions/Implications: The differences in pre-quiz scores were expected given the pedagogical assumptions of the flipped classroom; however, the lack of difference on post-quiz and test scores was not anticipated. This may be partially explained by focus group data revealing that students did not fully understand this pedagogical approach, did not have enough time to complete all pre-class assignments/readings, and did not perceive that some of the in-class activities facilitated their learning. Based on this study's results, it is recommended that further development and testing of this approach is needed.

Financial Competency: The Effects of a Teaching Intervention on RN to BSN Students' Knowledge of and Attitudes Toward Nurses' Financial Responsibilities in Healthcare

Teresa Hartmann, Millersville University of Pennsylvania

Background/Purpose: The changing healthcare climate has significantly restrained financial resources and challenged leaders to scrutinize expenditures. The concept of financial competency in nursing was derived from disciplines both in and outside of healthcare. The nine identified attributes became the foundation for exploring financial responsibilities of nurses at the bedside. The purposes of this study were to explore RN to BSN nursing students' knowledge of and attitudes toward financial competency in nursing, and to investigate the effects of a specific teaching intervention on their knowledge of and attitudes toward financial competency in nursing.

Theoretical Framework: Covell's theory of Nursing Intellectual Capital served as the theoretical foundation for this study.

Methods: A pre-test, post-test quasi-experimental study included RN-BSN students from two universities at four geographic locations. Two newly developed instruments measuring knowledge of and attitudes toward financial competency in nursing were developed, tested, and used as pre- and post-tests. Data analyses included descriptive statistics, Pearson correlations, independent and paired t-tests, and multiple analyses of variance.

Results: RN-BSN students were found to have high knowledge levels and positive attitudes regarding nurses' financial responsibilities in healthcare. There was a statistically significant, moderately low correlation between knowledge and attitude scores. After participating in an educational intervention, subjects had significant increases in their knowledge and attitude scores. Subjects in the intervention group had significantly higher knowledge and attitude post-test scores. RN to BSN students who discussed the topic of financial competency with others had higher knowledge and attitude scores.

Conclusions/Implications: The results of this study add to the literature regarding the reframing of nursing's practice toward financially responsible care. The results extend Covell's conceptualization of employer support in human capital to include continuing professional development of RN to BSN students. This study contributes a tested approach to educating nurses regarding financial responsibilities in practice. Nursing administrators can use the results to build a workforce that is prepared to address complex healthcare issues in a fiscally responsible manner. A financially competent nursing workforce will bring to light nursing's economic value, leading to a financial acknowledgement of nursing services in healthcare expenses.

Nursing Students Engaged in Active Research: A Qualitative Study

Rosemary Collier, Binghamton University [black down pointing small triangle] Geraldine Britton, Binghamton University

Background: Experiential learning is the most salient form of education. This method is used in clinical training in undergraduate nursing education. Our research team used observational learning in nursing research, engaging undergraduate students in an active and dynamic interdisciplinary research group at a research university in Upstate New York. The bulk of research activities were focused on tobacco and nicotine use and included all aspects of the research process including planning and designing, communicating with agencies and regulatory bodies, engaging with human subjects, collecting and analyzing data, and writing and reporting results. Students interacted with varied populations including pregnant women, health care providers, and members of their own University community.

Purpose: This study aims to explore the experiences of undergraduates participating in active research during their schooling in a baccalaureate nursing program.

Methods: This qualitative phenomenological study was undertaken to explore the experiences of these undergraduate students during their participation in the research group. The research team held three focus groups of 5-11 students; the first in 2008, the second in 2010, and the third in 2015. Students were asked questions in four domains: concerns, unexpected results, research results, and personal effects. Student and faculty members of the research team analyzed the content of these focus groups to identify overarching similar and differing themes.

Results: Twenty three total students participated in focus groups. Two key themes emerged from all transcripts: perception checking and lessons learned in the research process relative to both their tobacco and nicotine cessation research and their nursing education. Additionally, in the third transcript, the theme of organizational issues unique to the newly developed research practicum course emerged.

Conclusions/Implications: Including students in research as undergraduates promotes independence, confidence, and continued growth in both the research and clinical setting. By offering a semi-structured elective course, including mentoring opportunities, we provide an experience that is supportive, yet challenging, and encouraged immersion in research. Recommendations included establishing a formal mentoring program and continuing a program that was inclusive, maximized faculty -to-student interaction, and included active participation.

Paper Session A3: Adolescent Health

College Sexual Misconduct: Student Focus Group Views

Maeghan Dillon, Boston College [black down pointing small triangle] Ann Burgess, Boston College [black down pointing small triangle] Reina Lamade, Fairleigh Dickinson University [black down pointing small triangle] Sarah Chung, Dartmouth-Hitchcock Medical Center

Background: The media has brought attention to the alarming rates of sexual assaults on campuses. College students are a notably high risk group for rape and they fall within a developmental epoch referred to as emerging adulthood.

Purpose: The purpose of the study was to obtain the opinions of one of the main stakeholders, the population directly served (i.e., college students) as a crucial first step in developing a treatment program for students found responsible for sexual misconduct.

Methods: Focus group methodology with principles of participatory action research was employed to obtain the opinions of college students about treatment sanctions for student offenders. Fifteen questions were asked in all 3 focus groups composed of 11 females only, 4 males only and 8 mixed gender. This poster analyzes student responses to 5 questions: 1) Do you think students would participate in treatment if found responsible for sexual misconduct? 2) If a student is found responsible of sexual misconduct, what would be a fair sanction for a university to impose on this student? 3) If a student was suspended after being found responsible for sexual misconduct, should he/she return to school? 4) What sanctions would enhance student's feelings of safety? 5) How should a report of sexual misconduct be handled if both parties had been drinking?

Results: Data are discussed relevant to the following 4 categories of responses: 1) Different levels of sanctions for college sexual misconduct; 2) Safety of students; 3) Role of alcohol; 4) Types of treatment and outcomes.

Conclusions/Implications: Having risk assessment tools and specific treatment interventions (i.e., therapeutic sanction) can potentially reduce campus sexual misconduct, provide universities with a fair sanction option for students found responsible, and improve overall campus safety. This involves considering the needs and garnering the support of multiple stakeholders and working within institutional policy frameworks.

Trends in Bullying and School-Related Victimization Among US High School Students

Nancy Pontes, Rutgers University [black down pointing small triangle] Cynthia Ayres, Rutgers University [black down pointing small triangle] Carla Lewandowski, Rowan University [black down pointing small triangle] Manuel Pontes, Rowan University

Background/Purpose: Research has shown that school bullying victimization is associated with numerous adverse health outcomes. Over the past decade, US schools have been required to implement bullying prevention programs. Healthy People 2020 set a goal to reduce the prevalence of school bullying by ten percent and designated the Youth Risk Behavior Survey (YRBS) as the data set used to measure progress towards the goal. This research uses YRBS data from 2009, 2011, 2013 and 2015 (N=59,291) to investigate linear time trends for school bullying, electronic bullying, and school-related threats and injuries with a weapon for all students and separately for each gender.

Theoretical Framework: Based on previous theoretical relationships about the social and ecological foundations of bullying victimization and prevention efforts, this study tested whether these interventions are effectively reducing the prevalence of bullying victimization.

Methods: This research is a secondary analysis of YRBS health behavior-related survey data collected from a nationally representative 3-stage cluster sample design of US high school students. The binary (Yes/No) dependent variables for this study were electronic bullying, bullying on school property and threats or injuries by a weapon on school property, or to and from school. The independent variables were survey year, race/ethnicity, grade level, and gender. Data were analyzed using multivariate logistic regression with SPSS 24 Complex Samples(TM) which correctly incorporates the sampling design sampling weights for analyses to enable nationally-representative estimates.

Results: There were no significant linear trends among all students for school bullying victimization (OR=1.01, 95% CI=0.98-1.04) or electronic bullying victimization (0.98, 0.93-1.04), but there was a significant decrease in the likelihood of being threatened or injured with a weapon (0.91, 0.87-0.96). Separate analyses by gender showed that bullying victimization decreased significantly among males (0.93, 0.89-0.98) but unfortunately increased significantly among females (1.08, 1.04-1.12) during this time period. Analyses by gender showed that being threatened or injured with a weapon decreased significantly among males (0.88, 0.83-0.93) but not females (0.97, 0.90-1.03). There were no significant linear trends in the likelihood of electronic bullying victimization.

Conclusions/Implications: Current school-based bullying prevention efforts in the US appear to have been successful in reducing the incidence of school bullying among males but not among females during 2009 to 2015. Bullying victimization has increased among US high school girls, and future efforts are essential in targeting all forms of bullying victimization, especially among females.

Long Acting Reversible Contraceptives (LARCs): Understanding the Underutilization of This Potential Remedy for Adolescent Pregnancy and Implications for Condom Use

Carol Roye, Pace University [black down pointing small triangle] Keville Frederickson, Pace University [black down pointing small triangle] Alsacia Sepulveda Pacsi, Pace University [black down pointing small triangle] Anna Sahadeo, New York New York Presbyterian Hospital

Background: Despite declines in adolescent childbearing, the US has the highest rate among developed nations. Only 7% of adolescents use the most effective contraceptive methods - Long Acting Reversible Contraceptive Methods (LARCs), i.e. IUDs and implants. However, there is concern that LARC users may be less likely to use condoms. This has not been studied. And, we do not know why LARC use is so low.

Purpose: The study examined: 1) the attitudes of sexually active female adolescents (age 15 - 24) about LARCs, and their reasons for use and nonuse. 2) Condom use by LARC users.

Methods: Young women, mostly Hispanic (N=45), aged 15 - 24, were recruited in a family planning clinic. Data collection consisted of a questionnaire assessing demographics, sexual behaviors, condom and contraceptive use. Participants were interviewed about contraceptive and condom use and reasons for use and nonuse. Interviews were subject to thematic analysis. A thematic coding scheme was derived from the structure of the interview guide including attitudes about LARCs, concerns about acquiring HIV/STIs, and most recent episode of condom use and nonuse. Three themes were identified and synthesized and an overall theme emerged.

Results: The first theme, LARC Use focused on the reasons for its unpopularity. Participants heard it was uncomfortable and possibly causes infertility; while the few positive attitudes were related to "still getting your period" and "lasts a long time". Few reported LARC use. Menses are wanted as proof of no pregnancy. The second theme was Pregnancy Prevention is Primary, indicating that they want a method they trust to prevent pregnancy, but LARCs are not often in that category. The final theme was Condom Use and STI Prevention. Condoms were used if they didn't trust their partner or were not using birth control. Condoms were not used if they trusted their partner and had a hormonal contraceptive. The overall theme is: Hearsay Reduces LARC Use: Relationship Status Drives Condom Use.

Conclusions/Implications: Many adolescents do not want LARCs, because of misbeliefs that IUDs are uncomfortable, may cause infertility and are not effective. To improve LARC and condom use, nurses need to focus on STI prevention, as well as pregnancy prevention; while correcting misperceptions. We also need better understanding of how to address the "trust" issue in health promotion efforts for this population.

Young Parents' Perceptions of and Experiences with Relationship Violence: A Focus Group Study

Judith Herrman, University of Delaware [black down pointing small triangle] Katherine Haigh, University of Delaware

Theoretical Framework: The socioecological model provided a framework for organizing perceptions and potential strategies to address relationship violence in young people who are pregnant or parenting.

Background: Studies indicate that young people who are pregnant and parenting are at increased risk for victimization and/or perpetration of relationship violence.

Purpose: This study was designed to examine the thoughts of young parents about relationship violence.

Methods: This qualitative, descriptive study included five focus groups with 28 participants; 22 females and six males. Sample members were either pregnant or parenting, 16 to 22 years old, and recruited from teen parent assistance programs. The focus group guide asked teen parents about their lives as parents, young parent relationships, relationship violence and teen parents, ways to get help to have healthy relationships, and the consequences of relationship violence. Focus groups were held at program sites, audio-recorded, and transcribed verbatim while observational notes documented the non-verbal aspects of the focus groups. Data were analyzed using the focus group guide as a template and superimposed with elements of the socioecological model to organize the data into domains. Emerging themes were isolated to both provide insights into the issue and to inform the adaptation of a teen dating violence program for the unique needs of young people who are pregnant and parenting.

Results: Data analysis yielded themes related to stressors in their lives, choosing a romantic partner, sources of conflict, influences on teen parenting, the faces of relationship violence, and seeking help when in abusive relationships. Themes were further investigated using the individual, parent/family, relational (peer, partner), community, and societal factors surrounding intimate partner violence.

Conclusions/Implications: Analysis of young parents' perceptions through the lens of the socioecological model provides a springboard for nursing action. Nurses hold pivotal roles in detecting, preventing, and intervening with young parents experiencing or having the potential to experience relationship violence.

HABIT, a Community Health Worker Intervention, Improves Hydroxyurea Adherence and Psychosocial Health in Youth with Sickle Cell Disease

Arlene Smaldone, Columbia University [black down pointing small triangle] Deepa Manwani, Albert Einstein Medical Center [black down pointing small triangle] Nancy Green, Columbia University

Background/Purpose: Chronic disease management often deteriorates during adolescence. Community health workers (CHW) are increasingly recognized as a strategy to improve health outcomes for the underserved with chronic disease but has not been formally explored in adolescents with sickle cell disease (SCD). The purpose of this feasibility trial, Hydroxyurea Adherence for Personal Best in Sickle Cell Disease "HABIT", was to improve parent-youth self-management partnerships in medication adherence to hydroxyurea (HU) in adolescents 10-18 years with SCD.

Theoretical Framework: Self and Family Management Framework

Methods: We conducted a 2 site, R21 funded, randomized controlled trial (2:1 intervention allocation via computerized randomization plan with allocation concealment) to assess feasibility and efficacy of a 6 month CHW intervention augmented by text messaging on primary (hydroxyurea adherence) and secondary psychosocial (improved parent-youth concordance about self-management responsibility and generic and disease specific quality of life [QOL]) outcomes compared to standard treatment. This abstract focuses on changes in secondary outcomes from baseline to 3 and 6 months. All surveys were available in Spanish and English. Data were analyzed using descriptive and Wilcoxon signed rank statistics.

Results: 28 parent youth dyads (youth mean age 14.3+/-2.6 years, 43% female, 50% Hispanic) participated with 18 dyads assigned to the CHW intervention. Dyad attrition at 6 months was 11%. Dyads reported that they enjoyed interaction with CHWs, learned new information about HU and SCD, and did not find text messages burdensome. From enrollment to 3 months, dyad self-management concordance improved for intervention dyads (+1.3+/-2.1, p=0.03) but not controls (0.2+/-1.6, p=0.80). From 0-6 months, generic and disease specific QOL improved for intervention youth (generic +6.3+/-12.6, p=0.01; disease specific 6.1+/-17.3, p=0.33) but not for controls (-2.4+/-9.1, p=0.57; -1.2+/-17.5, p=1.0).

Conclusions/Implications: The HABIT intervention was feasible, acceptable to subjects and improved hydroxyurea adherence and psychosocial health. Based on these findings, a multi-site RCT powered to test intervention efficacy is planned.

Paper Session A4: Organizations and Workforce Issues

How Nurse Work Environments Relate to the Presence of Parents in Neonatal Intensive Care

Sunny Hallowell, Villanova University [black down pointing small triangle] Eileen Lake, University of Pennsylvania

Background/Purpose: Parental presence in the neonatal intensive care unit (NICU) is essential for families, especially mothers, to be partners and active participants in the care of their infants. Parental presence in the NICU is particularly important to achieve a smooth transition from hospital to home. However, NICUs vary in their policies on parent visitation and inclusion of parents in decisions about and care of their infant. Nurses are the principal caregivers in the NICU setting. The nurse work environment may influence whether parents spend time with their hospitalized infants. Features of work environments, such as a competent and supportive nurse manager, adequate staffing and resources, collegial relationships between physicians and nurses, nurse voice in hospitals matters and a nursing philosophy as the foundation for nursing care, may influence the extent to which parents find it easy and comfortable to spend time in the NICU. We utilized a national dataset to examine the relationship between the nurse work environment and the presence of parents in the NICU.

Theoretical Framework: Quality Health Outcomes Model

Methods: Design: Retrospective cross-sectional analysis. Sample: A national sample of U.S. neonatal intensive care units (N=104) where nurses (N=6060) reported on the characteristics of their unit and 15,233 infants they cared for on the last shift they worked. Setting: Neonatal Intensive Care Unit Measures: National Quality Forum endorsed Practice Environment Scale of the Nursing Work Index (PES-NWI) Analysis: Descriptive statistics were used to describe the hospital sample, independent and dependent variables. Bivariate and multivariate linear regression models were estimated at the unit level between the dependent variable (percent of infants that whose parents were present in each NICU) and independent variables (nurse work environment and nurse staffing). Continuous variables such as the PES-NWI subscale measures were standardized for ease of interpretation.

Results: On average, the parents of 60% of infants were present during the shift. This ranged across the NICU sample from 32% to 79% (SD = 9.7%). The PES-NWI composite score as well as two subscales, Nurse Participation in Hospital Affairs and Manager Leadership and Support, were significant predictors of parental presence in bivariate regression models. A 1SD higher score in the composite or either subscale was associated with a 0.25 SD increase in parental presence in the NICU, equivalent to 2.5 percentage points.

Conclusions/Implications: Parental presence in the NICU is significantly associated with better nurse work environments, particularly where nurses are well supported through managerial leadership and where nurses have the ability to participate in hospital affairs. These data suggest supporting professional nursing and strong nurse leadership are essential to the creation of a patient centered culture in the NICU that encourages and facilitates parental presence.

Nurse Practitioner-Physician Co-Management of Primary Care Patient Panels: The Provider Perspective

Allison Norful, Columbia University [black down pointing small triangle] Lusine Poghosyan, Columbia University

Theoretical Framework: Donabedian's quality of care model (structure, process, outcome) guided this qualitative study.

Background: Primary care organizations are under tremendous strain to deliver care with a concurrent primary care physician shortage and increased volume of insured patients. Expansion of nurse practitioner (NP) use has been shown to alleviate some of this strain as NPs provide high quality primary care. However, it has become difficult for individual providers to complete all recommended care guidelines as panel sizes continue to increase in size. NP-physician co-management of the same primary care patient panel has been proposed as a novel delivery care model where two providers share the responsibility of larger primary care patient panels, yet the literature fails to capture what providers think about co-management care delivery.

Purpose: The purpose of this qualitative study is to investigate the perspectives of NPs and physicians about co-managing primary care patient panels.

Methods: Using an interview guide, 24 in-person interviews (13 NPs and 11 physicians), lasting approximately 35 minutes each, were conducted before reaching data saturation. All recordings were transcribed, de-identified, and checked for accuracy. Two researchers used both a deductive and inductive process to code the data and identify constructs and themes.

Results: Providers believe that co-management increases adherence to recommended care guidelines, improves quality of care, and increases patient access to care. Effective communication, respect, and shared philosophy of care were identified as necessary for co-management to exist. Physicians and NPs report positive relations with each other in primary care settings and are optimistic about co-management models. However, organizational policy creates barriers for NPs to practice in a true co-management model.

Conclusions/Implications: NP-physician co-management may increase access to care and improve quality of care for larger primary care patient panels. Future research should focus on measurement of co-management attributes to determine how organizational policy influences this type of care delivery.

Emergency Department Weekend Presentation and Mortality in Patients with Acute Myocardial Infarction

Pamela de Cordova, Rutgers University [black down pointing small triangle] Mary Johansen, Rutgers University [black down pointing small triangle] Miguel Martinez, Emory University [black down pointing small triangle] Jeannie Cimiotti, University of Florida College of Nursing

Background/Purpose: Existing research suggests that patients admitted to acute care hospitals on weekends have poorer outcomes than patients who are admitted on weekdays. Further studies have found that patients admitted for acute myocardial infarction (AMI) on weekends had a higher mortality rate than patients admitted during the week. Most of this evidence pertains to acute hospital admissions, but very few studies have been conducted on weekend presentation for this patient population in the emergency departments. The purpose of this study is to determine if a weekend and holiday presentation is associated with an increase in mortality among AMI patients who presented to New Jersey emergency departments.

Theoretical Framework: The theoretical framework that guides this study is the quality health outcomes model.

Methods: A retrospective, cross-sectional study using three data sources representing all hospitals in New Jersey including patients 18-90 years of age who presented to the emergency department with symptoms of an acute myocardial infarction beginning January 1 2008 - January 31 2010. "Weekend" was defined as Saturday and Sunday and "Holiday" was defined as one of the six major US holidays in the year. Logistic regression analysis and propensity score matching was used to estimate the unbiased treatment effect of weekend presentation on mortality.

Results: There were 1,343 patients presenting to 73 emergency departments with the diagnosis of acute myocardial infarction across NJ. Of these patients, 382 (28%) patients presented on a weekend/holiday and 961 (72%) presented during weekday hours. Weekend presentation was significantly associated with an increase in mortality (B = 0.27; 95% CI [0.03, 0.52]). Other statistically significant covariates include patient age (B = 0.03; 95% CI [0.02, 0.05], hospital technology status (B = 1.15; 95% CI [-0.09, 0.67]), and nurse staffing (B = -0.19; 95% CI [-0.39, 0.01]).

Conclusions/Implications: In New Jersey, weekend presentation to the emergency department for an acute myocardial infarction was associated with increased mortality. This effect may be related to the limited availability of resources on the weekend when compared to weekdays. Future studies should examine potential variations of resources, nursing workload, and education and expertise of health care providers during the weekend specifically in the emergency department.

Impact of Nurse Fatigue and Nursing Handoffs on Patient and Nurse Safety

Melody Seitz, Notre Dame of Maryland University

Background/Purpose: Numerous research studies have examined nurse fatigue or patient handoffs and their impact on patient safety and nurses' personal safety. However, no studies have been found comparing fatigue and handoffs to determine if one causes more harm than the other. The purpose of this study was to determine differences between work-related fatigue, patient safety and nurses' personal safety; and nursing handoffs and patient safety among maternal newborn (MN) nurses who worked 8- versus 12-hour shifts.

Theoretical Framework: The hospital nurse force theory is the guiding theoretical framework for this study.

Methods: In this cross sectional study, a random sample of 221 MN nurses from across the United States completed an online survey to determine which shift was associated with more harm to patients and MN nurses. Participants answered questions about handoff quality, nurse accidents and injuries, errors, and work-related fatigue. Independent samples t-test and multiple regressions were used to analyze the hypotheses.

Results: Nurses who worked 12-hour shifts experienced more fatigue (statistically significant greater acute fatigue, p = .02), made more patient errors, including medication and near errors, and experienced more work-related injuries and accidents than those who worked 8-hour shifts. However, nurses who worked 8-hour shifts reported poorer handoff quality than those who worked 12-hour shifts.

Conclusions/Implications: Despite a lack of statistical significance, knowing maternal newborn nurses who worked 12-hour shifts experienced greater levels of fatigue, made more patient errors, and experienced more injuries and accidents may be clinically significant for patients and employers.

Advancing Systems Engineering Theoretical Perspective with Nursing Research to Improve Patient Quality and Safety

Amy Witkoski Stimpfel [black down pointing small triangle] Maja Djukic, New York University [black down pointing small triangle] Carol Brewer, SUNY Buffalo [black down pointing small triangle] Christine Kovner, New York University

Background/Purpose: In the era of the Patient Protection and Affordable Care Act, quality of care and patient safety in healthcare have never been more visible to patients or providers. Registered nurses (nurses) are not only key players in providing direct patient care but also in evaluating the quality and safety of care provided to patients and families. We aimed to determine common and unique predictors of nurse-reported quality of care and patient safety across acute care settings in a nationally representative cohort of nurses.

Theoretical Framework: The Systems Engineering Initiative for Patient Safety (SEIPS) theoretical model, which is composed of Work System or Structure, Process, and Outcomes, guided this study. We advance the model by discovering the model's factors that simultaneously predict nurse-reported quality and safety and the factors that are uniquely associated with either quality or safety assessments.

Methods: We analyzed cross-sectional survey data that were collected in early 2015 from 731 hospital nurses, as part of a 10-year panel study of nurses. Participants in the national study were mailed a survey to complete and return, following a modified Dillman design. Data analysis included completing descriptive statistics as well as multivariate linear and logistic regression modeling.

Results: The main results suggest significant predictors common to both quality and safety were job satisfaction and organizational constraints. In addition, unit type and procedural justice were associated with patient safety, while better RN-MD relations were associated with quality of care.

Conclusions/Implications: Our study is one of the first to examine what factors are common and which ones are unique to nurses' ratings of quality and safety, which advances the use of SEIPS model in patient quality and safety research. Increasing nurses' job satisfaction and reducing organizational constraints may be areas to focus on to improve quality of care and patient safety. Our results provide direction for hospitals and nurse managers as to how to allocate finite resources to achieve improvements in patient care.

Paper Session A5: Bio-Behavioral Research

Self-Management of Physical Activity in Adults with Type 1 Diabetes

Margaret McCarthy, New York University [black down pointing small triangle] Robin Whittemore, Yale University [black down pointing small triangle] Georica Gholson, Kimberly M. Brooks and Associates [black down pointing small triangle] Margaret Grey, Yale University

Background/Purpose: Adults with type 1 diabetes (T1D) make up a small portion of the overall diabetes population but have unique challenges in managing their diabetes, including frequent monitoring of blood glucose, taking insulin, carbohydrate counting, and engaging in physical activity (PA). Unfortunately, there is a scarcity of research on PA in adults with T1D. Aims: 1) To examine the patterns of PA and the biopsychosocial factors associated with PA in adults with T1D and 2) to examine self-management strategies employed while engaging in PA.

Theoretical Framework: The biopsychosocial model was used to explore PA and diabetes self-management.

Methods: We employed a cross-sectional design with a sample of adults with T1D who received care at an outpatient diabetes clinic. Clinical data were extracted from the medical record. The Patient Health Questionnaire-8 (PHQ-8) was used to measure depressive symptoms. The Hypoglycemia Fear Survey(HFS)-II assessed fear of hypoglycemia. The Barriers to Physical Activity-1 (BAPAD-1) scale assessed barriers to PA. The Yamax Digiwalker pedometer was used to measure one-week of step counts. Standard univariate statistics described the sample. Bivariate statistics included t-test, Pearson correlation, Chi-square and ANOVA. Independent variables significantly (p<0.05) associated with one-week step counts were included in a multivariate stepwise linear regression.

Results: The sample included 83 adults (65% female; 89% White) with a mean age of 45+/-17 years. The mean duration of T1D was 20+/-15 years and HbA1c level was 7.8+/-1.2%; 31% had at least one diabetes complication. The majority (63%) were overweight/obese and 22% had scores indicating symptoms of depression. Only 15% had step counts >10,000 steps/day. The highest rated barrier to PA was risk of hypoglycemia. Few (8%) always ate a carbohydrate before exercise to prevent low blood glucose, and the majority (56%) did not make changes to insulin before or during exercise. Factors positively associated with one-week step counts included male sex, and full-time employment; factors negatively associated were systolic blood pressure, body mass index, and BAPAD-1 score (all p<0.05). Only working less than full-time was independently associated with lower one-week step counts (p<0.05).

Conclusions/Implications: The rates of optimal PA in this population were low, and few made any changes in diet or insulin with PA. Understanding how PA is successfully incorporated into diabetes self-management may provide insight into potential interventions.

Chronic Stress, Cortisol, and Appetite-Related Hormones: Prospective Prediction of 6-Month Changes in Food Cravings and Weight in a Community Sample

Ariana Chao, University of Pennsylvania [black down pointing small triangle] Ania Jastreboff, Yale University [black down pointing small triangle] Marney White, Yale University [black down pointing small triangle] Carlos Grilo, Yale University [black down pointing small triangle] Rajita Sinha, Yale University

Background/Purpose: Adults in the US gain an average of 0.2 to 0.9 kg each year. Stress, cortisol, and orexigenic and anorexigenic metabolic hormones have been identified as key clinical targets related to weight and eating behaviors in pre-clinical and cross-sectional studies. However, few studies have prospectively examined how these factors are related to weight gain. The purpose of this study was to examine whether baseline chronic stress, morning cortisol, and appetite-related hormones (leptin, ghrelin, and insulin) predict future weight gain and food cravings in a naturalistic, longitudinal 6-month follow-up study.

Theoretical Framework: Selye's General Adaptation Syndrome

Methods: A prospective community cohort of three hundred and thirty-nine adults (age=29.1+/- 9.0 years; BMI=26.7+/-5.4 kg/m2; 56.9% female; 70.2% White) completed assessments at baseline and 6-month follow-up. At baseline, fasting blood draws were conducted to assess morning cortisol and appetite-related hormones levels. Weight, as well as, the Cumulative Adversity Interview and Food Craving Inventory were obtained at baseline and at 6-month follow-up. Data were analyzed using linear mixed models controlling for demographic and clinical covariates.

Results: Among the 49.9% of the sample who gained weight over the 6 months, the average gain was 3.5+/-3.2 kgs and 4.6+/-4.1% of initial body weight. Food cravings and chronic stress decreased over 6 months (ps<0.05). After adjusting for covariates, individuals with higher baseline ghrelin had significantly less reductions in food cravings over time (p=0.04). Furthermore, higher cortisol, insulin, and chronic stress were each predictive of greater future weight gain (ps<0.05).

Conclusions/Implications: These results suggest that ghrelin plays a role in increased food craving and reward-driven eating behaviors and highlights the importance of chronic stress and higher peripheral stress and metabolic hormones in weight gain in a community sample. Findings suggest that the addition of stress management interventions and assessing their efficacy in preventing weight gain may be important in curbing the obesity epidemic.

Enhancing Developing Relationships with Skin-to-Skin Contact

Dorothy Vittner, University of Connecticut [black down pointing small triangle] Xiaomei Cong, University of Connecticut [black down pointing small triangle] JoAnn Robinson, University of Connecticut [black down pointing small triangle] Jacqueline McGrath, University of Connecticut

Background/Purpose: To examine bio-behavioral mechanisms associated with maternal and paternal skin-to-skin contact (M-SSC/P-SSC) with premature infants. Specifically, to examine changes that occur in salivary oxytocin and cortisol levels during SSC and whether the process of SSC alleviates parental stress and anxiety while also enhancing developing mother-father-infant relationships.

Theoretical Framework: This study utilizes the theoretical underpinnings of Roy's Adaptation Model to provide a structure of knowledge for the implementation of SSC with healthy premature infants.

Methods: This randomized cross-over design study used a 3-day timeframe. The sample consists of 28 stable preterm infants (30 0/7 - 34 6/7 weeks gestational age between 3 -10 days old) and their mothers/fathers. After informed consent, each triad was randomly assigned to one of two sequences: M-SSC on day 1 and P-SSC on day 2; or P-SSC on day 1 and M-SSC on day 2. Infants' and parents' saliva samples for oxytocin and cortisol were collected pre-SSC, 60-min during-SSC, and 45-min post-SSC. Parental anxiety was measured at the same three time points. A parent-infant video was collected just prior to hospital discharge.

Results: Salivary oxytocin levels increased significantly during SSC for mothers (p<0.000), fathers (p<0.002) and infants (p<0.002). Infant salivary cortisol levels decreased significantly (p<0.000) during SSC as compared to before and after SCC. Parent anxiety scores also had a significant relationship with parent OT and SC levels. Parents with higher OT levels had more synchrony and responsiveness (p<0.000) in their interactions.

Conclusions/Implications: SSC provides an opportunity to active oxytocin release as well as to decrease mother-father-infant salivary cortisol levels. This is an important step in exploring oxytocin as a potential moderator to decrease stress and the effect on responsive interactions between mother-infant and father-infant. The nursing strategy of facilitating SSC should be used to reduce parent and infant stress in the NICU.

Nurse Faculty-Led Program with Wounded Warriors and Student Athletes: The College Warrior Athlete Initiative (CWAI)

Ann Burgess, Boston College [black down pointing small triangle] Paulette Thabault, Norwich University [black down pointing small triangle] Lynne Kiernan, Norwich University [black down pointing small triangle] Lorraine Pitcher, Norwich University

Theoretical Framework: An innovative initiative includes the overarching goal of the CWAI to support the transition for the Wounded Warrior (WW) from military service back to civilian life utilizing a wellness exercise framework.

Background: War and injury have long been a part of human history. Survivors are left with both physical and psychological injuries, and veterans of the Iraq and Afghanistan wars, collectively known as the Global War on Terrorism (GWOT), are no exception.

Purpose: The purpose of this nurse faculty-led initiative tests the battle buddy concept to replicate the lost military camaraderie with a collegiate work out buddy. Student athletes are paired with wounded warriors for a twice weekly workout followed by a wellness class taught by nurse faculty and other wellness experts and a research topic lecture taught by nursing and/or University faculty. Cohorts range from 5-9 warriors.

Methods: A holistic wellness 12-week program is designed to assist with Warrior reintegration transition while promoting health. The three health goals of the College Warrior/Athlete Initiative measure change in the warrior's weight and BMI (percentages of body fat and visceral fat, muscle mass and body water percentage). A Fitbit measures the sleep cycle and daily steps of the warrior and weekly bio-behavioral self-report surveys measure energy level, pain, fatigue, satisfaction with progress and self-esteem. Attitudes and symptoms of depression are measured with the Beck's Depression Inventory scale at week 1, 6, and 12.

Results: This paper with combined data from Boston College and satellite site at Norwich University presents results of 5 cohorts for a total of 25 wounded warriors indicating reduced weight and BMI, improved strength and conditioning and improved mood, energy and self-esteem.

Conclusions/Implications: The model is presented for other nursing schools/departments to bring post-9/11 veterans into contact with the health, athletic and educational resources of a college campus in order to improve veterans' fitness and wellness.

Stress Perceptions, Physiological Correlates and Quality of Life, in Patients with Irritable Bowel Syndrome

Kristen Weaver, National Institute of Nursing Research/NYU Rory Meyers College of Nursing [black down pointing small triangle] Gail Melkus, NYU Rory Meyers College of Nursing [black down pointing small triangle] Jason Fletcher, NYU Rory Meyers College of Nursing [black down pointing small triangle] Wendy Henderson, National Institute of Nursing Research (NINR)

Background/Purpose: Irritable bowel syndrome (IBS) is a chronic disorder of the gastrointestinal tract with physiological and psychological underpinnings. Patients with IBS often exhibit a dysregulated stress response and experience reduced quality of life; moreover, perceptions have been found to mediate symptomatology in this patient population. The purpose of this investigation was to explore perceived stress in patients with IBS in comparison to healthy controls (HC), examine physiological correlates and evaluate associations with perceived quality of life.

Theoretical Framework: National Institutes of Health Symptom Science Model

Methods: Participants were recruited to a natural history protocol at the National Institutes of Health in Bethesda, MD. Participants with IBS were diagnosed using Rome Criteria, and HC were included as a comparison group. All participants underwent a morning blood draw for cortisol quantification (timed to control for diurnal variation), and completed the Perceived Stress Scale (PSS) and Irritable Bowel Syndrome-Quality of Life Measure (IBS-QOL).

Results: Ninety-six participants were included for analysis; 32 were diagnosed with IBS and 64 served as HC. The sample consisted of 46 males and 50 females, with an average age of 27.91 +/- 7.89 years. Participants with IBS did not differ from HC in terms of age or levels of cortisol, but did significantly differ in PSS and IBS-QOL scores. Participants with IBS reported higher levels of perceived stress (p = 0.005) and lower quality of life (p = 0.001) in comparison to HC, with IBS-QOL scores a significant predictor of IBS grouping (Exp (B) .80, p = 0.001). Overall, a negative correlation was observed between perceptions of stress and quality of life (rs = -.24, p = 0.02).

Conclusions/Implications: This investigation of IBS utilized diverse research assessments, both physiological and psychological, to capture nuances of a complex disorder and facilitate understanding. Participants with IBS reported lower quality of life and higher perceived stress compared with HC, yet this stress response did not manifest physiologically. Recognizing a disconnect between subjective and objective markers may support the use of cognitive restructuring or biobehavioral interventions in this patient population. Further work exploring salient items on assessment inventories, participant demographics and additional markers of the stress response system, will guide our knowledge development and promote the design of personalized, therapeutic interventions for patients with IBS.

Symposium Session A6: Improving Older Adults' Cognitive and Functional Health: Innovative Approaches from the Aging RIG

Improving Older Adults' Cognitive and Functional Health: Innovative Approaches from the Aging RIG

Nikki Hill, Penn State College of Nursing

Integrative Summary: Cognitive and functional declines threaten older adults' health, well-being, and independence while also increasing caregiver burden. Nurse scientists are developing and testing novel assessment and intervention approaches to address the growing needs of our aging population. We present a symposium featuring cutting-edge research that enhances our understanding of cognitive and functional challenges as well as our approach to intervention. Our first presentation introduces new perspectives gained from a sorting task to guide the assessment of memory problems among older adults based on the specificity, time frame, and affective wording of items. Next, we will present the results of a systematic review examining the efficacy of cognitive rehabilitation in mitigating or alleviating cognitive dysfunction after chemotherapy among breast cancer survivors ages 65 and older. Third, findings will be presented regarding clinician, caregiver, and older adult acceptance of a low-cost, mobile robot to promote independence in community-dwelling elders. Fourth, we will present initial findings from laboratory-based testing of the DRESS system, an innovative automated dressing technology that can assist people living with advanced dementia as well as their caregivers. Finally, we present results of a pilot study testing the Evidence Integration Triangle for Behavioral and Psychological Symptoms of Dementia, an implementation strategy developed to help long-term care staff integrate nonpharmacological interventions into routine care. This symposium highlights the innovation and diversity of nursing science examining how we best understand and respond to the cognitive and functional needs of older adults across settings of care.

Pilot Testing the EIT-4-BPSD Intervention

Ann Kolanowski, Penn State College of Nursing [black down pointing small triangle] Barbara Resnick, University of Maryland [black down pointing small triangle] Kimberly Van Haitsma, Penn State College of Nursing [black down pointing small triangle] Elizabeth Galik, University of Maryland [black down pointing small triangle] Erin Vigne, University of Maryland [black down pointing small triangle] Paula Mulhall, Penn State University

Background/Purpose: Most people living with dementia experience behavioral and psychological symptoms that result in poor health outcomes and high costs of care. The Centers for Medicare and Medicaid Services now require that non-pharmacological interventions be used as a first line of treatment. Few staff know how to implement these interventions and less than 2% of nursing homes consistently use these approaches. The purpose of this study was to test an implementation strategy, Evidence Integration Triangle (EIT) for Behavioral and Psychological Symptoms of Dementia (EIT-4-BPSD), which was developed to help staff integrate non-pharmacological interventions into routine care.

Theoretical Framework: EIT-4-BPSD includes a four step approach implemented by an internal champion working with a Research Nurse Facilitator: Assessment of the Environment and Policies; Staff Education; Establishment of Person-Centered Care Plans; and Mentoring and Motivating of Staff.

Methods: This was a single group repeated measures pilot study comparing findings prior to and post implementation of EIT-4-BPSD.EIT-4-BPSD was implemented in two nursing homes and 21 residents were recruited. A Research Nurse Facilitator worked with facility champions and a Stakeholder team to implement the four steps of EIT-4-BPSD. Outcomes were evaluated using a Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) Model. Outcome measures at the level of the facility (environment and policy changes; care plans reflecting person-centered care) and resident (agitation, depression, pain, resistiveness to care and quality-of-life) were taken. Generalized estimating equations (GEE) were used to perform repeated measures analyses with outcome measures as the dependent variable.

Results: There was evidence of effectiveness with improvement in residents' quality of life and a decrease in agitation; adoption based on environment, policy and care plan changes; implementation and plans for maintenance beyond the 6 month intervention period.

Conclusions/Implications: The findings from this pilot study provide some preliminary support for EIT-4-BPSD, an approach that helps staff change how BPSD is managed within the nursing home.

Specificity, Time, and Feelings: How Older Adults Interpret Questions about Their Memory

Jacqueline Mogle, Penn State College of Nursing [black down pointing small triangle] Nikki Hill, Penn State College of Nursing

Background/Purpose: In older adults, perceptions of memory impairment can predict difficulties in daily functioning, future objective cognitive decline, and the development of Alzheimer's disease. However, the assessment of subjective memory varies substantially across studies; it remains unclear how older adults interpret different questions about their memory.

Theoretical Framework: Using a social-cognitive framework proposed by Cavanaugh and colleagues, we examined how older adults interpreted questions about memory using a free card sorting task.

Methods: Fifty-one participants (Mage = 74.4, SD = 9.98) were given 16 cards with different memory questions commonly used in aging studies (e.g., "How would you rate your memory at the present time?"). Cards were sorted using a free sorting protocol which instructed participants to sort without any input from researchers. Multidimensional scaling (PROXSCAL) was used to analyze the data; this approach creates a visual map of the relationships among items based on how often they tended to end up in the same pile.

Results: Analyses revealed three dimensions that explained 98% of the variance in similarities among items. The first dimension was based on how specific the item was: "How would you rate the memory problems you experience" was low specificity while "Do you find you forget people's names" was high specificity. The second dimension reflected whether the time frame for retrospection was well or poorly defined. An item with a well-defined time frame was "Compared to one year ago would you say your memory is[horizontal ellipsis]" while an item with a poorly defined time frame was "Do you feel you have more problems with memory than most." Finally, the third dimension indicated the degree of affective wording. An item about with highly affective wording was "Are you concerned you have a memory problem" while an item with lower affective wording was "Compared to other people your age, how would you rate your memory?".

Conclusions/Implications: This represents the first attempt to understand the underlying dimensions of subjective memory assessments from the perspective of older adult respondents. These dimensions can guide development of new assessment items that more precisely capture different aspects of the experience of memory problems in this age group. Better assessment tools will aid in the identification of those older adults most at risk for future cognitive decline.

Stakeholder Confirmation of Low-Cost Assistive Robot Activities to Support Older Adults in Their Activities of Daily Living

Justine Sefcik, University of Pennsylvania [black down pointing small triangle] Michelle Johnson, University of Pennsylvania [black down pointing small triangle] Mark Yim, University of Pennsylvania [black down pointing small triangle] Tessa Lau Savioke [black down pointing small triangle] Nicholas Vivio, University of Pennsylvania [black down pointing small triangle] Caio Mucchiani, University of Pennsylvania [black down pointing small triangle] Pamela Cacchione, University of Pennsylvania

Background: Creative solutions are needed to promote community-dwelling older adults' independence and reduce the risk of nursing home placement, particularly for those residing in low-income Supportive Apartment Living (SAL). A team of nurses and engineers [NSF:PFI-BIC IIP-1430216] were funded to develop a low-cost, mobile robot as a solution. Robotic features were designed after stakeholder focus groups (interdisciplinary clinicians, caregivers, and older adults) to gather information on activities the robot could perform to support older adults' in their activities of daily living. Stakeholders were associated with or members of a Northeastern Program of All-inclusive Care for the Elderly (PACE).

Purpose: Here we report on the follow-up focus groups with clinicians (4), caregivers (2), and older adults (3). We aimed to learn stakeholders' perceptions of prototyped features of a low-cost, mobile robot designed from the initial focus group information.

Methods: The clinicians, caregivers, and older adults, were shown videos of the robot completing four tasks with older adults: water delivery, walking accompaniment/encouragement, item retrieval, and game toss assistance. Participants were asked questions about each task and then about the robot overall. Focus group data were coded using directed content analysis based on the Almere Model to assess acceptance of technology by older adults.

Results: Results from the information gathered on the individual tasks from the three groups of stakeholders were that the water delivery, walking encouragement and item retrieval were perceived useful. The toss game was perceived to be less useful than the other tasks. The older adults expressed that they thought the robot overall would be easy to use.

Conclusions/Implications: The older adults and caregivers conveyed that the presence of the robot could allow the older adults to be more independent in their apartments. Implications of the findings and next steps will be discussed.

Design and Evaluation of an Automated Dressing Technology for People Living with Dementia

Winslow Burleson, New York University [black down pointing small triangle] Diane Mahoney, MGH Institute of Health Professions [black down pointing small triangle] Jeremy Rowe, New York University [black down pointing small triangle] Ed Mahoney, EDDEE Consulting

Background: People living with advanced stages of dementia (PWD) or other cognitive disorders face challenges remembering how to perform basic day-to-day activities, making them increasingly dependent on the assistance of caregivers. Dressing is one of the most common, and most stressful activities provided by caregivers due to its complexity and privacy challenges.

Purpose: In this paper, we present the first of its kind system (DRESS) that integrates research and practice to provide much needed independence and privacy to individuals with PWDs, and afford additional freedom to their caregivers.

Methods: For initial laboratory testing to evaluate the detection capabilities of the DRESS fiducial tracking system during each phase of the dressing process (using 2 clothing items: pants and shirt) prior to initiating in-home study, eleven healthy young participants (7 female / 4 male, age 19 to 41 - average age 25) were engaged for a single one-hour session. Each participant was asked to performed each of 9 dressing conditions 2 times interacting with the automated DRESS system following a complete randomized block design to assess system accuracy and guide future design. Finally, each session ended with a post-session survey. Video inspections were used to identify plausible detections that could occur often among participants and these were included as expected detections for each phase.

Results: Results indicated that the system was most reliable at reporting expected detections for acted errors of inside out pants and shirt in phase 1, followed by detecting each limb worn in phases 2 and 4 for both clothing items - missing only 4 out of 388 expected detections.

Conclusions/Implications: We have shown that it is possible to use a combination of sensors, intelligent software and fiducial tracking system to detect clothing orientation and position and thereby infer current state of dressing. This information can be used to track, identify errors, and prompt to assist individuals in dressing. This system has the potential to provide a viable option to provide automated dressing support for PWD dressing, while maintaining t independence and privacy, and providing caregivers with much needed respite.

BS, MS, Early Doctoral and Doctor of Nursing Individual School Selected Student Posters Session

BS Posters

Use of Lavender Aromatherapy in University Freshman College Students to Decrease Test Anxiety: A Randomized Control Study

Danielle Bard, Pace University [black down pointing small triangle] Martha Greenberg, Pace University

Background/Purpose: Anxiety, particularly test anxiety, is a pervasive problem among college students. Test anxiety is a type of state anxiety, experienced as concern or fear before, during, or following a test or performance assessment. The purpose of this pretest-post-test quasi-experimental design is to determine the effects of utilizing a lavender essential oil infused fragrance inhaler as an anxiolytic in freshman college students. The anxiolytic effects of the oil might reduce state and test anxiety, reduce stress and relax, and positively affect the students' sleep.

Theoretical Framework: Lavender essential oil is produced by steam-distillation of the flowering heads and leaves of the plant. Key active constituents of the oil are linalyl acetate and linalool. The true mode of action of fragrance aromatherapy remains speculative with effects being attributed to physiologic (amygdala) and psychologic (associations to an aroma) responses with Psychoneuroimmunology as an appropriate framework. Animal studies report a possible sedative effect as linalool acts on gamma aminobutyric acid (GABA) pathways, inhibiting binding of GABA and a depressant effect on neuro-transmission.

Methods: The study population from which the sample was drawn sample consisted of university freshman students on our suburban campus (n=400), over the age of 18, who were not pregnant nor had respiratory issues, e.g., asthma, consented to use aromatherapy or a control essential oil a minimum of 3 times per week, in the fall semester, prior to midterm examinations and through final examinations. Participants were instructed to "place the inhaler in or under one nostril, inhale slowly and deeply over five seconds, and repeat with the opposite nostril." The Westside Test Anxiety Scale, the Pittsburgh Sleep Inventory, and the Spielberg STAI were administered to the participants prior to the intervention and will be administered following the completion of the intervention.

Results: Data collection and analyses will be completed in the winter of 2017.

Conclusions/Implications: Will be written for final poster presentation following data analyses.

Assessing Knowledge and Beliefs Toward Inhaled Tobacco Products in College Students

Emily Krauch, University of Massachusetts-Dartmouth

Background/Purpose: Many of the students attending a university in Southeastern Massachusetts are from the local community, in which the Chronic Obstructive Pulmonary Disease (COPD) prevalence is 4.85% higher than the state average. The primary cause of COPD is tobacco inhalation. Research demonstrates that lifetime tobacco use typically begins by the age of 21. Therefore, it is important to understand tobacco knowledge, beliefs, and usage in the 18 to 24-year-old college population. The purpose of this study was to describe tobacco usage by students attending a university in Southeastern, MA and identify gaps in tobacco inhalation risk knowledge.

Methods: An exploratory-descriptive study design was used to address the research objectives. A sample of 209 university students between the ages of 18 and 24 completed an 84-question electronic survey that assessed their knowledge, beliefs, and behaviors regarding tobacco inhalation. The Psychological Risk Profile Questionnaire and a Primary Investigator developed Hookah Questionnaire were utilized to collect this data. Data was entered into SPSS and descriptive and correlational statistics were computed.

Results: 140 female and 69 male participants completed the survey. Although only 12.5% of students identified as being a current daily tobacco user, this was an increase in the number of students that are current tobacco users when compared with a previous campus survey conducted in 2015. Past daily and less than daily smokers comprised an additional 24% of student participants. Knowledge disparities were apparent in this sample regarding health risks associated with smoking different types of tobacco products, with participants believing all forms of tobacco were equally as harmful. Mean scores for perceived risk of illness as a result of using tobacco products were also found to be low. Cigarettes, cigars, and cigarillos scored high on social acceptance. Hookah was found to be the least socially acceptable, although participants believed that 47% of their peers had tried it. There were no significant correlations between health knowledge and tobacco usage.

Conclusions/Implications: There are still significant knowledge gaps regarding tobacco use in the college population. Targeted education is indicated in this population.

Smart Nutrition and Conditioning for Kids (SNACK): An Interdisciplinary Approach to Early Health and Wellness Education

Kevin Scott, The College of New Jersey

Background/Purpose: The purpose of the SNACK pilot study was to increase the fitness and health of children age 7-9 years of age in two Mercer county elementary schools. This was achieved by providing fundamental Integrative training (FIT) and health education in the areas of fitness, healthy eating and diabetes prevention. SNACK was implemented by Nursing, Health, and Exercise Science students with faculty guidance, provided an integrated program of fitness training, nutrition education and movement activities during physical education classes.

Methods: Four second grade classes in two Mercer County schools (School A & School B) with ethnically diverse populations were selected. One intervention and one wait-listed group were selected from each school. The intervention was performed twice a week for 45 minutes for 8 weeks. Pre/post study health and fitness assessments were completed on each child. To reinforce content a video format for parents, teachers, school nurses and children were developed for home viewing via school websites. Nutrition lesson plans were developed to educate the children on healthy eating in a fun, interactive manner during physical education class. Faculty Developed Questionnaire was distributed to the parents of the participants' pre/post intervention. This questionnaire was developed to determine baseline knowledge of healthy food choices, foods available at home, and physical activity at home and school. Physical Assessment was performed on the participants' pre/post intervention. Height, weight, blood pressure and pulse were taken and BMI's were calculated. *Children were examined for early manifestations of diabetes, such as acanthosis nigrans. Fitnessgram Fitness Test was performed on the participants pre/post intervention. This a valid and reliable test used to assess aerobic fitness, flexibility and muscle strength. In addition, other standard youth fitness tests were used to assess power (long jump), balance (single leg stand) and sprint speed (shuttle run). CATCH Nutritional Knowledge Instrument was used to measure nutritional knowledge pre/post intervention.

Results: CATCH Nutrition (knowledge) improved overall with the experimental group. CATCH Healthy Choices (survey) improved with experimental group. Parents at school B reported their children consumed less sugary drinks post intervention. Intervention group parents stated an increase in their child's physical activity post intervention. Parents reported no increase in consumption of vegetables post intervention overall. Parents at school B reported a significant increase in fruit consumption post intervention. While the control groups increased in junk food consumption, the experimental group at school B significantly decreased consumption. Post assessment school B families ate more meals together than school A. FIT, at schools A and B, significantly increased students ability to perform curl ups and pushups.

Conclusions/Implications: A collaborative effort between the nursing and PE department made it possible to combine fitness and health education together in one program. Both departments have the same objective to successfully reduce rates of childhood obesity and T2DM. MUSE included both Nursing and Education students, bringing together the educational aspects of school nursing and health education through personalized lesson plans. Childhood obesity is a well known public health concern in the United States, and is increasing in other developed countries worldwide. Latino, Native American, Pacific Islander, and African American children and children from lower income families have higher rates of childhood obesity (Hollar, et al., 2011). Obesity in children increases the risk of early diagnosis of hypertension, heart disease, and diabetes. Lifestyle modifications implemented at the earliest possible ages holds the most promise for sustainability and long term health benefits. Smart Nutrition and Conditioning for Kids (SNACK) is one example of an interdisciplinary approach to early intervention that teaches children how to be and stay healthy.

Experiences Related to Caregiver Burden and Health Status Among Heart Failure Caregivers

Holly Weinschenk, The Pennsylvania State University

Background: In the United States, heart failure (HF) is the leading cause of disability among the older adult population. An informal caregiver is vital to the health of patients with HF. Existing literature on caregivers has identified negative outcomes such as caregiver burden and decreased health-related quality of life. However, much of the research on caregiver outcomes has used quantitative methods. More research is needed to describe the individualized experiences which contribute to caregiver outcomes.

Purpose: The purpose of this study was to identify experiences related to caregiver burden and health status among caregivers of patients with advanced HF.

Methods: Participants included caregivers of patients with advanced HF with less than a 2-year predicated survival that were part of a larger longitudinal parent study. Ten spousal caregivers were included in this secondary analysis. A qualitative thematic analysis was completed to determine the experiences caring for a HF patient.

Results: Themes included: Role adjustment, I am stressed, It is not a burden, and Minimization of health needs. Caregivers reported adjusting their lifestyle and experiencing stress, but said it was not a burden. Caregivers prioritized the patient's health over their own and often waited until after the patient's death to seek medical help for their concerns.

Conclusions/Implications: Caregivers of HF patients describe negative experiences such as stress and sacrificing their personal time. However, caregivers are hesitant to describe these experiences as burdensome. They insist that caregiving is their job as spouse and that they do it out of love. Many caregivers experience their own health problems, but do not discuss their concerns because they feel their health is of lower priority than the patient's. Providers should assess the caregiver's health during patient in order to improve health outcomes for both the patient and the caregiver.

Parental Opinions About the Timing of Informed Consent in Pediatric Sepsis Research

Phoebe Hollyer, University of Pennsylvania

Background: Pediatric sepsis is a challenging and complex syndrome to manage. There is need for research to improve recognition and treatment of sepsis, though it can be challenging to navigate clinical research in pediatric emergency settings. Questions thus arise about the most appropriate manner to obtain informed consent for research during a potentially stressful time.

Purpose: To better understand parental opinions on the timing of informed consent in the Emergency Department (ED) setting, particularly for research on pediatric sepsis.

Methods: We developed a mixed-methods survey based on literature review, which we conducted in the ED of a large, urban academic children's hospital. Eligible subjects were parents/guardians of an ED patient <18 years of age who was at risk for sepsis, but not currently being treated for sepsis. The survey included questions about past medical history, general parental opinions about pediatric research, parental preferences about research in the context of a hypothetical sepsis scenario, and a Pediatric Trust in Physician Scale (PEDI-TiPS). Analysis included descriptive statistics and a logistic regression model to determine predictors of parental preference for delayed informed consent.

Results: One hundred parents/guardians were interviewed. Most parents had positive opinions associated with pediatric medical research, though many had mixed opinions about research involving their own child. Parents were asked about their preferred timing of informed consent during a hypothetical sepsis scenario with a research study involving blood sample collection. Sixty-five percent of parents reported preference for delayed consent when in a highly stressful emergent situation. In a logistic regression model parents with a history of a highly stressful pediatric ED visit AOR 2.8 (95%CI 1.0-8.0), high trust in physicians (PEDI-TiPS score) AOR 4.9 (95%CI 1.5-16.6), and male parents (female parent AOR 0.07 95%CI 0.01-0.56) were more likely to express preference for delay in consent.

Conclusions/Implications: Navigating informed consent for research in the pediatric emergency setting is challenging. We surveyed 100 families with a broad range of opinions about pediatric research and the timing of consent. Data from this study will be used to inform the consent process in future pediatric sepsis research studies.

Comparing Attitudes, Knowledge, and Behaviors Regarding Tobacco and Alternative-Tobacco Products Between Private and Public University Students in the Northeast

Josef Kampfe, University of Scranton [black down pointing small triangle] Emily Calderone, University of Scranton [black down pointing small triangle] Jacqueline Nugent, University of Scranton [black down pointing small triangle] Stefanie McGowan, University of Scranton [black down pointing small triangle] Jacqueline Vindici, University of Scranton

Background/Purpose: There is a rising incidence in the use of electronic cigarettes and hookah on college campuses. This has shown to lead to other high-risk behaviors, including the use of traditional tobacco products (e.g. cigarettes). The purpose of this study is to measure the differences in knowledge, attitudes, and behaviors associated with tobacco and tobacco-related products among students at a private and a public university in the northeast.

Theoretical Framework: The Theory of Planned Behavior suggests that an individual's knowledge and beliefs about the risks of tobacco-related products may be associated with the use of those products. Recent studies have shown that college students' perception of hookah and e-cigarettes as less harmful than cigarettes may lead to the use of these products.

Methods: The study employed a descriptive correlational research design using a 23-question survey. Participants included undergraduate and graduate students from both a private and a public university in the northeast. Surveys were administered at table-sit events in high traffic student centers on both campuses. SPSS was used to analyze the data. T-test and descriptive statistics were used.

Results: A total of 481 graduate and undergraduate students completed the survey, 259 participants at the public university and 222 at the private university. Thirteen percent of public university participants reported having smoked over 100 cigarettes in their lifetime versus 6.3% of private university participants and 45% of public university participants versus 25.8% of private university participants reported at least one instance of prior hookah use. Those who reported smoking over 100 cigarettes in their lifetime were significantly more likely to report that they would use hookah or e-cigarettes, and also significantly more likely to report that e-cigarettes had little or no effect on health when compared to non-smokers. In both schools, 18% of participants believe there to be no adverse health effects from e-cigarettes.

Conclusions/Implications: This intercollegiate project seeks to identify the knowledge, attitudes, and behaviors regarding use of cigarettes, hookah, and e-cigarettes amongst students on each campus. These findings suggest that there is a knowledge deficit regarding tobacco and tobacco-related products, which could lead to increased use of these products. The results of this study will be used to develop interventions to educate students about adverse health effects related to tobacco and tobacco-related products.

The Relationship Between Pain Catastrophizing, Pain Intensity, Stress, and Mental Health in Chronic Pain Patients

Leann Balcerzak, University At Buffalo [black down pointing small triangle] Janelle Garcia, University At Buffalo [black down pointing small triangle] Gina Bellavia, University At Buffalo [black down pointing small triangle] Patricia Nisbet, University At Buffalo [black down pointing small triangle] Loralee Sessanna, University At Buffalo [black down pointing small triangle] Yu-Ping Chang, University At Buffalo

Background/Purpose: Pain catastrophizing refers to the irrational process of exaggerating negativity, specifically in patients suffering from chronic pain. Catastrophizing thinking is characterized by three components; rumination about the negative experience, magnification of awfulness of the experience, and helplessness in confronting the experience. Pain catastrophizing impacts the way patients perceive pain which in turn could influence treatment outcomes and other psychological variables such as stress, anxiety and depression. This is an ongoing study aiming to examine the association between catastrophizing thinking, pain intensity, stress, and mental health in a sample of chronic pain patients who have been enrolled in behavioral intervention study.

Theoretical Framework: The theory of cognitive appraisal proposed by Lazarus and Folkman was used to guide this study.

Methods: Participants' baseline data from the main study were used to examine the association between variables of interest. Participants were recruited from primary care practices and a pain management clinic. Measures used in the study include the Pain Catastrophizing Scale, Patient Health Questionnaire, Generalized Anxiety Disorder Scale, Brief Pain Inventory, and Perceived Stress Scale. Descriptive and correlational statistics were used to analyze data. The inclusion criteria of the study are chronic pain patients who took opioids for chronic pain and had a depression score greater than 7 on the Patient Health Questionnaire.

Results: A total of 15 participants have been enrolled in the study. Preliminary findings indicate that catastrophizing thinking is associated with pain intensity and mental health.

Conclusions/Implications: Information regarding the associations between those variables would improve knowledge of the mechanisms behind catastrophic thinking in chronic pain patients so that specific treatment plans (e.g., behavioral interventions) can be tailored or developed to improve treatment outcomes.

Student Nurses' Comfort in Screening Patients for Disordered Eating Behaviors

Maura Tierney, Fairfield University

Background/Purpose: Nursing students will frequently encounter patients with disordered eating (DE) behaviors. It is important to identify these behaviors early as they may develop eating disorders or other clinical problems such as obesity or osteoporosis in addition to the mental health. If nurses have not been educated on DE, they may not recognize the symptoms.

Theoretical Framework: Constructivist learning theory was used whereby the learner takes in new information and constructs meaning based on their experience.

Methods: A national sample of n=75 student nurses filled out the Eating Attitudes Test-26 (EAT-26) and a survey on their practices and attitudes toward individuals with disordered eating.

Results: The sample consisted of white (76%), senior (62.7%) students from public schools (58.7%) working on their bachelor's degree (77.3%) with a mean age of 23.24 (SD 4.25) years. The mean EAT-26 score was 8.16 (8.78). Most participants (84%) agreed it was important to screen all patients. However, only 44% agreed that they had been taught how, 35.2% feel prepared to screen, and 29.3% saying they have not received any education on disordered eating. Those scoring above the EAT-26 cutoff of 20 (n=7) had higher rates of feeling prepared to screen (57.1%) and education on DE (85.7%) and screening (71.4%).

Conclusions/Implications: The majority of nursing students surveyed don't feel prepared to screen for DE. Those with higher scores on the EAT-26 had higher rates of education and preparation. We cannot address DE behaviors and the clinical problems associated with them without training nurses.

Door-to-Drug in Obstetrics: Time to Antenatal Corticosteroid Therapy in Patients at Risk of Preterm Delivery, and Factors that Influence Timing of Administration

Jiyun Choi, University of Delaware [black down pointing small triangle] Melanie Chichester, Christiana Care Health Services [black down pointing small triangle] Bailey Ingraham, Christiana Care Health Services [black down pointing small triangle] Lynn Bayne, Christiana Care Health Services [black down pointing small triangle] Matthew Hoffman, Christiana Care Health Services

Background/Purpose: To determine the time from presentation for care to administration of antepartum corticosteroids and factors which may influence timing

Theoretical Framework: 'Door-to-drug' is part of the AHA's recommendation for reperfusion therapy for STEMI, within 90 minutes of arrival for care. The concept is also used for stroke and sepsis. Antenatal corticosteroids are given to obstetric patients to improve neonatal outcomes. However, there is currently no standard of care regarding the timing of antenatal steroid administration beyond what patient populations which should receive them. We used the concept to review opportunities for improvement in door-to-drug time for obstetrical patients, as there can be critical time subinterval variations which affect timely care for these patients where there is potential for improvement.

Methods: Retrospective observational study of women presenting with obstetric complications, 240-336 weeks gestation, and given betamethasone at Christiana Care Health System from January 1-December 31, 2013. Univariate tests were used to compare the primary outcome (Door-to-Drug interval) among demographic and clinical characteristic subgroups. Linear regression was used to test for robust associations between the door-to-drug time and patient characteristics while adjusting for other covariates.

Results: 215 women presented with an obstetric complication. Median Door-to-Drug time was 175 minutes. Linear regression showed that patients with PPROM received corticosteroids 103 minutes sooner than the reference group (preterm diagnosis) (p<0.0001), those referred from a provider's office received corticosteroids 68 minutes sooner than women who self-presented to OB Triage (p=0.0044) and those dilated >2 cm on admission received corticosteroids 62 minutes sooner than those <2 cm (p=0.0061). Neither race/ethnicity, maternal age, gestation, day of the week or provider affected the time interval.

Conclusions/Implications: Median time from presentation to betamethasone administration was almost 3 hours. Women presenting with PPROM had a significantly shorter time, as did women referred from their provider's office and those that arrived dilated >2 cms. Once a decision to admit and treat a woman at risk for preterm delivery has been made, there should be little delay in administration of corticosteroids. As many factors can affect evaluation time, future research should focus on a standard decision to drug time interval.

The Impact of Workplace Bullying and Its Prevention in Healthcare: A Literature Review

Katherine Moon, New York University [black down pointing small triangle] Judy Alvarez, New York University [black down pointing small triangle] Keiko Ito, New York University [black down pointing small triangle] Kessya Joshua, New York University [black down pointing small triangle] Maria Heesoo Kim, New York University [black down pointing small triangle] Garlaine Norvil, New York University

Background: In the United States, nearly one-third of nurses experience bullying at work. Workplace bullying (WPB) is defined as bullying or harassment that is repeated, intimidating, or abusive. WPB may cause recipients to feel upset, humiliated, and vulnerable, which can increase stress and undermine self-confidence.

Purpose: To understand the impact of WPB in healthcare and to review the strategies of addressing WPB in hospitals.

Methods: Two electronic databases, PubMed and CINAHL, were searched using the keywords "bullying", "nurse", and "workplace violence." Studies were included for review if it was published in English and between 2011-2016, conducted in a hospital, and involved nursing staff.

Results: Six studies were included for review in this study. While WPB occurs between all members of healthcare staff, one study identified nurses as the main perpetrators of WPB. In the same study, it was found that WPB was associated with a loss in confidence (63%), increased anxiety (59%), and accounted for 30% of healthcare staff considering leaving their jobs. Furthermore, research has shown that WPB significantly increased nurse-assessed adverse events and perceived patient safety risk. Hospitals employed different strategies to address WPB, ranging from role-playing scenarios to mentoring and staff training. Major barriers to reducing WPB included lack of reporting of WPB by staff, unsupportive management, and no standards or protocols for identifying WPB and evaluating WPB interventions. None of the WPB interventions included nursing students, who contribute to patient care while in the hospital.

Conclusions/Implications: WPB has a significant negative impact on nursing care to patients and nurse outcomes. To reduce and prevent WPB, administrative commitment and managerial support are needed. While some hospitals are implementing WPB interventions, their effectiveness and sustainability need to be evaluated. Additionally, nursing students are an important part of the nursing workforce, therefore, nursing schools should consider incorporating WPB prevention in their curriculum.

Reducing Missed Endoscopy Appointments: An Evidence-Based Practice Project

Natalie Ferguson-Fowler, SUNY Downstate College of Nursing [black down pointing small triangle] Tashma Watson, SUNY Downstate Medical Center [black down pointing small triangle] Mohammad Faysel, SUNY Downstate

Background/Purpose: As the 3rd most commonly diagnosed cancer & the 3rd leading cause of cancer death in the United States, colorectal cancer is a major health concern. Colorectal cancer is 25% more frequent among blacks in comparison to whites. Blacks are 50% more likely to die of colorectal cancer than whites. Although colorectal cancer screening can reduce the incidence of & the mortality associated with this type of cancer, only 59% of the US population age 50 & above receive screening. Among those who are not receiving screening are a large number of people who have made but do not keep colonoscopy appointments. In an urban medical center, serving a predominately black population, the rate of missed colonoscopy appointments averages more than 30% annually. The mortality & morbidity associated with colorectal cancer is significant for the patient; &, for the community, in reduced access to services. Missed colonoscopy appointments also have implications for the healthcare facility with inefficient use of personnel & other resources & loss revenue. The problem of missed colonoscopy appointments was identified by an RN to BS student (the author) in an undergraduate research and evidence-based practice course as a major issue in the clinic. The purpose of this evidence-based practice project is to reduce the rate of missed colonoscopy appointments in an urban community especially among blacks.

Theoretical Framework: Pender's health promotion model is being used to guide the analysis of the problem and interventions to increase colonoscopy screening.

Methods: This inter-professional project involves colonoscopy clinic administration, &, nursing & informatics faculty & students. The steps to complete this project (in process) are to: describe and compare characteristics of people who miss and keep appointments; establish baseline levels of missed appointments; describe current pre-colonoscopy procedures; identify best practices; identify evidence-based interventions best suited to target patients; &, implement intervention.

Results: The impact of the intervention on the numbers of missed appointments & cost effectiveness of the intervention will be assessed.

Conclusions/Implications: If the intervention significantly reduces the number of missed appointments & is cost-effective, it will be adopted & the model used to address missed appointments in other clinics and services.

The Perceived Readiness Tool

Claire Donahue, Thomas Jefferson University [black down pointing small triangle] Jessica Dochney, Thomas Jefferson University [black down pointing small triangle] Kelly Davis, Thomas Jefferson University [black down pointing small triangle] Karen Dunham, Thomas Jefferson University [black down pointing small triangle] Nicole Beyer, Thomas Jefferson University [black down pointing small triangle] Christopher Evans, Thomas Jefferson University [black down pointing small triangle] Alyssa Fania, Thomas Jefferson University [black down pointing small triangle] Patricia Pollack, USF College of Nursing

Background/Purpose: In the Comprehensive Acute Rehabilitation Unit (CARU) at Thomas Jefferson University Hospital (TJUH) Hospital, there are many patients with traumatic and life-changing injuries and illnesses, who do not receive much time in the hospital to mentally and physically recover before moving on to their next setting. Even though these patients are treated by multidisciplinary teams including nurses, physicians, there was a need for a more specific tool designed to address a patient's "readiness" to be discharged. The Perceived Readiness Tool was constructed to be administered to the adult patients at the CARU at TJUH to evaluate physical, social, and emotional readiness before a discharge date. The tool measures the patient's perception of discharge readiness and more specifically, evaluates the physical, social, and emotional readiness for discharge. The goal of the Perceived Readiness Tool is to improve patient satisfaction and reduce hospital readmission rates.

Theoretical Framework: The framework of this study was developed using the premise of health promotion within high risk patient populations.

Methods: A literature review about "patient readiness for discharge" found that administration of varying readiness questionnaires before a patient was scheduled to be discharged may reduce the number of hospital readmissions and increase patient satisfaction. The tool was further developed through clinical observation.

Results: Currently, expert judges are in the process of reviewing this tool for content validity.

Conclusions/Implications: This poster will present a description about the development of the Perceived Readiness Tool and a content validity report.

Doll Therapy: An Approach to Calm and Enhance the Well-Being of Individuals with Agitated Dementia

Laura McCready, Cedar Crest College

Background: Given the global rise in the number of elderly people with dementia and advanced longevity, alternative non-pharmaceutical interventions are needed to assist people with their cognitive decline and to allow them to enjoy the final stage in their lives. Doll therapy is beginning to show promise for use in elderly individuals suffering from dysfunctional behaviors brought on by moderate to severe dementia. Doll therapy may afford nurses a cost effective strategy to help manage, calm, and enhance the well-being of those who suffer from challenging and often frustrating behaviors of agitation and aggression.

Purpose: The purpose of this project is to determine if the use of doll therapy is an appropriate therapeutic nursing intervention to calm and enhance the behaviors of individuals with agitated dementia.

Methods: A systematic search was conducted to locate peer reviewed research that addressed the PICO question "In patients with agitated dementia, does the use of a baby doll, induce a calmer demeanor? Using Advanced Search, and the Boolean phrase of "dementia AND agitation OR aggression AND doll OR baby doll OR doll therapy" AND doll" within the CINAHL and Wiley Online Library, 978 articles were found. Limiting years to 2009-2016 reduced findings to 431 and "in English" to 425. When limited to age 65+ was added, 239 articles were retrieved and narrowed down to 129 with the limit to over age 80. Within the US, only 50 articles were captured. When "dementia OR Alzheimers OR Lewy Body OR cognition disorders" were added, 11 articles were retrieved with only 8 found within academic journals.

Results: The evidence demonstrates that doll therapy is an effective intervention to calm behaviors, transform demeanor, and enhance the well-being of individuals with agitated dementia. Doll therapy provided statistically significant findings in promoting positive mood, behaviors, and social interactions for residents with dementia and having significant long-term effects. Substantial and encouraging evidence also indicated that doll therapy reduced behaviors of anxiety and agitation that may be associated with observed attachment needs of a person with dementia.

Conclusions/Implications: The introduction of dolls to agitated dementia individuals has a significant and beneficial effect on reducing behaviors of concern (i.e., agitation and aggression). Doll therapy be implemented within any setting where individuals with moderate to severe dementia are being cared for. Doll therapy can provide a calming effect, producing positive changes to mood and demeanor for many individuals with cognitive decline. Calmness improves quality of life and affords nurses a cost effective and nonpharmacological strategy to help manage, calm, and enhance the well-being of those who suffer from agitated dementia.

Patient Perspectives on Bedside Reporting

Alexander Krenz, West Chester University of Pennsylvania

Background: Effective communication with the patient is necessary for quality nursing care. It can lead to improved outcomes and the prevention of serious medical errors. Moreover, patient involvement is a necessary prerequisite for establishing patient-centered care.

Purpose: The purpose of this presentation is to evaluate the effect of bedside reporting on patients' perceptions of their own care.

Methods: A search for relevant literature dated between 2010 and 2016 was conducted using the CINAHL and MEDLINE databases. Four studies were selected: three qualitative studies and one quantitative study.

Results: Three main themes emerged from the literature. First, bedside reporting encourages patient participation. Second, bedside reporting allows for the patient to feel more informed. It also provides the patient with an opportunity to correct any perceived errors. Third, patients are generally not concerned with confidentiality at the bedside unless it pertains to sensitive issues.

Conclusions/Implications: Bedside reporting was looked upon favorably by most patients. When incorporated within the reporting process, patients tend to be more willing to be involved in care, collaborate more effectively with their healthcare team, and be more knowledgeable about their condition. Incorporating the patient within the reporting process facilitates effective nurse-patient communication. It also increases patient participation leading to more effective patient-centered care and the potential for increased patient safety.

An Evaluation of the Trends in Public Reporting in NJ Hospitals Among Adult Psychiatric Patients

Kathryn Riman, Rutgers University

Background: According to the American Psychiatric Nursing Association (APNA), the severity of illness among hospitalized mental health patients is worsening, leading to more pressure on nursing staff. Additionally, more nurses per hospital bed are associated with improved patient outcomes. Currently in New Jersey, the Department of Health and Human Services (NJDHSS) requires public disclosure of staffing levels in attempts to improve patient safety. The NJDHSS releases quarterly reports of the average nurse staffing over a three-month period.

Purpose: The purpose of this paper is to evaluate longitudinal trends in nurse staffing among adult closed psychiatric units and test relationships between hospital characteristics and locations with average staffing.

Methods: Data were procured from the New Jersey Hospital Association (NJHA) and covers the first quarter from December 31st to March 31st during 2009 to 2016. The NJDHSS uses the metric "number of patients/staff," which compares the number of patients to the number of nursing staff members on the unit during that shift. Quarterly datasets were combined into a master dataset. Staffing were compared for the registered professional nurse within the adult closed psychiatric unit beginning with quarter one across eight years. The trajectory in average staffing rates were compared for the position across eight years, in order to assess the impact public reporting has on staffing rates. Data were analyzed using Microsoft Excel.

Results: Thirty hospitals were included in the sample. From 2009 to 2016, the patient to nurse ratio were 6.71, 6.78, 6.36, 6.76, 6.31, 6.18, 5.99 and 5.98. With the exception of two years, 2010 and 2012, there was a negative correlation between year and patient to nurse ratio. With time, the number of patients per nurse decreased. Furthermore, from 2009 to 2016 staffing levels decreased by 10.9%.

Conclusions/Implications: The institution of public reporting of nurse staffing data has led to improvements in nurse staffing amongst the adult psychiatric population, and may be attributed to hospitals assuming responsibility to ensure safe staffing. Further examination can be done by studying staffing of the RN role by aggregating all the New Jersey hospitals staffing statistics and testing the nurse to patient ratio versus the year.

Application of the Pender's "Health Promotion Model" to a Perinatal Smoking Intervention: A Review of the Literature

Carmina Georgescu, Binghamton University [black down pointing small triangle] Lori Sprague, Binghamton University [black down pointing small triangle] Geraldine Britton, Binghamton University [black down pointing small triangle] Joyce Rhodes-Keefe, Binghamton University [black down pointing small triangle] Rosemary Collier, Binghamton University [black down pointing small triangle] Shai Lev, Binghamton University

Background/Purpose: Tobacco use during pregnancy has been associated with several adverse fetal outcomes. Despite these deleterious effects, pregnant women continue to smoke. Early prenatal care provides a peak opportunity for education regarding tobacco cessation. Factors known to affect abstinence include: demographics, knowledge, smoking history, perceived self-efficacy and motivational level. Pender's Model has been used to measure the effects that these constructs have on healthy behavior of people. Previous qualitative studies conducted by our Interdisciplinary Tobacco Use Research Program (ITURP) explored the experiences of pregnant smokers and their health care providers. They found that putting a "face to the problem" using a video format would capture pregnant smokers' interests during their prenatal visits. Therefore, the purpose of this study was to conduct a literature review exploring the application of Pender's Health Promotion Model to assist in the design of a study regarding a perinatal tobacco use video intervention.

Theoretical Framework: Pender's Health Promotion Model

Methods: Databases included CINAHL, Academic Search Complete, and Medline using the key term "Health Promotion Model" in conjunction with other key terms such as Pender, pregnancy, smoking, self-efficacy, knowledge, and motivation. Inclusion criteria were English, peer-reviewed and full text articles. Excluded were doctoral dissertations, meta-analyses, literature reviews, qualitative studies and work in text books.

Results: A total of 21 studies with a total of 5,301 participants were reviewed. Samples sizes ranged from 10 to 970 in each study. Two studies addressed health promotion in pregnant women, two studies addressed smoking, 19 were authored by nurses and 16 were published in nursing journals. Themes will be identified and detailed.

Conclusions/Implications: Nurses have a pivotal role in effectively addressing the effects of tobacco use with pregnant women. Pender's Health Promotion Model can serve as a framework that guides the nurse in delivering the message. An understanding of the relationships of the constructs that contribute to health promotion such as demographics, self-efficacy, knowledge and motivation is imperative.

Addressing the Social Determinants of Health: Strengthening Clinical and Community Partnerships

Maame Obeng, University of Connecticut

Background: Our study seeks to explore two geographically distinct communities, Bristol and Torrington, to examine how clinical care agencies and community-based organizations are working collaboratively to address the social determinants of health. Specifically, we will identify what current practices are in place within clinical care agencies and community-based organizations to address social determinants health, examine how clinical care agencies partner with community-based organizations to comprehensively address social and medical needs of patients/clients, and recognize potential barriers to or gaps in care. Methods: The student team defined social determinants of health and examined how they relate to health outcomes. The team then reviewed community health needs assessments from Bristol and Torrington and reviewed literature for current recommendations on addressing social determinants of health in clinical practice. From this review, 12 core interviews were formulated to ask clinicians and members of community-based organizations during field visits. Various clinical care agencies and community-based organizations within Bristol and Torrington were identified for site visits and interviews. Interview results were analyzed to identify linkages between clinical and community-based organizations and barriers to care. In total 12 interviews were conducted and evaluated, 7 with clinical agencies and 5 with community-based organizations. Results: Analysis of the community health needs assessment revealed an absence of community-specific data leading to inaccurate reflection of the health disparities within populations, in particular for income and poverty levels. There was also a lack of reporting on several social determinants of health demonstrating a need for clinicians and community-based organizations to further engage with one another to fully assess community needs. Community-based organizations and clinical agencies in both cities reported common barriers in terms of addressing social determinants of health and achieving effective collaboration which included: diversity of services, community partnerships and integration, assessment of social determinants of health, data collection and management, access to care, care coordination, marketing, and budget. Discussion: After reviewing interview results, key areas of opportunity for growth were identified for all agencies: access to care, data and assessment, and outreach and accessibility. In order to best address social determinants of health in practice, there must be a push to mandate education and training of all levels of staff and health professions students working in clinical care agencies and community-based organizations. Change at the policy level may help to ensure that various entities are maintaining standards of care, actively communicating with one another, and following current recommendations in addressing social determinants of health. Future research may build on this project to propose such legislative reform and/or implement educational programming.

Purpose: To examine how clinical care agencies and community-based organizations are working collaboratively to address social determinates of health by identifying what current practices are in place, examining how/if clinical care agencies partner with community-based organizations to comprehensively address social and medical needs, and recognizing potential barriers or gaps in care.

Methods: 1) Defined social determinants of health and examined how they relate to health outcomes; 2) Reviewed community health needs assessments and current recommendations; 3) Formulated 12 core interview questions; 4) Identified various clinical care agencies and community-based organizations in each community and conducted interviews at selected sites.

Results: Due to lack of community-specific data in the community health needs assessments, health disparities within populations (in particular income and poverty levels) were not fully accounted for. Absence of data regarding social determinants of health demonstrated a need for clinicians and community-based organizations to further engage with one another to fully assess community needs. Community-based organizations and clinical agencies in both cities reported common barriers in terms of addressing social determinants of health and achieving effective collaboration. From these barriers, key areas of opportunity for growth were identified: access to care, data and assessment, and outreach and accessibility.

Conclusions/Implications: In order to best address social determinants of health in practice, there must be a push to mandate education and training of all levels of staff and health professions students working in clinical care agencies and community-based organizations. Change at the policy level may help ensure that various entities are maintaining standards of care, active communication, and following current recommendations in addressing social determinants of health. Future research may build on this project to propose such legislative reform and/or implement educational programming.

MS Posters

Clinical Practice Guideline for Pediatric Preoperative Clearance

Sara Sloane, New York University [black down pointing small triangle] Christina Chiu, New York University [black down pointing small triangle] Preethi Fernandez, New York University [black down pointing small triangle] Erin Ginty, New York University [black down pointing small triangle] Annie Harrington, New York University [black down pointing small triangle] Amanda Imbriano, New York University [black down pointing small triangle] Stephanie Kramer, New York University [black down pointing small triangle] Maria Kyriacou, New York University [black down pointing small triangle] Sharon Lawi, New York University [black down pointing small triangle] Erin Miller, New York University [black down pointing small triangle] Alyssa Powell, New York University [black down pointing small triangle] Claire Short, New York University [black down pointing small triangle] Lauren Toscano, New York University [black down pointing small triangle] Ariel Warren, New York University [black down pointing small triangle] Monica Wengler, New York University

Background/Purpose: The goal of the preoperative clearance evaluation is to enhance patient safety and reduce morbidity and mortality related to anesthetic, intraoperative, and postoperative complications. While this evaluation serves as a medical checkpoint to assess for risk factors and anticipate potential problems, there is no identifiable clinical guideline for the pediatric population. The purpose of this capstone project is to develop a clinical practice guideline to standardize the pediatric preoperative evaluation and clearance.

Theoretical Framework: This study is guided by the principles of evidence-based research and clinical practice. Evidence-based practice (EBP) is the gold standard for clinical practice. In this framework, clinical decision-making is based on the best available evidence from the EBP guidelines.

Methods: The Agency for Healthcare Research and Quality clinical practice guideline was used for this study. A research librarian collaborated with 15 PNP third year students to establish a systematic literature search. Former PNP graduates consulted on this project. Inclusion and exclusion criteria were established. Highest quality EBP research studies were identified and reviewed by the 15 PNP students, the PNP consultants, and PNP faculty. The initial guideline draft was written based on the best available evidence. The guideline will be sent to experts in the field of pediatric surgery, including pediatric surgeons and pediatric nurse practitioners for review and comments. Reviews and comments will be evaluated by the PNP students, PNP consultants, and PNP faculty, and a final draft of the guideline for pediatric preoperative clearance will be written.

Results: The desired outcome is to provide a universal guideline for preoperative evaluation and clearance that can be applied to healthy children undergoing routine outpatient procedures. The guideline will be prepared by the time of this project presentation.

Conclusions/Implications: This guideline will include the minimum requirements for surgical clearance in regards to history, physical, diagnostic tests and labs, as well as inclusion and exclusion criteria for clearing pediatric patients for surgery. We believe that an evidence-based clinical practice guideline for pediatric preoperative clearance will be the foundation for quality and safety in caring for the pediatric patient scheduled for a surgical procedure.

The Use of Clinical Pathways to Standardize Care and Improve Access in Registered Nurse Led Visits

Caroline Shane, Villanova University

Background/Purpose: Clinical pathways are an essential tool used to standardize practice in nursing care. Literature regarding the role of the adolescent focused nurse led visits in primary care clinical practice is sparse. A clinical evidence-based pathway for sexually transmitted infection (STI) screening and testing was created and instituted in an urban primary care setting that utilizes nurses to conduct nurse led adolescent health care visits. This project aims to describe the use of clinical pathways by nurses in primary care to improve access and standardize care for adolescents. The clinical pathway provides nurses a tool to guide the nurse led adolescent health care visits, ensuring proper patient treatment and education.

Methods: Nurses were surveyed prior to and 2 months after implementation of the STI screening and testing pathway. Chart reviews were conducted to determine any change in the rates of STI testing occurred.

Results: The initial survey of the nurses indicated that the majority would like more guidance in leading these nurse led visits. Approximately 92% felt that a clinical pathway would assist in standardizing care. After two months of utilizing the pathway, patient outcomes were positively affected as STI testing rates increased, despite seeing a smaller overall number of patients in the summer months. An overwhelming majority of participating nurses (91%) cited a desire for more clinical pathways to use in this setting.

Conclusions/Implications: Because of the positive impact of the use of a clinical pathway in a nurse driven patient visit, further instituting additional pathways may be an important benefit to both nurses and patients. Development of four additional clinical pathways for the nurse led visits related to pregnancy testing, STI treatment, contraception refill visits, and emergency contraception visits is planned.

Perceptions of Heart Failure Terminality and End of Life Decision Making

David Everly Jr. The Pennsylvania State University

Background: Heart failure (HF) remains a worldwide epidemic, affecting over 5.7 million adults in the U.S. alone. Half of those with HF will die within 5 years of diagnosis. Although the unpredictable trajectory of HF ultimately ends in death, caregivers (CGs) often misunderstand the terminality of HF which may complicate decisions about treatment choices at the end of life (EOL).

Purpose: To determine how CG perceptions of the terminality of HF impacted the decisions made at EOL.

Methods: Participants included CGs who were part of a longitudinal parent study on the palliative care needs of patients with Stage D HF with less than a 2-year predicted survival. During content analysis, CGs of patients who died during study enrollment were divided into two groups based on their perceptions of HF terminality. Transcripts, including post-death interviews, were analyzed to determine group differences in treatment choices and EOL decision making.

Results: Twenty-five CGs from the parent study were included in the analysis. Therapies considered to be aggressive included endotracheal intubation, LVAD implantation, multiple cardioversions, hemodialysis, excessive utilization of emergency medical services, family initiation of CPR in the prehospital setting, and implantation of a feeding tube. Of the 25 CGs, 40% perceived the patient's HF as terminal. Sixty percent of the CGs who did not perceive HF terminality made aggressive treatment choices at EOL whereas only 30% of CGs who did perceive HF terminality made similar choices. CGs perceiving HF terminality were more likely to withdraw aggressive therapies (67%) than CGs not perceiving HFH HF to be terminal (44%).

Conclusions/Implications: The majority (60%) of the CGs did not acknowledge the terminality of HF which often led to aggressive therapeutic choices at EOL and a decreased likelihood of treatment withdrawal. More effective communication with CGs and patients diagnosed with HF, with an emphasis on advance care planning and goals of care throughout the disease trajectory is necessary.

Effects of Sustained Inflation Alveolar Recruitment Maneuver on Oxygenation in Patients with Acute Respiratory Distress Syndrome

Angela Nguyen, University of Pennsylvania

Background: Acute Respiratory Distress Syndrome (ARDS) is a deadly complication in critically ill patients that causes significant morbidity and mortality. Despite advancing technology, there has been little improvement in treating ARDS. Treatment is supportive with a large component involving techniques through mechanical ventilation, such as the highly debated recruitment maneuver. A recruitment maneuver is sustained increase in airway pressure with the goal to open collapsed alveoli. Recruitment maneuvers are served to improve oxygenation as part of a lung protection strategy. The most commonly used recruitment maneuver is sustained inflation. PEEP is usually set to 30-40 cm H2O for 30-40 seconds. Sustained inflation is effective in improving oxygenation and respiratory mechanics, decreasing pulmonary atelectasis, and preventing alveolar decruitment. However, sustained inflation is associated with hemodynamic instability, increased risk of barotrauma/volutrauma, increased intracranial pressure, and reduced clearance of alveolar fluid.

Purpose: The purpose of this poster is to critically review current literature regarding the effect of the sustained inflation recruitment maneuver on oxygenation in patients with ARDS.

Methods: Using Medline (PubMed), Embase, and Ovid databases, the terms Acute Respiratory Distress Syndrome, ARDS, and recruitment maneuver were used. After reviewing the results for relevancy, the search ultimately yielded three studies used in this literature review.

Results: All of the studies showed an initial increase in PaO2/FiO2, but the change was stastistically significant for only one study (P <0.05). Although there were improvements in oxygenation, all of the studies induced some degree of cardiovascular compromise. Overall, there was inconsistent results regarding the beneficial effects on oxygenation.

Conclusions/Implications: The evidence is insufficient to support using recruitment maneuvers as standard practice. Further large-scale research in the form of randomized, controlled trials needs to be done in order to explore the safety and efficacy of recruitment maneuvers.

Enhancing Nursing Undergraduate Student Attitudes Towards Those Living in Poverty Through Simulation

Colleen Spang, Pace University

Background: Nurses have a professional responsibility to advocate for eliminating health inequalities and social injustices among vulnerable populations. Use of effective learning strategies in nursing education are vital to the development of skills, knowledge, and attitudes towards those living in poverty. Implementation of two simulated experiences to mimic poverty experiences were utilized as affective learning tools to develop positive attitudes towards people living in poverty.

Purpose: The purpose of this pilot study was- (1) To assess undergraduate student attitudes towards people living in poverty, (2) To evaluate the effectiveness of two poverty simulation exercises within an undergraduate nursing curriculum.

Methods: The Undergraduate Perceptions of Poverty Tracking Survey (UPPTS) is a 39-item tool using a 5-point Likert scale to measure nursing students' attitudes pre- and post- intervention. Data were collected pre- and post- intervention on undergraduate freshmen nursing students from a private university in the Northeast, who participated in the Community Action Poverty Simulation (CAPS) or the Oxfam America Hunger Banquet. The CAPS simulates role-playing the struggles of those living in poverty. The Oxfam Hunger Banquet simulates the globally unequal distribution of food and resources.

Results: Data were collected for three semesters; spring 2015, fall 2015 and spring 2016. Data was collected in spring 2016 from graduating seniors, who had never participated in either experience and used as a control group. Paired t-tests were used to compare total scores of the UPPTS. For the spring 2015, Poverty Simulation mean UPPTS scores decreased from 141 to 113 and was statistically significant at the .05 level. Average scores for the fall 2015 Hunger Banquet changed from 143 to 145 and was not statistically significant. Average scores for the spring 2016 Hunger Banquet changed from 140 to 145 and was statistically significant. Average scores for the senior control group were 141.

Conclusions/Implications: Comparison of pre- and post- scores indicated the Poverty Simulation is more effective in stimulating a more positive view towards people living in poverty as compared to the Hunger Banquet.

Management of the Airway in the Prone Position

Didier Juste, SUNY Downstate College of Nursing

Background/Purpose: Background: In surgeries requiring patients to be positioned prone, the current practice recommended by the American Society of Anesthesiology is endotracheal intubation for airway management. The related complications are increased operating room procedure time, the necessitation of multiple care providers to assist with positioning, tracheal intubation is invasive and the direct cost to the institution and patient/payer is augmented. Purpose: is to examine the current research to determine if using a Laryngeal Mask Airway (LMA) is a viable alternative to tracheal intubation for procedures requiring the patient to be positioned prone.

Methods: Randomized control trials involving 20 patients undergoing elective procedures to be performed in prone position (provided they meet all the inclusion criteria). 10 patients would have their procedures done using an LMA, and 10 patients will have their procedure done 10 using Endotracheal intubation.

Results: Evaluate data based on several measurable parameters; Length of procedure time, Adverse outcomes (e.g. aspiration, hoarseness), cost of procedures, and patient satisfaction survey postoperatively.

Conclusions/Implications: Conclusions support the use of LMA in patients positioned prone for surgery then; Step 1). Duplicate the study with a larger sample size of 100 patients in multiple hospitals 2). Present EBP presentation at American Association of Nurse Anesthetist national conference. 3). Appeal to the American Society of Anesthesiology for a potential practice change.

The Development of Advanced Practice Nursing and Palliative Care Educational Needs: A U.S.-Israel Comparison

David Collett, Yale University [black down pointing small triangle] Shelli Feder, Yale University [black down pointing small triangle] Yafa Haron, Israel Ministry of Health [black down pointing small triangle] Dena Schulman-Green, Yale University

Background: Palliative care (PC) nursing is growing in the United States (U.S.) and Israel. Significant challenges to expanding PC infrastructure in Israel are professional education and provider roles in PC. Little is known about Israeli nurses' self-perceived competence in providing PC or their educational needs. Israel offers PC content within nursing curricula, though depth and availability vary. Israel's Ministry of Health (MOH) recently introduced the first advanced practice registered nurse (APRN) role in PC. In the U.S., PC APRNs are well-established, and the field can serve as a reference point for development of the role in Israel.

Purpose: Our purpose was to compare PC education and nursing roles in Israel and the U.S. in order to identify scope of education and clinical practice with the goal of improving PC nursing in both countries. Our specific aims were to assess the educational needs and opportunities of nurses working in PC and to describe the evolution of the PC APRN role in Israel.

Methods: We partnered with the Israel MOH to collect three forms of data by administering a nationwide survey, conducting key stakeholder interviews, and performing document analysis. We administered the End-of-Life Professional Caregiver Survey (EPCS) online to a sample of oncology and palliative care nurses whom we identified through the MOH and the Israel Oncology Nurses' Association. The EPCS is a valid, 28-item survey designed to assess core competencies in PC. We conducted key stakeholder interviews (n=11) on site in Israel, discussing perspectives on PC nursing education and practice. We gathered educational, organizational, and legislative documents to explore content and roles in PC nursing. Survey data analysis included univariate, bivariate, and multivariable statistics. We performed content analysis on interviews and documents to extract themes.

Results: Survey respondents (n=137) were mostly female (92%) with a mean age of 48.2 years (SD=10.4). Respondents felt most comfortable with speaking with other providers about the care of dying patients, addressing patients' and family members' fears related to the use of pain medications, and being present with dying patients. Respondents felt least comfortable with providing grief counseling for staff, encouraging families to complete advanced directives, and using non-drug therapies in the management of patients' symptoms. Interview themes included the belief that Israel was lagging in PC, a desire for greater public awareness of PC, and a need for increased definition and authority for APRNs. Analysis of documents revealed patients' legal right to quality end-of-life care, basic regulation of PC in health care settings, and a basic vs. complex structure of nursing education in PC.

Conclusions/Implications: While there is great interest in expanding PC and PC nursing roles in Israel, infrastructure lags behind intent. Efforts are being made to increase educational and practice resources for PC nurses. The creation of the PC APRN role is a major advancement that continues to be implemented and refined. We have described the landscape of PC and the PC APRN role in Israel. Israel and the U.S. are international leaders in healthcare. Our data contribute to mutual progress that can be shared with other countries working to develop PC and PC APRN roles.

The Health Belief Model in Breast Cancer Health Promotion Efforts: A Review of the Literature

Carlo Kariuki, Salem State University

Background/Purpose: According to BreastCancer.org, in the years 2015 to 2016 among women between the ages of 40 to 70 there were over 46,000 incidents of Breast Cancer-in situ, over 149,000 incidents of invasive Breast Cancer, and over 20,000 Breast Cancer related deaths. The Health Belief Model has been recognized effective in educating women on preventative measures such as Breast Self-Exams to facilitate early Diagnosis and treatment of Breast Cancer. This integrative review of the literature aims to explore the use of the Health Belief Model in health promotion efforts aimed at early diagnosis and treatment of Breast Cancer.

Theoretical Framework: The Conceptual framework utilized in this review is the Health Belief Model and its potential in increasing individual health awareness and health motivation as proposed by Hochbaum, Rosenstock, and Kegels in 1956.

Methods: A combined search of CINAHL Plus and OVID, for years 2011-2016 using the terms 'Use of Health Belief Model in Breast Self-Exams' yielded 55 articles published within the past 6 years.

Results: Findings from the identified articles will be explored in order to determine the appropriateness of the Health Belief Model as a theoretical framework for the development of a Breast Self-Exam educational program/ pilot program

Conclusions/Implications: Conclusions are pending. Implications for policy, practice, and research will be identified.

Early PhD Posters

Eating Disorder Recovery: A Metasynthesis

Carrie Morgan Eaton, University of Connecticut

Background: Defining the term `recovery' is a complex process in eating disorders. The lack of definitional consensus on eating disorder recovery generates a disconnect between the meaning of recovery in clinical settings, during various phases of treatment, based on diagnostic severity and chronicity, and among those who are inpatient versus outpatient. Nonetheless, researchers willing to extrapolate insight from individuals who have conquered an eating disorder and achieved recovery have the opportunity to gain vast clinical knowledge in the ED treatment and recovery process.

Purpose: A metasynthesis of eating disorder recovery was conducted to guide knowledge towards the myriad of experiences that explain recovery from the perspective of those who have struggled with and overcome an eating disorder.

Methods: Design:Noblit and Hare's meta-ethnographic, reciprocal approach was used for this metasynthesis. This method involves comparing study findings and translating each into the other through a series of seven phases. Sample:The final sample consisted of 10 qualitative studies published between 2011-2016. Data Collection: The CINAHL, PubMed, and PsycINFO databases were searched between 1/2011 to 6/2016 with such key words and combinations as eating disorder, recovery, and qualitative research. In addition, the search was repeated in each database with with anorexia nervosa, bulimia nervosa, and binge eating disorder. Two-hundred seventeen studies were found, and 10 met the inclusion criteria of: (a) the focus of the study was eating disorder recovery, (b) the research design was qualitative, (c) the participants were identified as recovered, and (c) articles within a 5 year period from 1/2011 to 6/2016). The relevant articles were evaluated using the Critical Appraisal Skills Program (CASP) guidelines.

Results: The metasynthesis revealed 5 overarching themes reflecting the complex psychological processes of eating disorder recovery: (a) the eating disorder as a life jacket, (b) drowning: recognizing consequences, (c) treading the surface: contemplating recovery, (d) swimming: the path towards recovery, and (e) reaching recovery: a sense of freedom.

Conclusions/Implications: The results of this metasynthesis demonstrate that healthcare providers have a significant opportunity to make a difference in the care experiences of individuals with an eating disorder. Unfortunately, this opportunity is often lost as eating disorders are minimized and misunderstood. By deciphering the experiences of eating disorder recovery, healthcare professionals have the opportunity to comprehend an eating disorder individual's actions and reactions. Early intervention cannot only interrupt the eating disorder cycle, but can help individuals improve their health and begin the journey towards life without the eating disorder life jacket.

Pain with Endocrine Therapy for Breast Cancer: 18-Month Survivor Experience

Zhu Yehui, University of Pittsburgh [black down pointing small triangle] Susan Sereika, University of Pittsburgh [black down pointing small triangle] John Merriman, University of Pittsburgh [black down pointing small triangle] Catherine Bender, University of Pittsburgh

Background/Purpose: Arthralgias and myalgia are the most commonly reported symptoms experienced with endocrine therapy for breast cancer. Reported to affect 36-87% of women with the disease, these symptoms are the most common reason women stop endocrine therapy due to the associated deterioration in their quality of life. However, the trajectory of pain during the course of endocrine therapy is not fully described and it is not clear whether some women experience more severe arthralgias and myalgia. The aim of this preliminary dissertation study is to identify distinct subgroups of temporal patterns or trajectories of the pain experience as measured by the Brief Pain Inventory (BPI) to serve as the basis for the development of tailored interventions to manage arthralgias and myalgias with endocrine therapy.

Theoretical Framework: The conceptual framework of the BPI suggests two pain dimensions, sensory (severity) and reactive (distress).

Methods: Using a prospective design, postmenopausal women diagnosed with hormone-receptor positive early stage breast cancer and prescribed endocrine therapy were assessed for their pain experience at pre-therapy, and 6, 12, and 18 months post-therapy initiation. Pain severity and distress in the past 7 days were assessed by the BPI Short Form with 11 items rated on a 0-10 scale. Group-based trajectory modeling was used to identify latent classes of trajectories of severity and distress of pain separately.

Results: Women (N=365) were on average 61.1 years of age, Caucasian (96.2%), married/partnered (67.2%), and well-educated (mean=14.74 years). Three distinct trajectory groups were identified for pain severity: constant no pain (24.9%; b[intercept]=-2.79, p<.01), low initial pain with linear increase (48.2%; b[intercept]=1.04, p<.01; b[linear]=0.04, p=.036), and moderate initial pain with linear increase (26.9%; b[intercept]=3.87, p<.01; b[linear]=0.07, p=.009). For distress, three distinct trajectories were found: constant no distress (40.2%; b[intercept]=-1.95, p<.01), low distress (60.3%; b[intercept]=1.65, p<.01), and moderate distress (9.5%; b[intercept]=5.43, p<.01).

Conclusions/Implications: This study shows that a significant proportion of women experienced low to moderate initial pain which increased over time and experienced constant low to moderate distress. Future efforts should focus on identification of predictors of high-risk subgroup membership.

Comparison of Debriefing Methods on Clinical Reasoning, Psychological Safety, and Learner Satisfaction in Simulation-Based Education

Lori Persico, Molloy College

Background/Purpose: Background: While much research focused Simulation-Based Education (SBE) as an emerging teaching method that has been used successfully in military, aviation and medical education, the evidence rarely accounts how debriefing affects the learners' experiences. Debriefing is an essential component of simulation-based education that fosters conceptual learning, critical thinking, and clinical reasoning. Purpose: To compare two different debriefing methods' effect on nurses' perception of psychological safety, satisfaction with development of clinical reasoning skills, and satisfaction with learning.

Theoretical Framework: The development of simulation as an education strategy is supported by several learning theories. The theoretical framework guiding this research is Kolb's Experiential Learning Model. The theory explains how knowledge development occurs through experience and how new knowledge is related to what is known and retained and provides a foundation to learning through simulation and debriefing.

Methods: This quasi-experimental, posttest study explored the effect of debriefing methods. The investigator used two debriefing methods during a simulation learning experience part of an orientation using the 3D Model of Debriefing: (1) Defusing, Discovering and Deepening (3D-DDD) and (2) the DEBRIEF method. These models have been articulated in the literature with clear distinctions in how debriefing is executed in the simulation experience. The debriefing faculty were appropriately trained on the models and observed by the investigator for treatment fidelity. The study measured the participants' experience including psychological safety and satisfaction, as well as clinical reasoning skills after each debriefing method. Study participants were divided into two groups and experienced one of the two models of debriefing as designed by the investigator. Debrief methods alternated so that all groups in each month were debriefed using the same method. The simulation center is used for academic and interprofessional educational programs for a large hospital system in the metropolitan New York area with over 60,000 employees. Power analysis was done to determine the sample needed for the study (n=128). Data collection occurred over several months until the final sample was reached (n=149). Preliminary analysis is in progress.

Results: In progress.

Conclusions/Implications: In progress.

Use of a Wellness Coaching Model Among Urban-Dwelling, Low-Income Older Adults: One-Year Outcomes of a Pilot Study

Bertha Lee, Northeastern University

Background/Purpose: The primary purpose of this study was to determine if low-income older adults who participate in a personalized wellness coaching model will have increased self-management behaviors (i.e. physical activity) as compared to a wait-list attention control group.

Theoretical Framework: This project is based on Troutman's theory of successful aging that supports individual determination of successful aging and an action plan to achieve life goals.

Methods: Partnering with the Boston Housing Authority (BHA), this pilot project implemented a wellness coaching model consisting of a comprehensive, geriatric assessment, an individualized healthy aging plan, and continued coach contacts to increase health self-management. The study sample included minority older adults residing in one of two BHA sites. Fifteen participants (5 females and 10 males, mean +/- SD: age = 77.4 +/- 7.9 years) were assigned to the intervention group and 13 older adults (7 females and 6 males, mean +/- SD: age = 75.8 +/- 9.1 years) from another BHA site made up the attention control group, which received the intervention six months later. Assessment tools used were interRAI's Health & Social Check-up and Lifestyle Survey.

Results: Independent and paired t-tests (p<0.05) were calculated to compare baseline and follow-up results. For example, preliminary analyses showed a statistically significant improvement in physical activity level at 6- and 12-month follow-up (p<0.006) for the intervention group.

Conclusions/Implications: Final results will be reported with implications for nursing practice and future research.

Middle School Students' Knowledge of Skin Cancer, Sun Protective Behaviors, and Perceptions of Acquiring Skin Cancer

Anna George, Molloy College

Background/Purpose: Increasing sun protection for children and making them aware of the dangers of the Ultraviolet rays of the sun may reduce their risk of developing skin cancer. Teaching sun protective behaviors in schools should start early in childhood. Developing comprehensive sun safety programs for children that are motivating and individualized will help them to get involved in the programs and also help to retain the information that they have learned during these programs. Sun protection of children in North America is generally lower than what is desirable. Many programs in place in schools help to improve sun safety knowledge, but students continue to tan. Approximately one person dies from skin cancer per hour in this country. Concurrently, many people do not follow sun protective behaviors. This is a serious public health concern. Therefore, optimal method for teaching students and motivating them to learn about sun protective behaviors and skin cancer should be developed. Studies have shown that using skin analyzer machine (SAM) is an effective methodology when teaching about skin cancer, as it shows the changes of the skin that cannot be visualized by the naked eye and it personalizes sun damage to the students. The premise behind this study using SAM is that the students who seek the tanned look or those students, who are not careful about protecting their skin, can be shown through the mirrors in the SAM, the damage sun has on their skin that is not visible by the naked eye such as brown spots.

Theoretical Framework: The conceptual framework that will be used in this study will be Positive Youth Development Model (PYD). PYD refers to intentional efforts of other youth, adults, government agencies, and schools to provide opportunities for youth to enhance their skills and abilities. Theoretical framework used in this study is Protection motivational theory (PMT), which was originally proposed by Rogers in 1975 to provide conceptual clarity to the understanding of fear appeals. PMT helps to offers suggestions for changing behaviors and it is educational and motivational. PMT proposes that the intention to protect one's self depends upon four factors: The perceived severity of a threatened event (e.g., skin cancer), the perceived probability of the occurrence, or vulnerability (in this example, the perceived vulnerability of the individual to develop skin cancer), the efficacy of the recommended preventive behavior (the perceived response efficacy), and the perceived self-efficacy (i.e., the level of confidence in one's ability to undertake the recommended preventive behavior).

Methods: The researcher is conducting an ongoing quasi-experimental study using a pretest and posttest design, which plans to examine the teaching methodologies that can be used in 6th, and 7th grade physical education classes. The teaching methodologies used were either lecture only or lecture and skin analyzer machine (which demonstrates sun damage) in combination. A total of 283 students were divided into three groups. All groups received a pretest in April 2016. All of the students will receive a posttest in October 2016 to determine the best teaching method for students.

Results: It is hoped that the results of a study using skin analyzer machine with middle school students will have significant and positive impact on the students, when compared to the lecture-only and control groups, and therefore use of skin analyzer machine can become an important educational adjunct when instructing students about skin cancer.

Conclusions/Implications: It is hoped that this research study will increase knowledge and perception of the students regarding skin cancer so that they, in turn, can educate their parents and family members and raise awareness of the dangers of tanning.

The Impact of Pre-Operative Surgical Stress on Gastroparesis in the Type II Diabetic Patient. Is the Type II Diabetic Patient at Increased Aspiration Risk During Anesthesia?

Amy Reed, The Catholic University of America

Background/Purpose: The purpose of this study is to determine the volume of gastric contents in the type II diabetic patient and to perform a risk assessment for pulmonary aspiration. Consensus exists that pulmonary aspiration is a potentially fatal anesthetic complication and current fasting guidelines only apply to healthy patients (ASA, 2011; Putte & Perlas, 2014). Pulmonary aspiration occurs when gastric contents enter the respiratory system. Degree of injury is associated with the amount of volume in the gastrointestinal tract (Cubillos et al., 2012). Gastroparesis and hyperglycemia are already well-established conditions associated with type II diabetics (Alakkad et al., 2015; Cubillos et al., 2012). In the presence of stress and activation of the sympathetic nervous system, these conditions can be exacerbated potentially placing this patient population at an increased risk for pulmonary aspiration during induction of anesthesia (Yamaguchi et al., 2006). Despite the existence of current fasting guidelines, no efforts have yet been made to determine if there is a relationship between type II diabetic patients undergoing elective surgery, salivary amylase levels and gastric contents.

Theoretical Framework: Using the Theory of the Allostatic Load, this study will assess type II diabetics undergoing elective surgery who have followed the current fasting guidelines in a 572-bed community teaching hospital in south central Pennsylvania.

Methods: Salivary amylase and blood glucose levels will be taken the morning of surgery to evaluate stress and glucose levels, respectively, and the gastric contents of each participant will be measured using ultrasonography at bedside in the pre-operative unit prior to leaving for surgery.

Results: This study is in the beginning stages of planning and no results are available.

Conclusions/Implications: Once the study is conducted, the data will reflect whether or not anesthesia providers need to consider individualized pre-operative fasting guidelines for type II diabetic patients to ensure optimization at the induction of anesthesia.

Screening for Urinary Symptoms Among a National Sample of Nurse Practitioners

Kimberly Angelini, Boston College

Background/Purpose: Overactive bladder (OAB) and urinary incontinence (UI) are common in women with reported rates higher than that of other chronic conditions (diabetes and asthma.) Symptoms often go underreported due to embarrassment and the false sense that symptoms are normal. Many national organizations encourage the importance of routine OAB and UI screening to identify symptoms and offer behavioral modification as first line therapy. Further, studies have shown that patients need to be asked directly about symptoms before they are willing to share. However, many providers remain uncertain of management options and are therefore reluctant to screen. As the primary health promotion provider, understanding their current screening practices of nurse practioners (NPs) will help to target areas for practice improvement. The purpose of the study was to describe NP's self-reports of screening for urinary symptoms, including OAB and UI, in female patients.

Theoretical Framework: The Public Health Prevention Model (PHPM) was used as a framework to support the practice of UI and OAB primary prevention screening to prevent symptom progression.

Methods: Design: The current study is a secondary data analysis of data collected as part of a cross-sectional study of nurse practitioners from across the United States. Sample/Setting: The original study recruited members of the American Association of Nurse Practitioners (AANP). A random selection of 1,000 mailing addresses from across the U.S. was provided by AANP. Measures: A 4-part consecutive mailer was sent to the provided addresses following the Dillman method of an introductory postcard, followed by the survey, and two reminder postcards. The postcards also had links to a web-based version of the survey. Providers were asked about their screening practices for urinary symptoms as well as the structure of their work setting.

Results: The mean response rate was 19%. The final sample consisted of 177 providers. Less than half reported screening all female patients for any changes in urination (n=76) and only 40.1% (n=71) reported screening young women (ages 16-30) for urinary symptoms.

Conclusions/Implications: Despite recommendations for routine screening by national organizations, this study demonstrates a missed opportunity in screening for OAB and UI. Future research is needed to understand barriers to screening in this population.

Is Pain Catastrophizing Associated with Pain Characteristics and Mobility Performance in Community-Living Older Adults? The MOBILIZE Boston Study II

Ampicha Nawai, University of Massachusetts-Boston

Background/Purpose: Catastrophizing may play an important role in the exacerbation and perpetuation of pain and may predict poor mobility in individuals with chronic pain. This cross-sectional study investigates the association between pain catastrophizing and pain characteristics and mobility performance in older population.

Methods: We studied 354 adults from the MOBILIZE Boston Study II who were aged >= 70 years (mean=84.5y) and enrolled between 2011 and 2015. Pain severity and pain interference were assessed by subscales of the Brief Pain Inventory (scored 0-10, grouped into quartiles). Pain distribution was classified as none, single site, and multisite. The Pain Catastrophizing Scale (PCS) was a 13-item scale, with scores ranging from 13-65. Mobility performance was assessed using the Short Physical Performance Battery (SPPB) and usual-paced gait speed. Linear regression models were performed to examine the association between pain catastrophizing and pain characteristics and mobility performance.

Results: One-fourth of all participants (24%) catastrophized pain. Among these participants, 81% reported chronic pain. Prevalence of pain catastrophizing was higher in younger participants and in those with osteoarthritis, depression, or anxiety (p-value<0.05). Average PCS score was higher in participants with moderate-severe pain compared to those with very mild pain or without pain (means =25.8, 23.2, and 21.8, respectively, p-value= 0.01). Also, PCS score was associated with pain interference and multi-site pain (p-value =0.004 and 0.006, respectively). After adjusting for sociodemographic and chronic conditions, the association between pain catastrophizing was independently associated with all pain characteristics; however, pain catastrophizing was not associated with mobility performance.

Conclusions/Implications: Pain catastrophizing is associated with high levels of chronic pain but not with mobility performance in older adults. Potentially, the assessment and treatment of pain catastrophizing may reduce pain intensity and pain-related disability in older people. Longitudinal research is needed to better understand the long-term effects of pain catastrophizing and functioning in older adults.

Integrity in Nursing Students: A Concept Analysis

Christine Devine, University of Massachusetts-Dartmouth

Background: Academic and professional integrity are valued and necessary qualities in nursing students. However, the integrity literature provides examples of behavior devoid of integrity, such as cheating, plagiarism, lying and deception. This results in blurred meaning and understanding of the concept of integrity in nursing students.

Purpose: In order to provide a clear and consistent meaning of the concept of integrity in nursing students a concept analysis was undertaken.

Methods: A literature review was conducted using the Cumulative Index for Nursing and Allied Health, Social Science Index, Psyc Info and Medline. Inclusion criteria included peer reviewed articles written in English, with no publication date limiter. A search of the term integrity uncovered an abundance of literature across disciplines. Nine articles were selected to illustrate the concept in non-nursing literature. Additional search terms were applied including: professional integrity with nursing students, professional integrity with nursing practice, nursing students with honesty and integrity, and integrity in nursing resulting in 648 titles. Each abstract was reviewed and articles without relevance to the study of integrity in nursing students and duplicate articles were removed, resulting in a final sample of 18 articles. Walker and Avant's (2005) concept analysis method was used to identify the attributes and characteristics of integrity in nursing students.

Results: A concept definition, defining attributes, model, borderline, related and contrary cases, antecedents, consequences and empirical referents were developed. Defining attributes of nursing student integrity were honesty, ethical behavior and professionalism. Antecedents to integrity included an academic culture of respect, characterized by student-faculty relationships derived from mutual respect, trust and a shared learning goal.

Conclusions/Implications: Honesty, ethical behavior and professionalism are defining attributes of integrity. The importance of faculty as role models of integrity is paramount. Future research should explore faculty perceptions of their role as models of integrity.

Nurses' Customization of Physiologic Monitor Alarms in Intensive Care Units

Halley Ruppel, Yale University

Theoretical Framework: Tanner's Model of Clinical Judgment will guide the qualitative strand of this mixed methods study. The model posits that nurses use noticing, interpreting/responding, and reflecting to make decisions in acute care settings.

Background: Alarm fatigue is a widely recognized patient safety concern. When nurses become desensitized to alarms, critical patient events may be missed, resulting in unintended patient harm. Reducing the number of non-actionable alarms is one mechanism to decrease alarm fatigue. Non-actionable alarms can be reduced by customizing alarm settings to the individual patient. Although the Joint Commission has a National Patient Safety Goal on Alarm Management, which addresses the issue of alarm customization, no studies have explored nurses' alarm customization practices, or factors that facilitate or hinder this process.

Purpose: The purpose of this study is to generate a complete understanding of nurses' alarm customization by integrating quantitative data describing nurses' customization practices with qualitative data on nurses' clinical judgment toward alarm customization.

Methods: This convergent parallel mixed methods study will integrate quantitative data on nurses' alarm customization practices with results from qualitative interviews. The study will be conducted in three intensive care units in an academic medical center in the northeastern United States. Quantitative data on the number and characteristics of customized alarms will be collected from the central monitoring system in all three units. Qualitative data will be collected via telephone interview with nurses from these units. Descriptive statistics will be used to analyze quantitative alarm customization data. Thematic analysis will be used to analyze qualitative data from the interviews. In the integration phase, data from the two strands will be examined side-by-side, assessing for complementarity of the data. Interview themes (qualitative) will be assessed for their ability to explain and clarify the observed customization practices (quantitative).

Conclusions/Implications: The results of this study are expected to provide a preliminary understanding of nurses' practices and clinical judgment regarding alarm customization. These results can be used to design interventions to enhance nurses' customization of monitor alarms, with the ultimate goal of reducing alarm fatigue.

Dyadic Experience of Symptom Burden and Health Perception Pre and Post LVAD Implantation

Julie Murphy, The Pennsylvania State University

Background/Purpose: Currently 5.7 million Americans live with heart failure (HF); an estimated 10% of these patients have advanced disease. As HF progresses, patients experience high symptom burden and a decline in health. Their informal caregivers (CG) also experience an increase in burden and decline in health associated with increased demands of caregiving. As the disease progresses, patients may require a left ventricular assist device (LVAD) to help alleviate symptoms and prolong life. Few studies have examined the burden of HF pre and post-LVAD implantation.

Methods: A longitudinal prospective study was undertaken with HF dyads (n = 20) following LVAD implantation. A Visual Analog Scale assessing the level of HF burden and health rating was administered retrospectively for pre-LVAD implantation, concurrently post-LVAD and 3 months later to both patients and CGs.

Results: Using multilevel modeling to account for nested observations (occasion in person, persons in dyads), we found patients and caregivers experienced a significant decrease in burden (Pt p= 0.0022, CG p=0.0030); related to HF including symptoms, treatments, caregiving, and financial burdens. Patients and CGs also experienced a significant improvement in health ratings (PT p < 0.001, CG p= 0.0327). Patients and CGs experienced similar decrease in burden, but patients experienced a threefold increase in perception of their own health following LVAD implantation. [LK3] [LK1]This is important for poster but not needed here [JR2] [LK3]As above.

Conclusions/Implications: HF dyads experience a decreased burden from both the patient and CG perspective post-LVAD. It is also noteworthy that both patients and CGs experience an increase in overall health ratings. The burden associated with advanced HF and LVAD implantation is important and needs to be addressed with comprehensive education and support provided within the dyad.

Factors Associated with Non-Acceptance of TB Testing and Evaluation Among Household Contacts Exposed to Tuberculosis

Elvy Barroso, City University of New York

Background/Purpose: The WHO reports that the incidence of TB is approximately 9.0 million new cases globally each year and approximately 3.3 million cases are missed by health systems as either undiagnosed or not reported. A single index case can infect up to 10 to 15 contacts over the course of a year. Thus, complete and timely evaluation of all contacts exposed to TB is crucial for decreasing the transmission and incidence of TB. Several barriers to testing of contacts have been identified, however, no studies specifically address contacts' non-acceptance to TB testing and evaluation. Both nurses and non-nurse managers conduct contact investigations (CI), but it is not known if there are differences in adherence to TB testing and evaluation based on type of provider. The study will seek to determine factors associated with non-acceptance of TB testing and evaluations as well as compare testing adherence rates among contacts manage by nurses versus non-nurse managers.

Theoretical Framework: Pender's Health Promotion Model (HPM) will guide the examination of factors that prevent contacts from accepting TB testing and evaluation.

Methods: A retrospective study of four years of data extracted from the New York City TB registry will be used to assess factors associated with contact's non-acceptance of TB testing and evaluation. Data elements include demographics, contact information, reporting and assignment, clinical disposition, and case management provider type. Logistic regression will be used to assess the probability of not accepting TB testing and evaluation based on independent variables and to assess differences between two independent variables: a nurse manager and a non-nurse manager with non-acceptance of TB testing and evaluation.

Results: In the process.

Conclusions/Implications: Study findings will provide data to facilitate health departments to develop appropriate strategies to increase contacts' acceptance of TB testing and evaluation.

Routine Exercise Positively Impacts Sleep in College Students

Erin Flaherty, Boston College [black down pointing small triangle] Carina Katigbak, Boston College [black down pointing small triangle] Jennifer Rowland, Boston College [black down pointing small triangle] Matt Gregas, Boston College

Background/Purpose: College students are known for sleep deprivation and inconsistent weekday and weekend sleep practices. Exercise may improve sleep, and is a potential target for sleep promotion. The impact of exercise on sleep in college students is not well studied. The aim of this study was to examine the relationships between routine exercise and nighttime sleep quality and duration in college students.

Methods: A web-based survey was used to characterize the relationship between exercise and sleep in a random sample of 440 undergraduate college students (response rate 22%). Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). According to exercise guidelines from the American College of Sports Medicine and the American Heart Association, the number of days per week engaging in exercise were examined, including doing moderate-intensity exercise like taking a brisk walk to increase heart rate for at least 30 minutes, and doing vigorous-intensity exercise like jogging and swimming for at least 20 minutes. Students who performed at least 5 days per week of moderate-intensity exercise, or performed vigorous-intensity exercise at least 3 days per week were classified as optimal exercisers meeting guidelines.

Results: Among the 440 respondents, 9.1% of students did not exercise at all (n=40), 29.8% exercised but did not meet the guidelines (n=131), and 59.8% exercised and met the guidelines (n=263). Significant differences were observed in subjective sleep quality (p=0.043) and habitual sleep efficiency (p= 0.029) among the three groups, with those who did not exercise reporting the poorest sleep quality and efficiency. Students who met the exercise guidelines had significantly fewer hours of sleep on the weekends (8.2 +/- 1.4) and less discrepancy in sleep duration between weekend and school days (1.4 +/- 1.6) compared to students who did not meet exercise guidelines (8.5 +/- 1.1; 1.9 +/- 1.5) and compared to those who did not exercise (8.7 +/- 1.8; 2.4 +/- 2.4). Self-reported GPAs were significantly higher in students with more consistent sleep duration (r=0.145, p=0.003).

Conclusions/Implications: Routine exercise has a positive impact on sleep quality and consistency of sleep duration during weekdays and weekends in college students, which may lead to greater academic performance. Routine exercise should be encouraged to promote healthy sleep behavior and improve sleep quality in college students.

The Impact of Cumulative Pain/Stress on Neurodevelopment of Preterm Infants in the NICU

Wanli Xu, University of Connecticut [black down pointing small triangle] Xiaomei Cong, University of Connecticut [black down pointing small triangle] Jacqueline McGrath, University of Connecticut [black down pointing small triangle] Wendy Henderson, Biobehavioral Branch, Division of Intramural Research, NINR, NIH, DHHS

Background/Purpose: Preterm infants experience numerous pain/stress in neonatal intensive care units (NICUs). The contribution of cumulative pain/stressors to altered infant neurodevelopment is still unclear. This study aims to investigate the impact of early life painful/stressful experiences on infants' neurobehavioral outcomes in NICUs.

Theoretical Framework: Studies show persistent painful/stressful stimulation in early life are associated with altered spinal neuronal circuits and enhanced sensory responses.

Methods: A prospective longitudinal exploratory study with fifty preterm infants recruited at birth and followed for four weeks. Cumulative pain/stressors were measured daily using modified NICU Infant Stressor Scale (NISS), which consists of 47 acute or short-term procedures (e.g., heel stick) and 23 chronic or long-term events (e.g., nasogastric tube in-situ). When infants reach 36-37 weeks post-menstrual age (PMA), a neurodevelopmental evaluation was performed using NICU Network Neurobehavioral Scale (NNNS). Demographic and other clinical information were also collected. Data analyses were conducted on linkages among pain/stressors and neurobehavioral outcomes in R.

Results: The majority of infants were female (53%), white (80%), born at 31+/-2 weeks PMA by cesarean-section (65%), and with 1431+/-465 g of birth weight. Infants experienced a total of 643.15+/-64.53 acute procedures (daily average: 22.97+/-2.30 procedures) and 1192.51 +/- 420.45 hours of chronic events (daily average: 42.59+/-15.02 hours) for the first 4 weeks. There was no change in the daily acute NISS scores over time, whereas, daily chronic NISS scores decreased during the first four weeks of infant life in the NICU. Both acute and chronic pain/stress experienced during early life significantly contributed to the neurobehavioral outcomes, particularly the stress/abstinence (Acute: F=5.30, P=0.03; Chronic: F=4.13, P=0.05) and habituation responses (Acute: F=-2.94, P<0.01; Chronic: F=-2.48, P=0.02) after controlling confounding factors.

Conclusions/Implications: Understanding mechanisms by which early life experience alters neurodevelopment will help clinicians to develop individualized interventions with neuroprotective strategies to improve infant health outcomes.

"Worsening of Symptoms" as Defined by Persons with Heart Failure: A Qualitative Study

Ludmila Santiago-Rotchford, University of Delaware

Theoretical Framework: Heart failure is a chronic disease that is managed by tolerance to severity of symptoms. The middle range theory Symptoms Experience in Time (SET) was used after initial analysis of data to describe how persons with moderate to severe heart failure perceive the experience of and individualize methods to manage these symptoms through key concepts of perception, time, distress, quality, and intensity (PTDQI).

Background: Typical symptoms of heart failure include shortness of breath, chronic coughing and wheezing, edema, fatigue, lack of appetite, impaired thinking, and increased heart rate. Current recommendations by the American Heart Association for self-management of heart failure include a reduced sodium, low fat diet, restriction of fluid intake, adherence to prescribed medication, and activity as tolerated. A disconnect exists between how persons with heart failure (PHF) and healthcare providers perceive the best ways to manage symptoms of disease exacerbation.

Purpose: The perceived experiences of how persons with New York Heart Association (NYHA) class III and IV heart failure manage worsening symptoms were explored.

Methods: A pilot qualitative study was conducted of three persons with NYHA Class III and IV heart failure using semi-structured interviews in a cardiologist's office. Key concepts were extracted from the transcriptions of the recorded interviews and themes were identified Themes included symptoms of worsening heart failure, modifications of behavior, and motivational factors.

Results: The most commonly reported perceived symptom was the inability to tolerate activity due to fatigue. Reported modifications included change in diet, fluid intake, adherence to medications, and other changes to daily life. Concern for family members was the major motivational factor in choosing to modify behaviors to manage symptoms of heart failure.

Conclusions/Implications: Varied descriptions of self- management of heart failure by the participants confirmed that strategies that PHF perceive as most effective should be individualized based on these perceptions. Objective tools that measure activity tolerance are available to evaluate readiness for discharge of PHF from the acute care setting. Future research will be conducted using mixed methods measuring physiological differences in tolerance of activity and perceptions of fatigue by PHF. This type of research will demonstrate the importance of interprofessional collaboration between nurses and physical therapists as a predictor to determine the ability of PHF to manage the symptoms of heart failure after discharge.

Exploring the Relationship of Parental Health Literacy with Neonatal Intensive Care Unit (NICU) Discharge Transition Readiness for Parents of Black Preterm Infants

Mia Waldron, Villanova University

Theoretical Framework: The framework guiding the study will be the revised Kenner Transition Model1 which operates on the grounding concept of transition as a crisis which demands a response in the person experiencing it 1.

Background: The U.S. ranks last among western nations in overall infant mortality rates and ranks second highest in rates of preterm birth among the same nation group4. The U.S. infant mortality data shows that Black infants have the highest incidence among all groups3,5. Infants born prematurely are among those at highest risk for infant death with Black women delivering premature infants at rates higher than all other U.S. groups3,8. Parental Health Literacy (PHL), defined as the ability to learn, read, comprehend, and act on health information specifically related to the care and condition of a dependent child2. Poorer child health outcomes and low levels of PHL, are linked, associated with inconsistent health promotion behaviors by parents 2, 6, 7.

Purpose: The purpose of the study will be to explore the relationships between levels of PHL, perceived discharge teaching effectiveness and parental readiness to provide care for their Black preterm infants at home after discharge from the NICU with parent and infant demographics as well as their infants' health overall.

Methods: A mixed method approach is proposed for this study of parents of Black preterm infants from a Level IV NICU, located in an urban area. Quantitative analyses of variance and regression analysis will determine relationships among the variables. Qualitative analysis of the perceptions of the parents, prior to and within 60- days post NICU discharge, will be by semantic content analysis of interview data organized into thematic categories for cluster analysis.

Results: The hypothesis is that PHL and NICU parent transition readiness will have a parallel relationship.

Conclusions/Implications: PHL and effective discharge teaching can contribute to the disparate infant morbidity and mortality outcomes experienced by U.S. Blacks, and, have widespread implications for nursing.

Socio-Demographic and Cultural Determinants of Women's Participation in Pap Smear Screening Programs in Low- and Middle-Income Latin American and Caribbean Countries: An Integrative Review

Erica Liebermann, New York University [black down pointing small triangle] Nancy VanDevanter, New York University [black down pointing small triangle] Mei Fu, New York University [black down pointing small triangle] Holly Hagan, New York University

Theoretical Framework: Fawcett and Ellenbecker's Conceptual Model of Nursing and Population Health (2015).

Background: Cervical cancer is highly preventable, yet mortality from cervical cancer remains high worldwide, with the majority of deaths occurring in low- and middle-income countries (LMICs). Cytology-based (Pap smear) screening programs for early detection of cervical cancer precursors have significantly reduced mortality in high-income countries, but in Latin America and the Caribbean, despite the existence of Pap smear screening programs, most countries have not effectively lowered the incidence of and mortality from cervical cancer. Epidemiologic studies in Latin America have shown that cervical cancer mortality is in part due to failure to achieve population coverage for Pap screening. In addition to health system barriers, there are socioeconomic and sociocultural barriers affecting women's demand for Pap smears. Country-specific studies have examined factors that affect women's participation in Pap smear screening programs across Latin America and the Caribbean.

Purpose: The purpose of this review was to explore the socio-demographic and cultural determinants of Pap smear screening participation among women in Latin America and the Caribbean.

Methods: This integrative review utilized thematic content analysis to integrate findings from a sample of 12 quantitative and four qualitative studies done across low-and middle-income Latin American and Caribbean countries.

Results: Socio-demographic determinants of Pap smear participation were income, education, whether a woman had a regular health care provider, and rural vs. urban residence. Cultural barriers were fear, embarrassment, gender roles, and lack of culture of preventive health.

Conclusions/Implications: This review demonstrates the complexities of the social determinants of Pap smear utilization among women in Latin America and the Caribbean. Its findings highlight a need to understand ways to engage women in the health care system, to promote preventive care, and to facilitate community-generated educational programs and solutions. The barriers and facilitators to Pap smear participation need to be examined in the context of currently available alternatives for cervical cancer screening.

Academic Progression and the Hispanic Nurse

Carmen Cruz-Torres, Seton Hall University

Background: Hispanic Americans are underrepresented in the nursing profession, accounting for 3 percent of all nurses (NSSRN, 2010). The lack of degree attainment beyond a BSN among Hispanic nurses (HNs) is evident in advanced practice roles in nursing, where graduate degrees are required for practice. Hispanic advanced practice nurses (APNs), account for 3.5 percent of all APNs, 3.9 percent of all nurse practitioners (NSSRN, 2010), and 1.7 percent of all nurse faculty (AACN, 2009a and 2009b). The Institutes of Medicine (2011) recommended that HNs achieve a BSN and beyond, and contribute to the science of nursing. HNs can provide culturally competent patient care to increasing numbers of Hispanics in the healthcare system, and also educate other nurses (Cooper & Powe, 2004). Academic progression for HNs has the potential to mitigate the shortage of HNs in leadership roles such as scientists, clinicians, educators, advocates and mentors. Nurses with advanced degrees are needed to serve as faculty, scientists, primary care providers, specialists and leaders throughout the healthcare delivery system (NLN, 2010).

Purpose: To explore existing barriers, academic supports, and mentorship that may influence academic progression among HNs.

Methods: A search of the literature using databases Medline, PubMed, and CINAHL, 09/2014 - 01/2015 was conducted. Fourteen articles with relevance to the concept of Academic Progression and the Hispanic nurse are included in this synthesis of literature.

Results: Limited research is published on academic progression in HNs; however, Valverde & Rodriguez (2002), use a model of institutional support and outlined barriers and supports for Hispanic doctoral students. Bond, Gray, Baxley, Cason, and Denke (2008) identified financial supports from scholarships, family and employment as essential for progression. Role models and mentors provided students with academic and moral support, and filled several roles including liaison, tutor, and supplier of information (Villarruel & Peragallo, 2004; Rivera-Goba and Nieto, 2007). Barriers identified included personal needs, academic needs, language needs, and cultural needs (Amaro, Abriam-Yago & Yoder, 2006). Bond et al. (2008) suggested the impact that heightening personal self-determination can have on success.

Conclusions/Implications: Successful academic progression of HNs beyond the BSN can be influenced by academic supports, but HNs also face barriers. Research that investigates measures that promote successful academic progression in HNs is needed.

Sample Demographics and Cultural Responsiveness in Psychosocial and Behavioral Interventions with Adolescents with Type 1 Diabetes: A Systematic Review

Jennifer Morone, University of Pennsylvania

Background/Purpose: The rate at which new cases of Type 1 diabetes (T1D) in youth < 20 years old is increasing in the U.S. is a mounting pediatric public health concern; and age, race and ethnicity have significant impacts. Specific social determinants of health and sociodemographic (SD) characteristics -racial/ethnic minority, low SES, single parent home and underinsured-have consistently been associated with poorer glycemic control (GC) and self-management (SM) in adolescents with T1D. The purpose of this systematic review was to evaluate sample demographics, and culturally responsive recruitment and reporting methods used in psychosocial and behavioral interventions focused on improving SM and GC in adolescents with T1D, to identify if studies were targeting these high risk groups and if current methods were being tailored to reach them.

Theoretical Framework: Using a social determinants of health and health equity theoretical perspective, this review applied a culturally responsive research (CRR) framework to evaluate relevant interventions.

Methods: Intervention studies, from 2006 to 2016, focused on adolescents (13-18yo) with T1D and improving SM and GC by psychosocial or behavioral methods, obtained from PsychInfo, PubMed and CINAHL, were evaluated using a CRR rubric.

Results: Twenty-eight studies met inclusion criteria; 14 reported on fewer than 3 of 7 SD categories. Of those that reported, overall study samples used convenience sampling methods, focused predominantly on white, middle-high income, moderately GC'd adolescents from two-parent households with private insurance. Majority of studies scored poorly in cultural responsiveness in reporting analysis and interpretation, and moderately in culturally responsive reporting of SD descriptions of participants. Overall, studies lacked detailed recruitment and sampling methods, as relates to cultural inclusivity, neglecting to apply deliberate recruitment efforts and use of culturally responsive assessments for difficult to reach high risk groups.

Conclusions/Implications: T1D intervention researchers must increase targeted efforts towards recruiting and sampling more high risk groups, by devising successful culturally responsive methods of recruitment and sampling through community based participatory research, and including expanded SD reporting. These efforts will engage high risk participants and improve existing and novel interventions by making them relevant to the unique needs, goals and priorities of highest risk SD groups.

Developing and Validating an Instrument to Measure Perceived Authentic Nurse Leadership

Marie Mulligan, Adelphi University

Background/Purpose: Study purpose is to develop and validate an instrument measuring perceived authentic nurse leadership by staff nurses that is grounded in a nursing theoretical framework to support nursing clinical practice and knowledge development.

Theoretical Framework: Conceptual framework was developed by synthesizing authentic leadership theory, concept of caring in nursing, and literature review on nurse leader attributes.

Methods: Quantitative Analysis Design: Polit & Beck's method of developing multi-item scale implemented: conceptualizing the construct, developing item pool, deciding scaling/scoring methods, evaluating wording features, readability, expert review of content validity, pilot testing and full-scale testing of the instrument. Full scale testing utilized a cross-over design comparing Authentic Nurse Leadership Questionnaire with Authentic Leadership Questionnaire. Test-retest reliability week 3, after baseline data completion. Sample: Expert panel included 20 masters/doctoral prepared RNs with nurse executive leadership experience. Pilot (n=20); full scale testing (n=320) included staff RNs providing 50% or more patient care. Setting: acute care. Measures: Demographic, Area Work-life, Authentic Leadership Questionnaire, Utrecht Engagement Questionnaire, Authentic Nurse Leadership Questionnaire Analysis: Descriptive, inferential statistics, exploratory factor analysis, structural equation modeling.

Results: ANLQ: 35 items, 5 subscales, (7 items each). Expert Panel: Content validity analysis determined three questions scored below the benchmark .8 for I-CVI and three questions scored below the .9 benchmark for S-CVI. Final questionnaire 29 items. Pilot study: Average response time: survey 1 to 2 is 5.8 days; survey 2 to 3 is 5.1 days. Cronbach alpha .987 for the 29-item scale Full study: Cronbach's alpha .985 for the 29-item scale. Construct Validity to be examined by exploratory, confirmatory factor analysis and hypothesis testing. Test-retest reliabilities for examination by ICC analysis.

Conclusions/Implications: Authentic Nurse Leadership Questionnaire maybe more reliable in the measurement of nurse leadership attributes in comparison to other validated Authentic leadership instruments.

Are Dysfunctional Beliefs About Sleep Correlated with Insomnia Severity in Lung Cancer Survivors?

Carleara Ferreira Darosasilva, University At Buffalo [black down pointing small triangle] Suzanne Dickerson, University At Buffalo [black down pointing small triangle] Carla Jungquist, University At Buffalo [black down pointing small triangle] Grace Dean, University At Buffalo

Background/Purpose: While sleep complaints are the core symptoms to diagnose insomnia, patients' beliefs about sleep may perpetuate or intensify insomnia. Brief behavioral therapy for insomnia (BBT-I) is a shortened non-pharmacological intervention that focuses on the modification of sleep behaviors over time. This study sought to explore the relationships between insomnia severity and patients' beliefs about sleep before receiving therapy for insomnia.

Theoretical Framework: This study was guided by Spielman's three-factor model of insomnia. The 3P model conceptualizes factors that contribute to the development and maintenance of insomnia including, predisposing (behavioral and genetics), precipitating (biopsychosocial) and perpetuating (mismatch between sleep ability and sleep opportunity).

Methods: A randomized controlled trial included stage I/II, non-small cell lung cancer (NSCLC) survivors with insomnia who were at least six weeks post-surgery. Participants were screened for sleep apnea and referred if they tested positive. Thirty-eight participants were randomly assignment into groups for BBT-I. Participants completed the 30-item Dysfunctional Beliefs and Attitudes about Sleep (DBAS) questionnaire and the 7-item Insomnia Severity Index (ISI), two valid and reliable instruments, at baseline. An analysis of covariance (ANCOVA) on DBAS items and total score with ISI total score for analysis.

Results: The participants had a mean age of 66.0 + 7.9 (range 53-82), female (62.8%), and Caucasian (88%). There was a main effect of dysfunctional expectations on levels of insomnia at baseline (F= 22.9, p=001) Beliefs that there is a right number of sleep hours (p=.000), thinking that insomnia is unfixable (p=.006), ruins life (p=.016), and fear of dying during sleep each had a significant effect on insomnia severity.

Conclusions/Implications: Unhelpful beliefs about hours of sleep need highly correlate with insomnia severity in NSCLC survivors. Sleep education is crucial to reduce inaccurate beliefs, change behaviors and treat insomnia with BBT-I.

Being a Male Professional Nurse: An Exploratory Analysis of the Relationships Among the Reason for Choosing Nursing, Satisfaction as a Caregiver, and Overall Job Satisfaction

Harmon Mercer, Adelphi University

Background/Purpose: It is essential that the nursing profession attract men to possibly alleviate the present nursing shortage and deter the prediction of a 2025 nursing staffing crisis and to enrich profession by their abilities (AACN, 2012). It appears that there may be a relationship between an increasing number of men entering nursing school and the development and expansion of roles in nursing informatics, as nurse practitioners and nurse educators. However, the profession needs more individuals entering the field of nursing who will provide direct patient care in order to address the anticipated shortage.

Theoretical Framework: Gender Role theory Gender role theory is grounded in the belief that individuals socially identified as males and females tend to occupy different ascribed roles within social structures and tend to be judged against different expectations for how they ought to behave (Shimanoff, 2009). Herzberg's Two-Factor Model of a theory of motivation. This theory postulates that intrinsic and extrinsic factors enable individuals to satisfy their personal needs and experience job satisfaction in a work environment. Herzberg's ideas of employee motivation offer a lens through which we can categorize variables that may influence job satisfaction in the profession of nursing (Herzberg et al, 1959).

Methods: This study used a quantitative descriptive correlational design. The independent variables chosen for this study were factors known to influence the role: working anywhere in the world, working in a variety of clinical or administrative settings, availability of continuous work, flexible schedules, a desire to help others, good financial incentive, nurses high degree of respect in society, family member was a nurse, previously employed in a service area and having the ability to change lives, and role satisfaction. The dependent variable was job satisfaction. To determine role satisfaction, the construct of compassion satisfaction was used. The subjects were selected from a non-probability convenience sample obtained from online (a national association for male nurses). The surveys were administered online using a propriety internet-based data collection system (Survey MonkeyTM). For this study the following instruments were used: The Professional Quality of Life Scale: compassion satisfaction subscale, and the Minnesota Satisfaction Questionnaire (MSQ).

Results: Pending

Conclusions/Implications: Pending

Closing the Gap: Educating BSN Students on the Concepts of Moral Distress, Compassion Fatigue, and End of Life Care Through Simulation

Cynthia Mitsakis, Endicott College [black down pointing small triangle] Sharon Milne, Endicott College [black down pointing small triangle] Alketa McManus, Endicott College [black down pointing small triangle] Bethany Nasser, Endicott College

Background: Nurses are faced with many challenging issues such as compassion fatigue, death and dying, and moral distress in their everyday practice. As such, it becomes essential to educate nurses on these topics, offering ways to mitigate the problems so that we are able to retain highly skilled nurses in an era of a nursing shortage. Few studies have dealt with these concepts in the setting of nurse education, and there is a knowledge gap related to these phenomena (Geraghty, Oliver, Lauva, 2016; Robinson, 2004; Sasso, Bagnasco, Bianchi, Bressan, & Carnevale, 2016). Addressing these issues in practice can begin with the education of nursing students, by educating them sooner so they have the tools to deal with these issues once they begin to practice as nurses. The purpose of this study is to introduce senior nursing students to the concepts of moral distress, compassion fatigue, and self-efficacy with end-of-life care during a community health course in their Baccalaureate curriculum. The research question is, "Does educating nursing students on the concepts of moral distress, compassion fatigue, and self-efficacy end-of-life care supply useful skills for them to take into practice?" Hamric (2014) defines moral distress as occurring "when an individual's moral integrity is seriously compromised, either because one feels unable to act in accordance with core values and obligations, or attempted actions fail to achieve the desired outcome" (p. 457). According to Figley (1995), compassion fatigue refers to "a state of exhaustion and dysfunction- biologically, psychologically, and socially - as a result of prolonged exposure to compassion stress and all that it evokes" (p. 253). End-of-life care (EoLC) is concerned with averting and easing pain experienced by people facing death (Allen & Watts, 2012).

Purpose: The purpose of this study is to introduce senior nursing students to the concepts of moral distress, compassion fatigue, and self-efficacy with end-of-life care during a community health course in their Baccalaureate curriculum. The research question is, "Does educating nursing students on the concepts of moral distress, compassion fatigue, and self-efficacy end-of-life care supply useful skills for them to take into practice?"

Methods: The study will be a mixed-methods, descriptive, exploratory study to assess the level of self-efficacy, moral distress, and compassion fatigue experienced by student nurses following an end of life clinical simulation. Students will be exposed to a variety of didactic modules on the concepts of end of life care, moral distress, compassion fatigue, and providing moral distress tool kit information developed by the ethics work group of the American Association of Critical Care Nurses (AACN, 2004). Students will be participating in an end-of-life care simulation followed by pre and posttests evaluating the students' knowledge, self-efficacy relating to end of life care and to identify the cause the greatest intensity and frequency of their moral distress and compassion fatigue. Students will be participating in an open debriefing focus group to describe their experiences. Approximately 70 senior nursing students will be the target sample for this research study. A self-efficacy tool on end of life care, developed by the researchers, will be utilized. A survey will be distributed to measure compassion fatigue and moral distress via SurveyMonkey(R). By introducing these concepts and providing opportunities for the students to practice dealing with issues during simulation scenarios, we will be able to provide the students with the necessary tools to be utilized in practice.

Results: Educate nursing students in the areas of moral distress, compassion fatigue and end of life care in order to prepare them for practice.

Conclusions/Implications: To educate nurses on these topics, offering ways to mitigate the problems so that we are able to retain highly skilled nurses in an era of a nursing shortage.

Use of Secondary Data for Doctoral Dissertations

Nathalie Dougoud, University of Rochester [black down pointing small triangle] Susan Stanek, University of Rochester [black down pointing small triangle] Robert Gramling, University of Vermont

Background: Secondary analyses can be effective, cost efficient, and prevent further burden to vulnerable populations. A multi-site cohort study was conducted to examine and describe palliative care consultations between adult patients with advanced cancer, their family members, and the palliative care team. Doctoral students worked as research assistants on the primary study and will use the data to conduct quantitative and qualitative secondary data analyses as dissertation studies.

Purpose: To demonstrate the use of a rich dataset from a very vulnerable sample for two distinct secondary analyses by doctoral students.

Methods: Methods of Dissertation 1: Knowledge of uncertainty experienced by patients with advanced cancer could aid in tailoring professional support. A secondary analysis will be completed to identify types of patient uncertainty in conversations between the palliative care team and patients with advanced cancer. A codebook will be created using Han's Taxonomy of Uncertainty and used to code the three types of patient uncertainty in the conversations. Types of uncertainty include personal, professional, and scientific uncertainty. The relationships between personal uncertainty and patients' self-rated prognosis will then be explored. Methods of Dissertation 2: Increased understanding of the family members' roles in clinical conversations involving cancer patients as their illness progresses could inform the development of interventions to support caregivers through the illness trajectory. A secondary analysis using a qualitative descriptive design will be utilized to explore and describe family members' participation and roles in palliative care consultation with patients who have advanced cancer. Each case has 3 data elements: medical record data, verbatim transcriptions of audio recorded palliative care consultations, and transcribed open-ended patient/caregiver interviews. Quantitative data will be used to guide a criterion sampling strategy, allowing comparisons of family member roles and participation across cases based on the patient's performance status.

Results: These dissertations are in development. When complete, findings will go beyond those of the parent study and serve as the initial focus for two new researchers' careers.

Conclusions/Implications: When study aims permit, faculty studies are valuable sources of data for students' secondary analyses, maximizing the contributions of vulnerable participants.

Antibiotic Use in Pediatric Long Term Care

Meghan Murray, Columbia University [black down pointing small triangle] Bevin Cohen, Columbia University School of Nursing [black down pointing small triangle] Elaine Larson, Columbia University School of Nursing [black down pointing small triangle] Lisa Saiman, Columbia University Medical Center, NewYork-Presbyterian Morgan Stanley Children's HospitalNatalie Neu, Columbia University Medical Center

Background/Purpose: Appropriate antibiotic use is a priority for improving patient safety, reducing antimicrobial resistance, and curtailing costs. Residents at pediatric long term care facilities (pLTCF) are at increased risk for healthcare associated infections (HAI) and inappropriate use of antimicrobials. We sought to describe the use of antibiotics to treat HAI in pLTCFS.

Theoretical Framework: Not applicable.

Methods: This is a prospective cohort study of residents at 3 pLTCFs in the New York metropolitan area. Relevant demographic and clinical data were collected at the study sites from 9/2012 through 12/2015. Appropriate antibiotic use was defined as the correct antibiotic for the susceptibility of an identified bacterial organism, either by susceptibility report or by expected patterns based on the local antibiogram and the Sanford Guide. Data analysis included descriptive statistics and logistic regression, when applicable. Significance was defined a priori as p <0.05.

Results: A total of 969 HAI occurred, with 58% of residents (413/717) having > 1 HAI and 79% of those (325/413) receiving at least one course of antibiotics. Antibiotic orders totaled 1090 with, with 8729 antibiotic-days and average course length of 9 days (range 1-60 days). Residents were more likely to receive antibiotics for an HAI if they were enrolled in the study > 1 year, had a neurologic disorder, had a tracheostomy, or were hospitalized at least once, when controlling for site (p <0.01). The most common HAI indications for antibiotics were respiratory tract (465, 48%), otitis (183, 19%) and skin/soft tissue (130, 13%). The most common antibiotics were penicillins (426, 39%), cephalosporins (215, 20%) and quinolones (155, 14%). Forty percent (383/969) of HAI had diagnostic testing sent; a pathogen was identified in 73% (281/383). Organisms identified were 66% bacterial (183/281), 30% viral (84/281), and 5% polymicrobial (14/281). Ten organisms were multidrug resistant: 6 extended spectrum beta-lactamases and 4 methicillin-resistant Staphylococcus aureus. Eighty-five percent of bacterial HAI were treated with appropriate antibiotic courses.

Conclusions/Implications: Diagnostic testing is an integral component of antibiotic stewardship. When a bacterial organism was identified, the majority of HAI were associated with an appropriate antibiotic course. However over a third of antibiotic treated HAI were associated with only a viral pathogen, highlighting the need for research on antibiotic stewardship interventions for pLTC.

The Role of Social Support on Acculturation Stress, Obesity, and Allostatic Load (AL) Among First and Second Generation Immigrant College Students

Lisa Garsman, Rutgers University

Background/Purpose: Cumulative psychological and physiological stress has been shown to contribute to poor mental and physical health, chronic diseases, and overall health disparities. Immigrants may experience high levels of acculturation stress due to language barriers, racism and discrimination, separation from family, and fear of deportation. This chronic stress may contribute to obesity and increased allostatic load (AL). The purpose of this study is to explore the relationships among acculturation stress, obesity, and AL among first and second-generation immigrant college students and to examine the role of social support as a moderator in these relationships.

Theoretical Framework: When an individual experiences real or perceived short-term stress, acute and chronic changes normally occur in the body's stress response system. If the stressor becomes long-standing and exceeds the body's ability to adapt, this process is referred to as increased allostatic load (AL). AL can lead to obesity, atherosclerosis, hypertension, and cardiovascular disease. AL is a composite index of biomarkers, including anthropometric measures (waist circumference, BMI, waist-to-hip ratio) which serves as indicators of obesity, metabolic syndrome, and atherosclerosis.

Methods: This study will use a cross-sectional design to examine the relationships among acculturation stress, obesity, social support, and allostatic load in a sample (n = 70) of racially and ethnically diverse college students. Acculturation stress will be measured using the Social, Attitudinal, Familial, and Environmental (S.A.F.E.) Scale. Acculturation level will be assessed using Acculturation, Habits, and Interests Multicultural Scale for Adolescents (AHIMSA). Perceive social support will be measured using the Multidimensional Scale of Perceived Social Support (MSPSS). A total allostatic load (AL) score will be calculated based on 9 biomarkers: blood pressure, body mass index (BMI), waist-to-hip ratio, as ell as total cholesterol, lipid panel, triglycerides, and HgA1C%. Analysis- Pearson's correlations and regression analyses will be used to analyze relationships among acculturation stress (S.A.F.E.), acculturation (AHIMSA), and perceived social support (MSPSS). A correlation matrix will be constructed to determine correlations between demographic variables, acculturation stress, and AL. Multi-step regression analyses will be conducted with acculturation stress, perceptions of social support, and AL.

Results: ongoing

Conclusions/Implications: ongoing

DNP Posters

The Development and Implementation of a Clinical Practice Guideline for Feminization of Girls with Turner Syndrome

Denise Gruccio-Paolucci, Villanova University

Theoretical Framework: The IOWA Model of Evidence Based Practice to Promote Quality Care is the theoretical framework chosen for this DNP project. The IOWA Model framework provides an organized structure for evidence based practice work. An overview of the IOWA Model is as follows. The first step in the IOWA model is to identification of a trigger which is defined either as a problem focused trigger or a knowledge focused trigger. The second step is to identify whether or not the clinical problem is a priority for the organization. Once identified as a priority, a team is formed and relevant research is assembled, reviewed, critiqued and synthesized. If the literature provides adequate evidence, clinical practice guidelines are designed and implemented resulting in a practice change. Ongoing monitoring and updated review of literature are required after initial literature review.

Background: Turner syndrome (TS) is a genetic condition resulting from loss of part or all of one of the X chromosomes. Turner syndrome occurs in 1:2500 live female births. While the two most common features of Turner syndrome are short stature and ovarian failure, girls with Turner syndrome can have multiple other medical issues including cardiac anomalies, renal anomalies, hearing loss, recurrent otitis media, nonverbal learning differences and autoimmune thyroid disease. Physical findings commonly occurring in Turner syndrome include low set ears, wide neck, low hairline, high arched palate, ptosis, cubitus valgus (wide carrying angle), hyperconvex nails, pigmented nevi, and scoliosis (Bondy, 2007). The clinical presentation of Turner syndrome is a highly variable. While some girls are mildly affected with very few of the physical features, others are more severely affected and experience multiple medical issues in addition to multiple physical features (Bondy, 2007). Short stature occurs in 98 % of girls with Turner syndrome with the average final height of girls with Turner syndrome being 4'8" (Bondy, 2007). Growth hormone therapy is the standard treatment for short stature in girls with Turner syndrome and has proven beneficial in improving final height outcome by two-three inches on average. Ovarian failure occurs in 95% of girls with Turner syndrome (Bondy, 2007). While 30% of girls with Turner syndrome may experience spontaneous pubertal onset, the majority of girls require estrogen therapy for the development of secondary sexual characteristics and menses. Of those who experience spontaneous onset of puberty, only 2-5 % progress to full pubertal development with regular menses thus the majority of girls with Turner syndrome require estrogen therapy to complete the feminization process (Bondy, 2007). Estrogen therapy is required for the development of secondary sexual characteristics, including breast development and menses, but in addition, estrogen is essential for establishment and maintenance of normal bone density in girls with Turner syndrome. Feminization with exogenous estrogen requires consideration of a multitude of clinical variables. These variables include: (1) timing of treatment initiation (2) estrogen formulation (3) dose escalation (4) final height outcome (5) bone health.

Purpose: The purpose of this Doctorate of Nursing (DNP) project is to develop and implement an evidence based clinical practice guideline (CPG) for feminization of girls with Turner syndrome. Currently, an evidence based clinical practice guideline (CPG) for feminization of girls with Turner syndrome does not exist. As a result, there is considerable variation in the treatment approach to feminization of girls with Turner syndrome. It is unclear which approach supports best patient outcomes in terms of timing of treatment initiation, estrogen formulation, dose escalation, final height outcome and bone health.

Methods: The project design is evidence based clinical practice guideline (CPG). The format of the clinical practice guideline will be an algorithm. Subjects The subjects of this project include Pediatric Endocrinology providers, Pediatric Endocrinologists and Advanced Practice Nurse (APN). Setting The setting of the project is a Pediatric Endocrinology outpatient practice in a large academic medical center including main hospital practice and practice sites in seven of the institution's satellite locations. Sponsors The project does not include any sponsors. Project Mentors The practice mentor is Dr. Vaneeta Bamba, MD, who is a Pediatric Endocrinologist who serves as both the Director of the Turner Syndrome Program as well as The Diagnostic and Research Growth Center. Stakeholders Stakeholders include Pediatric Endocrinology outpatient providers, patients with Turner syndrome and families of patients with Turner syndrome. Team Members The team members include the Practice Mentor, the Center for Nursing Research and Evidence Based Practice, EHR (Electronic Health Record) team members and the institution's IS (Information Systems) intranet team. Resources/Cost Analysis The project will not require any financial resources. There will be no cost associated with the project. Implementation (Intervention) The interventions include the following steps. A systematic review of the literature will be conducted. Based on the literature, an evidence based clinical practice guideline will be developed. The format will be an algorithm. It is likely that several algorithms will be required to accommodate various clinical scenarios. The CPG will then be implemented into clinical practice. The implementation will be accomplished as follows. The CPG will be presented to a committee of Pediatric Endocrinology clinicians in the division (MDs) in a scheduled committee meeting designated for the review of the CPG. The meeting will include open discussion. Following presentation and discussion, the recommendations of the committee will be reviewed by DNP candidate and practice mentor. Suggestions will be incorporated based on validity and support in literature. Final edits and/or revisions to the clinical practice guideline will be made if indicated. The clinical practice guidelines will then be finalized and implemented into practice. The CPG will be uploaded to the institution's intranet site for use by all Division of Endocrinology providers. Design: Evidence based.

Results: Three clinical practice guideline algorithms were designed and implemented into EHR for use by Pediatric Endocrine providers.

Conclusions/Implications: Clinical Implications: 1. Improvement in clinical care and patient outcomes. 2. Standardized care provides opportunity to evaluate effectiveness of care 3. Evidence based practice supports further opportunity for research. 4. Clinical practice guidelines enhance providers ability to provide care that is evidence based.

Cultural Bias in Screening Hispanic Children for Autism: A Systematic Review

Carolina Suarez, Florida International University [black down pointing small triangle] Thresia Gambon, Citrus Health Network, Inc. Maternal & Child Health Center

Background: Hispanics have become the largest minority group in the United States but due to differences in language, education, social economic status, and even culture, this group continues to face challenges in achieving health equity. In recent years, healthcare has focused on preventative medicine, and in pediatrics the attention has been drawn towards developmental screening, specifically in identifying children at risk for autism spectrum disorder. Standardized screenings have been developed to assist providers in identifying these children in a primary care setting. Previous reports had indicated that autism is not as prevalent in the Hispanic population but researchers are uncovering that issues with translation, interpretation, and cultural differences may hinder the use of these standardized tools with the Hispanic population.

Purpose: This systematic review sought to identify cultural bias that may be present in standardized autism screening tools that decrease their validity with Hispanic patients, decrease identification rates in a timely manner, and therefore increase healthcare disparities. To understand characteristics displayed in Hispanic children with autism that differ in comparison to other ethnicities and improve quality of care services to diverse populations.

Methods: A search was conducted using CINAHL database with search terms autism OR autism spectrum disorder AND Hispanic OR Latino. Restrictions included English language, full text, and publication between May 2006 to May 2016. The search generated forty-seven articles that were reviewed for inclusion and a total of seven articles met inclusion criteria.

Results: There are increased detection rates for White children in comparison to Hispanic children. This may be due to interpretation issues, translation issues, and cultural differences in standardized screening tools for autism that decrease their validity with the Hispanic population. There are also barriers to access of healthcare for the Hispanic population that contribute towards increasing healthcare disparities.

Conclusions/Implications: Rates of autism in Hispanic children are higher than previously reported. Future research should focus on validation studies of standardized screeners in diverse populations and identifying differences in characteristics of non-Hispanic and Hispanic children with autism. Overall, this will help improve advanced nursing practices and reduce healthcare disparities.

Effectiveness of U.S. Diabetes Conversation Map(R) Patient Education Program in Improving Glycemic Control

Ramanpreet Haus, University of Missouri-Kansas City

Background/Purpose: The prevalence rate of type 2 diabetes mellitus continues to increase annually. An estimated 29 million Americans are affected by type 2 diabetes. An additional 79 million Americans have prediabetes that will result in development of diabetes if effective risk prevention methods are not initiated. The increasing prevalence rate of diabetes is one of the leading causes of increased mortality and morbidity globally. Diagnosis of diabetes lowers life expectancy by up to fifteen years. Diabetes self-management patient education using the group based education method has been effective in significantly improving health outcomes. The purpose of this project is to evaluate the effectiveness of an 8-week group based education program using the U.S. Diabetes Conversation Map(R) in improving 3-month glycated hemoglobin (HbA1C) levels at a university affiliated outpatient diabetes clinic.

Theoretical Framework: The theory used to guide this project is the Health Belief Model.

Methods: A retrospective study will be conducted to determine the effectiveness of the U.S. Diabetes Conversation Map(R) patient education program in improving glycemic control. Improvement in glycemic control will be measured by reduction in HbA1C levels. Data will be collected from 50 patient electronic medical records at a university affiliated outpatient diabetes clinic. Inclusion criteria for data collection include diagnosis of type 2 diabetes, age 18 and older, and completion of the 8-week education program within the last two years, September 2014 to September 2016. Baseline HbA1C levels before program participation and 3 month HbA1C levels following completion of program will be analyzed using paired t-tests to determine statistical significance at .05. Demographic data such as age, gender, and ethnicity will be analyzed for associations with HbA1C using Pearson's chi-square.

Results: The findings are expected to support that diabetes self-management education using the U.S. Diabetes Conversation Map(R) is effective in reducing 3-month HbA1C level from the baseline HbA1C level. Data analysis will occur in January 2017.

Conclusions/Implications: Patient participation in group based diabetes education program using the U.S. Diabetes Conversation Map(R) may be effective in improving HbA1C levels and thus improving health outcomes, quality of life and reducing the economic burden of the disease.

Improving Dual Diagnosis Care in Acute Psychiatric Inpatient Settings Through Nursing Education

Kofi Bonnie, Yale University [black down pointing small triangle] Ruth McCorkle, Yale University [black down pointing small triangle] Jane Dixon, Yale University

Background: Patients with co-existing substance use and mental disorder (dual diagnosis) have complex and challenging care needs. They have an increased risk of homicide, suicide, homelessness, incarceration, multiple admissions and infectious diseases such as hepatitis C and HIV. Acute psychiatric care settings play a vital role in providing services for dual diagnosis patients who often do not voluntarily seek treatment. There is evidence that nurses working in these settings often have unmet learning needs regarding dual diagnosis care, posing a challenge to nursing practice with this clientele. This is significant in that recent data reveals that 57% of the psychiatric inpatients at an inner city hospital in Vancouver, Canada are characterized as dual diagnosis.

Purpose: To develop an educational module which will equip nurses with the skills and knowledge required to deliver evidence-based dual diagnosis care in acute psychiatric settings.

Methods: A survey of 74 nurses working in acute psychiatric settings was completed to identify their learning needs and challenges. This was followed by a comprehensive review of evidence from literature to identify competencies, knowledge, and skills needed to deliver dual diagnosis care. Content for the educational module was then validated by a panel of leading international experts on dual diagnosis. Two focus groups of acute psychiatric nurses were then conducted to discuss content. An 8-hour educational session was then developed and piloted using the content that was reviewed and validated.

Results: Thirteen content areas were identified and validated by experts. Evaluations from participants of the educational session suggest improved knowledge, skills and competencies in dual diagnosis care.

Conclusions/Implications: This project translates evidence into practice, contributes to the body of knowledge on dual diagnosis care and improves nurses' confidence and competency in delivering evidence-based care which also will improve patient care outcomes and experiences.

The Effectiveness of Patient-Centered Interventions on Falls in the Acute Care Setting

Donna Avanecean, Pace University [black down pointing small triangle] Dawn Calliste, Pace University [black down pointing small triangle] Teresita Contreras, Pace University [black down pointing small triangle] Yeogyeong Lim, Pace University

Background/Purpose: Unintentional falls during hospitalization remains a concern for healthcare institutions on a global level despite implementation of various improvement strategies. Patients admitted to acute care hospitals are at risk for falls leading to injury. Although the incidence of falls has been of heightened focus for many years and numerous studies have been done evaluating different approaches for falls prevention, fall rates continue to remain high in acute care settings. Patient falls risk scales tend to address only particular intrinsic and extrinsic factors but do not adequately assess the patients' current fall risk status, subsequently warranting a more patient-centered risk assessments and interventions. The objective of this systematic review was to evaluate the effectiveness of patient-centered intervention on fall rates and fall-related injuries in acute care hospitals.

Methods: PubMed, CINAHL, EMBASE and Nursing/Academic edition were search for published studies. Gray literature was also search for unpublished studies. Experimental and epidemiological study designs that evaluated patient-centered fall prevention interventions were considered for inclusion. Studies identified for inclusion were assessed for methodological quality and date relating to study methods; participants, interventions, and findings were extracted using standardized tools from the Joanna Briggs Institute.

Results: Five randomized control trials were identified for inclusion. Due to clinical heterogeneity the studies were presented in narrative format. Three studies demonstrated a statistically significant reduction in fall rates (p<0.04) while two studies showed no difference in fall rates between groups (p>0.5). Three studies measured the secondary outcomes of fall-related injuries; however, results demonstrated no difference in fall-related injuries between groups (p>0.5). In the three studies that demonstrated reduction in fall rates, personalized care plans and patient education based on patient's fall risk assessment were utilized.

Conclusions/Implications: The current study is an on-going DNP project. Preliminary results demonstrate patient centered interventions coupled with education could be effective in the prevention of falls in the hospitalized patient.

An Evidence-Based Approach to Improving Peripheral IV Catheter Placement in Adult Radiology Patients with Difficult Vascular Access Using Ultrasound Guidance

Brian Dobslaw, York College of Pennsylvania

Background/Purpose: Millions of imaging studies are performed annually in the United States using intravascular contrast to enhance diagnostic sensitivity and specificity. Establishment of peripheral intravenous access represents one of the most commonly performed radiology procedures. Multiple factors hinder vascular access including obesity, dehydration, intravenous drug use, chronic medical conditions and illness. As a result, repeated attempts at intravenous catheter placement are sometimes necessary, resulting in recruiting multiple providers and increasing procedural time and discomfort, patient dissatisfaction, clinician frustration, complication risk, and delays in care. Evidence revealed ultrasound guidance to be a teachable skill to first-line clinicians, reducing intravenous access attempts and improving catheter placement success. The purpose of this evidence-based quality improvement project was to implement the use of ultrasound guidance to facilitate peripheral intravenous catheter placement in adult patients with difficult venous access requiring intravenous contrast administration within the radiology department of an urban community hospital.

Theoretical Framework: The Johns Hopkins Nursing Evidence-Based Practice Model guided a thorough review of the literature and appraisal, synthesis and translation of the evidence.

Methods: Radiology technologists participated in ultrasound guidance education including didactic and hands-on training that was delivered by the lead nurse practitioner. Proficiency was demonstrated and ultrasound guidance employed on patients identified as having difficult access and requiring intravenous contrast administration.

Results: The number of intravenous catheter attempts, with and without ultrasound guidance, catheter placement success rates, number of completed contrast studies and incidents of contrast extravasation are being recorded through December 2016 and will be compared to pre-implementation data.

Conclusions/Implications: Evidence-based utilization of ultrasound guidance by trained first-line radiology department staff to place intravenous catheters in adult patients who might otherwise experience numerous, time-consuming attempts has the potential to improve the patient's experience of care, enhance the well-being of our patient population, and reduce associated costs.

The Feasibility of Implementing a Non-Pharmacological Weight Loss Program to Address Obesity in a Rural Community

Alea McClintock, The Pennsylvania State University

Background: Obesity is a complex health problem in the US that affects over one-third of adults, leading to higher morbidity and mortality rates. The percentage of adults that are obese is higher in rural areas as opposed to urban areas; rural communities do not have the resources to address the treatment of obesity.

Purpose: The purpose of this project is to address the limitations of managing rural obesity by assessing the feasibility of implementing an evidence-based physical activity and nutrition education weight loss program in one rural community. This project will be used to identify and implement sustainable solutions for the treatment of obesity in a rural community setting.

Methods: A descriptive study will be used to explore the feasibility of an 8-week non-pharmacological weight loss program that includes nutrition and healthy life style education for overweight or obese adult residents of a rural community (n=23) will be performed. Inclusion criteria: age 18 years or older; a BMI of 25 or greater; ability to attend all of the face-to-face group educational sessions located in the community building.

Results: A pre-test, post-test design will be used to measure changes in motivation for weight loss, changes in physical activity, changes in dietary habits, and weight loss. Demographic data and transportation data was collected at the start of the program and a satisfaction survey will be completed at the end of the program. Cost and attendance will be measured throughout the duration of the program.

Conclusions/Implications: A long-term goal of this project will be to implement sustainable solutions for the treatment of obesity in rural communities. In order to address the limitations and lack of resources that rural communities face when addressing the treatment of obesity, the engagement of key stakeholders, including community leaders and community residents, is necessary. The utilization of community outreach programs focused on promoting healthy lifestyles can help address the high rates of rural obesity. Addressing the most prominent barriers of cost and transportation can improve community outreach success. Further conclusions and implications will be identified upon analysis of the data.

Suicide Prevention in the Non-Psychiatric Hospital Setting: A Nurse Education Process

Terry Bird, Boise State University

Background/Purpose: Numerous studies indicate that nurses and other healthcare professionals receive little or no suicide-related education or training. Unfavorable attitudes about suicide can also negatively influence caregiver behaviors and impact patient care. Evaluations of Applied Suicide Intervention Skills Training (ASIST) as a gatekeeper training intervention consistently demonstrate enhanced knowledge, more favorable attitudes, and increased intervention skills. This project aimed to conduct a small-scale pilot of ASIST for hospital nurses and to build organizational capacity to advance suicide education policies and practices at the project site.

Theoretical Framework: This project used the three-phase system change framework of adopt, adapt, evolve to engage and mobilize stakeholders, conduct an evidence-based training pilot, and effect long-term system change to advance training efforts and ensure a clinically competent workforce at the project site.

Methods: A single comparison group pre/post testing design was used. A combination of purposive and theoretical sampling was used to recruit nurses and other professional disciplines within a regional healthcare system in Upstate New York. Pretest and post-test questionnaires were used to collect primary quantitative data to evaluate suicide-related knowledge and attitudes, and satisfaction with ASIST. Descriptive statistics and frequencies were performed for demographic, professional and personal experience with suicide, prior suicide education/training and satisfaction with ASIST. Paired t tests were performed to determine differences in suicide-related knowledge and attitudes.

Results: Thirty participants completed the ASIST intervention, 29 completed both pretest and post-test questionnaires. Mean post-test scores for knowledge and attitude increased by 17% and 11% respectively. Satisfaction scores for ASIST exceeded the desired outcome threshold. This small-scale pilot of ASIST supports a case to advance organizational suicide training efforts. The voluntary participation of non-nursing professionals such as social work, pastoral care, academia, and behavioral health, affirms the larger need for workforce development. The under-representation of nurses participating in this suicide education process corresponds to the evolve phase of the adopt, adapt, and evolve framework to develop clinical competency across disciplines and speaks to a need for long-term system change.

Conclusions/Implications: With the persistence of suicide as a leading cause of death, having a competent clinical workforce is critical to prevention efforts. Accomplishing this goal will require efforts on multiple levels. Health care systems must be willing to commit the necessary resources to support organization-wide policies and procedures to mandate cross-discipline suicide prevention training. Mandatory staff development and continuing education for relicensure can serve as important motivational factors for individuals, disciplines, and employers and drivers of policy change.

Pre-Exposure Prophylaxis for HIV Prevention: Improving Adherence by Reducing Anxiety in Men Who Have Sex with Men

Rusty Greene, Hunter College

Background/Purpose: When prescribed as pre-exposure prophylaxis (PrEP), the antiretroviral medication Truvada has proven highly effective at preventing HIV among men who have sex with men (MSM). However, both prescribers and MSM have expressed concerns that PrEP may increase high-risk sexual behaviors. This controversy has created a stigma that may affect PrEP uptake and adherence. Research has shown that MSM may take PrEP to not only protect themselves from HIV in sexual situations, but to also reduce HIV-related anxiety in their daily lives. This secondary benefit may increase PrEP uptake and adherence.

Theoretical Framework: Peplau's Interpersonal Relations Theory

Methods: Design: Prospective cohort study. Sample: Two cohorts presenting for PrEP. Both cohorts of 20 MSM are convenience samples. Setting: Project STAY, a sexual health clinic in New York City. Measures: Both cohorts have been receiving clinic-based counseling when initiating PrEP. The second cohort has also been receiving Next Step Counseling (NSC), a patient-guided and "sex-positive" form of counseling. HIV-related anxiety is being measured in both cohorts at initial visits and 30-day follow up visits using the Worry About Sexual Outcomes Scale. Analysis: Paired sample T-tests and descriptive statistics.

Results: Data is currently being collected and results are pending.

Conclusions/Implications: Reductions in HIV-related anxiety may be related to increased adherence to PrEP regimens. Nonjudgmental, "sex-positive" counseling such as NSC may be the key to reducing stigma, HIV-related anxiety and HIV transmissions in MSM on PrEP.

Enhancing Adult Protective Service Workers' Abilities to Detect Physical Signs of Elder Abuse: An Educational Curriculum Pilot Project

Anh Tran, Hunter College

Background/Purpose: Adult Protective Service (APS) workers are responsible for investigating allegations of elder abuse (EA). Accurate assessment of visual clues, such as body language and physical signs/markers of abuse, are essential to the investigation as well as the ability to effectively communicate with other providers such as nurses, physicians, and law enforcement. There is evidence that APS workers who are trained to detect EA are better equipped to assist older adults obtain needed resources than untrained workers, yet there are no national standards for APS education/training. APS worker training regarding physical signs of abuse and communication is lacking.

Theoretical Framework: Diffusion of Innovations model is used to guide this Capstone project.

Methods: Design: Pre/Post pilot and feasibility study Sample: Experienced APS workers employed in the Manhattan, New York. Setting: Brookdale Center for Healthy Aging at Hunter College and Manhattan APS offices. Measures: (1) knowledge pre/post-test and (2) self-efficacy assessment on identifying physical signs of abuse and communication (3) training and (4) pocket resource guide evaluation. Analysis: Paired sample T-test, descriptive statistics.

Results: To be assessed, project is ongoing.

Conclusions/Implications: Nurses have an increasing role in caring for clients in the community setting, including the care of the vulnerable older adult population. Providing education to enhancing the ability of APS to recognize and communicate the physical signs of EA will likely enhance communication with healthcare and other service providers, improve identification of abused older adults that will lead to better case management and linkage to support services.

Skin-to-Skin Contact in the Operating Room after Cesarean Section with Full Term Newborns to Improve Breastfeeding and Facilitate Vital Sign Stability

Amanda Lawrence, York College of Pennsylvania

Background/Purpose: Neonatal exposure to temperatures in an Operating Room (OR) after cesarean section (CS) can cause a stressful transition to extrauterine life. Skin-to-skin (STS) contact can facilitate a more stable transition period for the newborn. STS is defined as placing the naked newborn prone in only a hat and diaper on the bare chest of the mother and covering them with a warm blanket. Research demonstrates that STS contact between the mother and the newborn within one hour after delivery allows greater physiologic stability in the newborn and promotes higher breastfeeding success at discharge. The purpose of this evidence-based practice project is to implement skin-to-skin contact in the OR after CS with full-term newborns to improve breastfeeding rates and facilitate vital sign stability, in a small 93-bed community hospital.

Theoretical Framework: The Johns Hopkins Nursing Evidence-Based Practice Model was used to guide the evidence search, appraise and synthesize the literature, and translate the evidence.

Methods: Translation of the evidence began in September 2016 after gaining stakeholder buy-in. The obstetrics/gynecology office staff were educated on the patient education handout. Hospital nursing staff completed an education module, including a pre-and post-test. A demonstration of STS contact in the OR occurred during the nursing staff OR skills day. A STS nursing policy was written. Lastly, a trial week of STS occurred in late September prior to going live with the practice change on October 1.

Results: Outcome metrics including newborn temperature, heart rate and respiratory rate, along with breastfeeding rates at discharge are being collected from October to December 2016 and will be compared to data from 2015.

Conclusions/Implications: Implementation of STS contact after CS is extremely beneficial and can help to improve patient care and maternal and neonatal outcomes. Implementation can also assist the hospital in working towards attaining Pennsylvania's Keystone 10 Initiative, a quality improvement plan aimed at breastfeeding support.

Incidence and Risk Factors Associated with Hyperactive, Hypoactive and Mixed Delirium in Two Adult Medical Intensive Care Units

Sharon O'Donoghue, Northeastern University [black down pointing small triangle] Susan DeSanto-Madeya, Boston College [black down pointing small triangle] Alistair Johnson, Massachusetts Institute of Technology [black down pointing small triangle] Tom Pollard, Massachusetts Institute of Technology

Background/Purpose: Time spent in delirium has been attributed to long-term cognitive and functional deficits as well as a significantly reduced quality of life for patients who survive an intensive care unit (ICU) stay (Pandharipande et al. 2013). While the incidence of delirium is high, it is often under recognized by ICU clinicians. The challenge is that delirium can present in three ways: hyperactive, hypoactive and mixed. These different presentations, complicated by a fluctuating course, often makes it difficult for clinicians to accurately identify delirium. The purpose of this study is to distinguish the incidence and risk factors associated with the three types of delirium in the hopes of improving identification.

Theoretical Framework: The theoretical framework used to guide this is the Synergy Model. Nurses must possess certain competencies to meet the universal needs of their patients. These competencies are attained through education and the utilization of evidenced based practice. One competency, clinical judgment, is derived from the nurse's skills and ability to critically think. Providing nurses with risk factors associated with the three types of delirium may aid in critical thinking skills. Optimal outcomes are achieved when synergy exists between the patient's characteristics and the nurse's competencies.

Methods: Data stored in the Medical Information Mart for Intensive Care (MIMIC) and originally collected between July 2013 and July 2016 was used for this retrospective secondary analysis. The study population consisted of patients who were admitted to two medical ICUs at a single tertiary academic medical center, who screened positive for delirium utilizing the Confusion Assessment Method in the ICU (CAM-ICU) and stratified by level of sedation using the Richmond Agitation Sedation Scale (RASS). Risk factors were extracted from the database utilizing PostgreSQL, a reliable and secure management system by one clinician and two data analysts. Descriptive and comparative statistics will be used to analyze the data.

Results: This is ongoing research.

Conclusions/Implications: The incidence of delirium has been studied but not stratified to the three types of delirium. The identification of risk factors which may vary from one type of delirium to another may facilitate the identification of delirium. The information obtained from this project may also provide a foundation to then explore if certain interventions could be more effective in improving outcomes for a specific type of delirium.

The Impact of a Trauma-Informed Model of Care on Staff Turnover and Secondary Traumatic Stress in Child Welfare Workers at a Care Management Organization

Diane Silbernagel, Saint Peter's University

Background/Purpose: There is a need to address secondary traumatic stress among child welfare workers using a systematic, organizational approach to reduce staff turnover and improve the quality of care delivery to children. New Jersey child welfare services are delivered via Care Management Organizations that often fail to meet the federally mandated goals of child safety, protection, permanency, and well-being. Child well-being is often not addressed, and knowledge regarding trauma-informed care is often lacking among child welfare workers. The purpose of this capstone project was to investigate whether implementation of trauma-informed care practices in a child welfare service delivery setting resulted in decreased turnover and secondary traumatic stress (STS) symptoms among workers. Using the evidenced-based National Child Traumatic Stress Network Child Welfare Trauma Training Toolkit, a Care Management Organization's service delivery design was changed to become trauma-informed and the impact of the change evaluated using measures of turnover rates and workers' compassion fatigue, secondary traumatic stress, and professional quality of work life. This project was guided by this question: At a Care Management Organization, will the use of the evidenced-based Trauma-Informed Child Welfare System Toolkit model, compared to the use of standard operating practices for routine care coordination, reduce staff turnover and reports of secondary traumatic stress in child welfare workers within a 2-month period? The two-fold purpose of this capstone project was (a) to implement trauma-informed knowledge into the service delivery activities and work environment of a Care Management Organization (CMO) that serves over 650 children a month who have a history of traumatic adverse events and (b) to evaluate if replicating the evidence-based Child Welfare Trauma-Informed Training (CWTT) Toolkit practices and implementing a trauma-informed service delivery system resulted in a decrease in STS and turnover in the CMO staff serving an urban population in Northern New Jersey.

Theoretical Framework: The theoretical framework in this study was based on Melnyk and Finout-Overholt (2013) model for implementing evidence-based practice, the theories of trauma and the essential elements of the evidence-based Trauma Training Toolkit as well as the change model developed by Rosswurm and Larrabee (1999). Rosswurm and Larrabee recommend a six step model for implementing evidence-based practice change (1999). The Child Welfare Trauma Training Toolkit model was based on knowledge of the human neurobiological stress reaction, the bio-psycho-social impact of trauma, and the characteristics of a trauma-informed child welfare system. A trauma-informed child welfare system is defined as: a system in which all parties involved recognize and respond to the varying impact of traumatic stress on children, caregivers, families and those who have contact with the system. Programs and organizations within the system infuse this knowledge, awareness and skills into their organizational cultures, policies and practices. They [will] act in collaboration, using the best available science to facilitate and support resiliency and recovery (Creating Trauma-informed Child Welfare Systems: A Guide for Administrators, 2012, p. 11). The following seven essential elements of the Toolkit created a structure and process for implementing the best evidence-based practices into the CMO service system: 1. Maximize physical and psychological safety for children and families. 2. Identify trauma-related needs of children and families. 3. Enhance child well-being and resilience. 4. Enhance family well-being and resilience. 5. Enhance the well-being and resilience of those working in the system. 6. Partner with youth and families. 7. Partner with agencies and systems that interact with children and families (Child Welfare Trauma Training Toolkit: Trainer's Guide, 2013). The overarching goal was to change the CMO practice model, which required that CMO leadership and staff were equipped with the tools and skills necessary to sustain the change, manage their own STS, and create a workplace environment that would enable them to better assist the children and families in their care.

Methods: This capstone project's design was an innovation in practice that was evidence-based and used system changes such as policies and practice changes to create a trauma-informed culture. The evidence-based trauma-informed care model was tested through the National Center for Child Traumatic Stress and successfully demonstrated improvements in service delivery and client outcomes at the California Chadwick Center for Children and Families. The setting for this evidence-based practice project was a Care Management Organization which serves an urban/suburban area in Northern NJ. The convenience sample was the 45 direct care providers, the care managers, who following an informed consent process, received the intervention which was the two day training of the Toolkit followed by a 2 month period during which work groups implemented action plans to integrate the 7 essential elements of the Toolkit model. The measures used were the Secondary Traumatic Stress Survey (Bride et al., 2009) and the ProQOL (Stamm, 2010) Professional Quality of Life Scale which measures STS as well as compassion fatigue, compassion satisfaction and burnout. The measures were administered before the training days and at the end of the 2 month work-group period. Data analysis included paired t test, descriptive, correlational and inferential statistics. Turnover was measured over 61 days.

Results: Results are pending the second data collection date on November 28th. The CMO pre-intervention turnover rate in June 2016 was 12%. The 61 day period for measuring turnover ends November 30, 2016.This rate will be bench marked against June 2016 and the turnover rate for October and November of 2015. The STSS and ProQOL survey results will be compared pre and post intervention and corelational analysis will be done related to descriptive statistics. Anecdotal feedback related to the process evaluation will be included in the analysis findings.

Conclusions/Implications: Findings from the data analysis are not available at this time. Anecdotal feedback indicates that the CMO staff found the Toolkit to be an effective framework for integrating trauma-informed care in the organization and for guiding an organizational action plan to be implemented over the next 9 months. As this was an organizational change, the time allocated requires a greater period of time for implementation of the action plans. Overall the CMO has a greater awareness of trauma-informed care throughout its operations and is moving forward with changes to strengthen use of the seven essential elements.

Development of a Standardized Patient Simulation to Address Prescription Opioid Misuse in Older Adults with Chronic Pain

Jade Cassalia, University At Buffalo [black down pointing small triangle] Molli Warunek, University At Buffalo [black down pointing small triangle] Tammy Austin-Ketch, University At Buffalo [black down pointing small triangle] Yvonne Scherer, University At Buffalo [black down pointing small triangle] Yu-Ping Chang, University At Buffalo

Theoretical Framework: The experiential learning theory was selected as the theoretical underpinning for this study.

Background: Prescription opioid misuse is a serious problem in older adults with chronic pain. Mental health problems (e.g., depression) are also common co-morbidities in this population. Motivational interviewing (MI), a low-cost brief intervention has been widely used to prevent substance abuse in primary care. However, primary care providers receive very little education or training on brief interventions related to substance abuse so they are not equipped with the knowledge and skills for delivering such interventions.

Purpose: The study aimed to develop a standardized patient simulation designed to teach students how to utilize MI intervention in chronic pain patients who misuse prescription opioid and then examine the effect of such an educational intervention on doctorate of nursing practice (DNP) students' learning outcomes. The abstract only presents the development of the standardize patient simulation, assessment checklists, and students' feedback on their learning experiences.

Methods: This simulation was incorporated as part of a Health Assessment course and a total of 31 DNP students participated in the study. The standardized patient simulation was developed by an expert panel consisting of psychiatric-mental health professionals, MI experts, addiction researchers, and experienced educators. A thorough review of literature and clinical guidelines was conducted to formulate the simulation. The simulation used a structured case scenario in applying MI technique to address prescription opioid misuse in older adults with chronic pain and depression. Checklists assessing MI techniques were also developed to evaluate students' skills during the simulation. The standardized patients (actors) received training using lecture and role play.

Results: Findings indicated that students were satisfied with their learning outcomes and provided positive feedback on the standardized patient simulation.

Conclusions/Implications: Our findings suggested that MI education using a standardized patient simulation approach can be effectively delivered within a DNP curriculum to better prepare students to address prescription opioid misuse in the older adult population.

Evaluation of Practice Standards for Prescribing Oral Chemotherapy Using ASCO/ONS Guidelines

Janice Carsello, Thomas Jefferson University

Theoretical Framework: Donebedian

Background: Oral chemotherapy anticancer agents are a promising and effective way to treat many types of cancer. The use of oral chemotherapy agents, including traditional cytotoxic drugs, targeted cancer therapies, and hormonal agents, as a treatment strategy for cancer has risen significantly in the past few years creating new challenges for oncology practitioners. Oncology practices are well organized to deliver intravenous therapies in outpatient clinics and this treatment modality is still indicated for some patients. The processes for prescribing and obtaining oral chemotherapy agents, educating patients, and monitoring for adherence, toxicities, and side effects require different workflows. These changes will undoubtedly place increased demands on an already overburdened infrastructure at many busy medical oncology practices. The prescribing of oral chemotherapy agents has outpaced the infrastructure that is needed to deliver care to this patient population safely and efficaciously. Standards of practice, published by the American Society of Clinical Oncology and the Oncology Nursing Society in 2009, were revised in 2013 to incorporate language specifically addressing the safe administration and management of oral chemotherapy agents. To date, there exists no literature that specifically evaluates how well a medical oncology practice adheres to those published standards for oral chemotherapy agents.

Purpose: The purpose of this practice inquiry project is to scrutinize current practice as compared to the practice standards for prescribing oral chemotherapy agents and for managing those patients who receive then at the Thomas Jefferson University's Department of Medical Oncology.

Methods: Needs assessment involving financial and reimbursement sustainability, scrutinize current practice standards against published guidelines.

Results: The results of this project will inform the researcher as to whether to develop a nurse-practitioner led oral chemotherapy clinic.

Conclusions/Implications: Inform system-wide decision to implement oral chemotherapy standards and implement nurse-practitioner led oral chemotherapy clinic.

Implementation of a New Method to Track Propofol in an Endoscopy Unit

Catherine Horvath, Georgetown University Hospital

Background/Purpose: Propofol is a widely used anesthesia induction agent and is easily accessible in most healthcare facilities. Unlike regulated or scheduled drugs, propofol is inconsistently tracked, leading to inaccurate inventories, incorrect billing, and unrecognized diversion. The goal of this project was to implement a new method of tracking propofol in a single high-use setting, with the aim of accounting for 100% of the drug.

Theoretical Framework: The Iowa Model of Evidence-Based Practice to Promote Quality Care, along with Kurt Lewin's Unfreeze-Change-Refreeze model, was utilized to assist with the integration of best evidence into practice and to facilitate organizational change.

Methods: For two, 2-week observation periods, data was extracted from an automated medication management system or pharmacy inventory system, anesthesia records, and pharmacy billing sheets for cases in a GI Endoscopy unit, and compared pre- and post-implementation of a new tracking and accounting protocol of individual drug trays, pharmacy reconciliation, and restructured billing forms. Variables included amount of propofol (a) inventoried; (b) dispensed; (c) administered; (d) returned; (e) billed; (f) wasted, and (g) missing.

Results: Pre-implementation (n=300), 10% cases had no record of propofol removal from the automated medication system. Of the 90% that did, 25% had an amount signed out that did not match the amount administered. Thirty-one percent of all propofol was unaccounted for during this 2-week period. Further 19.7% of cases did not have a billing form located. Post-implementation (n=308) of the process change, unaccounted for propofol decreased to 26% of all cases (p=n.s). The percentage of missing billing forms decreased from 19.7% to 5.8% (p=0.00).

Conclusions/Implications: Data suggest notable amounts of propofol were unaccounted for and not billed for in the GI Endoscopy unit prior to the protocol change. Post-protocol change data reveals modest improved accounting of the medication and significant cost-capture. Improvements may enhance inventory reconciliation, availability of drug stock, and potentially result in a decreased risk of unrecognized diversion.

An Initiative at an Urban Comprehensive Cancer Center to Improve the Utilization of Advanced Care Planning for Patients Enrolled on Clinical Trials of Novel Oncologic Therapies

Andrew Wolanski, University of Massachusetts-Boston

Background/Purpose: Expert consensus recommends advance care planning for patients with less than a year's life expectancy or at any critical decision point in the cancer treatment trajectory. Evidence suggests that many barriers exist which can often delay or prevent a patient-centered goals of care discussion. The literature speculates that avoidance of this topic is due in part to lack of adequate communication skills by providers when faced with the need to discuss these sensitive topics. The purpose of this doctoral nursing practice quality initiative is to improve the competence of providers with guiding participants on clinical trials toward advance care planning through the implementation of a didactic and experiential educational module. Thr aim of this intervention is to teach better integration of a semi-structured goals of care discussion into clinical trials.

Theoretical Framework: The basis for this project is Kotter's eight step process for transforming change.

Methods: Medical and nursing providers at an urban comprehensive cancer center who enroll adult subjects with advanced cancers to clinical trials which utilize novel investigational anticancer therapies will attend an education module to learn how to improve semi-structured guided discussions with trial participants regarding goals of care and advance care planning. The analysis will utilize descriptive statistics such as percentages, means and modes of response to quantify the number of recorded goals of care discussions and the number of advance care plans that are recorded in the electronic medical record among aggregates of participants for six weeks before and after the intervention.

Results: In Process.

Conclusions/Implications: It is postulated that providers will document an increased incidence of goals of care discussions and that participants on clinical trials will demonstrate increased utilization of advance care planning.

Reducing Complications Related to IV Fluid Administration in the Acute Care Setting

Katherine Connolly, Seton Hall University

Theoretical Framework: The guiding principles for this DNP project were grounded in Donabedian's Quality Framework and the 2004 Transforming Care at the Bedside (TCAB) initiative. The project was built around Donabedian's principle that innovations in process begin at the structural level and included constructs from the TCAB initiative such as engaging frontline providers in quality improvement processes, focusing on care team vitality and expanding evidence based patient care.

Background: Recent studies have indicated a higher complication rate associated with intravenous (IV) fluid administration than previously believed, with select populations at considerable risk. Adverse effects impact recovery time, length of stay, cost, patient safety and survival. Related complications are largely preventable and unmet educational needs are well documented.

Purpose: The purpose of this DNP quality initiative was to bridge the gap between evidence and practice related to the management of in IV fluids in the hospital setting, highlighting the critical role of nurses in effecting change in the health delivery system

Methods: An educational initiative developed for bedside nurses was coupled with system level interventions to minimize risk related to IV fluid administration in one community hospital. The content included recommendations from clinical practice guidelines and data from several studies supporting a shift to more conservative fluid management strategies. The sessions emphasized assessment skills and critical thinking to enhance therapeutic effectiveness and prevent complications.

Results: The project was well received by nursing staff and leadership. The anticipated effect will be a reduction in the overutilization of IV fluids, resulting in a lower complication rate. An exit survey indicated that the information provided would influence nursing practice at the bedside and the content was subsequently adapted for integration into the hospital's RN orientation program.

Conclusions/Implications: A lack of awareness exists regarding convincing data supporting more judicious fluid administration practices and the need for improved clinical assessment and management skills. Appropriate clinical management of IV fluids and early recognition of complications can prevent adverse events that negatively impact a range of patient outcomes.

Effectiveness of Collaboration Between Emergency Department and Intensive Care Unit Teams on Mortality Rates of Patients Presenting with Critical Illness: A Systematic Review

Anna Sahadeo, Pace University [black down pointing small triangle] Elizabeth Hynes, Pace University [black down pointing small triangle] Kerchelle McDowald, Pace University [black down pointing small triangle] Svetlana Direktor, Pace University

Background: Critically ill adult patients in emergency departments (ED) face higher risks of mortality caused by reduced level of care received in the ED. Compounding factors include nurse and physician training and experience in delivering critical care, ED overcrowding, and overextention of ED manpower. Some hospitals have implemented collaborative programs between the ED and intensive care unit (ICU) to decrease the mortality risk associated with critically ill ED patients. The objective of this systematic review was to evaluate the effectiveness of collaboration between ED and ICU teams on mortality rates of critically ill adult patients in the ED.

Purpose: See background

Methods: A comprehensive literature search was conducted across PubMed, CINAHL, EMBASE, and Cochrane CENTRAL through August 2016. Gray literature was searched for unpublished studies. Quantitative studies of critically ill adult patients in EDs who received care from a collaborative team of ED and ICU providers were considered for inclusion. Included studies were assessed for methodological quality and data relating to study methods, participants, interventions, and findings were extracted using standardized tools from the Joanna Briggs Institute.

Results: Three observational and two before-and-after studies were included. Three studies evaluated the EDICU model. One showed an increased mortality in cardiac patients (p<0.01), a decreased mortality in patients with alimentary conditions (p<0.001), and comparable mortality for patients needing medical and neurological ICU care[JTS1]. One study showed a statistically significant higher mortality rate (p<0.01) in the EDICU due to patients being older, sicker, with multiple comorbidities. Another showed no difference in mortality rates for septic patients admitted to the EDICU. In one study, the MET model had worse mortality than predicted for patients transferred to the ICU late in the course of their critical illness (p=0.05) whereas early transfer showed no difference in mortality from predicted (p=0.9). One studied evaluating improved communication between ED and ICU attending physicians showed no impact on mortality (p=0.82). [JTS1]Is there a p value for this?

Conclusions/Implications: Preliminary review of the data shows that some ED-ICU models are more effective at reducing mortality than others. Final analysis is pending and will be included in the presentation.

Discharge Pain Scores: A Useful Quality Indicator?

Tina Humbel George, Washington University, School of Nursing [black down pointing small triangle] Katherine Patterson Kelly, Children's National Health System [black down pointing small triangle] Brenda Martin, Children's National Health System [black down pointing small triangle] Sean Alexander, Children's National Health System [black down pointing small triangle] Ashley Darcey-Mahoney, George Washington University, School of Nursing [black down pointing small triangle] Yunfei Wang, Children's National Health System

Background/Purpose: With the increased attention to quality care outcomes, the rate of hospital readmission is a focus area for regulatory, accreditation, and consumer agencies. Children with sickle cell disease (SCD) are frequently admitted to the hospital for vaso- occlusive crisis (VOC). These patients often suffer from both chronic and acute pain making evaluation and treatment challenging. Pain is the primary reason patients return to the emergency room and/or require hospital readmission and contributes to an increased rate of hospital utilization accounting for 79-91% of emergency room visits and 59-68% of hospital admissions (cite the authors and year only). Current quality improvement efforts to decrease readmissions for this patient population concentrate on initial treatment (e.g. time to administration of initial analgesic) and not the entire hospital visit. In an effort to identify other quality indicators for pediatric patients with SCD, we will examine the usefulness of discharge pain scores as a quality indicator that predicts readmissions in this high-risk population.

Theoretical Framework: Using Donabedian's framework, we will examine discharge pain scores (process) in relation to readmission data (outcome) for pediatric patients with SCD admitted for VOC.

Methods: A de-identified database has been constructed using data extracted from the electronic health records of a Middle Atlantic freestanding children's hospital. The database contains 2230 encounters of 501 unique patients with an admission or discharge diagnosis of SCD with VOC over a three-year period. The relationship between discharge pain scores and 14 and 30-day readmissions from this cohort will be examined using logistic regression to explore associations and develop odds ratios. The proposed study was deemed a quality improvement project by our IRB and therefore not under IRB oversight.

Results: Analyses will be completed by the end of 2016. We will be reporting the results of our completed analyses.

Conclusions/Implications: The advantage of using a quality improvement framework empowers nurses to evaluate potential improvements from data found in the electronic health record. By leveraging a standardized framework, anecdotal observations by clinical staff can be systematically evaluated for their utility as quality indicators that have a meaningful impact on patient care.

Increasing Early Palliative Care Consultations in Intensive Care Utilizing Nurse Champions

Catherine Shah, Saint Mary's College Notre Dame

Background/Purpose: Problem/Significance: WHO places palliative care as a priority for care and states that prompt initiation results in psychosocial and physiologic benefits surrounding chronic illness management. Palliative Care screening is not initiated early enough to plan and provide for patients and their families. Inpatient Palliative Care consultation, when delayed, increases length of stay and decreases quality of life, pain, and depression for patients managing chronic illness. Patients with palliative care save an average of $300 per day and approximately $1700 per admission. Palliative care at one university hospital re-appropriated 8 million dollars a year to other departments by providing care.

Theoretical Framework: Iowa Model

Methods: By using MeSH headings and search criteria of palliative care and pain or depression, 56 suitable articles were returned from a search of EBSCOHost, CINAHL, Medline, Guideline Clearinghouse and PubMed. Search criteria were altered so articles appearing in peer reviewed journals since 2008 were returned. Fifteen articles were chosen for analysis. Using the Melnyk-Overhault grading scales articles were categorized as follows: three level I, one level II, two level IV, two level V, four level VI, and two level VII.

Results: Articles examined demonstrated the need for palliative care consults to start as soon as possible, and a knowledge deficit in the GP population. Patients and families had more positive opinions of end-of-life care when Palliative Care is involved.

Conclusions/Implications: Charge nurse champions will be provided education regarding screening tools and palliative care eligibility. The Palliative Performance Scale, PPSv2, will be utilized to determine appropriateness for referral. Adult patients (>18yrs) will be screened with admission to a 900 bed urban teaching hospital to two intensive care units over 1 month with primary diagnoses of CHF exacerbation, PNA, COPD exacerbation, CVA, septic shock, cardiogenic shock, and metastatic cancer. Identifying exacerbation of chronic disease affecting ADLs will be the focus of screening. The PPSv2 score will be calculated between the charge nurse and admission nurse at the time of the admission assessment, and recommendations for consult will be made to the primary team. A chart review will be conducted and basic statistical analysis will be performed to determine effectiveness of the intervention including eligibility criteria and palliative consultation order placement.

The Impact of an Enteral Feeding Protocol on Nutritional Support in Critically Ill, Mechanically Ventilated Patients

Christina Wolleon, Saint Peter's Univeristy

Background/Purpose: Although proper nutrition has been found to be an essential factor in health maintenance and restoration in the critically ill patient, research has indicated that this population often falls victim to malnutrition while in the intensive care unit. Malnutrition has been associated with increased morbidity, mortality, and length of stay. Conversely, early initiation of nutritional support has been associated with reduced mortality and morbidity, decreased length of stay, lower rates of infection, and decreased time on mechanical ventilation. Enteral feeding protocols have been found to combat the risk of malnutrition in the critically ill who are mechanically ventilated, with data suggesting that they may reduce time to initiation of feedings, reduce interruptions, and reduce time to reaching goal feeding rates. The goal of this paper is to develop an enteral feeding protocol for critically ill, mechanically ventilated patients in a local community hospital based on evidence collected and measure the impact of this protocol on enteral feeding initiation, advancement to goal rate, and length of stay.

Theoretical Framework: Not Applicable

Methods: This evidence-based project focused on those critically ill, adult patients in the critical care unit (CCU) who were intubated and being mechanically ventilated, taking place in the CCU of a community hospital located in North Bergen, New Jersey. Prior to initiation of the enteral feeding protocol, a chart review to collect data involving all mechanically ventilated patients in the CCU without contraindications to enteral nutrition upon admission over the previous 3 months was performed. After implementation of this intervention, all mechanically ventilated patients admitted into the CCU without contraindications to enteral nutrition were selected for data collection for this study. Contraindications to enteral nutrition include intestinal obstruction or ileus, abdominal trauma, active gastrointestinal hemorrhage, bowel ischemia, and severe hemodynamic instability or circulatory shock. Mechanically ventilated patients who expired during admission or were discharged to hospice were also excluded from this study. The proposed enteral feeding protocol for this evidence-based project is based on the recommendations of the Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) outlined in their 2016 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient (McClave et al., 2016). After Institutional Review Board approval of this evidence-based project, a retrospective chart review of critically ill, mechanically ventilated patients covering a three month time frame was performed and data pertaining to time of intubation, time of enteral feeding initiation, time goal enteral feeding rate was achieved, and length of hospital stay was collected. After implementation of the proposed enteral feeding protocol, similar data was collected over a three month period via a prospective chart review. Time to enteral feeding initiation, time to goal enteral feeding rate, and hospital length of stay were measured pre- and post-intervention to determine the impact of the enteral feeding protocol. Average times of pre- and post-interventions measures were calculated and an independent t-test was performed to statistically determine whether mean differences calculated from each group are significantly different.

Results: A total of 40 subjects were included in data collection for this evidence based project, with 23 subjects in the pre-intervention group and 17 in the post-intervention group. The pre-intervention group consisted of 10 females (43.5%) and 13 males (56.5%), while the post-intervention group consisted for 7 females (41.2%) and 10 males (58.8%), with average ages of 70.04 years and 70.24 years pre- and post-intervention respectivel. Statistical analysis found no difference between groups based on gender (X2 = 0.021, df = 1; p = 0.884) or age (t = -0.34, df = 38, p = 0.973). Data regarding race and diagnosis in each group were also collected and compared, showing no statistical difference between the pre- In the pre-intervention, time taken to reach nutrition goal rate ranged from 34.48 hours to 189.2 hours, with an average time of 78.07 hours. In the post-intervention group, time taken to reach nutritional goal rate ranged from 15.02 hours to 87.55 hours, with an average time of 47.9 hours. With the introduction of the enteral nutrition protocol, the time to goal dropped significantly by 30.15 hours (t = 3.162; df = 29.81, p = 0.004). In the pre-intervention group, time to initiation of enteral nutrition ranged from 12.35 hours to 114.22 hours, with an average time of 43.9 hours. In the post-intervention group, time to initiation of enteral nutrition ranges from 10.17 hours to 80.3 hours, with an average time of 32.7. While there was a 11.2 hour drop in time to initiation of enteral nutrition post-intervention, statistical analysis did not find a significant decrease in this variable (t = 1.441; df = 38, p = 0.158). Moreover, while there was a 6.7 hour decrease in average length of stay after the initiation of the enteral nutrition protocol, the drop was found to be insignificant (t = 0.176; df = 38, p = 0.861). and post-intervention groups based on these variables (race: X2 = 2.289, df = 4; p = 0.683; diagnosis: X2 = 4.54, df = 5; p = 0.475). Calculation of Pearson's r coefficient was also performed to determine whether there was any correlation between length of stay and time to initiation of enteral nutrition or time taken to reach nutritional goal rate. Though there was a positive relationship between length of stay and time to initiation of enteral nutrition, it was weak and insignificant (r = 0.127, p = 0.436). A moderate positive relationship was found between length of stay and time taken to reach nutritional goal rate, however, it was also insignificant (r = 0.289, p = 0.071).

Conclusions/Implications: An abundance of research has found that the critically ill, mechanically ventilated patient is at increased of malnutrition, a condition associated with poor patient outcomes. Research has further established the benefits of starting enteral feedings within 24 to 48 hours in this population, such as reduced mortality and morbidity, decreased length of stay, lower rates of infection, and decreased time on mechanical ventilation. Interventions to promote early and complete nutrition are vital to improving outcomes in these patients. Other than significantly improving time taken to reach nutritional goal rates, the data from this project did not reflect a significant impact on outcomes. It is suspected that this is largely the result of the small population size, a major limitation in this study. The reduction in times for all outcome variables measured is promising, but further collection of data until a sufficient population size is reached is necessary in order to make a definitive conclusion based on this research. Nevertheless, previous data has suggested that enteral protocols have the potential to effectively reduce time to initiation of feedings, reduce interruptions, and reduce time to reaching goal feeding rates. Based on this information, it has been concluded that the use of enteral nutritional protocols should be standard in all intensive care units, in an attempt to improve outcomes and minimize complications among the critically ill, mechanically ventilated patient.

Support, Education, and Advocacy (SEA) for Metastatic Breast Cancer (MBC): A Program of Care to Improve Quality of Life, Enhance Support Services, and Provide Optimal Cancer Care Among Women Diagnosed with Metastatic Breast Cancer

Victoria Reiser, University of Pittsburgh

Background/Purpose: Among women diagnosed with breast cancer, up to 30% will develop metastatic breast cancer (MBC) (Torre, et al., 2012). The five-year survival rate is estimated to be 25% (American Cancer Society, 2011). Patients diagnosed with MBC have unique treatment, symptom management, and care management needs as opposed to those with early stage disease in a curative treatment paradigm. Patient navigation for advanced cancers of the lung and colon and early-stage breast cancer has positively impacted care coordination, patient understanding of treatment, quality of life, physical functioning, financial burden, and access to support services (Arnout, et al., 2013; Kunos, et al., 2015; Lee, et al., 2011). This same effect could be replicated among all patients with MBC fulfilling their unique needs. The purpose of this project is to evaluate the effect of the SEA MBC Program of Care on: Aim 1, Patient reported outcomes specifically cancer related distress, including physical and psychological, Aim 2: Appropriate referral to social work, palliative care and recruitment to clinical trials, and Aim 3: In addition, the program will be evaluated for feasibility, acceptability by clinicians and patients, and estimated cost.

Theoretical Framework: The Metastatic Breasts Cancer diagnosis may cause impaired quality of life, financial toxicity, and unique supportive needs. Patients develop interest in latest treatment, clinical trials and personalized medicine. The SEA MBC Program of Care addresses these consequences through patient education at the time of diagnosis, weekly nurse navigator chart review and team meetings.

Methods: Comparative pre-and post-design of outcomes associated with the SEA MBC Program of Care Participants/Setting: Magee Women's Hospital Breast Cancer Center of the University of Pittsburgh Medical Center with an estimated 200 women with MBC in active treatment to be included in this project. Data Collection: Six month pre-and post the SEA MBC Program of Care chart review evaluating outcomes associated with: symptom incidence and distress, anxiety and distress, referrals to social work and palliative care and recruitment to clinical trials. This will begin in December 2016 and be completed in June 2017. Paired t-tests, Xi square analysis, or appropriate non-parametric equivalents will be utilized in data analysis.

Results: This is an ongoing project, and post-implementation data collection will be completed in June 2017.

Conclusions/Implications: This SEA MBC Program of Care will be the method by which state of the art evidence based care and support will be delivered to this unique patient population through existing resources.

Unwanted Mouth Sores - a "Chip" Away

Alecia Kidd-Francis, Stony Brook University [black down pointing small triangle] Kathleen Shurpin, Stony Brook University

Background/Purpose: Background: Oral mucositis is a debilitating complication among patients receiving chemotherapy. Of the 1.2 million patients receiving chemotherapy, more than 400,000 patients will develop oral mucositis. Oral mucositis potentially prolongs hospitalization and incurs the need for parenteral nutrition and pain management. Purpose: To evaluate the addition of oral cryotherapy to standard oral care regimens on the incidence of oral mucositis.

Theoretical Framework: The IOWA model informed this study by providing a framework to identify the problem of oral mucositis and focus on solution development with implementation of oral cryotherapy as an evidence-based change in practice.

Methods: The study will be conducted on a bone marrow transplant (BMT) unit using a convenience sample (n=128) of newly hospitalized patients with hematological malignancies undergoing chemotherapy. Patients receiving oral cryotherapy (ice chips) in addition to standard oral care will be compared to matched historical controls of patients receiving only standard oral care to evaluate incidence of oral mucositis using the World Health Organization (WHO) Oral Toxicity Scale. In phase 1 (n=64), a retrospective data/ chart review of electronic medical records will be conducted to determine the baseline incidence of oral mucositis prior to the initiation of oral cryotherapy. In phase 2 (n=64), a prospective data collection will be conducted from the electronic medical records. A chi-square analysis will be used to examine the effectiveness of the implementation of oral cryotherapy.

Results: Pending

Conclusions/Implications: Pending

I've Got the Power: Nurses' Moral Distress and Perceptions of Empowerment

Kathleen DiGangi Condon, Stony Brook University [black down pointing small triangle] Kathleen Shurpin, Stony Brook University [black down pointing small triangle] Jeffrey Berger, Stony Brook University

Background/Purpose: Nurses experience moral distress when they view themselves as powerless to take the ethically right course of action. Moral distress is especially prevalent in intensive care unit (ICU) nurses and has widespread, deleterious effects on nurses and patients. Empowerment is advantageous for nurses. Involving palliative care services in patient care may reduce moral distress because it is active in domains relevant to the sources of moral distress. The purpose of this study is to evaluate the effect of a nurse-administered palliative screening tool on nurses' levels of moral distress and perceptions of structural and global empowerment.

Theoretical Framework: Corley's model for a theory of moral distress informs this study. It recognizes that moral distress negatively affects several constituencies (nurses, patients, and organizations) and that moral distress is predicated on nursing as a fundamentally moral profession.

Methods: A pre-test post-test pilot study design will be conducted with day shift medical ICU nurses. Prior to the intervention, nurses will attend an in-service that provides an overview of the palliative care consult service. Demographic data, nurses' moral distress, and experience of structural and global empowerment will be collected by survey. Moral distress will be evaluated using the Moral Distress Scale-Revised (Adult Nurse Version).Structural and global empowerment will be quantified using the Conditions for Work Effectiveness Questionnaire-II and the Global Empowerment Scale, respectively. Nurses will use a palliative screening tool on their patients daily and provide the results to the ICU physician during an eight-week intervention period. Nurses' moral distress and perceptions of structural and global empowerment will be reassessed following the intervention.

Results: Pending

Conclusions/Implications: Pending

Increasing Parental Knowledge Related to the Human Papillomavirus (HPV) Vaccine

Joseph Cipriano, Rutgers University

Background/Purpose: The human papillomavirus (HPV) is the most common sexually transmitted infection in the United States (Obulaney et al., 2016). There are approximately 79 million Americans infected with HPV (Centers for Disease Control and Prevention, 2015). Completion rates for HPV vaccine across the United States have only rose to 39.7% for adolescents (Kepka, Ding, Bodson, Warner, & Mooney, 2015). The U.S. Department of Health and Human Services has set a Healthy People 2020 goal of having 80% of adolescents fully vaccinated against HPV. With the introduction of the HPV vaccine there has been an increase in attention to HPV in the media, often resulting in conflicting or confusing information about the vaccine (Teitelman et al., 2011). Primary care providers carry the responsibility and challenge of educating parents on the benefits of the HPV vaccine during office visits, which are time limited and often their chief complaint takes precedence over vaccine education (Obulaney, Gilliland, & Cassells, 2016). In order meet the Healthy People 2020 goal of 80% series completion rates for HPV vaccines, there need to informed education to address the important benefits of the HPV vaccine and dispel misinformation about the vaccine (Grandahl et al., 2014; Grimes et al., 2013; Warner et al., 2015). The purpose of this Doctor of Nursing Practice (DNP) capstone project is to increase parental knowledge of the HPV vaccine. A second purpose of this project will be to evaluate parental attitudes toward vaccination protocols in general.

Theoretical Framework: Andrew Tannahill's Health Promotion model (1985) serves as the theoretical framework for the practice improvement need of the capstone project. Tannahill's model is constructed of three concepts: Prevention, Health Education, Health Protection.

Methods: Design: Pretest/Posttest design with educational intervention Sample: 75 parents or legal guardians of adolescents ages 11-16 Setting: Pediatric offices within a Federally Qualified Health Care Center in Bridgeton, NJ Measures: The Parental Attitudes Module consists of three factors, assessing the benefits of vaccines in general, the harms of vaccinations and the trust in the health care providers (Gilkey et al., 2016). This instrument is a useful tool to identify parents at risk for refusing adolescent vaccines (Gilkey et al., 2016). The survey questions use an 11-point scale ranging from 0 (strongly disagree) to 10 (strongly agree). Higher scores indicate a positive parental attitudes towards vaccinations. The Parental Attitudes Module was utilized in the National Immunization Survey (NIS) -Teen household survey conducted by the CDC in 2010 the modified "HPV Vaccine Knowledge Survey" is a validated tool that specifically measures parental knowledge of the HPV vaccine. The modified instrument is a self-reported 11 item Likert scale which will test parental knowledge about HPV and the HPV vaccine pre & post intervention. Analysis: The statistical methods to be employed are paired T-test and Pearson's Chi Squared. The paired T-test is indicated to measure before and after observations on the same group or subjects. The Pearson's Chi-Squared will measure how well the observed distribution of data fits with the distribution that is expected.

Results: Results are still in progress

Conclusions/Implications: It is theorized that parents with increased knowledge of the vaccine would be more willing to consent to their adolescent receiving the vaccination for HPV.

Implementation of Opioid Overdose Management Training

Serena M Natal, Rutgers University

Theoretical Framework: Andrew Tannahill's Health Promotion Model. This model presents health promotion as three overlapping concepts: health education, prevention, and health protection. Harm Reduction Principles. Harm Reduction is a pragmatic health approach aimed at improving social well-being, health, and quality of life.

Background: In 2014, it was estimated that 1.9 million people aged 12 and older had an opioid use disorder. In America, opioid overdoses are responsible for approximately 78 deaths per day. Heroin or another opioid was the primary drug for almost half of the 64,766 admissions to substance abuse treatment facilities in 2014 in the state of New Jersey.

Purpose: The aim of this project is to improve practice through development and implementation of an educational intervention on management of opioid overdose. Another aim is to improve willingness of substance abuse treatment staff to implement this education into substance abuse treatment.

Methods: The intervention consists of a PowerPoint presentation, hands on training on intranasal naloxone assembly and administration, and question and answer session. Data was collected through use of a demographic survey, a pre-training questionnaire, and a post-training questionnaire. The pre-test post-test design was implemented using the Opioid Overdose Knowledge Scale (OOKS) and the Opioid Overdose Attitudes Scale (OOAS). To keep consistent with the content of the training provided, minor changes were implemented to the scales. Summary descriptive statistics will be calculated for the demographic data. A paired t-test will be utilized to analyze the OOAS and OOKS.

Results: The results are not available at the time of this submission as data analysis has not taken place.

Conclusions/Implications: The capstone project is not complete and conclusions and implications are not available at this time.

Pre-Exposure Prophylaxis Education's Effect on Sexual Behaviors of Gay and Bisexual Men

Randulf Erguiza, Georgetown University

Theoretical Framework: Pender's Health Promotion Model (HPM) will be utilized in the study. This behavioral change model takes into account patient's experience, demographic profile, and capacity to engage in healthy behaviors.

Background: Although pre-exposure prophylaxis (PrEP) is prescribed to prevent transmission of human-immunodeficiency virus (HIV), it does not prevent people from other sexually-transmitted diseases (STDs). Studies of PrEP use have demonstrated high risks for gay and bisexual men (GBM) regarding engagement in risk compensating sexual behaviors which increase their susceptibility to sexually-transmitted disease.

Purpose: The aim of this study aims is to elicit an understanding of the effect of PrEP education on the sexual behaviors and STI rates of a purposive sample of GBM. The results are intended to inform the development and promulgation of evidence-based, effective PrEP education for GBM, and ultimately for the broader population of people with HIV/AIDS.

Methods: This quasi-experimental intervention study to be conducted in Oakland, California will involve a purposively-selected sample 25 gay and bisexual males ages 21 years and older who will initiate or who are on PrEP. The two study phases are: 1) a brief educational intervention and pre-post assessment of knowledge, attitudes, and practices (KAP), in February 2017; and 2) a follow-up assessment of KAP, in May 2017. The educational intervention entails the presentation of PrEP and STD videos from the Centers for Disease Control and Prevention. The pre-post KAP assessment includes an STD-PrEP knowledge questionnaire, a sexual behavior questionnaire, and an in-person semi-structured interview. The interview will be used to generate themes on current sexual behavior, sexual intent, post-intervention sexual behaviors, and perception about educational intervention. Data analysis will utilize descriptive statistics, Pearson Product-Moment, paired dependent (t test), and Chi-square tests. The open-ended responses will be analyzed using the editing style of analysis.

Results: Study still ongoing.

Conclusions/Implications: Study still ongoing

Poster Session I: Meet the Researchers

Summative High-Fidelity Nursing Simulation

Fernanda Andrade Brito, New York University

Background/Purpose: Nursing programs across the United States are increasingly using clinical simulation as a teaching strategy to complement and/or substitute for traditional clinical experiences. While the National Simulation Study (2014) provided robust evidence that simulation can produce equal or superior student outcomes when compared to traditional teaching methods, most studies simply describe students' emotions, attitudes, communication skills, and knowledge. Several gaps exist in the nursing simulation literature including the need for research that (a) links simulation learning to patient outcomes, (b) assesses clinical competence and readiness for entry-level nursing practice, and (c) investigates the use of simulation as an evaluation method. The purpose of this descriptive pilot study is to investigate the use of high-fidelity (HF) clinical simulation as a summative clinical competence evaluation of baccalaureate of science (BS) nursing graduates. The research aims are to (1) use HF simulation to evaluate BS nursing graduates' clinical competence in caring for a patient with a commonly occurring diagnosis and (2) identify critical elements of entry-level clinical performance that graduates are able and unable to perform.

Theoretical Framework: The NLN Jeffries Simulation Theory (2016) and the INACSL Standards of Best Practice: SimulationSM (2013) will guide this study.

Methods: A convenience sample of traditional and accelerated graduates from a large metropolitan BS nursing program will be invited to participate in the study shortly after graduation and before they have taken NCLEX. Their program incorporates throughout the nursing curriculum 50% of the clinical hours in simulation and 50% in traditional clinical sites. Participants will be asked to answer a short demographic survey, complete one fifteen-minute HF simulation session that will be video recorded and rated using the Clinical Competency Assessment (CCA) tool, and undergo one ten-minute debriefing session. The CCA tool and simulation scenario were developed and validated by content experts from academic and clinical settings and inter-rater reliability will be established prior to the start of the study.

Results: Demographic data will be analyzed using descriptive statistics. Multivariate analysis will be used to analyze CCA tool scores, items, and categories.

Conclusions/Implications: This pilot study aims to inform whether simulation can be used as a method to evaluate expected entry-level clinical competence in recent BS nursing graduates.

The Effect of High Frequency Low Dose Simulation on Nursing Skills in the Simulated Environment

Susan Chin, New York Presbyterian Hospital [black down pointing small triangle] Jeffrey Perlman, New York Presbyterian Hospital [black down pointing small triangle] Alpa Basu, New York Presbyterian Hospital [black down pointing small triangle] Susan Venturini, New York Presbyterian Hospital

Background/Purpose: The purpose of our study was to determine if frequent, self-directed, low dose simulation sessions would improve skill competency for the initial steps of newborn resuscitation for neonatal nurses in the simulated environment.

Theoretical Framework: The Dreyfus Model of Skill Acquisition.

Methods: A randomized controlled trial with a crossover design was utilized to assess skill and knowledge retention of RN's in a level III NICU. Subjects completed the following at study entry, 2 months and 4 months: a self assessment survey questionnaire regarding the cognitive component of NRP skills, and work experience; A simulated performance of the initial steps of resuscitate. Evaluated by investigators with a standardized, 10-item tool. Group A subjects performed self-directed simulation each work shift. Group B subjects were given the option to complete this activity as desired. Subjects recorded each simulation session in a logbook. At 2 months, the groups "flipped" so that Group B completed the self-directed simulation each time they worked, and Group A completed the activity as desired.

Results: 70 nurses were enrolled with 67 completing the study (Group A =31 and group B=36). With frequent practice, the following skills significantly improved: time to call for help was reduced by reduced by 24+/-64 seconds (p=0.001); and the percentage of nurses performing positive pressure ventilation within 30 seconds increased from 29% to 49% (P=0.03). A significant decrease was noted for all nurses in both groups who failed to call for help from study start at 42% to the 4 month end point at 19% (p=.003). The crossover group A was analyzed for knowledge and skill retention at 4 months (2 months without daily skill practice). Skill and knowledge improvement and retention was demonstrated for the crossover A group. Time to call for help decreased in minutes from baseline to the 2 and 4 month assessment points (P=.03). Cognitive scores for MRSOPA, the corrective action steps for effective ventilation, improved significantly from baseline to the 2 and 4-month assessment points ( p=. 001). Clinical skills score to indicate competency improved from baseline to 2 months and were retained at 4 months. (p=0.014). The percentage of subjects that obtained competency with a clinical skills score of >= 8 increased from 33% at baseline to 59% at 2 months and 58% at 4 months.

Conclusions/Implications: High Frequency, self-directed simulation is associated with significant improvement in basic resuscitation skills. Clinical skills score increased significantly. Competency in providing the initial steps of resuscitation was realized with at least once monthly practice. Knowledge of important ventilation corrective steps increased 4-fold. Cognitive step of time taken to call for help decreased significantly post training. Skills gained via high frequency, self-directed simulation are retained for at least two months.

Nursing Doctoral Education: A Survey of Reported Experiences and Expectations of PhD/DNP Students by Faculty WhoTeach and/or Advise in U.S. Doctoral Programs

Veronica Feeg, Molloy College [black down pointing small triangle] Aliya Kuerban, Molloy College [black down pointing small triangle] Mabel Korie, Molloy College

Theoretical Framework: Evaluation of doctoral education is predicated on the elements and standards of the scientific associations in the discipline and are prescribed by the profession's major accrediting organizations and high level scientific assessment authorities such as the Carnegie Institute on the Doctorate.

Background: With the recently reported exponential growth of DNP programs and the concerns related to the discipline's parallel terminal degrees, it is important to understand what we expect of the graduates of these different doctoral education paths. These programs use a variety of doctorally prepared nurse faculty to teach the next generation of nurses who will hold the highest degrees in practice, education or research.

Purpose: The purpose of the study was to explore the experiences and expectations of doctoral faculty teaching and/or advising in U.S. doctoral programs using the elements and standards related to the PhD and DNP programs specified by the American Association of Colleges of Nursing (AACN) and the quality indicators described and used in assessment by the Carnegie Institute on the Doctorate (CID). The major question of the study is: What are the program experiences of doctoral faculty and their reported expectations for doctoral student outcomes in their respective PhD and DNP programs?

Methods: This survey included quantitative descriptive items and several open-ended questions. Data collection was from a sample of over 500 faculty from doctoral programs who attended the annual AACN Doctoral Education Conferences. The pilot sample response (n=83) were attendees in 2013 who received an email invitation to participate anonymously. The survey items were a combination of elements from the AACN standards related to DNP education and essentials of PhD programs with modified questions from the CID. Participants were asked to respond to questions about their teaching and advising experiences, and their opinions about their expectations for student outcomes in their respective programs. Following modification of the instrument, the second survey will be sent to email addresses from the 2016 AACN Doctoral Education Conference list.

Results: Participants from the pilot study were from 32% PhD only, 51% DNP only, and 17% both doctoral programs nationally. To date, descriptive statistics indicate disparate faculty experiences in doctoral education and lack of clarity in program expectations. Content analysis of the open-ended questions yielded themes of ambiguity and disconnect between program goals and expectations.

Conclusions/Implications: There is wide variation in faculty PhD and DNP experiences and disparate expectations among faculty who teach and advise doctoral students. The future of nursing is predicated on the evolution of new knowledge from PhD education and continuous improvement of practice from DNP education that needs to be understood.

Reducing Nursing Student Test Anxiety: A Systematic Review

Brenna Quinn, University of Massachusetts-Lowell [black down pointing small triangle] Anya Peters, University of Massachusetts-Lowell

Background/Purpose: College students are at risk for poor evaluations, lost scholarships, or relinquished educational opportunities every time they sit for an exam. Nursing students are plagued by test anxiety due to high-stakes testing practices commonplace in nursing education. Chronic stress, heavy academic workloads, and rigorous progression standards are antecedents of test anxiety in nursing students. The purpose of this project was to identify interventions helpful in decreasing test anxiety in nursing students.

Theoretical Framework: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines directed this review.

Methods: Four electronic databases (Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Research Complete, Education Resources Information Center (ERIC), and Medline/PubMed) were searched using the terms nurs*, anxiety, test, NCLEX, strategies, and exam*. Research articles were included for review if the following criteria were met: available in the English language, published in peer-reviewed scholarly journals, and published between 2006 and 2016. Articles were analyzed to identify effective test anxiety reducing interventions among nursing students.

Results: A total of 69 non-duplicate articles were identified. Seven articles were included for review following application of the PRISMA guidelines. Following analysis, two categories of test anxiety interventions for nursing students were identified: environmental adjustments and student behavior modifications. Environmental adjustments, such as diffusing essential oil, playing classical music, or the presence of a therapy animal, may help nursing students decrease test anxiety. Behavior modifications including biofeedback relaxation techniques, guided reflection, and the use of "magic pencils" were also instrumental in reducing test anxiety.

Conclusions/Implications: Faculty members should consider employing test anxiety reduction interventions described in this report. Nursing programs should carefully consider new or existing progression standards and make sure that standards are set according to evidence-based practices. Policies should support best interests of both the nursing program and students; expectations of the school and faculty should not be made at the cost of increasing student anxiety and prohibiting students from graduation or attempting licensure exams unnecessarily. There is a lack of intervention studies in this area. Future research priorities include studying the effects of test anxiety reduction interventions on exam grades. Specifically, there is a critical need for research comparing exam scores with and without test anxiety reduction strategy implementation.

An Examination of Senior Baccalaureate and Associate Degree Nursing Students' Attitudes Toward Working with Hospitalized Patients and Their Parents or Families

Ann Marie Paraszczuk, Molloy College [black down pointing small triangle] Debra Mendelson, Molloy College [black down pointing small triangle] Sarah Browne Bradwisch, Molloy College

Background/Purpose: In the Patient and Family-Centered Care (PFCC) delivery model, the importance of family to individuals of all ages is acknowledged and the family is included in the plan of care. One assumption in PFCC implementation is that attitudes toward working with patients and families would be similar, but research indicates discrepancies exist in pediatric healthcare personnel's attitudes toward working with hospitalized children and their parents. Because PFCC is critical to promote quality, nursing programs have incorporated this concept into curricula to better prepare graduates for practice. Examination of nursing students' attitudes is warranted to identify whether educational preparation reflects acceptance of this model and to provide insight into strategies to promote this concept with nursing students. The purpose of this study was to examine graduating students' attitudes from three nursing programs toward working with hospitalized children and parents and patients and families. The reliability of the modified Working with Families Questionnaire with this population was also investigated.

Theoretical Framework: The PFCC developed from the Family-Centered Care model (FCC) that recognizes the importance of family to a child's well-being and incorporates the child and family's needs into the plan of care. PFCC extends this approach to care to patients of all ages.

Methods: The Working with Families Questionnaire, with reliability and validity demonstrated when used with pediatric healthcare personnel, was expanded to also obtain responses toward working with adult patients and their families and was distributed to nursing students several weeks prior to graduation. Using a semantic differential scale, responses to questions related to working with children/parents and patients/families were collected using a web-based survey. Electronic questionnaires were collected anonymously; consent was implied when these were submitted. The data obtained from the three schools of nursing in New York were combined for analysis resulting in a sample of (N=90).

Results: Results for the entire sample indicated that student responses toward working with children/patients were significantly more positive than their responses toward working with their parents/ families (p<.000). The results were similar when the sub sample of baccalaureate and associate students were examined. As in studies with healthcare personnel, age (r=.44, p<.000) and number of children (r=.28, p<.008), were participant variables associated with more positive attitudes toward working with parents/families. The Cronbach alpha for this instrument was .946

Conclusions/Implications: These findings suggest that nursing graduates entering practice may experience difficulty incorporating the PFFC approach into their patient care. Research is warranted as a basis to develop effective pedagogical strategies to assist nursing students with application of this concept in practice.

STATE OF THE SCIENCE: The Impact of High-Fidelity Simulation in Prelicensure Baccalaureate Nursing Education

Fernanda Andrade Brito, New York University

Background/Purpose: Nursing programs across the U.S. rely upon simulation to complement or substitute traditional clinical experiences. The purpose of this integrative review was to determine the current state of the science on the impact of simulation in prelicensure baccalaureate of science (BS) nursing education programs in the U.S. to answer the question: Does the use of high-fidelity (HF) simulation as a teaching/learning strategy impact student achievement of expected BS learning outcomes needed for delivering quality safe nursing care?

Theoretical Framework: This review was guided by Whittermore and Knalf (2005), Ganong (1987), and the TREND taskforce (Jarlais, Lyles & Crepas, 2004).

Methods: Six electronic databases were searched (CINAHL, PubMed, Educational Resources Information Center (ERIC), Joanna Briggs Institute (JBI), Web of Science and Google Scholar databases) using a modified PICO framework. Keywords searched included nursing education, baccalaureate, undergraduate, HF, patient and clinical simulation, evaluation, and outcome. Studies were excluded if the sample included graduate, associate, diploma, and LPN students, low or middle-fidelity simulation, or if the study was conducted abroad. Non-nursing studies that focused on other forms of simulation, unpublished manuscripts, dissertations, and abstracts were also excluded.

Results: The literature search yielded a total of 631 items. After abstracts and full texts were reviewed, 11 studies (one RT, seven quasi-experimental, and three descriptive) published between 2009 and 2014 met all the inclusion/exclusion criteria. The specific outcomes reported in the 11 studies were CPR knowledge, cardiac protocols, acute medical, pediatric, elderly, and home care, and communication skills. This review found that most studies reported (a) small non-probability convenience samples, (b) researcher-developed instruments that lacked validity and reliability testing, and (c) only used descriptive statistics. Overall, the methodology of these studies did not follow a rigorous research protocol that could be replicated.

Conclusions/Implications: Unfortunately this review was unable to answer the question posed. Future research should focus on using appropriate sampling techniques, similar research methodologies, include comparable variables and outcomes, and use valid and reliable instruments to produce a meaningful body of knowledge that can inform education, practice, and policy regarding the use of HF simulation for developing expected nursing competencies of new graduates.

"Oh, Now I Get It"...Teaching Qualitative Data Analysis Using Graduate Students' Narratives of Their Own Experiences with Fatigue

Kimberly Fenstermacher, York College of Pennsylvania [black down pointing small triangle] Cherie Adkins, York College of Pennsylvania

Background: Teaching graduate students to appreciate qualitative research is challenging. Students often have a preconceived notion that only quantitative research, specifically, RCTs can be used to deliver evidence-based practice.

Purpose: This presentation describes a simple, engaging classroom exercise that uses students' written narratives to explore the shared phenomenon of fatigue in a way that unravels the mystery of qualitative data analysis.

Methods: Advanced practice nursing students in a graduate level research course are asked to write a response to the question: "Tell me about a time when you were extremely fatigued. What was it like for you?" Student responses are submitted anonymously and voluntarily, a week ahead of class. The data are de-identified. Following a lecture on qualitative data analysis methods, students receive a copy of everyone's responses which serve as a mock data set. Faculty guide the students in the coding of the data using open, axial, and selective coding. Students actively participate in the analysis and theory building.

Results: As students participate in the coding process, they are invited to link the emerging concepts into a meaningful relationship to develop a theory of fatigue. Collectively, the class works as the research team to analyze the data. Semester after semester, the resulting theoretical conclusions that the students reach about the phenomenon of fatigue are overwhelmingly similar: Contributing factors to fatigue, manifestations of fatigue and consequences of fatigue with a core category of "pushing through".

Conclusions/Implications: Using a mock data set to engage students in qualitative data analysis is a meaningful way to help demonstrate analysis as well as facilitate students' appreciation for and understanding of qualitative inquiry. It is important for graduate nursing students to value the contribution that qualitative research offers to both theory-building and the delivery of evidence-based practice.

Meeting Needs of the Novice Nurse in the Emergency Department

Chrstine Wendt, Morristown Medical Center [black down pointing small triangle] Charlene Welsh, Morristown Medical Center [black down pointing small triangle] Patricia Primmer, Morristown Medical Center [black down pointing small triangle] Mildred Kowalski, Morristown Medical Center

Theoretical Framework: Benner's (2001) novice to expert theory is being used to support this quality improvement project. The needs of the nurse in the emergency department (ED) require unique skills due to high stress and fluid environment. The nature of the environment presents challenges to orientation and development of skills. Benner's approach of gradual expertise is used to address these issues.

Background: Historically, nurses had a minimum of two years' experience prior to entering the chaotic and demanding environment of the Emergency Department (ED). Currently, countless EDs are utilizing diversely structured programs to orient new nurses with mixed success. Published evidence inspired the structure for this innovative ED new graduate nurse orientation project.

Purpose: The purpose of this study is to engage nurse stakeholders and gain insight to the effectiveness of the program and evaluate impact on confidence and perceived skill level. Retention and job satisfaction will be evaluated at one year.

Methods: This mixed methods quality improvement project incorporated both survey and focus group methods. The study population (N=11) included new graduate nurses, hired between December 2015 and August 2016. The training configuration includes diverse educational sessions coupled with on-unit clinical hours daily, during the first four weeks of orientation. Clinical specialist and nurse educators provide clinical support at the bedside during the initial orientation. This design allows for an accelerated comfort level with essential skill sets. After initial on boarding, participants are assigned preceptors and rotated through various shifts until completion of their orientation (16 weeks). Data collection includes the repeated measures of the Casey-Fink graduate nurse experience survey at baseline, 16 weeks, and 12 months. Focus groups were conducted by a nurse researcher at 4 and 16 weeks, and will be repeated at 12 months.

Results: Interim data show the value of the program from the perspective of the participants. Growth in terms of confidence levels were reported in focus groups. Casey Fink repeated measure data are outstanding (due December 2016). Focus groups identified ideal scheduling, preference for clinical learning over classroom lectures and an appreciation for specialized lectures.

Conclusions/Implications: The focus group provides an opportunity to obtain participant feedback about the project throughout the initial year of inception. Limitations of the study include; a small sample size and limited demographic diversity. The results of the study may be valuable for other similar ED. Concerns regarding the capability of the new graduate nurse in a critical care setting such as the ED must be addressed by providing a comprehensive educational and clinical orientation within a successful structure. Areas for further research to ascertain effective forms of clinical and instructive learning may be identified through this study.

Nursing Faculty Perspectives on Teaching About Autism Spectrum Disorders

Marcia Gardner, Seton Hall University [black down pointing small triangle] Patricia Suplee, Rutgers University

Background/Purpose: The prevalence of autism spectrum disorder (ASD) in the U.S.is now 1:68 eight-year-olds. These children in time become adults needing tailored health care. Nursing education programs should include best- practices for care of people with ASD across the lifespan. The study's purpose was to explore nurse educators' knowledge of best-practice care of people with ASD and its integration into nursing curricula.

Theoretical Framework: The study context is self-regulated learning theory, which specifies that motivation, planning, and metacognition influence learning actions and behavior.

Methods: The study was conducted via an online survey. Using random cluster sampling, quantitative data from 295 nurse educators in programs across the U.S. were captured. Items were derived from best practice literature for care of people with ASD. An expert panel established content validity of the instrument. Data were exported for analysis with STATA to derive descriptive and correlational statistics.

Results: Seventy-three percent of the sample taught in pre-licensure programs. The most frequently reported clinical specialties were adult care (26.8%), pediatrics (12.5%), and obstetrics (12.1%). Almost 75% reported no ASD-specific continuing education in the past five years. Thirty-six percent reported a personal relationship with someone with an ASD. A majority reported very low or some knowledge of best care practices and medications typically used in this population and felt poorly prepared to teach students about the condition. More than half reported feeling uncomfortable about caring for people with ASD in their typical practice settings; those with a personal relationship with someone with ASD were significantly more likely to report feeling comfortable (p=0.0). Adult specialties were significantly more likely to report low knowledge in general (p=.026). Clinical instruction faculty were unlikely to seek experiences with patients with ASD for their students, yet half of the sample indicated such experiences were important or very important. About half of those who taught clinically-related courses reported including no instruction about ASD in their classes.

Conclusions/Implications: The sample mirrored the population of nurse educators in the U.S. They felt inadequately prepared to teach their students about patients with ASD. Despite recognizing its importance, they rarely included ASD- related material or clinical experiences in their courses. Findings suggest a need for more accessible continuing education about ASD, particularly for those in adult specialties. Pre-licensure nursing curricula should include more exposure to ASD. There were few graduate program faculty in the sample, but implications for graduate curricula are likely similar. Integration of learning activities to build competencies for best-practice care of people with developmental disabilities and ASD, including clinical exposure to the population is clearly needed.

Infection Prevention and Control in Baccalaureate Nursing Education: Identifying Content, Teaching Strategies and Gaps

Mary Lou Manning, Thomas Jefferson University [black down pointing small triangle] Monika Pogorzelska-Maziarz, Thomas Jefferson University

Background/Purpose: Healthcare-associated infections continue to pose a significant burden to healthcare systems. These potentially preventable infections have significant health, social and economic consequences and are recognized as a major risk to patient safety. Antibiotic resistant infections and emerging and re-emerging infectious diseases represent ongoing threats to population health. For example, the CDC has named the escalating resistance to antibiotics as one of the top 5 threats to health in the United States. Integrating infection prevention and control concepts and content in baccalaureate nursing education is crucial to ensure that nurses have the essential knowledge, skills and abilities to recognize, prevent and manage infections across populations and health care settings.

Methods: A review of the literature (2000-2016) was conducted to identify infection prevention and control curricula in baccalaureate nursing programs. The search yielded 226 articles and 42 articles met the inclusion criteria.

Results: Articles fell into two categories: evaluation of student IPC knowledge, compliance, and competency (n=19) and description of teaching strategies used by faculty to teach IPC content (n=23). The student knowledge and clinical skills most often evaluated were hand hygiene, use of barrier precautions and isolation procedures. The most frequent faculty teaching strategies for teaching IPC topics included simulation, games and lecture.

Conclusions/Implications: There is a significant lack of evidence indicating how baccalaureate nursing programs are preparing nurses to implement safe and appropriate infection prevention and control practices. Most studies evaluated IPC content and/or student outcomes for one undergraduate course in one school of nursing. We found no evidence of undergraduate IPC concept-based curricula. Integrating IPC core competencies into baccalaureate nursing programs is crucial to ensure that nurses have the essential knowledge, skills and abilities to keep patients safe. If IPC is to become an integral component of nursing education, then standardized curricula for ongoing education should be developed. There is a significant collegial opportunity for nurse educators, clinicians, and researchers to build and evaluate an IPC curricula.

Building a Culture of Teaching Excellence: Evaluation of a New Center for Educational Research and Innovation

Ann Marie Mauro, Rutgers University [black down pointing small triangle] Debora Tracey, Rutgers University [black down pointing small triangle] Jeannette Manchester, Rutgers University

Background: The nursing faculty shortage is well documented and is expected to increase with the retirement of an aging faculty workforce. Newly recruited faculty often bring clinical practice expertise with little formal education in teaching methods and pedagogy. Both new and existing faculty may need support to implement best practices in teaching excellence, foster collaborations in interprofessional education (IPE), and build nursing education science in order to advance quality care for individuals, families and communities.

Purpose: The aim was to evaluate the first year outcomes of a newly established Center for Educational Research and Innovation (CERI) to build a culture of teaching excellence, foster collaborations in IPE, and advance nursing education science in a large, public school of nursing.

Methods: A mixed methods design was used to assess CERI outcomes in a school of nursing with 105 full-time faculty and 1679 students on 3 campuses at a research-intensive university in the northeast US. Data were collected using 1:1 interviews, focus groups, program evaluation surveys, and center reports. Qualitative data were analyzed using thematic content analysis and descriptive statistics were used to examine quantitative data.

Results: Qualitative themes revealed faculty development needs (teaching, academic role, scholarship), curricular issues (BS, DNP, PhD), and civility concerns (faculty-faculty, student-faculty). Faculty development seminars implemented were highly rated (mean 4.6 on 1-5 scale), 19 faculty sought 1:1 consultations (14 had 2 or >), and multiple continuing education events were offered. Increases in simulation based education and IPE events for undergraduate and graduate students occurred. Three major external educational research program grants were obtained.

Conclusions/Implications: First year CERI outcomes showed strong initial progress toward its goals. New initiatives should be based on evaluation data, evidence-based best practices, and continued input from faculty, students, and clinical partners. Research is ongoing to assess outcomes and guide future planning.

Transforming Student Nurses' Beliefs About Childbirth

Judith Lothian, Seton Hall University

Background: Maternity care in the US is far from evidence based with a high cesarean rate and rising maternal mortality rate. Maternity nursing textbooks reflect the norm of medicalized birth, and nursing students' clinical experiences take place in hospitals that are often not evidence based. Research suggests that knowing 'best evidence' does not change practice unless there is a change in attitudes and beliefs.

Purpose: The purpose of this study was to determine if an evidence based undergraduate maternity curriculum can transform attitudes and beliefs about birth.

Methods: A curriculum was designed that addressed not just cognitive and psychomoter objectives but affective objectives. Birth art was used as a way to evaluate changes in attitudes and beliefs about birth. Students were asked at the start of the first class to draw a picture of birth and themes were developed. During the semester students viewed videos of home births and documentaries on the history and culture of birth and the business of birth. There was an emphasis on evidence based care. Their clinical experiences were analyzed for 'what could have been different'. The midwifery model of care was highlighted. At the end of the semester the students again drew a picture of birth. Themes were developed and compared to the birth art themes from the first class. The research was reviewed by the IRB and classified as exempt.

Results: The initial birth art themes reflected typical US beliefs about birth: birth takes place in hospitals, mothers are in bed, there is a great deal of medical equipment, mothers are fearful and in pain, mothers and babies are not together, nurses and doctors tell mothers what to do. The pictures at the end of the semester were strikingly different. The mothers were up and moving, midwives not doctors attended the births, mothers and babies were together, there was no medical equipment and birth very often was outside the hospital.

Conclusions/Implications: The nursing students' end of the semester art reflected a change in beliefs and values. Nurses who value the normal physiologic process of birth and believe that women have an inherent ability to give birth are more likely to provide evidence based care that facilitates normal physiologic birth. Maternity nursing curricula can be designed that transform nursing student's attitudes and beliefs about birth and this has the potential to influence the care that is provided to women and babies. Birth art is a valuable way to evaluate changes in beliefs about birth.

Integrating Mental Health Assessment Skills in the Treatment of Physically Traumatized Children: Educating Staff Nurses and Defining Predictors of Posttraumatic Stress Disorder (PTSD) in the Pediatric Intensive Care Unit (PICU) at an Urban Children's Hospital

Susan Zannoni, University At Buffalo

Background/Purpose: A critically ill child in a pediatric intensive care unit (PICU) is exposed to an array of extreme psychological stressors. A PICU hospitalization can result in both acute and chronic negative psychological changes in children such as acute stress disorder (ASD) and long term consequences such as posttraumatic stress disorder (PTSD). The application of evidence-based education in trauma-informed care with registered nurses (RN) identifies children who may be at risk for acute psychological distress in the PICU. Registered nurses can (1) increase their knowledge and assessment skills regarding identification and early intervention with children at risk for ASD/PTSD and (2) increase the accuracy of referrals to the social worker by identifying patients at risk for ASD.

Theoretical Framework: Symptoms of ASD may be unnoticed due to severity of concurrent illness/and or injury. Roy's adaptation model of nursing incorporates the interrelated biological, psychological, and social systems and considers how the patient strives to maintain a balance between these systems.

Methods: An educational video was provided by The National Child Traumatic Stress Network (NCTSN) via linked program: the intervention (n = 6), control group with no intervention (n = 7). The design measured the effects of the education on the participant's knowledge, opinions, and self-rated competency by methods of a pre/posttest survey (38-item Likert scale). Fifteen nurses participated in the pretest, 13 in the posttest. Before and after intervention, ASD referrals were calculated. Palliative care and patients < 2 years old were excluded from referrals. Pre/post test design with an intervention and control group. Demographic variables used descriptive statistics. Measures of central tendency were computed for the intervention and control group mean scores on dependent variables of interest. Paired sample t test was conducted separately for intervention and control groups to examine preliminary results.

Results: Results indicated that the development of an educational video could improve opinions about trauma informed care in RNs and increase the ASD referrals. Pre and posttest intervention group mean scores indicate the intervention significantly improved opinion levels (p < .05, t = 3.27). The ASD referrals increased from 27% to 44%: a 61% increase in referrals as related to census.

Conclusions/Implications: Mental health education in the PICU enables the RN to identify potentially traumatic aspects of medical care, support adaptive coping, and screen for ASD indicators. Identifying high risk children will result in appropriate referrals aimed at reducing long term emotional and psychological consequences.

The Interprofessional Communication Scale

Susan Egger, Thomas Jefferson University

Background/Purpose: The interprofessional communication scale for baccalaureate nursing students was developed after a comprehensive literature search revealed a gap in published scales to quantitatively measure interprofessional communication skills in baccalaureate nursing students.

Theoretical Framework: The overall framework for this scale is the Transactional Model of Interpersonal Communication and the Situation, Background, Assessment and Recommendation tool. The interprofessional communication scale is a 26-item instrument that is rated on a 5-point Likert scale.

Methods: The interprofessional communication scale was tested with baccalaureate nursing students in a pilot study (N = 10). The scale was then used in a descriptive, correlational dissertation research study (N = 130).

Results: The interprofessional communication scale was a valid and reliable scale to measure baccalaureate nursing students' perceived interprofessional communication skills.

Conclusions/Implications: The interprofessional communication scale is useful in nursing education. Additional research is recommended for this scale to continue to test validity and reliability as a contribution to nursing science.

Somewhere Over the Rainbow: Bridging the Gap of Transgender Nursing Care

Stephanie Chung, Kean University [black down pointing small triangle] Kristen Patterson, Lacey Twp. Middle School

Background/Purpose: Currently published literature on the transgender population is limited. Lesbian, gay, bisexual, transgender and questioning (LGBTQ) articles are represented less than 0.3% in the medical literature (Poteat, German & Kerrigan, 2013). Much of the research encompasses transgender nursing care with the more widely discussed and grouped LGBTQ health issues. There are no known nursing organizations that have have issued guidelines on the nursing care of transgender patients (Zunner & Grace, 2012). Similarly, at a June 2016 ANA meeting in Washington DC, nurses verbally affirmed that they are ill-prepared to care for this population. This review strives to address the importance of transgender care and illuminate the many health and social vulnerabilities this population experiences.

Theoretical Framework: Transgender theory is an emerging theory that embraces the lived experience of transgender and transexual individuals (Nagoshi & Brzuzy, 2010). This theory provides an all-encompassing framework for understanding and empowering individuals with multiple, intersectional identities (2010).

Methods: A scoping review of national literature was conducted to analyze the integration of transgender teaching in existing nursing curriculums nationwide.

Results: Clear integration of transgender nursing care remains difficult to find in the literature and in nursing school curriculums. Transgender individuals experience social and economic marginalization, including much higher rates of HIV infection, smoking, drug and alcohol use and suicide attempts than the general population. Areas for nursing improvement regarding delivery of care were clearly identified.

Conclusions/Implications: Transgender individuals are typically grouped within LGBTQ, however, there are clear differences in the transgender group alone. Nursing needs to advance its knowledge of vulnerable populations, especially the transgender population, beginning with raising awareness and providing more education in nursing curriculums and programs.

An Integrative Review: Clinical Reasoning in Nursing Education

Mirinda Tyo, University of Massachusetts-Dartmouth [black down pointing small triangle] Mary McCurry, University of Massachusetts-Dartmouth

Background/Purpose: Various educational strategies are used to promote clinical reasoning in nursing education. Evidence to support which approaches are most effective in promoting higher-level thinking in nursing students is limited and results are mixed. The purpose of this study was to explore teaching strategies used to promote clinical reasoning in nursing education and identify the outcomes used to evaluate their effectiveness.

Theoretical Framework: Whittemore and Knafl (2005) was utilized.

Methods: An integrative review framework by Whittemore and Knafl (2005) was applied to examine empirical and theoretical literature to answer the guiding research questions, 1) What types of teaching strategies are commonly used to promote clinical reasoning in nursing students? 2) What outcomes/methods are used for measuring effectiveness of educational approaches to teach clinical reasoning in nursing education? CINAHL, ERIC, Medline, and PsychINFO were searched using a combination of search terms. The initial 195 articles were narrowed to twenty that fit the search criteria and purpose of the review.

Results: Educational strategies used to promote clinical reasoning included simulation (n=8), active learning strategies such as case studies, reflection, and collaborative learning (n=4), teaching strategies such as think-aloud or case studies paired with simulation (n=4), and experiential or clinical experiences (n=4). While most studies (n=5) used satisfaction surveys to measure student engagement, few studies identified evaluation methods for effectiveness of teaching strategies outcomes. Methods identified included observations by clinical instructors and paper-based exams.

Conclusions/Implications: Today's increasingly complex and diverse health care environment requires nurses to be advanced thinkers. Clinical reasoning skills have a direct impact on outcomes for patients, families and communities. Improving clinical thinking requires development of innovative, effective teaching strategies. Self-reported satisfaction surveys, while useful for student engagement, do not provide a comprehensive evaluation of teaching strategies used to teach clinical reasoning. Specific instruments that can accurately evaluate teaching and learning strategies are needed to advance this educational initiative and improve quality of care.

DNP Students' Ability to Recognize and Assess Interprofessional Collaborative Practice: Evaluation of a Clinical Practicum Experience

Mary Lou Manning, Thomas Jefferson University [black down pointing small triangle] Monika Pogorzelska-Maziarz, Thomas Jefferson University

Background: Interprofessional collaborative practice (IPCP) is playing an increasingly important role in health care delivery. According to the AACN DNP Essentials (2006), "DNP graduates have preparation in methods of effective team leadership and are prepared to play a central role in establishing interprofessional (IP) teams." Integrating IPCP clinical learning opportunities within an online DNP program is challenging.

Purpose: Describe the results of a practicum experience designed to help students recognize and evaluate competency-based characteristics of well-functioning IP teams.

Methods: Between June 1 and August 5, 2016 students enrolled in the DNP leadership course observed the IPCP behavior of self-selected teams using the Jefferson Team Observation Guide (JTOG). Each observation was accompanied with a written reflection. The JTOG is a 14-item validated tool, based on the core competency domains for IPCP as defined by the Interprofessional Education Collaborative. The JTOG measures IP communication, roles/responsibilities, values/ethics, teamwork, and leadership. Each item is measured on a 4 point Likert scale. Mean overall scores, as well as scores for each of the 5 domains, were calculated to examine the behaviors of the observed teams. Bivariate analyses were conducted to assess whether scores differed by setting (inpatient, outpatient, other), type of observation (patient care planning or process/system improvement) or observer participation in the team.

Results: Ten post-Master's DNP students conducted 84 observations in 11 health care facilities. The overall mean score across all observations was 3.44 (SD +/- 0.48). The mean scores across the 5 domains ranged from 3.54 (SD +/- 0.49) for roles/ responsibilities and 3.37 (SD +/- 0.65) for values/ethics. There were no differences in the overall or domain-specific scores by observer participation in the team or by type of setting. However, patient care observations were scored higher on the values and teamwork domains (p = 0.014 and 0.061, respectively). High JTOG scores did not always correspond with negative written reflections.

Conclusions/Implications: Students found the practicum "valuable," and the IPCP lessons learned "readily applicable to daily practice." Findings suggest the practicum experience increased students' ability to recognize and assess IPCP, as well as their ability to identify areas for improvement. However, given the consistently high JTOG scores, it may be that written reflection is sufficient.

Having the Conversation: Impacting Suicide Rates in a Third World Country

Janet Knecht, University of Saint Joseph [black down pointing small triangle] Mary Lou Graham, University of Saint Joseph [black down pointing small triangle] Beth Fischer, University of Saint Joseph

Background: Guyana, a former British colony in South America that gained its independence in 1966, is the third poorest country in the Western hemisphere (http://www.worldbank.org/en/country/guyana/overview#1). Guyana suffers the highest suicide rate in the world, with 44.2 suicides per 100,000 persons per year (WHO, 2014). In contrast, the global average is 16 suicides per 100,000 per year. Suicide is the leading cause of death among young people ages 15-24 and it is the leading cause of death among females and the second leading cause of death among males. In 2002, the University of Saint Joseph in West Hartford, CT established the Guyana Immersion Project (GIP) to provide trained personnel, expert guidance, and other resources requested by ministry leaders in Guyana as well as an international experience for students. The World Health Organization (WHO) advocates suicide prevention through development of health care workers to identify and manage mental health disorders. Sadly, however, there are limited resources for those seeking help. There is a shortage of social workers and psychologists and no operating crisis hotline (Guardian, 2015; http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_guy_en.pdf). Nurses are front-line agents in Guyana's healthcare system but these nurses are not sufficiently trained at the present time to identify and assess those at risk of suicide.

Purpose: To provide non psychiatric nurses throughout Guyana, SA with an educational intervention designed to increase their knowledge and self-efficacy in starting the conversation related to suicide with patients throughout Guyana.

Methods: This will be a mixed-methods study. Nurses were selected as the best audience for these workshops/trainings, as they are the first-line caregivers and referral agents in Guyana. They have been recruited from both urban and interior regions. The quantitative component will measure knowledge and self-efficacy of nurses pre- and post-intervention. The qualitative component will consist of focus group sessions post-intervention to determine themes presented by participants in the program. The data will be analyzed using Krippendorff's (2004) method of content analysis.

Results: Ongoing

Conclusions/Implications: According to the WHO, the staggering statistics regarding poverty, suicide, and chronic illness are a call for action to address this phenomenon. The government is engaged in this process and has been collaborating with our University for over a decade. There is a need to establish strong "train-the-trainer" programs for nurses to promote sustainability in the region.

Perceptions of Accelerated Bachelor of Science in Nursing Program Graduates Regarding Andragogical Practices Employed by Faculty

Mary Hanson-Zalot, Thomas Jefferson University

Background: Accelerated, post graduate bachelor of science in nursing programs gained a foothold in colleges and universities across the United States in the 1970s and continue to increase in number. Despite program growth, there is little evidence in the literature exploring these graduates' perceptions of teaching practices used by faculty that have prepared them best to attain program outcomes and engage in professional nursing practice.

Purpose: The purpose of this phenomenological research was to examine accelerated, second-degree prelicensure baccalaureate graduates' perceptions of the andragogical practices employed by faculty that prepare students best to begin practice as entry level professional nurses.

Methods: A phenomenological approach was used to conduct this investigation. The investigator used purposeful sampling methods to identify potential participants for the study from two, private, non-profit universities located in the Northeast section of the United States. Graduates from accelerated, prelicensure, second-degree baccalaureate programs were contacted by e-mail and invited to participate. Twenty-four individuals were successfully recruited. Once informed consent was obtained, demographic data were collected from the participants and each participant engaged in a one-on-one semi-structured interview with the researcher, either face-to-face or via telephone. Digital voice recordings of the sessions were transcribed. Quality checks were incorporated to strengthen the study methodology and presentation of findings that included verbatim transcription of interviews through the use of two digital voice recordings, member checking by having participants review and comment on their spoken words, and an expert debriefing session where consensus was reached on agreement of codes for the first five transcripts generated. Concept mapping was employed as a means to identify themes related to the research questions posed.

Results: Six themes emerged from the data derived from 24 interview sessions. These themes included: (a) range of experience and perception, (b) the context of knowledge, (c) checking in versus checking out, (d) it's not just about strategy: The influence of passion and connection, (e) practice in action, and (f) program demands as preparation for career demands.

Conclusions/Implications: Two significant findings of this study are that faculty attributes of passion and expert knowledge hold prime importance for second-degree learners. It behooves nurse educators to enhance learning environments for this cohort by altering curricula and creating methodologies that capitalize on student prior learning. Engaging in such practices will not only assist with establishing best practices for teaching, but prompt true transformation for these students preparing for the contemporary, professional nurse role.

A Review of Consumer-Based Devices as Data Collection Tools in Research

Margaret McCabe, Children's Hospital-Boston [black down pointing small triangle] Kate Donovan, Children's Hospital-Boston [black down pointing small triangle] Candace Shaw, Children's Hospital-Boston

Theoretical Framework: This integrative review will be guided by the methods of Whittemore and Knafl (2005).

Background: Technological advancement has lead to the development of consumer-based devices, including activity trackers and various monitors, which may be useful for data collection in research. Although experience with and information about use of the devices in research is somewhat limited, the technology is being used increasingly in innovative studies around the country. Researchers may find these devices useful and may not realize they are often capable of collecting more information than is marketed to the consumer.

Purpose: This integrative review of recent studies of consumer-based devices as data collection tools will be useful to a variety of researchers as they consider innovative and useful tools for real time data collection.

Methods: An extensive literature search will be performed with the assistance of a medical librarian. Articles will be included if they are written in English and published between 2010 and 2016 to capture the most recent information. Full text articles will be reviewed using a systematic approach and the MINORS quality index will be completed for each primary source when appropriate. Data will be extracted from the primary sources for descriptive purposes. A constant comparison method will be used to analyze the data.

Results: This work is ongoing, findings from this integrated review will be summarized and presented in poster format.

Conclusions/Implications: As the world of consumer-based devices continues to expand at a rapid rate, integration of this resource as a data collection tool has the potential to enrich nursing research. It is critically important that potential users of current technology have a clear understanding of its potential benefits and risks in the context of research. The goal of this work is to provide nurse scientists with current information to guide decision-making when considering consumer-based devices as tools for research data collection.

Deliberate Practice of IV Medication Procedures by Student Nurses: Feasibility, Acceptability, and Preliminary Outcomes

Deborah Leveille, Massachusetts College of Pharmacy and Health Sciences [black down pointing small triangle] Nancy Morris, University of Massachusetts-Worcester [black down pointing small triangle] Carol Bova, University of Massachusetts-Worcester [black down pointing small triangle] Sybil Crawford, University of Massachusetts-Worcester

Theoretical Framework: Vygotsky's Zone of Proximal Development (ZPD) served as the study framework. According to Vygotsky's ZPD and Assisted Performance theory, learning can be achieved with the assistance of a more knowledgeable other (MKO) such as a teacher or a peer. The ZPD theory consists of four stages: Stages I and II require assistance from MKO; Stage III, performance of the skill is developed. Stage IV, skills are lost without deliberate practice.

Background: Medication errors continue to be one of the most prevalent problems in healthcare related to patient safety, often resulting in injury or death, with higher incidences of error occurring with intravenous medications. Despite the effort to integrate QSEN competencies into undergraduate nursing programs, recent QSEN reports indicate programs continue to lack adequate opportunities for practicing the KSAs required for safe practice.

Purpose: The purpose of this study was to explore the use of deliberate practice (DP) with second-degree nursing students in developing and maintaining fundamental intravenous medication management practices required for safe practice.

Methods: A feasibility study using a two-arm, single-blind, randomized controlled trial (RCT) design. Convenience sample nursing students enrolled in an accelerated graduate program (N = 32) were invited to participate; 19 enrolled, and 12 completed the study. Students (n = 12) received three 30-minute one-on-one bimonthly practice sessions with an expert nurse (intervention group focused on IV skills and attention control group on skills unrelated to IVs). Pre- and post-intervention instruments tested participants' confidence with IV management and safety skills. Primary outcome was their ability to safely administer and monitor IV medications during a 20-minute videotaped medication administration scenario.

Results: Participants completing the study reported positive experience (100%); 91.7% found DP sessions essential to learning. Change in confidence scores for IV skills were significantly (P =.210) higher in the intervention group (2.97-4.14 = 1.50 change) compared to the control group (2.71-3.77 = 1.04 change). Significant differences were found in overall medication administration skills between groups (t[-2.302], p = 0.044) in favor of the intervention group. Overall scores were low, only 16-42 (26%-70%) of the total 60 steps required for safe practice were performed.

Conclusions/Implications: Students reported DP sessions beneficial and they felt more confident in performing skills but three 30-minute sessions (90 minutes) was not adequate to develop, maintain, and refine all the skills associated with safe medication practices. Determining the length and duration of DP sessions as well as comparing the efficacy of DP sessions between individual and group sessions with varying doses and frequencies is needed to advance our understanding of using DP within nursing education.

Moral Distress in Undergraduate Nursing Students: What Keeps You Up At Night?

Veronica Feeg, Molloy College [black down pointing small triangle] Jennifer Baierlein, Molloy College [black down pointing small triangle] Renee Buonaguro, Molloy College [black down pointing small triangle] Jennifer Withall, Molloy College

Theoretical Framework: Jameton sorts moral and ethical problems in the hospital into three different types including moral uncertainty, moral dilemma and moral distress. His working definition provides the context for moral distress in this study: "Moral distress arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action."

Background: Moral distress suffered by nurses has had an array of effects from no effect to leaving the profession. Nursing students in their novice role have minimal firsthand experience in moral dilemmas involving decision making. For some nursing students their only insight into moral decision making may be from viewing heartfelt predicaments in a television medical drama. In clinical situations, they may have heightened awareness of the moral dilemmas that provoke moral distress. Their limited experience in healthcare makes them susceptible to visceral symptoms of moral distress. Understanding what issues might contribute to personal distress is important for nurse educators to target ethics education that takes into consideration how students perceive morally distressful situations.

Purpose: The primary purpose of this study was to describe how nursing students experience difficult situations that are morally distressful and the frequency in which these events have occurred in their education experience. The secondary purpose was to identify "what keeps them up at night" and how these experiences have affected them.

Methods: Based on a previous study done in 2015 on a national sample of nursing students (n=1,620) that described moral dilemmas and "doing the right thing," a new survey was developed with items developed and distributed to a new national sample of nursing students who planned to attend the annual National Student Nurses Association (NSNA) annual conference in 2016 (n=132). A web-based survey was distributed to the email addresses of students who were registered to attend the session "What Keeps You Up At Night?" Participants were asked if they had experienced the 22 morally distressful items, what other events had occurred in their clinical or classroom experiences, and how "distressed" each of these situations might be. Additional open-ended questions asked them to describe what might have helped to ease their distress and what, if any, positives resulted from the experiences.

Results: Descriptive statistics from the quantitative items yielded a rank order of the "most" distressful to the "least" distressful experiences and frequency of occurrence. Qualitative analysis using constant comparison with three judges yielded several themes that described the students' moral distress and its impact on their career plans.

Conclusions/Implications: Understanding what situations stress students morally can help nursing educators plan interventions to minimize the negative impact of moral distress.

Validation of a New Standarized Tool for Undergraduate Nursing Students' Clinical Performance Throughout the Curriculum

Joohyun Chung, University of Massachusetts-Dartmouth

Background/Purpose: Clinical performance evaluation in nursing education has been recognized as a major component of the undergraduate nursing curriculum. Particularly it's essential to identify students who are underperforming during their clinical and to track their clinical performances throughout the curriculum. The aims of this study were to (a) develop an integrated set of standarized assessment insruments that include all clinical performance evaluation for each clinical course throughout the curriculum and to (b) evaluate the new standardized assessment instrument's psychometric properties and ability to assess clinical performance throughout the curriculum.

Theoretical Framework: The instrument was centered on four defined competency domain that were developed to facilitate student learning and progression within the nursing program and to contribute to graduate success in a dynamic healthcare environment.

Methods: A two-phase methodological design was used. In the first phase, a standardized clinical assessment tool was developed in order to measure students' clinical performances in each clinical course (N=9). In the second phase, the validity and reliability of the newly developed assessment instrument was examined. The internal consistency reliability was evaluated by calculating Cronbach's alpha coefficient and Item reliabilities were assessed by inter-rater reliability between faculty and students. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to assess the psychometric properties of the instrument.

Results: The internal consistency using Cronbach's alpha coefficient was 0.68. A two-factor model identified and confirmed with EFA and CFA was used in the new assessment tool to assess 268 undergraduate nursing students from one university.

Conclusions/Implications: Use of the new standardized tool is helpful for nursing faculty to develop remediation strategies for underperforming nursing students throughout the curriculum.

Practicing Expert Nurses (PENs) Re-write Clinical Education: A Dedicated Education Unit

Mildred Kowlaski, Morristown Memorial Hospital [black down pointing small triangle] Kathleen Vnenchak, Morristown Memorial Hospital [black down pointing small triangle] Patricia Primmer, Morristown Memorial Hospital [black down pointing small triangle] Olivia Petzoldt, Morristown Memorial Hospital [black down pointing small triangle] Wendy Silversetein, Morristown Memorial Hospital

Theoretical Framework: NA

Background: Confidence, critical thinking and transitioning to the culture of a hospital are all challenges for nursing students. To address these issues, a dedicated education unit (DEU) used a structured team approach.

Purpose: The collaborative efforts of the school and unit personnel provided an optimal clinical learning environment capitalizing on the expertise of all involved and integrated students into the workplace. PENS remain engaged in critical thinking and role modeling as mentors and students join the current clinical setting and contributed to improved nursing care.

Methods: Seventeen students and ten PENs formed teams to promote evidenced based nursing care. Anxiety, HESI, self-efficacy and Casey Fink were measured at three time points. Focus groups and NCLEX pass rates were also measured.

Results: As expected all students improved on the HESI scores over the semester. The average score pre DEU was 831 and post DEU was 912. National average is 837. All seventeen students passed their NCLEX with sixteen of the seventeen passing in 75 questions. Focus group findings for the PENs revealed a sense of accountability and empowerment with regard to student instruction. The students felt the experience was positive and felt like part of the team. DEU students had exposure to more skills which may have impacted their self-efficacy. The DEU collaboration provided an atmosphere for student learning and professional development. Student nurses were recruited. PENs incorporated the DEU experience in their peer review and set goals for professional growth. Students presented EBP posters at a Research Conference.

Conclusions/Implications: Leveraging the expertise of clinicians and faculty, a collaborative approach heightened engagement of students, faculty and staff, forming strong partnerships. This model resulted in a high NCLEX pass rate (100%) and professional role acceptance by students.

Empowered Holistic Nursing Education (EHNE): A Mid-Range Theory to Empower Diversity in Research and Nursing Education

Katie Love, University of Saint Joseph

Background: Empowered Holistic Nursing Education (EHNE) is a mid-range theory to help holistic nurse educators provide culturally responsive education and create a student-centered classroom. Currently, theories and pedagogies created by other disciplines are used as the theoretical basis for nursing pedagogy. EHNE was created as a nursing pedagogy and reflects nursing's foundational principles of holism, caring, and multicultural practice.

Purpose: The EHNE theory and its five core concepts will be explored, along with both utilization as a pedagogy for practice, and application to diversity in research.

Methods: The mid-range theory of EHNE developed from the four stages of theory development: Inductive, explication, deduction, and retroduction. An extensive literature review was conducted, concept analysis done, and then materials were synthesized and integrated with the experiences of this researcher to develop the mid-range theory.

Results: The five core concepts of this mid-range theory are Prior Knowledge, Contextual Teaching-Learning, Interconnectedness, Self-care, and Meet Them Where They Are. These concepts all support holistic approaches to care, reflect a contextual learning experience, and underscore the importance of a reciprocal relationship between students of all academic levels and faculty. The congruence of EHNE with multicultural, ethical, holistic, and caring evidence-based practice supports EHNE as a nursing pedagogy. Contemporary nursing practice advocates for a model of patient-centered care for diverse patient populations. EHNE re-envisions nursing education to be student-centered in the same way.

Conclusions/Implications: EHNE creates an empowered classroom by role modeling advocacy against bias and discrimination, of doing self-care, and co-creating emancipatory knowledge. EHNE is currently being used by several doctoral candidates as the theoretical framework for the dissertation research with diverse and global populations. Because of the congruence of EHNE with multicultural, ethical, holistic, and caring evidence-based practice, there is support for EHNE as a nursing pedagogy. EHNE synthesizes empowerment and emancipatory pedagogies with concepts of holism to create a learning environment with more cultural responsiveness and support for diverse classrooms.

The Critical Research Evaluation Tool (CRET): Teaching and Learning Tool to Evaluate Research for Cultural Competence

Katie Love, University of Saint Joseph

Background: The Critical Research Evaluation Tool (CRET) is a 45-item tool ideal for teaching students how to evaluate research for its researcher worldview, applicability to multicultural populations, and ethics surrounding potential harms to communities. The tool's construct validity was assessed and confirmed for total and individual items using t-tests, and found to be statistically significant (p<0.001). Internal consistency was calculated with Cronbach's alpha, at 0.96.

Purpose: Nursing is focused on providing appropriate multicultural care, to decreasing health disparities, and providing the best possible care for all communities. To provide "best cultural care" through the use of the CRET, nurses will develop an understanding historical/social/political experiences, and how those experiences impact health and interactions with the healthcare system.

Methods: The CRET was implemented in 11 nursing research courses, including twice in a traditional baccalaureate undergraduate program, four times in an RN-BS program, and five times in a graduate level course. A pragmatic qualitative design was used, wherein as a part of their written CRET papers the students were asked to provide a reflection answering three questions. Data was collected on a convenience sample with an n=138, and analyzed by organizing into themes.

Results: Student reflections were analyzed and fell into three themes, 1) Celebrating nursing research: Learning the fundamentals, 2) Seeing research through a new lens: Recognizing the impact of worldview, and 3) Closing the gap between us: Discovering community engagement.

Conclusions/Implications: It is hoped that the CRET will provide nurses with a more critical view of evidence. There are a few tools for helping students learn to critique a research article, but only the CRET includes a critical analysis the article for multiculturalism and social justice. The CRET could also be a useful tool for nursing faculty teaching critical perspectives related to health disparities and disenfranchised peoples. It is hoped that the inclusion of the CRET in a nursing research curriculum will provide nurses from all levels of preparation with a more critical view of how evidence can be applied to diverse populations, how to evaluate research for its bias, and how to develop their own research to minimize the barriers between historically oppressed groups and healthcare providers.

Secondary Traumatic Stress in Pediatric Nurses

Marni Kellogg, University of Massachusetts-Lowell [black down pointing small triangle] Margaret Knight, University of Massachusetts-Lowell [black down pointing small triangle] Jacqueline Dowling, University of Massachusetts-Lowell [black down pointing small triangle] Sybil Crawford, University of Massachusetts Medical School

Background/Purpose: Secondary traumatic stress (STS) is a state of mental distress or arousal resulting from indirect exposure to the traumatic situation of another individual, for which one has a concern or interest. STS is intrusive, and can lead to a variety of emotional reactions such as sadness, anger, tension, worry or avoidance. The literature indicates that STS is a problem in some specialty areas of nursing and may lead to nurses leaving the profession, yet no studies have examined STS in pediatric nurses using a valid and reliable measure. The purpose of this ongoing study is to investigate STS and coping responses in pediatric nurses. This study will also examine the relationship between age, years of pediatric nursing experience and STS levels, and the relationship between anxiety, job satisfaction and STS levels.

Theoretical Framework: This research will be guided by the Transactional Model of Stress and Coping. This theory assumes stressful experiences are interpreted as person-environment transactions. An individual's stress level at any moment is the outcome of these encounters and depends on how an internal or external stressor is perceived by the individual considering his/her current resources. This model is helpful as it suggests that each individual's perception of a stressor determines his/her stress level (Lazarus & Folkman, 1984). Some pediatric nurses may find traumatic patient experiences to be more stressful if they do not have the appropriate coping processes available, thus they are more susceptible to stress and STS as the result of caring for traumatized patients.

Methods: This research is a predictive correlational study. Non-probability, convenience sampling was used to recruit pediatric nurses who are certified through the Pediatric Nursing Certification Board. The researcher has obtained 350 completed surveys from a random sample of Certified Pediatric Nurses. The researcher utilized the STS Scale, the Brief COPE, Generalized Anxiety Disorder-7, The Brief Index of Affective Job Satisfaction, the Marlowe-Crowne Social Desirability-Short Form, and collected demographics. Descriptive statistics are being calculated to describe demographics, and the prevalence of STS symptoms in the study population. Multiple linear regression analyses are being used to test hypothesis while controlling for social desirability.

Results: All data has been collected and is currently being analyzed. Results will be presented via poster presentation.

Conclusions/Implications: Research examining the problem and common coping responses will promote a better understanding of STS in pediatric nurses. To protect nurses' psychological and physical health, it is important to acknowledge and understand this experience in pediatric nurses. Reference Lazarus, R., & Folkman S. (1984). Stress, appraisal, and coping. New York, NY: Singer Publishing Company.

A New Tool to Measure Certified Registered Nurse Anesthetist Organizational Climate: Instrument Adaptation

Donald Boyd, New York Presbyterian Hospital [black down pointing small triangle] Lusine Poghosyan, Columbia University

Background/Purpose: No tool exists measuring certified registered nurse anesthetist (CRNA) organizational climate. The purpose of this study was to adapt an existing, validated, survey tool to measure CRNA organizational climate.

Theoretical Framework: Conceptual underpinnings from empirical and theoretical work on organizational climate guided this study. CRNA organizational climate is the perception of CRNAs regarding structures within their organizations that affect behavior and outcomes.

Methods: The Nurse Practitioner Primary Care Organizational Climate Questionnaire was selected for adaptation. Participants were purposively selected NY State CRNAs. Content validity testing was accomplished through one in-person meeting of six expert CRNAs. Experts were asked to evaluate item relevance, participate in a group discussion, and recommend additional items. Next, pilot testing was conducted to determine internal consistency reliability through a cross-sectional survey. Thirty CRNAs answered a web-based survey and rated their degree of agreement of items in their primary practice setting from 1 = Strongly disagree to 4 = Strongly agree. Items were arranged into five subscales. Pilot data were analyzed and Cronbach's alphas, inter-item correlations, corrected item-total correlations, and Cronbach's alphas if item were deleted were calculated. Items with low inter-item correlations or item-total correlations <.30 or >70 were considered for removal.

Results: Experts determined that all 34 items were relevant and content-valid. Based on the group discussion, five new items were added resulting in a 39-item instrument. After pilot testing, four items were removed and one subscale was split into two because of low inter-item correlations. Six subscales demonstrated high internal consistency reliability (with respective Cronbach's alphas): CRNA-Anesthesiologist Relations (.753), CRNA-Physician Relations (.833), CRNA-Administration Relations (.895), Independent Practice (.830), Support for CRNA Practice (.683), and Professional Visibility (.772). The 35-item instrument was named the Certified Registered Nurse Anesthetist Organizational Climate Questionnaire (CRNA-OCQ).

Conclusions/Implications: Further refinement of the CRNA-OCQ is necessary to reliably measure and assess CRNA organizational climate. This evidence may help to improve patient and provider outcomes and maximize CRNA contributions to care, which may impact cost, quality, and access to care.

Nurse Perceptions Regarding Clinical Deterioration of Patients

Andrea Fischer, Reading Health System [black down pointing small triangle] Debra Stavarski, Reading Health System [black down pointing small triangle] Vicki Smith, Retired [black down pointing small triangle] Melissa Armstrong, Reading Health System [black down pointing small triangle] Kim Slate, Reading Health System [black down pointing small triangle] Barbara Patterson, Widener University

Background: Failure to rescue is one of several nurse-sensitive outcomes gaining importance in the evaluation of quality of care (Schmid, Hoffman, & Happ, 2007). When physiological signs are not consistently monitored, recorded but not acted upon, or there is a delay in response to abnormal observations, deterioration goes undetected (Nwulu, Westwood, Edwards, Kelliher, & Coleman, p. 371).

Purpose: This study was to describe and understand nurses' experiences recognizing clinical deterioration.

Methods: The study was a descriptive qualitative design. Four focus group discussions occurred in the acute care hospital with nurses from medical-surgical nursing units with two or more years of experience, and experience with rapid response situations. Data were recorded and transcribed, using open and axial coding.

Results: Eight factors were identified as influencing recognition and response to clinical deterioration. Factors affecting recognition of deterioration were workload, resources, experience, team communication, and knowing the patient. Factors affecting response to deterioration included relationships, nurse/physician communication, and teamwork. Clinical nursing judgment affected recognition of and response to clinical deterioration.

Conclusions/Implications: Findings highlight the need for interventions to enhance and support intraprofessional collaboration to facilitate recognition of and response to clinical deterioration. The study supports the importance of a healthy work environment. Measures to improve these areas of clinical practice will have a positive impact on quality of care as well as patient safety. This study affirmed the value for nurses to be confident in their ability to communicate during handoffs, recognize clinical deterioration signs, and know their resources and supportive entities. Nursing staff must communicate vital surveillance data between each other to insure early recognition of clinical changes.

No Puffs, ENDS, or Butts About It: Preparation for a Tobacco Free Campus Policy Initiative Through the Identification of Educational Needs and Interventions for a University Population

Nicole Sala, Binghamton University [black down pointing small triangle] Brittany Bungert, Binghamton University [black down pointing small triangle] Rebecca Feinman, Binghamton University [black down pointing small triangle] Rosemary Collier, Binghamton University [black down pointing small triangle] Lori Sprague, Binghamton University [black down pointing small triangle] Joyce Rhodes Keefe, Binghamton University

Background: Electronic nicotine delivery systems (ENDS) and hookah use has increased in recent years. There is mixed research on these products' utility as a reduced harm alternative to traditional cigarettes in current smokers. The danger of ENDS use in young adults otherwise naive to nicotine is an increased likelihood to smoke traditional cigarettes, contributing to the renormalization of smoking. Additionally, during hookah sessions tobacco exposure is ten times that of traditional cigarettes. Population wide prevention and cessation efforts, such as tobacco free campus policies and educational initiatives have been shown to be effective.

Purpose: This study used a mixed-methods approach to describe behaviors, perceptions, and knowledge regarding alternative tobacco products to identify effective educational interventions to support a tobacco free campus policy change on a northeastern campus.

Methods: Over 1,100 surveys were collected and analyzed using SPSS 22.0 from six survey events over four years at a northeastern university. One additional event, occurring this fall, will be included in final analyses. Three focus group transcripts were conducted regarding alternative products and interventions preceding a tobacco free campus policy intervention.

Results: Of the preliminary surveys available, 873 were analyzed. The majority were undergraduates 89.8% (N=733), 8.7% (N=76) were graduates, and 1.4% (N=12) were not pursuing a degree. Third and fourth year undergraduate students were more likely to use e-cigarettes (p=.011) than their first and second year counterparts. Those using hookah stated exposure occurred through friends (48.8%, N=145), family (5.4%, N=16), or proximity to product (3.7%, N=11). Most respondents reported using hookah in a bar/lounge (N=120). Of those surveyed, 69.5% (n=219) reported not knowing any ingredients in ENDS, and 58% (n=181) respondents reported not knowing any ingredients in hookah. The focus group themes identified include 1) mixed messages received from media regarding health effects, 2) desire for educational interventions, and 3) influences of social acceptance on attitudes toward alternative tobacco products.

Conclusions/Implications: The knowledge gap identified by the survey, and the desire for clear and comprehensive information indicates that a campus-wide educational intervention addressing misinformation and reasons for use may help promote a tobacco free campus.

Utilization of Registered Nurses in Primary Care Interprofessional Teams: A Cross National Comparison and Review

Allison Norful, Columbia University [black down pointing small triangle] Grant Martsolf, University of Pittsburgh [black down pointing small triangle] Lusine Poghosyan, Columbia University

Background/Purpose: Individual primary care physicians (PCPs) would require an estimated 21 hours/day to complete all recommended care guidelines. Team-based care is proposed to alleviate this strain but is dependent on a clear understanding of the responsibilities of each team member. The literature has widely explored the use of non-physician team members, such as nurse practitioners and physician assistants, yet fails to define the use of registered nurses (RNs) in primary care. The purpose of this review is to identify and synthesize all studies that investigate RN roles and responsibilities in primary care teams.

Theoretical Framework: The Interprofessional Teamwork for Health and Social Care model was applied during the synthesis of this review.

Methods: A PRISMA search resulted in sixteen studies conducted across five countries. Whittemore and Knafl's methodologic guide for integrative reviews was used. Studies underwent quality appraisal, data reduction and comparison. Over 5,000 RN-patient encounters and 1,100 RNs working in primary care made up the collective sample. Settings included private practices, government-funded clinics, and academic/hospital-affiliated offices.

Results: RNs roles are complementary to the PCP visit but dependent on effective task delegation from the PCP. Robust policy/protocol enables extensive clinical responsibilities that alleviate PCP and organizational workload. RN roles contribute to chronic disease management, care coordination, polypharmacy management, and specialty population care. The most frequent clinical responsibilities include medication administration, wound care, vaccinations, and education. Organizational tasks include quality assurance, policy maintenance, referrals, and patient complaints. In the U.S. there was limited use of primary care RNs in research and policy maintenance. The presence of medical assistants enable RNs to manage more complex patients.

Conclusions/Implications: Organizational policy variability yields an underutilization of RNs in primary care. This review illuminates RN roles and responsibilities across countries so organizations and policymakers can optimize RN use thereby alleviating strain to complete care guidelines and improve quality of care.

Mindfulness Practices Used With Nurses in Work Settings: Integrative Review

Jin Jun, New York University

Background/Purpose: Stress and burnouts are common among nurses. Managing occupational stress for nurses is important because stress can adversely affect attitudes, staff morale, job satisfaction, turnover rates, communication, emotional and physical health, quality of life, and most importantly, quality of care. Mindfulness is defined as non-judgmental-present moment awareness and has become a core construct in certain stress-reduction programs. The purpose of this integrative review is to critically appraise the current literature on mindfulness practice used with nurses at work. The specific aims are to 1) explore the types of mindfulness practices, 2) evaluate the effectiveness of mindfulness practices, 3) examine the feasibility of mindful practices.

Methods: Integrative review by Whittemore and Knafl was used. PubMed, PyschInfo, ProQuest, Web of Science, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were used for a comprehensive search. The inclusion criteria were primary intervention studies examining mindfulness practice used with nurses at work. Review papers, white paper, or opinions were excluded.

Results: Twelve articles were included in the review. The majority of mindfulness practices used were guided meditation in group settings or at home (n=10), one study explored the use of the online program, and another study examined the use of a combination of the interventions. The duration of interventions ranged from 4-week to 8-week. Regardless of the type, duration, or the sample of the interventions, the mindfulness practices all resulted in improvement in the participants' well-being (n= 4), stress level (n= 8), burnout (n= 3), anxiety level (n=4), cognition (n=2), empathy (n=1), resilience (n=2), and general health (n= 4). The studies The interventions for mindfulness practice also did not require extensive training or time for nurses to reap the benefits.

Conclusions/Implications: Nurses deal with a great deal of stress in their lives and at work. An integrative review of the use of mindfulness practice holds promise for increasing individual well-being, workplace resilience, empathy, and decreasing stress.

Integrative Review of Nurses on Boards

Lisa Sundean, University of Connecticut [black down pointing small triangle] Jacqueline McGrath, University of Connecticut [black down pointing small triangle] E. Carol Polifroni, University of Connecticut [black down pointing small triangle] Kathryn Libal, University of Connecticut

Theoretical Framework: The philosophical tenets of feminism underpins the integrative review and addresses marginalization, power imbalances, and inequalities associated with patriarchal and gendered norms. At the board level, a feminist perspective ensures governance decisions serve the best interests of all people and not the privileged interests of few, thus ensuring the social justice imperative inherent in nursing.

Background: The Institute of Medicine/National Academy of Medicine recommends nurses lead on boards of directors to shape healthcare transformation. The call for nurses on boards (NOB) is supported by may nursing organizations; however, only 5% of healthcare board seats are occupied by nurses in the US. Expert nurse leaders advocate for NOB as a critical role to support healthcare advancements. Few studies; however, focus on this emerging nursing leadership role.

Purpose: The purpose of the integrative review was to: 1. Synthesize the extant research evidence about NOB; 2. Identify gaps in the research; 3. Make recommendations for research and practice.

Methods: The integrative review is a systematic review research design and was informed by the PRISMA guidelines. The search was conducted from June-December 2015 and reassessed in May 2016. Inclusion criteria included studies focused on or making recommendations about NOB. No time limits were imposed. Approach included database search, hand search, citation snowballing and tracking. Rigor of studies was assessed. Comparative analysis was conducted between studies and led to the emergence of categories.

Results: Thirty-one studies were evaluated and 11 were included in the review. Comparative analysis led to the identification of 5 categories: Missed opportunities, call to action, barriers and marginalization, nurses' voice, and power of the nurse-on-board. The themes describe missed opportunities to engage NOB, professional barriers, and marginalization. Recent studies reiterate the call for NOB, demonstrate the unique experiences of NOB, and suggest NOB are related to overall healthcare board performance.

Conclusions/Implications: A dearth of research exists about NOB and the extant literature does not demonstrate a coordinated program of research about this important topic. Board service is a critical role for nurses as a means to lead and influence healthcare transformation. A coordinated program of research about NOB is recommended to substantiate this emerging leadership role as it relates to healthcare transformation, social justice, and healthcare outcomes.

Nurses' Perceptions of Monitor Watchers

Halley Ruppel, Yale University [black down pointing small triangle] Marjorie Funk, Yale University

Background: Monitor watchers are personnel employed to watch central cardiac monitors and alert clinicians of patient events. Research has indicated that about 50-60% of hospitals may use monitor watchers, although results of one study suggested that the presence of monitor watchers was not generally associated with fewer adverse outcomes. Monitor watchers must work closely with the patient's nurse to communicate changes in the patient condition. The presence of monitor watchers alters nurses' workflow and responsibilities; however, the effect of monitor watchers on nursing practice has not been explored.

Purpose: The purpose of this study is to examine nurses' perceptions of monitor watchers in hospitals.

Methods: This study is a secondary qualitative analysis of comments written by nurses on a 2016 national survey of monitor watcher use in acute care settings. The purpose of the primary study was to examine the use of monitor watchers and their characteristics, training and practices in hospitals. In the primary study, an online survey was distributed through a link in electronic newsletters of two nursing organizations. The survey allowed participants to type optional comments at the end. The prompt for the open-ended comments was, "Please add any additional comments that you feel are important to consider when using monitor watchers." For the present study, those comments are analyzed using qualitative content analysis in Atlas.ti software.

Results: Of the 411 nurses who participated in the primary study, 83 provided comments in response to the prompt above. In our preliminary analysis of these data, nurses perceive monitor watchers to directly affect their workflow, both negatively and positively. Nurses who work with monitor watchers expressed concern over monitor watchers' ability to discern critical events. They also noted logistical challenges presented by adding monitor watchers to a system of care. Respondents contrasted the use of monitor watchers to the use of middleware as an alarm management strategy.

Conclusions/Implications: Nurses' work is affected by the presence of monitor watchers, and this study provides a preliminary assessment of how nurses perceive monitor watchers. These results can be used to inform and guide future research on the use and effectiveness of monitor watchers and their relationship to nursing workflow.

Need for Specialized Support Services for Nurses Assaulted in the Psychiatric Area

Lois Moylan, Molloy College [black down pointing small triangle] Marybeth McManus, North Shore-Long Island Jewish Health System [black down pointing small triangle] Meritta Cullinan, Molloy College

Theoretical Framework: NA

Background: Assault of nurses in the psychiatric setting is an ongoing global concern. In a prior study by these authors, many nurses reported concern about the lack of supportive interventions offered to nurses after the assault event.

Purpose: A follow-up study was done to investigate the perceived need of assaulted nurses for specialized support groups to assist them in dealing with the experience.

Methods: Design: Mixed Methodology. A quantitative, cross sectional survey descriptive research design was done to assess assaulted nurses' perceived need for specialized support groups. The survey also gathered data relating to the reporting of the assault. A qualitative narrative section was added to gather data that might have been missed in the quantitative segment. Participants: The sample consisted of 57 previously assaulted nurses currently working at five acute care psychiatric sites. Setting: 1. A large multi-site healthcare system with acute care psychiatric settings in the New York City metropolitan and surrounding suburban area. 2. American Psychiatric Nurses Association Discussion Forum. Data Collection: After IRB approval, a packet containing instruments, a demographic form and consent were delivered electronically using Snap survey software. Analysis: Descriptive statistical analysis was provided by the Snap program. Further inferential statistical analysis was done using the SPSS program.

Results: Study findings showed that if specialized support groups were available, 57% of the nurses might be interested in attending these, and 41% would be interested in attending these. These nurses also reported multiple signs and symptoms of post-traumatic stress disorder. Additionally, it was found that a majority of assaults are not reported for multiple reasons.

Conclusions/Implications: Considering the serious negative impact of assault on nurses and their desire for follow-up support, there is a need for the availability of supportive services.

Making Sense of Moral Distress Within Cultural Complexity

Toby Bressler, Maimonides Medical Center [black down pointing small triangle] Elizabeth Smith, Maimonides Medical Center [black down pointing small triangle] Debra Hanna, Molloy College

Background: Many studies of moral distress have explored nurses' experience of caring for patients. Acting ethically in accordance with professional nursing practice and in concert with professional values is the core of nursing. Moral distress involves situations in which moral values are challenged. Moral distress can be related to the nurse's locus of control, his or her ability to protect the patient's wellbeing, close and constant physical presence at the bedside, and other situational variables.

Purpose: To explore the nurses' experience; to determine if nurses experience moral distress and if so, to determine contributors and consequences, coping strategies, and ideas for addressing identified issues.

Methods: A qualitative study of 27 nurses (71% participation rate) was conducted using semi-structured focus groups which were audiotaped and transcribed. Our research team conducted analysis of excerpts from focus groups. Using descriptive, axial coding, the team independently reviewed and coded excerpts from consecutive focus groups, revising the coding scheme and categories based on emerging findings into higher-level themes that describe the experiences described by the participants.

Results: Content analysis revealed three levels of themes: universal themes (workload, lack of appreciation), themes common to other studies of nurses in end-of-life care (aggressive medical treatment, providing unrealistic hope to patients and families), and unique interconnected themes (significance of teamwork cultural mismatch, nurses' expectations of their role not being completely met). The main finding was an incongruence of perspectives, described as depth-of-field dissimilarity, in which the focus and depth of perspective depends on the person doing the looking. We will provide exemplar quotations to illustrate each of higher-order themes and sub-themes.

Conclusions/Implications: Nurses want to practice in an environment where they feel professional satisfaction and pride in their work. Providing care that conflicts with one's conscience and ethical values on a frequent basis is unhealthy and contributes to moral distress. This study suggests that depth-of-field dissimilarity can be used to develop educational strategies, interventions, and research to address moral distress and cultural complexity. Nurses need to accept the values of their patients and families, reconciling personal values that may be different and learn to navigate their own web of emotions and build resilience through recognition, support and education. Moral uncertainties and ethical dilemmas are inherent in the practice of nursing. As nurse leaders we need to support our colleagues to develop skills which enhance wellbeing, work together to create organizational strategies to mitigate moral distress, and help nurses grow through their experiences of moral distress.

Nurses' and Physicians' Perceptions of Interprofessional Collaboration: An Integrative Review

Inderani Walia, New York University

Background/Purpose: Studies have shown that effective interprofessional collaboration between nurses (RNs) and physicians (MDs) is critical to the delivery of quality care to improve patient outcomes, increase staff motivation and reduce turnover. Nursing and medicine are two distinct disciplines that are educated and clinically trained differently; yet post-graduation are expected to seamlessly come together in the healthcare setting for the common goal of providing safe patient care. Nurses and physicians comprise the largest portion of the healthcare workforce and the need to improve nurse-physician collaboration is essential. To work collaboratively and provide safe, high quality patient care, a greater understanding of the disciplines and their views on interprofessional collaboration is necessary.

Theoretical Framework: This integrative review followed the guidelines outlined by Whittemore and Knafl (2005).

Methods: This integrative review of U.S. and non-U.S. studies from the last ten years explored the state of the science of RNs' and MDs' perceptions of RN/MD collaboration. This review (a) used electronic data-bases to retrieve 1,968 studies, (c) determined 13 met the inclusion criteria which were analyzed using standardized critiquing criteria, and (d) synthesized the findings. Studies were considered if the stated purpose was to examine perceptions or attitudes of collaboration of both nurses and physicians in the study, were U.S. or non-U.S. European countries, and were published during the ten-year time line noted previously.

Results: This review (a) used electronic data-bases to retrieve 1,968 studies, (c) determined 13 met the inclusion criteria which were analyzed using standardized critiquing criteria, and (d) synthesized the findings. Studies included in this review include ten quantitative studies, of which six are U.S., two non-U.S. qualitative studies and one mixed-method.

Conclusions/Implications: The conclusion drawn was that the majority of studies found that RNs had a more favorable perception of collaboration than MDs. In contrast, MDs were more satisfied with collaborative decision making than were RNs. Additionally the tools used to study this issue had varying validity and reliability lending little confidence in the findings. Thus, there is insufficient evidence to support why these differences exist and how to improve RN/MD collaboration to enhance patient-centered care. Further studies are needed, in particular, phenomenological studies to gain insight into this issue in order to grow nursing science to improve the quality of care to individuals, families, and communities. Implications for practice and academic settings include their implementing the recommendations of the following documents to help foster RN/MD collaboration: Interprofessional Education Collaborative Expert Panel's (2011) Core Competencies for Interprofessional Collaborative Practice and the Future of Nursing (IOM, 2011).

Patient Complexity Factors and Their Influence on Nurses' Perception of Staffing Adequacy

Margaret Duffy, North Shore University Hospital

Background/Purpose: Nurse leaders must consider the influence of nurse-specific and patient-specific factors on nursing workload and nurses' perception of staffing adequacy when developing nurse staffing plans. All of the factors that influence individual nurses' perception of staffing adequacy are not known. The purpose of the study was to determine if selected patient complexity factors not consistently captured in the measurement of patient acuity by commercial staffing software influence nurses' perception of staffing adequacy.

Theoretical Framework: The theoretical framework for the study was a synthesis of the Roy Adaptation Model (RAM) at the individual and group levels and selected components of economic theory as applied to health care. A theoretical proposition of RAM was tested to describe the interaction between the group subsystems and the RAM modes in relationship to the goals of an organizational system.

Methods: The study employed a complex predictive correlational research design that included multiple logistic regression analysis with six predictors, bivariate analyses, and repeated measures of patient, shift, and nurses' data. Twenty-six Registered Nurses (RNs) from two patient units contributed data from 1,605 different patients. The number of shifts with complete data used for final analysis was N = 294.

Results: Disruptive behavior (r= -.274) and family demands (r=-.186), were negatively correlated with nurses' perception of staffing adequacy and explained 10% of the variance in a regression model. There was a negative correlation between total shift factor score (r=-.418), derived from the presence of patient complexity factors, and nurses' perception of staffing adequacy. No correlation was found between perception of staffing adequacy and nurse staffing variables. The RAM proposition was supported.

Conclusions/Implications: The differences among the predictors revealed the nature of perception of staffing adequacy and led to new explanations of why patient acuity, classification, ratios, and financial data are outdated paths to knowledge about safe staffing. Nurses need different types of support to meet patient needs and help them deal with negative aspects of their workload. These findings inform the science of nurse staffing by showing which variables might now be collected in large data systems.

Choosing Wisely: Radiation Oncology Private Practices Slow to Incorporate Evidence Based Practice

Bonnie Jerome Demilia, Rutgers University

Background/Purpose: Hypofractionated radiation therapy (RT) is a clinically efficacious short course of treatment for certain patients after breast conservation surgery, but it is underused in the United States as compared to Canada and the United Kingdom. It has been recommended for use by the Choosing Wisely program, a program to encourage physicians to identify the value of treatments that are regularly used. The aim of this study was to evaluate the use of hypofractionated RT over time in a large, privately owned radiation oncology practice in the United States.

Methods: This cross sectional study utilized a cancer database maintained by a private radiation oncology physician group. Bivariate associations of patient, geographic location and tumor variables were tested with the Pearson's chi square test. Covariates found through bivariate analysis to be associated with hypofractionation with p values of < 0.5 were included in a multivariate logistic regression model, with the addition of tumor grade which is an important clinical finding that has been found to be associated with the effectiveness of hypofractionated RT. The logistic regression model was used to identify an association between covariates and the odds of receiving hypofractionation therapy.

Results: Of the 5959 women in the database, 230 or 3.86% of the total cases received hypofractionated RT. The number of women that were treated with the shorter course of radiation increased over the study period, from 1.4% of patients in 2004 to 8.76% of patients in 2013 (p < .001). In the logistic regression model, the significant factors related to the use of hypofractionation were age, with older women more likely to receive hypofractionation, particularly women over 80 years of age (OR 7.14; 95% CI 3.61-14.1; p < .001), facility location, with the West as the area in which women were most likely to receive hypofractionation (OR 7.93; 95% CI 4.01-15.66; p < .001), and year of surgery with 2013 as the year in which a woman's chance of receiving hypofractionation was highest (OR 6.94; 95% CI 2.60-18.49; p< .001).

Conclusions/Implications: A significant majority of patients for whom hypofractionated RT would be appropriate did not receive it. The factors associated with the use of hypofractionated RT were nonclinical. The increase in the use of the short course of treatment over the course of ten years is consistent with recent US studies, and is consistent with the typical diffusion of medical innovation which will show an increase over time. For many women with early stage breast cancer, hypofractionated radiation therapy is a clinically efficacious choice, with a decreased risk of complications and morbidity. While this treatment is standard of care in Canada and the United Kingdom, it is vastly underutilized in the United States. Nurses should be aware of treatment alternatives that have been found to be clinically appropriate, yet may not be in widespread use as a result of non-clinical factors.

Perceived Barriers to Attending Psychiatric APRN Programs

Lisa Harrison, University of Connecticut [black down pointing small triangle] Thomas Van Hoof, University of Connecticut

Background: In Connecticut, there is a critical shortage of psychiatric prescribers, which creates a barrier to accessing mental health treatment for patients. In spite of increased autonomy and reported high levels of job satisfaction for psychiatric nurse practitioners, as well as funding opportunities for advanced practice psychiatric nursing education, this shortage persists.

Purpose: The purpose of this study is to examine the perceived barriers to increasing the number of psychiatric nurse practitioners in Connecticut.

Methods: Surveys with open and close ended questions regarding perceived barriers to increasing the numbers of psychiatric APRN graduates were developed and administered via Qualtrics to representatives of schools of nursing in CT offering clinical graduate programs as well as CT licensed registered nurses. For both participant groups, close ended questions were analyzed using descriptive statistics. Open ended questions were analyzed using Krippendorf's content analysis. All results were reported in aggregate to protect the confidentiality of the participants.

Results: 7 participants from schools of nursing responded. Grants and scholarships were available. Barriers were that there is a shortage of qualified faculty, there were too few local programs, not enough flexibility for graduates, a shortage of clinical sites, and that the programs were expensive to offer. 185 RNs responded. 27% considered becoming psychiatric APRNs. 28% didn't want to return to school and 43% didn't like psychiatric nursing in school. Other perceived barriers were related to work/life balance, program issues, the psychiatric APRN role, and the patient population.

Conclusions/Implications: Results indicate that there are misperceptions about the psychiatric APRN role, opportunities available, and the patient population. RN-level education changes as well as increasing awareness of opportunities available could help increase the number of APRNs.

Vicarious Posttraumatic Growth in Certified Nurse-Midwives: A Mixed Methods Study

Cheryl Beck, University of Connecticut [black down pointing small triangle] Jamie Rivera, Westfield State University [black down pointing small triangle] Robert Gable, University of Connecticut

Theoretical Framework: Tedeschi and Calhoun's posttraumatic growth model was the theoretical framework that underpinned this mixed methods study.

Background: Posttraumatic growth refers to the positive psychological changes experienced as a result of struggles with highly challenging life events. When this growth occurs in clinicians due to caring for patients who are traumatized, it is termed vicarious posttraumatic growth. It has been reported that 29% of certified nurse-midwives (CNMs) experienced high to severe levels of secondary traumatic stress after attending traumatic births.

Purpose: The purpose of this study was to investigated the following research questions: (1) What are the levels of vicarious posttraumatic growth in CNMs who have struggled after attending traumatic births? (2) To what extent do CNMs examine their core beliefs after traumatic births? and (3) What are the experiences of CNMs regarding vicarious posttraumatic growth?

Methods: A convergent parallel mixed methods design was used. Both the qualitative and quantitative methods were prioritized equally. The quantitative and qualitative data were kept independent during data analysis and then the results were mixed during the interpretation phase. The American College of Nurse-Midwives sent out e-mails to all CNM members with a link to the electronic survey. CNMs completed the Posttraumatic Growth Inventory and the Core Beliefs Inventory in the quantitative portion. For the qualitative portion CNMs responded to a statement asking them to describe their experiences of any positive changes in their beliefs or life after attending traumatic births. IBM SPSS 23.0 and Krippendorff's content analysis were used to analyze the quantitative and qualitative data, respectively.

Results: The sample consisted of 425 CNMs who completed the quantitative portion and 315 (74%) who completed the qualitative portion. CNMs reported a small degree of both disruption of their core beliefs and vicarious posttraumatic growth. Personal Strength was the dimension of the Posttraumatic Growth Inventory that reflected the highest growth followed by Appreciation of Life, Relating to Others, Spiritual Change, and New Possibilities. In the qualitative findings Personal Strength was also the category of vicarious posttraumatic growth most frequently described. TheCore Beliefs Inventory scores accounted for 43% of the variance in CNMs' posttraumatic growth.

Conclusions/Implications: This study confirmed a positive relationship between the degree that a CNM's core beliefs are challenged and the amount of vicarious posttraumatic growth that is experienced. The process of re-examining ones' beliefs about the world such as, the meaning of life, things that happen to people are fair, one's strengths and weakness, and relationships with others, can be key to vicarious posttraumatic growth in clinicians.

Evaluating a Clinical Pathway-Based, APRN-Managed Care Model in a Pediatric Acute Care Environment

Danielle Altares Sarik, Nemours/Alfred I. duPont Hospital for Children [black down pointing small triangle] Elizabeth Johnson-Salerno, Nemours/Alfred I. duPont Hospital for Children [black down pointing small triangle] Stacey Bachman, Nemours/Alfred I. duPont Hospital for Children [black down pointing small triangle] David Hancox, Nemours/Alfred I. duPont Hospital for Children

Background/Purpose: Despite the critical role that nurses play in providing care to hospitalized patients, limited data on the relationship between advanced practice registered nurse-led (APRN) care models and pediatric outcomes exist. Upon identifying barriers to care of common pediatric conditions leading to admission, an interprofessional team developed a plan to create a 24 bed limited-stay, pathway-based, inpatient unit to streamline treatment. In 2014, the APRN-managed unit was opened with the goal of standardizing care, improving outcomes, and increasing nurse autonomy and satisfaction. The purpose of this study was to examine clinical outcomes (length-of-stay, 30-day all cause readmission) as well as nurse-reported experience measures associated with this model of care.

Theoretical Framework: This research was shaped by Donabedian's Structure-Process-Outcomes Model. We propose that changes in the hospital structure (building of a new unit) and process of care (nurse-led, clinical pathways) may lead to changes in patient outcomes (length-of-stay and readmission). Studies suggest that clinical pathway-based care may provide improvement in outcomes, but limited research exists.

Methods: This study is a retrospective review of seven main categories of pediatric admissions (asthma, bronchiolitis, cellulitis, dehydration, gastroenteritis, pneumonia, infections of/affecting the upper respiratory tract) to the unit of interest from January 1-December 31, 2015. Patients were included in the analysis if they had a primary discharge diagnosis falling into one of the seven categories and were admitted to the unit of interest. The hospital system of interest is a 200-bed, Magnet-recognized, mid-Atlantic, pediatric acute care hospital. Descriptive statistics and multiple regression analysis were used to assess the outcomes of care provided.

Results: Significant differences between average length-of-stay by condition on the new unit and similar conditions cared for on other units were noted. Additionally, 30-day readmission rates were considerably lower for patients treated on the new unit. Nurse experience as measured by the Practice Environment Scale was higher than the average for similar institutions, with 96% of surveyed RNs reporting that they planned to stay on the unit.

Conclusions/Implications: This model offers a solution to standardize care for common pediatric conditions, while increasing nurse autonomy and decreasing length of stay and readmission. This model demonstrates the importance of nurses in high quality care.

The Effect of Public Reporting on Cardiac Outcomes for Acute Myocardial Infarction Patients: A Systematic Review of the Evidence

Pamela de Cordova, Rutgers University [black down pointing small triangle] Kathryn Riman, Rutgers University

Background/Purpose: Public reporting of patient outcomes has been implemented to reflect provider and hospital quality for consumers. For patients with an acute myocardial infarction (AMI), public reporting may provide data about whether a patient received a percutaneous coronary intervention (PCI) and the outcome of the procedure. Currently, this type of public reporting exists in three states - New York (1991), Massachusetts (2005), and Pennsylvania (2001). Given the controversy of public reporting, researchers have been examining the effectiveness of the public reporting process. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the purpose of this systematic review is to assess the relationship between the process public reporting and cardiac outcomes for AMI patients.

Theoretical Framework: NA

Methods: A systematic search of Ovid-Medline, PubMed, and CINAHL was conducted. Studies included were full-text primary research studies that were published in peer-reviewed journals, written in English and examined the effectiveness of public reporting. Methodological quality of studies was evaluated following a validated instrument that assessed: research design, intervention measurement if applicable, threats to validity, and appropriate statistical analyses. Two evaluators rated each study independently and then discussed the results to come to consensus.

Results: There were 415 articles screened, and fifteen articles were included in the review. Eleven articles received a weighted average score of greater than 75% on the evaluation criteria indicating high quality methods. Out of 15 studies, eight groups of researchers found significant relationships between public reporting and increased quality outcomes for AMI patients. Public reporting may also be associated with interventional cardiologists caring for less high-risk patients because these providers will not be penalized if they operate only on patients who are likely to survive.

Conclusions/Implications: The evidence was mixed on whether the process of public reporting improves quality of care for the AMI population. Although there were weaknesses in the strength of some of the evidence, cardiac nurses should inform AMI patients about balancing the accountability and possible risk aversion of an interventional cardiologist in public reporting states.

Trends in Nurse Workforce Capacity Building in Sub-Saharan Africa

Laura Ridge, New York University [black down pointing small triangle] Robin Klar, New York University [black down pointing small triangle] Amy Stimpfel, New York University [black down pointing small triangle] Allison Squires, New York University

Theoretical Framework: Hilderbrand and Grindle's (1996) model for Dimensions of Capacity

Background: "Capacity building" is an international development strategy receiving billions of dollars of investment annually and utilized by major development agencies globally. However, there is a lack of consensus around what "capacity building", or "capacity" itself, means. Nurses are frequent targets of capacity building programming in sub-Saharan Africa as they provide the majority of healthcare in that region.

Purpose: This study explored how "capacity" was conceptualized and operationalized by capacity building practitioners working in sub-Saharan Africa to develop its nursing workforce.

Methods: This integrative review of fourteen papers utilized conventional content analysis to assess how capacity building practitioners working in sub-Saharan Africa utilize the term "capacity" in the nursing context. Content analysis was conducted separately for how capacity building practitioners described "capacity" versus how their programs operationalized it. Hilderband and Grindle's (1996) "Dimensions of Capacity" model was assessed for fit with "capacity"'s definition in the field.

Results: Analysis showed primary themes for conceptualization of capacity building of nurses by practitioners included: human resources for health, particularly pre- and post- nursing licensure training, and human (nursing) resource retention. Other themes included: management, health expenditure, and physical resources. There are several commonly used metrics for human resources for health, and a few for health expenditures, but none for management or physical resources. Overlapping themes of operationalization include: number of healthcare workers, post-licensure training, and physical resources. The Hilderband and Grindle (1996) model was a strong fit with how capacity is defined by practitioners working on nursing workforce issues in sub-Saharan Africa.

Conclusions/Implications: This review indicates there is strong informal consensus on the definition of "capacity" and that the Hilderbrand and Grindle (1996) framework is a good representation of that consensus. This framework could be utilized by capacity building practitioners and researchers as those groups plan, execute, and evaluate nursing capacity building programming.

Barriers and Facilitators of mHealth Adoption in Hospitals: A Survey of Nurse Executives

Rose Ann DiMaria-Ghalili, Drexel University [black down pointing small triangle] Swathi Veeravalli, Drexel University

Background/Purpose: Researchers are developing various mobile health (mHealth) applications and digital health technologies targeting patients and consumers to support chronic disease self-care management. Reports are emerging on positive findings from the use of mobile health technologies, yet it is unknown what barriers prevent wide-spread adoption in hospitals. The purpose of this online survey is to identify barriers and facilitators perceived by hospital nurse executives to the adoption of mobile health technologies for chronic disease self-management.

Methods: The Mobile Health Adoption in Hospitals Survey (MHAHS) was developed using a Modified Delphi methodology. Since there are no surveys on adoption of new mobile health technologies in hospitals, we adapted items from a Dutch Survey on factors influencing eHealth adoption by Dutch hospitals (Faber, 2014), CDC National Health Care Survey, Barriers to Medical Device Integration: CNO Survey Results (Iattic Systems, 2015) and a survey on Barriers to Telemedicine in Acute Care Units (Rogrove et al 2012). After several drafts of the survey, the MHAHS survey was reviewed by four content experts. Based on their feedback, the final MHAHS was developed. The online survey, developed on Qualtrics: Online Survey & Insight Platform, will be launched once approved by IRB. A convenience sample of Chief Nurse Executives across PA, NJ, NY and DE will be invited to participate in the survey.

Results: In progress.

Conclusions/Implications: Identifying perceived barriers and facilitators can lead to a better understanding of systems that are needed to support new mobile health technologies, with the ultimate goal of improving patient outcomes.

Accuracy of Intake and Output Monitoring in Hospitals: A Pilot Study

Rose Ann DiMaria-Ghalili, Drexel University [black down pointing small triangle] Marianne Mallon, Drexel University [black down pointing small triangle] Christine Chen, Drexel University [black down pointing small triangle] Zachary Hathaway, Drexel University [black down pointing small triangle] Yosefa Birati, Drexel University

Background/Purpose: Intake and output monitoring is a routine component of nursing care in the hospital setting. A recent unpublished online survey conducted by our team found that in a sample of 174 hospital nurses, 55% reported the intake and output chart in the hospital setting as accurate. This is problematic as in some acute and chronic conditions (e.g., heart failure, malnutrition) patients are often placed on strict intake and output monitoring and/or a fluid restriction in the hospital setting to guide treatment. The objective of this pilot study is to explore the accuracy of oral intake in the intake and output record in the hospital setting.

Methods: Patients (N=5) with heart failure who had a physician order for strict intake and output monitoring and/or fluid restriction were enrolled in the study. Trained research assistants prospectively monitored and weighed all food and fluid intake consumed by patients during an 8 to 12 hour period with a research grade food and fluid scale. Research assistants remained on the nursing unit and weighed all food trays entering and exiting the room and also directly observed and weighed food and fluid consumed at the patient bedside every 30 minutes. Foodworks software was used to calculate the amount of water in each food item consumed. Research measurements of oral intake included oral intake from liquids only and oral intake from liquids and food. Upon completion of the study, research measurements were then compared to the oral intake documented in the electronic medical record (EMR) during the corresponding data collection period.

Results: Results to be presented.

Conclusions/Implications: Findings will be used to guide the development of a larger study on nutritional intake monitoring.

Nurse Practitioners' Patient Panels in Primary Care and the Impact of Organizational Structures

Lusine Poghosyan, Columbia University [black down pointing small triangle] Jianfang Liu, Columbia University [black down pointing small triangle] Allison Norful, Columbia University

Background/Purpose: The nurse practitioner (NP) workforce represents a significant supply of primary care providers (PCPs). However, only in certain primary care clinics do NPs practice to their fullest capacity as PCPs to deliver care to their own patient panel. In others, NPs only deliver episodic care. To date, little is known about this variability. We investigated the nurse practitioner (NP) role in care delivery and understand whether work environments were associated with the NP role as primary care providers (PCPs) with their own patient pane.

Theoretical Framework: Theories on organizational climate indicating that organizational structures affect how employees perform and their job outcomes guided the study.

Methods: A cross-sectional survey design was used to collect data from 163 primary care practices in Massachusetts employing NPs. We recruited 807 primary care NPs; 314 completed and returned the mail survey, yielding a response rate of 40%. An item asked NPs to report if they deliver ongoing continuous care to their own patient panel (PCPs) or not (episodic care). The work environment was measured with the four subscales of the Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ). The multilevel Cox regression models investigated the influence of practice-level NP work environment on NP role as PCPs.

Results: Practice-level Independent Practice and Support subscale, one of the NP-PCOCQ subscales, had a significant positive effect on NP PCP role (Risk Ratio=2.33; 95% CI: 1.06-5.13): with one unit increase on this subscale, the incidence of the NPs serving as PCPs within their employment settings doubled.

Conclusions/Implications: Supporting NP independent practice within organizations is associated with NPs having their own patient panel. Policy and organizational change should focus on promoting NP work environments so NPs can deliver ongoing continuous care to their patients as PCPs, which can be an effective strategy to increase the primary care capacity and improve care quality.

Using Patricia Benner's Framework: The Relationship Between Registered Nurses' Clinical Experience and Clinical Decision Making Processes in the Critical Care Environment

Kristi Stinson, Seton Hall University

Background/Purpose: The purpose of this descriptive correlational study was to examine the relationship between registered nurses' clinical experience and clinical decision-making processes in the critical care environment. The participants were 413 primarily white (91%), critical care nurses ranging in age from 19 to 68 (M=45.56) from across the United States. Participants were classified as experts based on Patricia Benner's (2001) classifications, in both experience in nursing in general (88%) and in critical care (82%) in particular.

Theoretical Framework: The theoretical framework was based on Benner's From Novice to Expert model. Benner developed an intuitive, humanistic decision making model that described five levels or stages of skill acquisition in nursing clinical knowledge: novice, advanced beginner, competent, proficient, and expert. The five levels reflect changes in three general aspects of skilled performance and decision making: 1) a move from reliance on abstract principles to the use of past concrete experiences, 2) a change from viewing a situation in multiple fragments to seeing a more holistic picture, and 3) a movement from detached observer to active performer. Each level is characterized by increased reliance on past clinical experience.

Methods: A descriptive correlational research design was used to look at the relationships between the study variables. Multiple regression was used to analyze the data.

Results: There were no differences seen in scores between the five Benner categories (novice, advanced beginner, competent, proficient and expert). However, when looking at the existing literature that used the CDMNS, this sample scored higher, possibly suggesting that critical care nurses with more clinical experience have more positive clinical decision making skills. Based on the description of the sample, the majority of the participants (83.1%) were "experts" according to Benner's (2001) classifications. The study sample was obtained through use of a professional organization, the American Association of Critical Care Nurses, and unknowingly yielded a high number of experts.

Conclusions/Implications: The sampling technique used in this study to unknowingly solicited a high number of nurses with advanced clinical experience. The overall CDM scores for the sample were high yet there were no strong correlations found between CDM and clinical experience. The relative homogeneity of this sample likely skewed the results. To avoid a homogenous sample, replication of this study using a different sampling technique is recommended, with attention to recruiting equal numbers of participants from each of Benner's categories. Further investigation looking at these two variables in the critical care environment is needed.

Paper Session B1: Evidence Based Practice

Using Feedback Intervention Theory to Guide Clinical Dashboard Development: A Case Study in Home Care

Dawn Dowding, Columbia University [black down pointing small triangle] David Russell, Visiting Nurse Service of New York [black down pointing small triangle] Jacqueline Merrill, Columbia University [black down pointing small triangle] Nicole Onorato, Visiting Nurse Service of New York [black down pointing small triangle] Robert Rosati, VNA Health Group

Theoretical Framework: Feedback Intervention Theory (FIT), a hybrid theory which integrates a number of behavioral theories, to explain the effects of feedback on performance.

Background: Feedback provided to clinicians on their performance is important for improving health care quality. Dashboards are a form of Health Information Technology (HIT) that display information in a visualized format that can be used to help provide feedback on quality measures.

Purpose: Using FIT as a theoretical basis to a) identify existing quality measures related to the care of patients with congestive heart failure (CHF) that are relevant to home care nurses and under their control and b) explore if and how nurses' numeracy and graph literacy affect their comprehension of data presented in a visualized format.

Methods: a) Focus groups conducted with nurses (n=61) working in a large not for profit home care agency. As a means to determine what feedback items to include in the dashboard the participants prioritized 23 statements derived from evidence based practice guidelines for managing patients with CHF. Discussion explored their rationale for priority rankings. b) An experimental research design using an online survey. Measures included numeracy, graph literacy and comprehension of visualized data. 196 nurses from 2 home care agencies were randomly allocated to 1 of 4 experimental conditions.

Results: The feedback ranked highest by the nurses were items for tracking of vital signs, symptoms and weight changes. The second highest ranked statement was about educational goals the patient had achieved. Nurses most easily understood information presented in the format of a bar graph. There was an interaction between numeracy, graph literacy and comprehension. Nurses with low numeracy were less able to interpret line graphs, those with low graph literacy were less able to interpret spider graphs, and those with low literacy and numeracy were less able to understand information presented in a table.

Conclusions/Implications: Dashboards need to be designed with the characteristics of the user in mind. Important issues include variation in how nurses comprehend data presented in different visual formats, and ensuring that feedback matches information needs. Findings of this study will be used to develop dashboards for home care nurses at the point of care.

Application of a Modified Version of the Diabetes Prevention Program with Adolescents

Kimberly Geria, Rutgers University [black down pointing small triangle] Janice Beitz, Rutgers University

Background: Prevalence of type II diabetes mellitus (T2DM) has significantly increased over the past 10 years in adult and adolescent populations, disproportionately among African-American and Latino populations. Prevention programs focusing on maintaining healthy diet and exercise habits have shown to be effective in preventing or delaying T2DM onset in adults and adolescents.

Purpose: The purpose of this Doctor of Nursing Practice scholarly capstone project was to increase T2DM prevention awareness and decrease T2DM risk factors in adolescents by offering a school-based disease prevention program using a modified version of the Centers for Disease Control and Prevention (CDC) Diabetes Prevention Program (DPP) curriculum. Project goals involved: after project implementation, participants would demonstrate an increase in food knowledge, physical activity, healthy food choices, self-efficacy to exercise and choose healthy foods, and a decrease in body mass index and waist circumference.

Methods: A quasi-experimental one-group study with a pre-test/post-test design and a qualitative component was performed to determine impact of a modified version of the CDC DPP on adolescent participants' (N = 101) T2DM risk factors and health-promoting behaviors. Project implementation was incorporated into the health education curriculum at a public charter school located in the economically challenged City of Camden, New Jersey. This population was selected due to high prevalence of T2DM risk factors including obesity, sedentary lifestyle, T2DM family history, and ethnicity.

Results: Results revealed a statistically significant (p < .001) increase in participants' food knowledge, self-efficacy for choosing healthy foods and performing exercise, healthy food choices, and amount of weekly aerobic exercise and statistically significant (p < .05) decrease in participants' body mass index and waist circumference after project implementation. Qualitative data revealed substantial positive feedback highlighting newly learned healthy habits and anticipation of maintaining healthy diet and exercise habits.

Conclusions/Implications: The modified version of the CDC DPP successfully impacted adolescents' health-promoting behaviors, and increased nutritional and physical activity self-efficacy. The capstone results indicate that the CDC DPP can be tailored to accommodate diverse settings, benefit various types of learners, and produce an impact on high-risk populations.

A Study of a Continuing Education Program on Neurological Assessments of the Acute Stroke Patient and the Effect on Clinical Nursing Practice

Catherine Curley, Widener University

Background/Purpose: The purpose of this study was to evaluate the effectiveness of neurosciences education sessions on knowledge of neurological assessment and the adherence to an evidence-based clinical practice guideline in professional nurses working with acute stroke patients.

Theoretical Framework: Meleis' Transitions Theory provided the theoretical framework for this study, identifying role transitions and the barriers to implementing change in achieving the assimilation of knowledge to practice. Transitions are the result of change and also result in change and can be varied in the timespan of the actual end result (Meleis et al., 2000). Essential to any transition is engagement by an individual to gain knowledge, identification of processes to be modified with the new knowledge, and actively initiating change in the practice. A determinant of transition completion is the demonstration of skill mastery needed to manage the experience affected by the change. In this study, the outcomes of improved neurological assessment demonstrate a transition to skill competency, most specifically adherence with the acute stroke patient protocols as per standards.

Methods: A pre test, post test quasi-experimental design was employed for this study. Knowledge of the course content was analyzed at three points, immediately pre and post session and in one month. The evaluation of the assimilation into practice was determined with the medical record analysis of a random sample of registered nurses who participated in the educational intervention and testing.

Results: Analyses of the pre test in comparison to the immediate post test (p = .069) and comparison of immediate post to one month post test (p = .90) scores were not statistically significant for a difference in knowledge. Inspection of the electronic medical record audit data (N = 26), however, showed a significant increase in adherence to the neurological assessment protocols from pre education to post education (p = .023) audits.

Conclusions/Implications: The findings of this study emphasize the need for nursing research to expand beyond an assessment of knowledge after an educational intervention. Identifying the impact of education practice through nursing research may provide empirical evidence of the benefits to conducting studies of knowledge assimilation to expert clinical practice. The implications for nursing science and research are evidenced in the outcomes of conducting an EMR audit to actually determine practice performance in relation to an educational intervention. Nurses participating in this study were previously educated on the standards of nursing care for acute stroke patients. The knowledge test scores did not change significantly post educational intervention. Nurses in this study improved their practice in the documentation of completed assessments of stroke patients and therefore benefitted from the reminder of clinical protocol.

Music Therapy and Pain Management in Patients with End-Stage Liver Disease

Sonia Pathania, Mount Sinai St. Luke's Hospital [black down pointing small triangle] Courtney Vose, New York-Presbyterian/Columbia University Medical Center [black down pointing small triangle] Larry Slater, NYU Langone Medical Center/NYU College of Nursing [black down pointing small triangle] Ann-Margaret Navarra, NYU Langone Medical Center/NYU College of Nursing

Background/Purpose: Evidence from numerous studies demonstrates the effectiveness of Music therapy (MT) for reducing pain intensity and analgesic use among patient populations in the acute care setting. A quality improvement assessment including patient satisfaction with pain control was conducted at a large urban academic medical center in the Northeastern U.S. among a cohort of end-stage-liver-disease (ESLD) patients receiving acute care, in-patient services. Resulting metrics showed a need for improved pain control.

Theoretical Framework: The purpose of this Doctorate of Nursing Practice (DNP) evidence-based capstone project is to evaluate whether the implementation of a MT intervention would reduce pain intensity and analgesic use, and improve patient satisfaction with the pain management plan among patients with ESLD in an acute care setting.

Methods: The implementation framework used for this project is the plan-do-study-act cycle. Four nurse champions were trained on implementing the project, and data collection was conducted on the unit during a six-week period. The MT intervention entailed 30-minutes of self-selected music, delivered daily via iPads and earbuds, over one to three consecutive mornings to eight participating ESLD patients. Instruments utilized consisted of the numeric pain rating scale (NPRS), an audit tool to monitor analgesia use, and a pain management satisfaction survey. Outcome measures assessed pre/post the MT-intervention were pain intensity, analgesic usage, and patient satisfaction. Descriptive statistics were computed to describe the patient characteristics, and change in selected outcomes assessed pre and post the MT intervention.

Results: Among the eight included patients assessed post-MT intervention, there was a 10% reduction in pain scores with a 25% decrease in analgesic use. Additionally, patient satisfaction scores increased 30%.

Conclusions/Implications: Findings from this project provide support for the application of MT interventions as an adjuvant to pharmacological modalities to enhance pain management among in-patients with ESLD.

A Quality Improvement Project to Determine the Effectiveness of a Group Educational Intervention for Improving Transition Readiness for Caregivers of Adolescents with Cerebral Palsy Using the Anticipatory Guidance Model

Maureen McSwiggan-Hardin, NYU Langone Medical Center/NYU College of Nursing [black down pointing small triangle] Melanie Applegate, New York University

Background/Purpose: The lifespan for children with Cerebral Palsy (CP) has increased over the past two decades, creating a critical need for a seamless transition from pediatric to adult healthcare for adolescents with CP and their caregivers (CGs). There are many barriers to transition of care, which can result in negative outcomes for both the patients with CP and their CGs. Improving transition readiness (TR) for CGs may lesson these barriers. This Quality Improvement (QI) project was developed to improve TR of CGs of adolescents with CP. The specific aim was to conduct a QI project to improve TR via an educational program based on a needs assessment and process analysis of CGs.

Theoretical Framework: Two models guided the development of this QI project: The Iowa Model of Evidence-Based Practice to Promote Quality of Care and the evidence-based Anticipatory Guidance framework.

Methods: The educational interventions were conducted by a family nurse practitioner, a social worker, and a specialist in vocational training with expertise in caring for adolescents with CP. To determine changes in CGs' TR, the Transition Readiness Assessment Questionnaire (TRAQ) was administered as a pre and post-test on the day of the educational intervention and one month later. Process measure outcome questions were used to assess the CGs' use of the transition guidance and personal use of the educational materials immediately post intervention and one month later. Date were analyzed using descriptive statistics, including means and standard deviation from the pre-test to post-test results, and bar graphs. Process data were summarized in narrative form.

Results: Fourteen CGs of adolescents with CP participated in the QI educational intervention. Thirteen CGs responded at the one-month follow up. Preliminary data analysis revealed positive responses overall of the CGs to the educational intervention.

Conclusions/Implications: The primary outcome was improvement in TR of CGs as their adolescents with CP transition to adult healthcare. Final conclusions and results will be summarized at the time of the presentation.

Paper Session B2: Health Promotion: Focus on HIV

Black Women's Approaches to Encourage Male Partners to Get Tested for HIV: The Influence of Interpersonal Context on Approach and HIV Testing Behavior

Kerry Nolte, University of New Hampshire [black down pointing small triangle] John Griffith, Northeastern University [black down pointing small triangle] Barbara Guthrie, Northeastern University [black down pointing small triangle] Tiffany Kim, Northeastern University

Background/Purpose: Black women are disproportionately affected by HIV and predominantly infected through heterosexual sex. Preventing HIV is a national priority and increasing status awareness through testing will identify those positive for HIV and potentially decrease rates of new infection. Encouraging a partner to test may increase status awareness. Prevention campaigns provide general recommendations to talk to a partner about testing, but do not provide specific approaches with established efficacy. To address this gap, we examined the relationship of approaches to encourage HIV testing, interpersonal context (IC), and HIV testing behavior.

Theoretical Framework: This study was guided by Social Penetration Theory (SPT). SPT describes processes of social interactions and how these lead to or dissuade closeness and trust within a relationship. The IC is conceptualized as the dyadic dynamics that influence decision-making regarding safer sex practices. The IC is the prelude to the nature and type of conversations one initiates with their partner.

Methods: A purposive sampling strategy recruited a sample of 158 18-29 year old sexually active Black women from community-based settings. In this cross-sectional study, participants completed study measures on a tablet device or via a secured link. Multiple and logistic regression examined the IC (as measured by partner type, relationship closeness, authenticity, sexual pressure, and perceived partner risk), HIV Testing Approach Scale (HTAS) approaches, and whether an individual and partner had tested for HIV.

Results: Sampling was successful in recruiting a sample of Black women at risk for HIV from heterosexual sex due to personal or partner behaviors. The Black sample was diverse in terms of race and ethnicity. Results indicated that 1) elements of IC (partner type, authenticity, and sexual pressure) are related to HTAS approaches among Black women; 2) whether a partner has tested for HIV is greatest predictor of whether an individual tests for HIV, although IC factors (partner type and perceived partner risk) were also significant; and 3) the approaches associated with partner HIV testing were Active Persuasion and Decisive Collaboration.

Conclusions/Implications: The greatest predictor of HIV testing, for both female respondents and their male partner, was whether the partner had tested. This indicates that encouraging a female to test may act as a motivator for a partner to get tested. Active Persuasion and Decisive Collaboration approaches may be promoted as effective strategies to encourage a male partner to test for HIV. These findings provide recommendations for practitioners to consider IC in HIV prevention counseling and promote effective approaches.

Development of a Nurse-Delivered Tailored Intervention to Reduce Cardiovascular Risk in Persons Living with HIV

Patricia Cioe, Brown University

Background: Persons living with HIV (PLWH) are at elevated risk for cardiovascular disease (CVD) when compared with the general population. The American Heart Association has outlined general population primary prevention guidelines in which increased physical activity and healthy diet are the cornerstones of CVD risk reduction. However, few interventions have been specifically designed to address lifestyle modification for CVD risk reduction in PLWH who have not been diagnosed with heart disease.

Purpose: The goal of this study was to employ qualitative methods to develop and tailor a culturally relevant intervention to improve the adoption of heart-healthy behaviors in those living with HIV.

Methods: Face-to-face qualitative interviews were conducted with 30 PLWH to examine learning needs, priorities, and preferences for an intervention that addressed CVD risk and the adoption of heart-healthy behaviors. Participants were recruited from two inner city HIV/immunology clinics in the Northeast U.S. Interviews were recorded and transcribed verbatim.

Results: Participants (N = 30) were 70% male, had a mean age of 54.4 years (range 41-72 years), and were living with HIV for 18.8 years. All were taking antiretroviral therapy and had an undetectable viral load. Participants had not been diagnosed with CVD, however, 50% identified as current daily smokers. Major themes related to: 1) a need for personalized feedback and advice; 2) having choices; 3) small changes and goal setting; 4) visual aids; 5) effect of, or restrictions due to, HIV on any behavior change.

Conclusions/Implications: Conclusions: Qualitative feedback regarding the elements of an intervention to reduce CVD risk in PLWH included features specific to this population and informed the development of a tailored intervention. Implications for Practice: Using qualitative methods to develop a tailored intervention for PLWH may improve clinical outcomes for this population.

Pilot HIV Prevention Study for Adolescent Young Women

Ellen Long-Middleton, University of Vermont

Theoretical Framework: The Information-Motivation-Behavioral Skills (IMB) Model was used to underpin this study.

Background: HIV and AIDS are a threat to the lives, health and well-being of individuals worldwide. Among women of reproductive age, AIDS is the leading cause of death globally. Heterosexual transmission of HIV is the primary mode of infection in women, and adolescent young women are particularly vulnerable. As there is no cure for AIDS and no vaccine to protect against HIV, behavioral HIV prevention interventions are imperative. Motivational interviewing (MI) and behavioral skills building (BSB) are modes of behavioral interventions proven to be efficacious. Yet there is a need for further studies to establish proven HIV prevention interventions in general, and specifically studies that are geared toward reducing heterosexually mediated HIV infection in culturally diverse adolescent young women. Given that adolescents utilize primary health care services, an opportunity exists to reach adolescent young women and adapt proven HIV prevention interventions to their needs in primary care settings.

Purpose: The purpose of the study was to describe a pilot HIV prevention intervention for a culturally diverse sample of adolescent young women.

Methods: A mixed methods approach was used to pilot an HIV prevention intervention for Black, Latina and White adolescent young women aged 15-19 years at a community health center and university-based adolescent primary care site. Prior to implementing the intervention, fidelity was established and training needs of health care providers were determined. Feasibility for the intervention was established through measurement of time to complete the study survey, implement the intervention, and enroll participants. Qualitative data were collected to assess integration of the intervention into the primary care setting.

Results: Fidelity of the MI/BSB intervention was established after 15 hours of training. Completion of the survey by participants and implementation of the intervention by the researcher was 4.5 and 13.8 minutes respectively. Two participants were recruited per 4-hour clinic session. There was no disruption in clinic schedule or utilization of physical resources during the study.

Conclusions/Implications: Pilot data support that a one-on-one HIV prevention intervention is feasible in a primary care office setting. Development of larger, longitudinal investigations is needed to measure the outcomes of an MI/BSB interventions on HIV risk reduction behaviors.

The Newly Single Widowed Older Adult African American/Black Woman (WOAAW) Navigating Intimacy After a Long-Term Monogamous Relationship

Jeanine Cook-Garard, Nassau Community College

Background: The WOAAW faces challenges when planning to redefine her future. Ending a long-term relationship may leave women uncertain of the future, feeling lonely and vulnerable. Widows, in particular, are subject to socially unfavorable situations leading to negative health outcomes including STIs. African Americans/Blacks have the most severe burden of HIV of all racial/ethnic groups in the United States. In 2010, African American women accounted for 6,100 (29%) of the estimated new HIV infections among all adult and adolescent African Americans. This number represents a decrease of 21% since 2008. Most new HIV infections among African American women (87% or 5,300) are attributed to heterosexual contact.

Purpose: The purpose of this research was to understand the decision-making and planning process of the WOAAW involved in navigating new sexual intimacy after a long-term monogamous relationship, where there is potentially an increased risk of sexually transmitted illnesses.

Methods: The sample consisted WOAAW, age 55 or older, who had been in a monogamous marital relationship for approximately 10 years or more, widowed for approximately one year or more. Various sampling strategies were utilized including purposive, convenience, snowball, theoretical, and stratified random, consistent with GT methodology. The number of participants was 25.

Results: The basic social psychological problem was a need to redefine self after widowhood. Spiritually guided decision making for intimacy was identified as the core concept or mid-range theory for the WOAAW as they relied heavily on God, a higher power, and the church to alleviate feelings of loneliness and loss. Five categories emerged from the widows who were interviewed: a) HIV/STI Matters to Me, b) Relationship Re-ordering, c) Redefining Myself, d) Living Through It, and e) Financial Stability. The basic social psychological problem was solved through intimacy in a sexual and non-sexual context. Intervening conditions that influenced intimacy decision making were: age/experience, Afrocentrism, knowledge, time, spirituality, and gender/role. Seven decision-making strategies associated with spiritually guided decision making for intimacy were: denying, accommodating, avoidance, reliance, reminiscing, planning, and pursuing support.

Conclusions/Implications: Spiritually guided decision making for intimacy was identified as the core concept as the WOAAW reported the process of how spirituality was an integral component of decision making after widowhood despite the possibility of HIV/STI exposure. It was identified that the imbalance of spirituality over practical health-promoting behaviors may affect intimacy decision making, predisposing widows to STI/HIV. This study provided the groundwork for developing a mid-range theory that informs the health care community of ways to deliver culturally sensitive informed care to this growing segment of the population.

Intersections of HIV Risk, Substance Use and Marginalized Identity in a Rust Belt Urban, Transgender Population

Adrian Juarez, SUNY Buffalo [black down pointing small triangle] Yu-Ping Chang, University At Buffalo

Theoretical Framework: This grounded theory used an intersectionality lens and was informed by Bronfenbrenner's Ecological Systems Theory to construct social context.

Background: "Seek, test, treat and retain" (STTR) strategies promoted by HIV prevention researchers and clinicians, envision the possibility of HIV eradication. The first step in these mathematically-based strategies is universal HIV testing (seek/test). Evidence supports that knowing HIV status leads to better HIV health outcomes in HIV+ individuals (decrease in HIV infectivity, improved linkage to care, decreased high-risk behaviors, higher medication adherence and lower economic health care costs) and lower HIV infection in HIV- individuals. However, certain historically marginalized population groups such as transgender males-to-females (MTF), do not benefit from knowing HIV status as this group has been found to have some of the highest HIV testing rates yet continue to experience disproportionate HIV infection rates and poor HIV outcomes. There is little understanding to why the transgender-MTF population do not benefit from STTR interventions.

Purpose: The purpose of this grounded theory exploration is to construct a theoretical understanding of transgender HIV testing decision-making, substance use history and subsequent sexual behavior.

Methods: A constructivist grounded theory approach was used in this examination into the HIV testing decision-making processes, substance use history and sexual behaviors of a transgender population in a Rust Belt urban area situated on the Great Lakes. This grounded theory consists of several components: 1.) theoretical sampling; 2.) data collection; 3.) data analysis; 4.) sorting. Data was collected from seven (n=7) transgender-MTF.

Results: HIV testing in this transgender population was associated with potential HIV exposure associated with high -risk sexual behaviors (condomless sex, sex work, forcible sexual assault, IV drug use). Substance use was associated with decreased inhibition in a sexual behavior decision-making context, social interactions with peers at transgender-friendly venues and as a coping mechanism for social isolation secondary to gender-identity social rejection.

Conclusions/Implications: The transgender population continues to experience social isolation related to gender-identity social rejection. Substance use, mostly alcohol, is associated with increased risky sexual behavior. This understudied population requires further examination to locate high risk HIV behaviors in their specific context in order for STTR interventions to be targeted and appropriately initiated.

Paper Session B3: Theory Guided Research

The Patient Decision-Making Process Regarding Left Ventricular Assist Devices (LVADs)

Judy Dillworth, New York University [black down pointing small triangle] Michele Shedlin, New York University [black down pointing small triangle] Victoria Dickson, New York University [black down pointing small triangle] Alex Reyentovich, NYU Langone Medical Center [black down pointing small triangle] Jennifer Pavone, NYU Langone Medical Center [black down pointing small triangle] Maureen Geary, NYU Langone Medical Center [black down pointing small triangle] Debra Robbins, NYU Langone Medical Center

Theoretical Framework: A conceptual model developed for this research used variables from other models to illustrate the complexity of the decision-making process regarding LVADs. This model was used to design the case study, develop the interview guide & collect relevant data. Its structure and content evolved with data collection & analysis. The revised conceptual model incorporates the results of this study.

Background: More than 915,000 new cases of heart failure (HF) are diagnosed every year in the United States. With more people surviving to old age, there will be a greater number of patients with HF who will have to make decisions about treatment and the use of life-extending technology such as the LVAD, a means of mechanical circulatory support. Little is known about the needs of patients with HF and how they make decisions related to this technology.

Purpose: This study explored the process of decision-making made by patients with HF regarding acceptance or declination of an LVAD, from multiple perspectives with consideration of contextual factors (institutional/public policies, availability) at a single academic medical center.

Methods: A multiple case study was conducted using a heterogeneous sample of patients (46 to 76 years old) who accepted an LVAD as a bridge to transplant, a bridge to decision, destination therapy or declined. Patients were interviewed after the decision was made and prior to LVAD implantation. There were seven "cases", each consisted of at least 4 participants: patient, physician, caregiver & nurse, for a total of 31 interviews. Data collection involved semi-structured, in-depth interviews & multiple sources of information (medical record, educational materials & observations). Data were analyzed using atlas ti7 software. Data clusters and patterns of co-occurring codes were explored using thematic analysis. Data were triangulated and themes examined within & across cases. The conceptual model guided the interview questions & was revised as recurrent themes emerged.

Results: The overarching theme was the salience of survival; patients wanted to live longer with a better quality of life. Additional decision-making factors included: patients' perceived severity of illness; information; perceived attributes of the LVAD; acceptability of technology; family acceptance and support; expectations and future orientation with the LVAD.

Conclusions/Implications: Contrary to prior studies, decisions were not automatic, but involved a thoughtful & complex process. Patients considered self-care, the acceptability of the LVAD and the anticipated adaptations required to "live normally". Nurses have a critical role in providing education, ensuring patients' understanding of the information and empowering patients to broaden their self-care management skills to include management of the LVAD. Importantly, patients identified bedside nurses to be crucial in responding to their fears and concerns, an important component of shared decision-making.

Interactive Learning for Effective Interprofessional Collaboration: Using Case Simulation for Interprofessional Education Orientation

Brenda Janotha, Columbia University

Background/Purpose: To evaluate the effect an interprofessional collaboration case simulation activity with graduate Nurse Practitioner students and Dental students has on teamwork/ collaboration, professional identity, and roles/ responsibilities.

Theoretical Framework: Structuration Model of interprofessional collaboration (D'Amour et al., 2004), conceptualizes the process of collaboration into 4 dimensions: shared goals/ vision; sense of belonging; structuring clinical care; and governance.

Methods: Pretest posttest experimental study was developed to assess to what extent a case simulation activity has on interprofessional collaboration, professional identity, and roles/responsibility. A convenience sampling of Nurse Practitioner students (n=44) and Dental students (n=160) who engaged in a case simulation orientation were recruited to voluntarily participate in a survey study. A one day orientation between the Schools of Nursing and Dentistry has been conducted annually for the past three years, this year the researcher adapted this orientation to include an interactive learning experience, the case simulation. Additionally, students were recruited to voluntarily participate in the pretest posttest survey to assess student outcomes. The Readiness for Interprofessional Learning Scale (RIPLS), a valid and reliable tool, was used to measure student teamwork/collaboration, professional identity, and roles/responsibility. This tool has four sub-scales all with reported Cronbachs alpha < 0.60.

Results: Preliminary statistics show significantly improved RIPLS scores following the activity. Additional data interpretation will be conducted to evaluate possible relationships between the subjects and the outcomes, as well as to provide validation and reliability data on the RIPLS tool.

Conclusions/Implications: Interprofessional education of primary care nurse practitioner students and dental students provides multiple opportunities for collaboration and fosters appreciation of professions. Future health care demands all providers meet the needs of the patient in real-time regardless of the point of service location. By educating tomorrow's health care providers in an interprofessional environment we are promoting collaboration and ensuring best patient outcomes. Applying an interactive simulation activity has shown to promote students teamwork/collaboration, professional identification, and understanding and respect for roles/responsibility.

Evolutionary Concept Analysis of Nursing Autonomy

Yu-Ching Chuang, University of Rochester [black down pointing small triangle] Marie Flannery, University of Rochester

Background/Purpose: Nursing autonomy is consistently related to improved patient outcomes. Although the concept of nursing autonomy has been examined in multiple studies, limited consensus exists on the meaning of autonomy. Thus, the aim of this investigation was to analyze the concept of nursing autonomy as it has evolved over time.

Theoretical Framework: Rodgerian evolutionary concept analysis.

Methods: Rodgers' evolutionary methodology of concept analysis was conducted. Using the keywords of autonomy, nursing, and critical care references (n=32) spanning 1950 to 2015 were identified and critiqued. Inclusion criteria reflected sampling of articles from different decades. Studies from eastern countries were excluded due to potential cultural and professional developmental differences between nursing practice in western and eastern global locations.

Results: The concept analysis identified six attributes in nursing autonomy: 1) personal characteristics, 2) competence, 3) decision-making, 4) collaboration, 5) moral distress, and 6) environment. While identifying the attributes, a three-stage historical pattern emerged with changing attributes predominating in different time periods. The three stages are initial stage: personal characteristics (1960-1990s), second stage: decision-making (the late 1990s to 2000s), and third stage: interprofessional collaboration (2000 to present).

Conclusions/Implications: Nursing autonomy is not a stable concept, rather predominating attributes have changed over time. The current focus on interprofessional collaboration is an attribute that could potentially enhance or detract from the development of professional autonomy in nursing. The evolution is similar to Gadow's ethical dialectic of nursing. The current stage of inter-professional collaboration fuses the prior two stages while emphasizing moral attributes of autonomy. A further analysis of nursing autonomy including global articles may reveal cultural variation in the concept as it has evolved in eastern countries.

The Theory of Attributed Dignity

Cynthia Jacelon, University of Massachusetts-Amherst

Theoretical Framework: The over arching framework used for development of the Theory of Attributed Dignity was symbolic interaction. In this framework, individuals derive meaning from their interactions and act on the basis of those meanings.

Background: Work on the development of the concept of dignity has increased over the last 10 years. Researchers have focused on dignity in healthcare, dignity at the end of life, and dignity for individuals with altered cognitive states. Less attention has been given to the role of dignity in community dwelling older adults. The theory of attributed dignity explains the role of dignity in these individuals.

Purpose: The purpose of this presentation is to present the theory of attributed dignity including antecedents, attributes, measurement, and management and relationships with health and optimal aging.

Methods: The theory of Attributed Dignity was developed using qualitative and quantitative methods over the course of several research studies. Methods included grounded theory, instrument development techniques, factor analysis, and regression techniques.

Results: Attributed dignity is a distinct concept, changes over time, is positively related physical and mental state, can be measured, and is managed by individuals using a combination of introspective, interactive, and active strategies.

Conclusions/Implications: Attributed Dignity is an attributed, dynamic cognitive component of the self, comprised of a sense of self value, self in relation to others, perceived value from others, and behavior that demonstrates respect toward self and others. It is a manifestation of an individual's inherent dignity, is important for health and wellbeing in older individuals, and changes in relation to human interactions.

Using the Health Disparities and Outcomes (HDO) Model to Evaluate Population Health Outcomes in the Severely Mentally Ill

Emily Hauenstein, University of Delaware [black down pointing small triangle] Elizabeth Merwin, Duke University [black down pointing small triangle] Rachael Clark, University of Delaware

Theoretical Framework: The Health Disparities and Outcomes (HDO) Model

Background: The conceptual model presented integrates two decades of collaborative research in disparities from the senior authors and incorporates recent extant theory, research, and social policy derived from an integrative, systematic literature review.

Purpose: To present the third generation of the HDO model for assessing illness trajectories and outcomes among the disabled seriously mentally ill (SMI).

Methods: The conceptual model presented integrates two decades of collaborative research in disparities from the senior authors and incorporates recent extant theory, research, and social policy derived from an integrative, systematic literature review.

Results: The HDO Model, originally created to explain the complexity of obtaining health care in rural settings, has been revised and updated based on two decades of empirical work and is applied to the SMI who face higher rates of morbidity and mortality than the general population. Using the empirical and related literature, the authors describe individual, community, and system level factors that reflect a life span understanding of risk, intersecting and accrued hazards associated with multiple disadvantages, and the difficulty obtaining health care that meets accepted standards.

Conclusions/Implications: The revised model will be used to compile individual trajectories for three chronic illnesses common to the SMI population and to identify changes in illness trajectories associated with factors and events measured at each level of the HDO model.

Paper Session B4: Adult and Older Adult

Chronic Diseases Associated with Tooth Loss in the US Adult Population

Yuqing Zhang, University of Massachusetts-Boston [black down pointing small triangle] Suzanne Leveille, University of Massachusetts-Boston [black down pointing small triangle] Jerry Cromwell, University of Massachusetts-Boston

Background/Purpose: Among people aged 65 and over in US, about one in five are edentulous. Tooth loss and edentulism not only interfere with nutritional intake, but also cause discomfort and negatively impact self-esteem and quality of life. As a health issue, tooth loss is a preventable problem that can be addressed by nurses. In recent years, selected chronic diseases and conditions, for example, diabetes, have been identified as possible risk factors for tooth loss. However, data on the relationship between multiple chronic conditions and tooth loss in the US adult population is lacking. Therefore, this study aimed to assess the association between major multiple chronic conditions and tooth loss in US adults.

Theoretical Framework: conceptual model of nursing and population health (CMNPH) (Fawcett & Ellenbecker, 2015).

Methods: We performed a secondary data analysis using the US 2012 Behavioral Risk Factor Surveillance System (BRFSS), a national cross-sectional telephone survey about health conditions and health behaviors among US adult (>= 18 years) non-institutionalized residents. Variables were derived from BRFSS's Standard Core Questionnaire. Descriptive analysis including means, standard deviations, and percentages were calculated. Sample weights were applied. The step-wise multinomial logistic regression method was used to examine the relation between several chronic diseases and reported tooth loss.

Results: Among the sample (N=471,107, mean age 55 years, 60% female), 48% reported having no tooth loss, 30.6% reported having lost 1 to 5 teeth, 13.5% reported having lost 6 or more but not all their teeth, and 7.7% reported losing all their teeth. Adjusted for demographic characteristics, socioeconomic status, smoking, BMI, and dental care, the chronic diseases that were associated with edentulism were: COPD (RR 2.18, 95%CI 2.08-2.29); diabetes (RR1.49, 95%CI 1.44-1.56) arthritis (RR 1.49, 95%CI 1.44-1.54); cardiovascular disease (RR 1.38, 95%CI 1.30-1.45); stroke (RR 1.31, 95%CI 1.24-1.40); kidney disease (RR1.16, 95%CI 1.08-1.25); cancer (RR1.06, 95%CI 1.01-1.11); asthma (RR1.06, 95%CI 1.01-1.11). For those reporting having lost 1 to 5 teeth, all of the above chronic diseases were associated except stroke, cancer and asthma. Weighted results were not materially different from the unweighted results.

Conclusions/Implications: Multiple chronic diseases were associated with edentulism and tooth loss. Nursing care for people with chronic diseases could be informed by this finding thus to better attend to patients' oral health needs.

Effect of Self-Management Support and Family Participation Enhancing Program for Delayed Progression of Diabetic Nephropathy in Thai Adults with Type 2 Diabetes

Somsak Thojampa, Naresuan University [black down pointing small triangle] Kenje Gunda, Naresuan University

Background/Purpose: Type 2 diabetes mellitus (DM) is increasingly becoming common in developing countries including Thailand. Uncontrolled hyperglycemia can lead to progression of severe complications for persons with DM which include diabetic nephropathy and can, later on, lead to kidney failure. Self-management support and participation of social groups, specifically the family of the patient, can help people with DM in controlling the complications of their disease from progressing; in this case, the advancement of diabetic nephropathy. The aim of this study is to develop a self-management support program based on self-regulation theory with the participation of the family and to evaluate its effect on self-efficacy, self-management behavior and delaying the progress of diabetic nephropathy in adults with type 2 DM.

Theoretical Framework: Self-regulation Theory was used in this study to develop the self-management support program, and Social Cognitive Theory was used to set a framework to enhance family participation in delaying the progress of diabetic nephropathy.

Methods: This is a quasi-experimental research. The sample consisted of 60 Thai adults with type 2 DM, 30 for the control group and 30 for the experimental group. The participants in the experimental group attended a self-management support and family participation enhancing program for 8 weeks. The interventions included a video presentation, manual, and health education with a family member in a focus group. Data were collected before attending the program and evaluated on the 8th and 12th weeks after the program. The instruments used for the data collection were (1) automatic physiological measures: HbA1c, systolic and diastolic blood pressure, serum creatinine (SCr) and glomerular filtration rate (eGFR), (2) the health behaviors for delayed progression of diabetic nephropathy questionnaire (CKD-SM), (3) the chronic kidney disease self-efficacy questionnaire (CKD-SE) and (4) the demographic questionnaire. Data were analyzed using descriptive statistics, Chi-square and hypotheses were tested using Independent t-test and Paired t-test.

Results: The mean scores of the health behaviors and self-efficacy were significantly higher as well as the SCr and the eGFR results of the experimental group were significantly lower than that of the control group after attending the self-management and family participation enhancing program.

Conclusions/Implications: The findings of this study indicate that the self-management and family participation enhancing program promote and support health behavior change and leads to better control of delayed progression of diabetic nephropathy in Thai adults with type 2 DM. This can be applied by health care professionals in health care centers as a supplement to their usual care in dealing with persons with type 2 DM.

Mothering with Advanced Cancer: "You've Got to Find That Little Thing That's Going to Make You Strong"

Toby Bressler, Maimonides Medical Center [black down pointing small triangle] Janet Arida, University of Pittsburgh [black down pointing small triangle] Sara D'Arpino, Massachusetts General Hospital [black down pointing small triangle] Samantha Moran, Massachusetts General Hospital [black down pointing small triangle] Alaina Carr, University of Denver [black down pointing small triangle] Teresa Hagan, Massachusetts General Hospital

Background: While many women diagnosed with cancer are also mothers, research focused on patients' quality of life during and after cancer treatment rarely accounts for how motherhood impacts women's cancer experiences. Mothers with ovarian cancer are at particular risk for experiencing additional demands given their substantial symptom burden and accelerated disease progression.

Purpose: To describe the experience of mothers with ovarian cancer to elucidate how their roles as mothers and patients with cancer impact each other.

Methods: Our research team conducted a secondary analysis of excerpts from focus groups from a parent study of women with advanced ovarian cancer recruited from an advocacy organization and a clinical trial. Using descriptive, axial coding, the team independently reviewed and coded excerpts from four consecutive focus group, iteratively revising the coding scheme based on emerging findings and group consensus. We then organized the final codes into higher-order themes that describe the breadth of experiences described by women.

Results: Among the thirteen participants, eight discussed motherhood during the focus group. All women were White (8/8, 100.00%) and had earned at least an associate's degree (6/8, 75.00%); the mean age of participants was 48.38 (SD = 7.17). A minority of women were married (3/8, 37.50%). The mean time since diagnosis was 7.43 months (SD = 4.69) and half (4/8) of women were currently receiving treatment. Themes reflected participants' evolving self-identities from healthy woman and mother to cancer patient to woman mothering while facing cancer. Sub-themes related to how motherhood was impacted by symptoms, demands of treatment, and gaining control and acceptance of living with cancer. We will provide exemplar quotations to illustrate each of higher-order themes and sub-themes.

Conclusions/Implications: The experience of motherhood inextricably impacts how women who are mothers experience cancer and how they evolve as survivors. Characterizing the experiences of women facing cancer while mothering can enhance the ability of health care providers to understand and address the needs of this vulnerable population. Nurses caring for patients with children should assess, support, and advocate for the particular needs of these patients.

Symptom Occurrence, Severity and Quality of Life During Cancer Treatments

Jaimol Sreedhar, Widener University

Background/Purpose: Patients with advanced cancer often experience multiple coexisting symptoms during treatments. The primary purpose of the study was to examine the relationship among cancer therapy-related symptom occurrence, severity, health-related quality of life, selected variables related to the cancer condition, and selected demographic variables. Secondary purposes were to examine cancer patients' reported symptom occurrence/ severity and self-care methods used by ethnicity (African-American vs. Caucasian) and by age groups.

Theoretical Framework: The study conceptual framework was a modification of frameworks developed by several scholars. Symptom experience is an individual patient's response to their symptoms.

Methods: This study used a descriptive correlational design. Data were collected from a convenience sample of 110 cancer patients receiving cancer treatments at one eastern U.S.A. site. Tools used included the: Demographic Form, Health Form, Karnofsky Performance/Functional Status, and Treatment/ Medication Profile, Therapy-Related Symptoms Checklist (TRSC), Health- Related Quality of Life Linear Analogue Self Assessment (HRQOL- LASA), the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C-30 (EORTC QLQ-C 30), and the Symptom Alleviation Self-Care Methods (SA-SCM). Data were analyzed using SPSS-23.

Results: Significant relationships were found on multiple linear regression analysis between TRSC symptom occurrence/severity and gender (t (103) = 2.07, p=.04), economic status (t (103) = -2.53, p=.01), and disease stage (t (103) = 4.31, p=.000). Significant associations were found between HRQOL and economic status (t (103) = 2.11, p=.04), and ethnicity [(African American, t (103) = 2.01, p=.04), (Asian & Hispanic, t (103) = 2.04, p=.04)]. Path analysis supported the significant findings. Patients with high symptom occurrence/severity reported low HRQOL. The majority of participants reported their use of self-care strategies was helpful.

Conclusions/Implications: Oncology nurses are in an influential position to educate, motivate, and support patients and families to manage the patients' treatment-related symptoms effectively.

Paper Session B5: Family

An Examination of the Family Role in Promoting the Functional Recovery of Hospitalized Older Adults

Marie Boltz, Penn State College of Nursing

Background: Hospitalization results in functional decline in 35-50% of older adult patients, and is associated with longer hospital stays, unplanned hospital readmissions, dependence on formal/informal care, and mortality. Family-centered, Function -focused Care (Fam-FFC) is an educational empowerment intervention that engages the patient and family in goal development, implementation, and evaluation. Fam-FFC demonstrated improvements in patient delirium and functional outcomes, while decreasing family caregiver (FCG) anxiety and increasing preparedness for caregiving.

Purpose: This secondary analysis of Fam-FFC evaluates the nature of family engagement and FCG characteristics associated with return to baseline function

Methods: Data from chart extraction, patient evaluation, activity logs, and interviews with FCGs recruited from five medical units of two hospitals (94 dyads) examined: a) the nature of family engagement; b) its association with post-discharge physical function (Barthel Index), controlling for patient demographics, co-morbidity (Charlson Comorbidity Index), cognition (Mini-cog), delirium (Confusion Assessment Method) and baseline function and; c) FCG perspectives of enablers of function.

Results: Family engagement was enacted through four main roles: advocate, decision-maker, direct care, and companion. Stepwise regression demonstrated that FCG educational level (t=7.3. p < .0001) and the advocate role (t = 4.0, p < 0.001) were associated with return to baseline function at two months post-discharge. Content analysis of FCG interviews identified enablers to patient function/well-being: staff skills; staff accessibility, and environmental factors.

Conclusions/Implications: Findings underscore the need for organizational support of the role of FGCs as patient advocates. Future research will examine the uptake of Fam-FFC across educational /health literacy levels.

Randomized Controlled Trial of the Veterans' In-Home Program for Veterans with TBI and Their Families: Report on Family Outcomes

Helene Moriarty, Villanova University [black down pointing small triangle] Laraine Winter, Philadelphia VA Medical Center [black down pointing small triangle] Keith Robinson, Philadelphia VA Medical Center [black down pointing small triangle] Catherine Piersol, Thomas Jefferson University [black down pointing small triangle] Tracey Vause-Earland, Thomas Jefferson University [black down pointing small triangle] Brian Newhart, Philadelphia VA Medical Center

Background/Purpose: Traumatic brain injury (TBI), now recognized as a major public health problem in military and civilian populations, creates many challenges for families as well as patients. Few intervention studies have considered both the needs of the person with TBI and his family and included both in the intervention process. To address this gap, we designed an innovative intervention for veterans with TBI and families-the Veterans' In-home Program (VIP)-targeting veterans' environment, delivered in veterans' homes, and involving their families. In this paper, we report on VIP's acceptability to family members and efficacy in improving their well-being, operationally defined as depressive symptomatology, caregiver burden, and caregiver satisfaction at follow-up (3-4 months after baseline).

Theoretical Framework: The intervention was guided by the person-environment fit model and family systems theory.

Methods: In this randomized controlled trial, veterans and family members were interviewed in their homes at baseline and then randomly assigned to VIP or the control condition. The VIP intervention consisted of 6 home visits and 2 phone calls delivered over 3-4 months. The control condition consisted of usual clinic-based care and 2 phone calls. Standardized outcome instruments for family members included the CES-D (for depression), the Caregiving Appraisal Scale (for burden and satisfaction), and 3 acceptability measures.

Results: Eighty-one veterans with TBI (primarily mild) and their respective 81 family members (mean age=42, SD=12.51; 94% female; 73% spouses, 15% mothers) participated. Family members in VIP had significantly lower depressive symptom scores and significantly lower burden scores when compared to Controls at follow-up. Satisfaction did not differ between groups. Family acceptability of the intervention was high.

Conclusions/Implications: VIP represents the first evidence-based intervention that considers both the veteran with TBI and the family. VIP had a significant impact on family member well-being and thus addresses a large gap in previous research and services for families of veterans with TBI.

Anticipatory Loss: The Phenomenological Experience of Non-Caregiving Adult Children with Parents over 65

Connie Kartoz, The College of New Jersey [black down pointing small triangle] Munira Wells, Seton Hall University

Background: The United Nations (2015) notes that expanded lifespans are "poised to become one of the most significant social transformations of the twenty-first century." Healthy life expectancy is now nearly 14 years for a 65 year old individual (USDHHS, 2013). The qualitative experience of adult children with healthy parents is poorly described in the literature, as the limited data that exists is largely dated.

Purpose: The purpose of this presentation is to present results from a study exploring the lived experience of non-caregiving adult children of aging parents, as technology and extended life span impact the family life course.

Methods: After IRB approval of this phenomenological study, convenience and snowball sampling were used to recruit 12 women and 4 men who are predominantly from an upper socioeconomic group in the MidAtlantic region, though 3 sets of parents live abroad. The sample contains 2 African Americans, 1 Pakistani, 1 Indian, and 2 Western European participants. Two audio taped in-depth interviews per participant using open ended prompts such as: "describe what is like for you to have a parent over the age of sixty-five" were professionally transcribed. A hermeneutic phenomenological approach, which is both descriptive and interpretive in nature, was used to analyze the transcriptions. The researchers first independently read and coded the data, followed by mutual validation. Once all relevant codes were established, researchers identified sub-themes and main themes, including one of anticipatory loss.

Results: Participants experience both sadness and joy as they reflect on family history in an effort to predict how an unknowable future may unfold as parents age. Subthemes contributing to an experience of anticipatory loss include: worry, guilt, assessment of parent function, acceptance of parent personality and striving to connect parent and grandchild.

Conclusions/Implications: Anticipatory grieving is previously described for terminally ill dyads and associated with poor decision-making. The anticipatory loss in this sample appears to prompt healthy coping activity. Implications for healthcare providers include a richer understanding of adult children as they live through this family developmental stage. Researchers may utilize this understanding of anticipatory loss to develop better conceptual definitions and measurements, thus allowing exploration of possible relationships between anticipatory loss of parents, support exchanges with parents and future caregiving decision-making.

The Effect of Deep Breathing Relaxation Intervention on Caregiver Strain and Blood Pressure in Family Caregivers of Persons with Dementia

Jean Petrilack, Abington Jefferson Health [black down pointing small triangle] Elizabeth Gonzalez, Drexel University [black down pointing small triangle] Thomas Hardie, University of Pennsylvania

Background/Purpose: Family caregivers of persons with dementia (PWD) provide vital care to the PWD and a huge savings to our national health economy. Family caregivers focus on providing care for PWD and tend to neglect their own health. The stress that family caregivers face on an ongoing basis from fluctuations and changes in condition and problem behaviors of PWD has an effect on the physical and mental health of caregivers. This pilot study examined the effects of a deep breathing relaxation intervention on blood pressure and caregiver strain in family caregivers of PWD.

Theoretical Framework: Allostatic load was used as a theoretical framework that explains the body's complex physiological system failure to adapt to continued stress. Increased sympathetic nervous system activity can result in illness and deterioration in health of caregivers

Methods: A quasi-experimental one group pre and post test design was used. Forty family caregivers living with and caring for PWD participated in the study. Family caregivers were recruited from hospital outreach programs, support groups, adult day cares, life care communities. Blood pressure and Modified Caregiver Strain Index were collected at baseline and 30 days after the deep breathing relaxation intervention. Data was analyzed using descriptive statistics, paired t-test and repeated measures analysis of covariance ANCOVA, multivariate analysis of covariance (MANCOVA).

Results: The findings showed that deep breathing relaxation intervention significantly decreased caregiver strain scores (p<0.0005) with a significant decrease in systolic BP (p=0.014) but not diastolic (p=0.167). There was a significant interaction between pre and post caregiver strain scores and deteriorating illness of PWD, caregiver or both (p=0.013) with 37.3% of the variance in increased caregiver strain post intervention.

Conclusions/Implications: The findings supported the allostatic load framework. Healthcare professionals (HCP) must educate caregivers about the importance of self-care and the negative effects of chronic stress on health. HCP must assess changes in strain of caregivers. Family caregivers can be taught relaxation techniques that are not time consuming, easily learned and used.

Pilot Testing the COPE Intervention with Family Caregivers of Frail, Older Adults

Meredith MacKenzie, Villanova University

Background: Family caregivers provide crucial support to frail older adults, enabling them to continue living in the community. However, caregivers often experience significant physical, emotional and financial distress related to caregiving which can lead to burn-out and depression.

Purpose: This study aimed to pilot test a psychoeducational intervention known as the COPE (Creativity, Optimism, Planning and Expert Information) and examine its acceptability and efficacy in a sample of family caregivers of frail, community-dwelling older adults.

Methods: Participants had weekly 1-hour sessions for three weeks with a nurse to identify caregiving challenges, receive education and create an action plan. The Patient Health Questionnaire (PHQ-9) and Caregiver Reaction Assessment (CRA) were used to assess mood and burden pre- and post-intervention. Sessions were recorded and participants interviewed about the program post-intervention.

Results: Fourteen family caregivers enrolled in this study, all non-Hispanic African Americans. The average participant was a 57 year old female with some college/trade school attendance, who spent >20 hours/week caring for her parent. Pre-intervention, the average caregiver reported moderate depression (mean PHQ9 score 8.1). Post-intervention, they reported minimal depression (4.4, p<0.02). Pre-intervention, caregivers rated schedule disruption as the area of greatest burden on the CRA (mean domain score 2.8). Post-intervention, there was no change (2.8, p<0.9). The study was highly acceptable to caregivers, who expressed appreciation. Caregivers felt that having in-home visits provided support while alleviating the additional schedule demand of going to a support group.

Conclusions/Implications: This study was more effective at improving mood than reducing burden. There is a clear need to identify alternative ways of providing support to caregivers unable to attend traditional support groups. Telehealth mechanisms and peer-to-peer interventions should be explored, along with nurse visits.

Symposium Session B6: Practice Transformation: A Healthcare System's Design for Discovery and Knowledge Translation

Practice Transformation: A Healthcare System's Design for Discovery and Knowledge Translation

Lily Thomas, North Shore-Long Island Jewish Health System [black down pointing small triangle] Jane White, Adelphi University [black down pointing small triangle] Myrta Rabinowitz, North Shore-Long Island Jewish Health System [black down pointing small triangle] Jennifer Darcy, North Shore LIJ Health System; Cohen Children's Medical Center [black down pointing small triangle] Jane Barr, North Shore-Long Island Jewish Health System

Integrative Summary: The purpose of this symposium is to present a health system's design for facilitating discovery and knowledge translation through coordinated programs of research and evidence-based practice aimed at improving care delivery and patient outcomes. The nation's 14^th largest health system has over 15,000 nurses working in its 21 hospitals, 3 long term care centers, a home care network, hospice care and over 450 ambulatory practices.

All presentations are related to the theme of facilitating practice transformation at the macro-meso-micro-system level through research and evidence-based practice and will highlight: a) The system's journey towards building a culture of discovery and practice transformation, b) clinical and academic-practice partnerships as a vehicle for strengthening research and EBP (presenting a new model of collaboration), c) From Inquiry to Evidence-based Practice A Blueprint for Achieving Clinical Nurse EBP Competencies System-wide, d) Strategies used to improve outcomes by igniting research and EBP in a specialty hospital, and e) An exemplar of transforming practice through evidence.

A clearly articulated vision, mission, and methodological framework are foundational to successful strategies for building and sustaining the organizational and individual capacity for research and evidence based practice.

A Methodological Perspective of Transforming Practice Through Evidence: An Exemplar

Jane Ellen Barr, North Shore-Long Island Jewish Health System

Background/Purpose: This presentation exemplifies evidence based practice (EBP) as a methodological approach for decreasing Medical Device Pressure Injuries (MDPI) in an acute care facility. The reduction of MDPI that result from the use of devices applied for diagnostic or therapeutic purposes, is an area in which there is limited research. An acute care facility's pressure injury incidence data showed MDPI accounted for 65% of injuries. Common sources of MDPI included respiratory equipment, feeding tubes, orthopedic equipment, and elimination catheters.

Theoretical Framework: An Evidence-Based Practice model was used as the methodological approach to guide clinical staff to identify the clinical problem, gather, appraise, and synthesize the evidence. After conducting gap analysis, a newly designed MDPI prevention strategy was implemented and evaluated. The MDPI prevention strategy, a D.E.V.I.C.E.S. Bundle, integrated the evidence, clinical expertise and patient's preferences.

Methods: The EBP initiative began with an interdisciplinary taskforce whose goal was to develop and implement an evidence-based bundle to decrease MDPI. Internal data was collected about the scope of the problem using surveys, observational studies, and policy review. Prior to designing strategies, barriers and facilitators were identified at the individual, unit, and organizational level. The D.E.V.I.C.E.S. Bundle was developed using deductive methodology from the evidence synthesis and established International, National, and Professional Organization's Pressure Injury Prevention Guidelines.

Results: The implementation of the D.E.V.I.C.E.S. Bundle resulted in standardized care protocols and a decrease incidence of MDPI by 98% which has been sustained for > 2 years.

Conclusions/Implications: Using an Evidence-Based Practice Model as a methodological strategy resulted in improved patient outcomes and facilitated staff's proficiency in using EBP as an approach to decision making and care. The D.E.V.I C.E.S. bundle has been disseminated and awarded recognition at local, regional and national levels.

Leading the Way: The Journey Towards Building a Culture of Discovery and Practice Transformation

Lily Thomas, North Shore-Long Island Jewish Health System

Background/Purpose: The purpose of this presentation is to describe the system's journey from vision to strategic design and implementation of a culture of inquiry leading to discovery and practice transformation. Background This is the journey of over 15,000 nurses in the nation's 14th largest health care system with 21 hospitals, Long term care centers, over 450 ambulatory practices, home and hospice care networks, and the Feinstein's institute for Medical Research. The vision was to establish a culture of inquiry and stimulate perpetual questioning as a precept for discovery. Effective responses to questions would require the coordinated capacity and competence of the individuals and organizational resources for facilitating research, EBP, and Implementation science.

Theoretical Framework: Donabedian's paradigm was used as a foundation for establishing structures and processes leading to the desired practice improvements and outcomes.

Methods: A Research and EBP council was strategically placed in the organizational and nursing administration structure with delineated links between the system, hospital, and unit levels. Standards for research and EBP as well as outcome metrics were established. A scientific review committee was created at the system level to review and approve nursing research studies ensuring methodological rigor and utility of studies.

Results: In the last 8 years, over 110 IRB approved research studies were conducted; one of the discoveries included Trombley Brennan Terminal Tissue Injuries (skin changes at end of life) impacting end of life care. Multiple evidence-based practice improvements were implemented; Specific improvements will be presented using selected performance metrics for research and clinical outcomes. Findings have been disseminated locally, nationally, and internationally.

Conclusions/Implications: Developing and sustaining a culture of inquiry requires commitment of resources including, appointment of nurse researchers, protected time, and infrastructures and processes that maximize the organizational and individual capacity and competence for research and EBP.

From Inquiry to Evidence-Based Practice A Blueprint for Achieving Clinical Nurse Competencies System-Wide

Myrta Rabinowitz, North Shore-Long Island Jewish Health System

Background/Purpose: The purpose of this abstract is to describe the methodology employed to attain System-wide establishment of evidence-based practice competencies in the nation's 14th largest care System. In 2003, the IOM Report identified 5 core areas of focus required for providing the highest quality of care possible. The IOM's goal is that 90% of decision making made in the clinical setting be evidence based by 2020 (IOM, 2010). One of these core areas of focus is nurses engaging in Evidence-based Practice (EBP) as a method to close the gap between scientific knowledge and healthcare practice. In response to this call to action, multiple education programs in EBP were delivered across the health system.

Theoretical Framework: Donabedian Model

Methods: Guided by findings of two internal research studies on EBP, the System Nursing Research and EBP Council convened a doctorally prepared task force for developing a standardized EBP program to meet the requirement of EBP competence for all nurses. The Clinical Nurse EBP Competency Program is a 3 Phase Program that begins with curriculum and tool development at the macro level, followed by preparing for implementation at the meso level and validating EBP competencies as well as facilitating evidence-based practice improvements at the micro level.

Results: Completion of the three phases prepares nurses to evaluate and use evidence based finding in their practice as well as the organization's goals of evidence-based practice improvements.

Conclusions/Implications: System- wide design for achievements at macro-meso-micro level require specific infrastructures and processes for achieving the desired outcome.

Clinical-Academic Partnerships as a Vehicle for Strengthening Research and EBP

Jane White, Adelphi University

Background/Purpose: Academic-clinical partnerships today are aligned with contributing to both research and knowledge translation for the discipline. This presentation will describe the evolution of a new academic -practice partnership model for strengthening research and evidence based practice.

Theoretical Framework: AACN/AONE Guiding Principles

Methods: In designing this model two major partnerships formed. The new role of the Visiting Nurse Scientist collaborating with the Vice President for System Nursing Research for facilitating Research and EBP functioned to strengthen the program of research and EBP. The VP appointed as a Visiting Scholar teaching a major course in one university contributed to a PhD program's goal of infusing clinical research into its program. Academic partners from local to national universities serve on the System's Research and EBP Council as active members or in an advisory capacity. Academic partners also serve on sub committees such as the System's Scientific Review Committee and Nursing Research Conference Planning Committee. Academic partners participate as faculty in multiple course offerings and designing and implementing projects. Health system nurses who were doctoral students and candidates collaborated with front line nurses in strengthening research and EBP.

Results: An increase in the number of research studies and EBP projects and their quality resulted. Doctoral students and candidates increased their knowledge of research and EBP as well as the value of academic-clinical partnerships to build strength for nursing science.

Conclusions/Implications: Collaboration and partnering is necessary to contribute to nursing's knowledge base. Former models do not address today's goals related to building integrated programs of research and practice. New models must be developed to ensure partnerships meet these contemporary goals for each entity.

Igniting the Spirit of Research and EBP in a Specialty Hospital

Jennifer Darcy, North Shore LIJ Health System Cohen Children's Medical Center

Background/Purpose: Cohen Children's Medical Center is a Magnet designated 209 bed hospital dedicated to the care of children and families. As the medical center began its journey for magnet accreditation, the practices in regard to research and EBP were reviewed and evaluated. Leadership identified the need to inculcate research and EBP at every level of practice. The challenge was to ignite the spark for inquiry in all nurses including administration, management and staff RNs.

Theoretical Framework: Donabedian's paradigm

Methods: A PhD prepared RN was appointed as Administrative Director of Nursing Research and serves on the Health System's Research and EBP Council. The processes to ignite the spirit of inquiry included a hospital wide campaign "Something to Chew on". The campaign included the revitalization of The Children's Medical Center Research and Evidenced Based Practice Council. The council also functions as the policies and procedures committee resulting in staff level nurses providing the level of supporting evidence for each policy. A research corner was created on each unit to provide updates on research and EBP. Leadership delineated that the research and evidenced based practice council would be held during designated protected time monthly.

Results: Hospital achieved Magnet designation. EBP has increased 10 fold and research studies have doubled from the year prior. Research and EBP is disseminated locally and nationally.

Conclusions/Implications: Igniting the spirit of inquiry relies on adequate structures and processes. These include having a doctorally prepared RN to mentor and encourage the staff, a structured platform, protected time and programs and implementation of initiatives designed to increase individual capacities and competence.

Paper Session C1: Mental Health

Maternal Anxiety Related to Prenatal Diagnoses of Surgical Fetal Anomalies

Abigail Wilpers, Yale University [black down pointing small triangle] Holly Kennedy, Yale University [black down pointing small triangle] Diane Wall, Yale-New Haven Hospital [black down pointing small triangle] Marjorie Funk, Yale University [black down pointing small triangle] Mert Bahtiyar, Yale University

Theoretical Framework: This study examined allostasis within the context of maternal response to perinatal stress.

Background: A growing number of surgical fetal anomalies are being detected during pregnancy. These diagnoses may contribute to maternal anxiety.

Purpose: The purpose of this study was to 1) Compare anxiety in women with and without surgical fetal anomalies; 2) Examine the relationship of sociodemographic and clinical characteristics with anxiety in women with a surgical fetal anomaly; 3) Explore the relationship of women's awareness of a nurse care coordinator on anxiety in women with a surgical fetal anomaly; and 4) Describe strategies for emotional support that could be provided at a fetal care center for women with a surgical fetal anomaly.

Methods: This prospective comparison pilot study took place at a fetal care center in a Northeast academic medical center. After informed consent, women in their second or early third trimester of pregnancy (n-44; 19 diagnosed with surgical fetal anomalies and 25 without anomalies) completed data on sociodemographic characteristics and anxiety (Spielberger State-Trait Anxiety Inventory). Women with fetal anomalies also answered questions about their experience at the fetal care center. An independent t-test was used to compare anxiety levels between the two groups. Independent t-test, one-way ANOVA, or Pearson's correlation were used to investigate associations between sociodemographic and clinical characteristics with maternal state anxiety.

Results: Women were 30.2 +/--7.5 years of age, had an average 16 years of education with 50% white. Women with fetal anomalies had higher state anxiety scores than women without fetal anomalies (43.58 vs. 29.08, p=0.002). There were no other significant differences between the two groups. In women with fetal anomalies, maternal age was positively correlated with state anxiety (r=0.59, p=0.008). A majority of women (68%) reported that knowledge of the nurse care coordinator decreased their anxiety. However, the correlation between awareness and state anxiety was not statistically significant (p=0.16). For methods of emotional support, women showed the most interest in speaking with families who had a similar experience.

Conclusions/Implications: Women with a surgical fetal anomaly exhibit high levels of anxiety, with older maternal age a risk factor for higher levels of anxiety. Knowledge of the fetal care center nurse coordinator role may have a positive effect and should be studied further.

A Qualitative Examination of Trauma Recovery in Young Urban Female Survivors of Commercial Sexual Exploitation and Domestic Trafficking Within the Context of a Community Based Participatory Approach

Joan Kearney, Yale University [black down pointing small triangle] Mary Byrne, Columbia University [black down pointing small triangle] Jessica Trudeau, Girls Educational and Mentoring Services [black down pointing small triangle] Mary Magargee, Columbia University [black down pointing small triangle] Jasmine Johnson, Girls Educational and Mentoring Services [black down pointing small triangle] Patricia Semeraro, Columbia University

Theoretical Framework: The study was grounded in the community based participatory approach. Additional supporting frameworks included Harvey's ecological theory of trauma recovery as well as Herman's work on the construct of complex trauma.

Background: This research is an exploratory, qualitative examination of the meaning of trauma recovery and its association with pathways out of commercial sexual exploitation in young urban females in Harlem, New York City. Despite the very high risk status of these girls in multiple areas, we have little information on the pathways they take once they enter a community based treatment or other supportive program. Additionally, there is no commonly accepted understanding of the nature of trauma recovery in these young women in a community setting. This Community Based Participatory Research grant was conducted in partnership between investigators from the Columbia University School of Nursing and the Girls Education and Mentoring Services (GEMS) in New York City.

Purpose: To address the gap in our knowledge regarding specific aspects of trauma recovery in this group of young women, this study examined the characteristics, components and processes of trauma recovery in young urban female survivors of commercial sexual exploitation and domestic sex trafficking who attended a well known community based program.

Methods: A qualitative descriptive design was employed using focus group and individual interviews for data collection. Thirty one young women using GEMS services, 7 staff members, 4 persons in GEMS leadership roles and 2 from another leading agency were interviewed. A semi-structured interview guide examined: 1) the meaning of trauma recovery to participants; 2) services and activities deemed necessary for recovery; and 3) the nature of leaving "the life". Emergent content analysis was employed to analyze data. Community based participatory principles and practices were followed including: partnering of Columbia researchers with GEMS members in the design and procedures of the study as well as collaboration on data interpretation; formation of a joint advisory board, and joint efforts in dissemination of findings.

Results: Thematic analysis revealed a multidimensional model of recovery expressed by survivors and those who work with them. Findings center around intrapersonal, relational, and community and societal processes.

Conclusions/Implications: Results of this seminal study inform current thinking and practice on intervention and framework for recovery with respect to group of young women. Implications indicate the need for broad, trauma- informed approaches which consider social context and the uniquely dynamic, complex and non-linear long term nature of recovery in this population.

The Knowledge, Attitudes, and Self-Reported Behaviors of Psychiatric Nurses Towards Obese Psychiatric Patients on Atypical Anti-Psychotropic Medications

Marcia Williams, Molloy College

Background/Purpose: The advancement of psychiatric treatment has resulted in a higher prevalence of obesity among the psychiatric population related to the side-effects of the newer atypical anti-psychotics. This study address nurses' attitude towards obesity, focusing on psychiatric patients. Negative attitudes and low knowledge about psychiatric patients on atypical anti-psychotics can interfere with psychiatric nurses' therapeutic potential to support patients with health promotion behaviors. The purpose of this study is to develop an instrument to measure the knowledge, attitudes, and self-reported behavior of psychiatric nurses towards the mentally ill obese patient. The secondary purpose is to determine if psychiatric nurses' knowledge, attitudes and behaviors are different when the patient is obese versus normal weight.

Theoretical Framework: Albert Bandura's (1998) theoretical framework of health promotion from the social cognitive theory perspective is used to guide this study. The social-cognitive aspect works on keeping people motivated to sustain healthy habits.

Methods: This study uses a two-phased descriptive design, to develop and psychometrically test one instrument that can be used in future studies. In phase one existing instruments were adapted using 6 expert panelists for content validity. The instrument consists of four subsections; the knowledge (NKAAM), general attitudes towards obesity (NATOP), intrinsic attitudes (IATOP), and the self-reported behaviors (SRBTOP) subsections. In the second phase, the instrument was given to a national sample (n= 149) of psychiatric nurses. Two developed vignette scenarios, of an obese and a normal weight individual with severe mental illness, were randomly assigned to the participants via on-line survey questionnaire or sealed non-identifying paper questionnaires. Data analysis include instrument testing, parametric testing, t-test, ANOVA, and chi square.

Results: Findings indicate the nurses were knowledgeable about the medications and their side-effects but unknowledgeable about dosages. Positive correlation was found between years of psychiatric experience (p=.015) and participant's weight. T-test found significance between the 2 groups on items "strong-willed[horizontal ellipsis].weak-willed", "sociable[horizontal ellipsis].not sociable", "attractive[horizontal ellipsis].unattractive", and "trusting[horizontal ellipsis].suspicious" with more bias from the obese patient vignette. ANOVA and post-hoc tests found more bias in the older nurses towards the obese patient. On the SRBTOP subsection significance was found between the 2 groups (p=.000) on the mean scores and several items indicating bias towards the obese patient in the vignette.

Conclusions/Implications: This instrument is a step towards measuring the negative attitudes nurses may have towards psychiatric patients who are obese. Also, understanding nurses' underlying knowledge and attitude will identify and direct educational needs of psychiatric nurses, in academia and in the clinical areas.

Mindfulness-Based Cognitive Therapy for Perinatal Anxiety: Postpartum Follow-Up and the Role of Home Practice

Janice Goodman, MGH Institute of Health Professions [black down pointing small triangle] Chistina Luberto, Massachusetts General Hospital [black down pointing small triangle] Elyse Park, Harvard Medical School

Background/Purpose: Mindfulness-based interventions (MBIs) have shown promising efficacy for improving mental health outcomes among perinatal women. The authors' recent pilot study of CALM Pregnancy, a Mindfulness-Based Cognitive Therapy (MBCT) intervention adapted for pregnant women with high anxiety, showed significant improvements in anxiety, worry and depression, and significant increases in self-compassion and mindfulness from pre- to post-intervention. The current study extends the original study to begin to address two key gaps in the perinatal MBI literature: the maintenance of prenatal intervention effects post-partum, and the relationship between home mindfulness practice and outcomes.

Theoretical Framework: Integration of theory and methods from eastern contemplative traditions and western psychology to enhance self-regulation and improve mental health.

Methods: In this single-arm pilot study, 23 pregnant women with elevated anxiety completed the CALM Pregnancy intervention, which included weekly 2-hour group classes and 30-40 minutes of daily home mindfulness practice between classes. Participants completed relevant self-report measures pre- and post-intervention and at 3 months postpartum. Home practice data was collected throughout intervention and follow-up phases. Analyses included descriptive statistics, one-way repeated measures ANOVAs, zero-order correlations, and independent samples t-tests.

Results: Improvements in anxiety, worry, mindfulness, and self-compassion from baseline to post-intervention were maintained post-partum (p's<.05), and improvements in depression showed further improvements from post-intervention to post-partum (p<.001). Participants were generally adherent to home practice recommendations during the intervention (54%-80% weekly adherence), and continued practicing at post-intervention (91%) and post-partum (55%). Home practice during the intervention was not significantly correlated with outcomes at post-intervention, and only significantly correlated with worry at follow-up (r=.87, p<.001). Home practice at follow-up was only marginally related to improved worry at follow-up (p=.05).

Conclusions/Implications: MBCT may be associated with maintained improvements in mental health outcomes for perinatal women. Many women practiced mindfulness consistently during and after the intervention, but mindfulness practice might not be responsible for improved outcomes. Research and clinical implications are discussed.

Community Reintegration in Military Veterans with Traumatic Brain Injury: The Key Role of Depression as a Mediator

Helene Moriarty, Villanova University [black down pointing small triangle] Laraine Winter, Philadelphia VA Medical Center [black down pointing small triangle] Gala True, Philadelphia VA Medical Center [black down pointing small triangle] Keith Robinson, Philadelphia VA Medical Center [black down pointing small triangle] Thomas Short, West Chester University

Background/Purpose: Traumatic brain injury (TBI) has been called the "signature wound" for soldiers returning from the Iraq and Afghanistan combat theaters. Community reintegration (CR) is a serious challenge for military veterans, especially for those with TBI. Posttraumatic stress disorder (PTSD), depression, bodily pain, and limitations in physical functioning-common comorbidities with TBI in veterans-have all been associated with reduced CR, but their interrelationships are unclear. The role of depression as a possible mediator of effects on CR has not been examined. We tested depressive symptoms as a possible mediator of CR's associations with physical limitations, PTSD, and bodily pain.

Theoretical Framework: An ecological framework guided the study.

Methods: This cross-sectional study used baseline data from a larger randomized controlled trial that evaluated the impact of an in-home intervention for veterans with TBI and their families. Eighty-three veterans with TBI recruited from a Polytrauma program at a Veterans Affairs medical center participated. Standardized instruments measured CR, depressive symptoms, physical limitations (limitations in physical functioning), bodily pain, quality of the relationship with key family members, and sociodemographic characteristics. PTSD was determined through review of the electronic medical record. Data were collected in veterans' homes.

Results: Depressive symptoms totally mediated the relationship between physical limitations and CR and the relationship between PTSD and CR. The bodily pain-CR association was not significant after quality of relationship was entered into the regression models.

Conclusions/Implications: Findings suggest that the effects of PTSD and physical limitations on CR may be mitigated through effective treatment of depression. Interventions to increase CR of veterans with TBI should focus on depression, a treatable condition. Replication of our mediation findings in larger veteran and civilian samples with TBI is needed. The mediating role of depression observed in our study is clinically compelling and points to an important direction in clinical practice and future research.

Paper Session C2: Chronic Illness

Fatigue in Parkinson's Disease: A Qualitative Descriptive Study Exploring the Individual's Perspective

Amy Bruno, MGH Institute of Health Professions

Theoretical Framework: Not applicable

Background: Fatigue in Parkinson's disease (PD) is a major cause of disability and is associated with lower quality of life. It is often under-assessed by health care providers and under-recognized by individuals with PD as being part of their neurological disorder. A comprehensive literature review revealed that there is a lack of descriptive research from the individual's perspective regarding fatigue definitions in PD, self-management strategies, and its impact on quality of life.

Purpose: The aim of this study was to uncover how individuals with PD define this symptom, the effect it has on one's quality of life, self-management strategies to lessen fatigue, and how individuals perceive their health care providers recognize and manage their PD-related fatigue.

Methods: The study utilized a qualitative descriptive design with responsive interviewing as developed by Rubin and Rubin. In-depth interviews were conducted to gain a rich description of the experience of PD-related fatigue. The sample of eight participants included six males and two females. Participants were recruited from local PD support groups using purposive and snowballing sampling techniques. Strategies from Schatzman and Strauss' field research were used to guide data collection and analysis of the transcripts.

Results: Five themes were revealed through data analysis and included: the symptom experience, what fatigue is not, accommodation, loss, and mental fortitude. These main themes were discovered to exist in the data across several of the research questions and for the majority of the participants. Each of the main themes were further analyzed. The symptom experience included the subthemes of: symptom identification, daily and pervasive symptom, evolvement over time, and seeking validation. What fatigue is not consisted of the subthemes: tiredness, sleepiness, and depression. Accommodation encompassed alteration in daily routine, engagement in activities, and conservation of self. The theme of loss was expressed as role loss, loss of activities, and changing sense of self. Mental fortitude included the subthemes of taking control/perserverance, acceptance, and positive attitude. Fatigue had a significant effect on QOL and participants described self-management strategies that decreased fatigue. Half of the participants did not discuss fatigue with their health care providers either because they did not bring it up during office visits or the provider did not assess for the presence of fatigue.

Conclusions/Implications: Implications of this research for practice include the importance of assessing for fatigue at every office visit and teaching about self-management strategies. Future research may focus on the development of an intervention study to examine the effect of exercise on fatigue and the exploration of fatigue as part of a symptom cluster with other non-motor symptoms of PD.

Somali Older Adults' and Their Families' Perceptions of Adult Home Health Services

Sarah Miner, New York University

Background: Home health care (HHC) refers to the delivery of health and personal care services in the home by paid health professionals and/or paraprofessionals. Somali older adults face a number of challenges that impede their access to HHC services, but there is promising evidence indicating that HHC services can improve their health outcomes. Further exploration of Somali families' perceptions of these services can demonstrate what is needed to improve their access and experience with HHC.

Purpose: The specific aims of this study were to: (1) Explore factors influencing utilization of adult HHC by Somali older adults and their families resettled in the US; (2) Describe Somali older adults' and their families' perceptions of and experiences with the services offered by adult HHC.

Methods: This study used a community-engaged, qualitative descriptive approach with the participation of Refugees Helping Refugees (RHR), a non-for-profit organization in a northeastern US city. A total of 14 Somali families who had received HHC services for an older adult participated. Data collection included 15 home visits, 17 semi-structured interviews and 16 debriefing sessions. Data analysis began early and continued throughout the project using qualitative content analysis.

Results: Somali families recognized HHC services were needed and believed having services in the home eliminated barriers and facilitated learning. Families' experiences and perceptions of HHC depended on whether they trusted the person coming to their home. Somali families value HHC but wanted it to be supportive of their traditional beliefs and family structure, and were particularly interested in better access to consumer-directed programs. Families believed better understanding of HHC services was needed, and HHC agencies should work with the Somali community to improve cultural understanding of HHC professionals and HHC experiences for Somali families.

Conclusions/Implications: Somali older adults and their families' descriptions of HHC suggest it can play a role in improving their health. Future research should provide a better understanding of the most effective models of HHC delivery and the impact of HHC professionals' relationships on health outcomes. This should include methods of HHC delivery that use a community health worker and involve community outreach with culturally and linguistically diverse populations.

The Effect of Heart Failure on Health-Related Quality of Life during Critical Transitions in the Life Course

Alison Walsh, Penn State College of Nursing [black down pointing small triangle] Lisa Kitko, Penn State College of Nursing

Theoretical Framework: Ferrans' Conceptual Model of HRQoL and the Lifespan Developmental Perspective were integrated to guide this research.

Background: Heart failure (HF) is an epidemic impacting approximately 6 million Americans with 1.4 million of those under the age of 65. Patients living with HF report significant impacts to their perceived health-related quality of life (HRQoL). The majority of the current evidence has been conducted with older individuals living with HF and limited data exists on HRQOL in younger individuals and the impact of HF on life course.

Purpose: To explore the effect of HF on HRQoL during critical transitions earlier in the life course.

Methods: Participants with HF (n=18) between the ages of 38 and 54 were recruited from two hospitals. Semi-structured qualitative interviews were conducted to explore the complex, subjective nature of what constitutes HRQoL and how it is affected by HF during critical transitions identified by participants in the life course. Interviews continued until saturation was reached. Data were analyzed utilizing a thematic analysis approach.

Results: Seven themes emerged: Role fulfillment, autonomy, financial impact, perception, retrospective life changes, symptom burden, and outlook. Participants frequently linked HRQoL to accomplishing life goals and to a sense of productivity and purpose. This was reflected in how participants with HF perceived their roles as a parent, caregiver, spouse, employee, and friend have been affected by HF. Participants reported depression, anxiety, and fatigue. The majority of participants also expressed regret for life choices that may have led to the progression of their HF.

Conclusions/Implications: Younger individuals living with HF have a markedly different perception of what constitutes HRQoL than their older counterparts. This is largely a result of how HF affects critical transitions that traditionally occur earlier in the life course such as establishing a career, meaningful relationships, family, and financial security. In order to provide holistic care to patients living with HF, interventions to improve HRQoL should be considered in relation to the heavy burden of psychosocial symptoms and the alterations in role fulfillment experienced by the younger population.

Predictors of Health Literacy in Elderly Portuguese Immigrants with Heart Failure

Kristen Sethares, University of Massachusetts-Dartmouth [black down pointing small triangle] Cheryl Westlake, Azusa Pacific University

Background/Purpose: There are over one million Portuguese immigrants residing in the United States. Immigrants have unique healthcare challenges due to issues with language, access, and cultural differences. Health literacy, the ability to obtain, process, and understand basic health information to make health decisions and navigate complex health care systems, is associated with self-reported health and clinical outcomes. Latino immigrants have worse health literacy than Asian immigrants and other ethnic and racial groups in the United States. While factors that influence health literacy have been explored in a number of immigrant and ethnic populations, little is known about these factors in Portuguese immigrants. The purpose of this study is to describe health literacy levels and predictors of health literacy in elderly, Portuguese immigrants with heart failure.

Methods: Data on demographics (age, gender, education, marital and financial status), comorbidities (Charlson Comorbidity Index), cognition (Clock Draw Score, CDT, 0-10) and health literacy (S-TOFHLA, 0-16 inadequate, 17-22 marginal, 23-39 adequate) were collected during hospitalization. Demographic (age, education, financial status) and clinical variables (cognition, comorbidities) were regressed on health literacy.

Results: The sample of 60 adults was predominately older (75 +/- 13.9 years), male (50%), poorly educated (9.3+/- 3.5 years), married (59%), with enough income to make ends meet (46%) and 2 comorbidities (41%), and were cognitively intact (69%). The majority had less than adequate health literacy [inadequate (59%), marginal (13%), adequate (28%)]. The regression model explained 65% of the variance in health literacy levels (p < .001). Four predictors contributed significantly to the model age (beta = -.301, p = .003), years of education (beta = 1.369, p =.002), comorbidities (beta= -1.945, p =.011), and cognition (beta = .789, p = .045).

Conclusions/Implications: The majority of Portuguese immigrants demonstrated less than adequate levels of health literacy. Older age, lower educational level, more comorbidities, and lower cognition all predicted health literacy. Assessment of health literacy and alternate educational strategies may be needed to enhance the health of Portuguese immigrants.

Beliefs About Use of Complementary Health Approaches for Parkinson's disease

Ju Young Shin, University of Delaware [black down pointing small triangle] Ryan Pohlig, University of Delaware [black down pointing small triangle] Barbara Habermann, University of Delaware

Background/Purpose: Parkinson's disease (PD) is the second most common neurodegenerative disorder, which is prevalent among older adults in the United States. Despite the high prevalence of complementary health approaches (CHA) use among people with PD, little is known about CHA users' beliefs about CHA. The purpose of this study was to describe CHA users' beliefs about the effectiveness, safety and risk of CHA.

Theoretical Framework: This study was influenced by the literature review on beliefs about CHA use in PD. Twelve items regarding beliefs about CHA were developed by researchers and were reviewed by a group of PD experts and three people with PD.

Methods: This study used a sub-sample (n = 70; 38 males) from a larger research project which aimed to quantify the portion of community-dwelling people with PD who used CHA. Those who reported using CHA in the past 12 months were asked about their CHA beliefs. Respondents answered 12 additional questions based on a 6-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 = somewhat agree, 5 = agree, and 6 = strongly agree).

Results: Most respondents were Caucasians (92.9%), currently married (88.6%), and not working (88.6%). The average respondent was 69.34 years (SD = 8.54), had 16.44 years (SD = 2.93) of education, and had been diagnosed for 6.73 years (SD = 5.52). The CHA used by the respondents included natural products and mind and body approaches. On average, respondents believed CHA were somewhat effective in controlling or managing their PD motor (M = 4.17, SD = 1.20) and non-motor symptoms (M = 4.13, SD = 1.13). The necessities for CHA use were general health (M = 4.74, SD = 1.13) and PD management (M = 4.57, SD = 1.17). Respondents disagreed with the idea that CHA might have possible adverse effects (M = 2.87, SD = 1.32) and potential interactions with prescription medications (M = 2.94, SD = 1.39). They were willing to share their CHA use with doctors and/or nurses (M = 5.26, SD = .65).

Conclusions/Implications: In conclusion, more scientific evidence on the effectiveness and safety/risk of CHA is needed to assist individuals' informed decision about using CHA and allocation of their healthcare spending. Nurses and other healthcare professionals need to be aware of CHA users' beliefs about CHA used for PD and of the need of provision of adequate information and resources, including locating qualified CHA practitioners or databases of CHA.

Paper Session C3: Organizations and Workforce Issues: Focus on Leadership and Staff Nurse Issues

Nursing Leadership and Pressure Ulcers in Acute Care Hospital Units

Chenjuan Ma, New York University [black down pointing small triangle] Binna Lee, New York University

Background/Purpose: Enhancing nursing leadership has been highlighted as an opportunity as well as challenge for improving nursing care and patient outcomes. While there are studies aiming to define and describe nursing leadership, there is a lack of empirical evidence linking nursing leadership to objective patient outcomes at the patient-care unit level. The purpose of this study is to identify the extent to which nursing leadership is associated with hospital-acquired pressure ulcers (HAPUs) in acute care hospital units.

Theoretical Framework: This study was guided by the Quality Health Outcomes Model (QHOM).

Methods: This study used a cross-sessional design. Data was obtained from the National Database of Nursing Quality Indicators. Nursing leadership was measured by the Supportive Nursing Management Scale (SNMS), which was completed by 24,034 registered nurses (RNs). Data from individual RNs was aggregated at the unit level. The final sample included 958 units of 5 types (i.e., critical care, step down, medical, surgical, and medical-surgical combined) from 168 acute care hospitals nationwide. A two-level logistic regression model was used to estimate the association between nursing leadership and HAPU rates, when controlling for hospital and unit characteristics.

Results: Overall units had a mean SNMS score of 4.33 (SD=0.61), and there was a significant difference in the SNMS scores by unit type (p=0.010). On average, units had a HAPU rate of 2.6%. Unit HAPU rates varied significantly by unit type (p=0.000). It was highest on critical care units with a rate of approximately 5.0% and lowest on surgical units with a rate of 1.4%. Estimates from our regression model indicated that one-unit increase in the SNMS score was associated with 16% lower odds of having a HAPU (OR = .84, 95% CI: .77-.92) in a unit. Other unit and hospital factors that influenced unit HAPU rates included nurse staffing, working experience as a nurse, and hospital Magnet status.

Conclusions/Implications: Units in which nurses reported stronger leadership and support from their nurse managers are more likely to have significantly lower HAPU rates. Our finding implies that nursing leadership can make a significant contribution to improving patient outcomes.

How Nurse Manager Leadership and Workplace Effectiveness Affect Hospital Patient Safety

Jessica Smith, University of Pennsylvania [black down pointing small triangle] Karen Morin, Bronson Methodist Hospital [black down pointing small triangle] Eileen Lake, University of Pennsylvania

Background/Purpose: Favorable nurse staffing and nurse work environments have been linked to better patient and nurse outcomes in multiple large studies using sophisticated quantitative methods (Aiken et al, 2014; McHugh et al, 2016). However, confidence that a team of nurses can solve problems (i.e. workplace effectiveness) has not been studied as a modifiable feature of nurse work environments that could be associated with patient safety culture. The purpose of this study was to determine whether hospital patient safety culture is associated with modifiable features of the hospital nurse work environment, namely workplace effectiveness and nurse manager leadership.

Theoretical Framework: Donabedian's (1980) structure-process-outcomes conceptual framework was the theoretical basis for this study.

Methods: Hospital staff registered nurses at 5 hospitals, 3 of which were Magnet recognized, were surveyed. A cross-sectional, correlational design was employed. Linear regression models were estimated to explain the variance in patient safety culture explained by manager leadership and workplace effectiveness. The following instruments were administered online: 1) the Hospital Survey on Patient Safety to measure patient safety culture; 2) the Collective Efficacy Beliefs Scale to measure workplace effectiveness; 3) the Practice Environment subscale of the Nursing Work Index to measure nurse manager leadership; and 4) a demographic information form.

Results: Among the respondent sample of 233 nurses, half of the participants were 35 years of age and under. Most participants (76%) held a bachelor degree in nursing. Mean workplace effectiveness was 4.95, which is equivalent to agree on a six point Likert response scale from strongly disagree to strongly agree. Nurse manager leadership influences workplace effectiveness (b = .60, p < 0.01); for each unit increase for nurse manager leadership, workplace effectiveness can be expected to increase by .60. Nurse manager leadership influences patient safety climate perceptions (b = .36, p < 0.01); for each unit of increase for nurse manager leadership, patient safety climate can be expected to increase by .36. Greater workplace effectiveness is associated with more positive perceptions of patient safety cultures (b = .21, p < 0.01); for each unit increase for workplace effectiveness, patient safety climate can be expected to increase by .21.

Conclusions/Implications: This sample of predominantly magnet hospital nurses exhibited a high degree of workplace effectiveness. Adequate nurse manager leadership and increased workplace effectiveness is associated with better patient safety cultures in hospitals. Future research efforts should be made to understand how registered nurses define workplace effectiveness in order to investigate this phenomenon with more accuracy in health systems.

Development of a Board Readiness Competency Survey for Nurses

Lisa Sundean, University of Connecticut

Background/Purpose: Nurses are needed to serve on boards of directors to promote health and advance quality healthcare through organizational governance leadership. However, board readiness skills are not well understood by nurses. Healthcare governance has moved toward a competency-based model for recruitment of directors. Competencies are useful for nurses who are preparing for board governance leadership roles. The purpose of the study was to develop an instrument for nurses to self-assess competencies for healthcare board service.

Theoretical Framework: Bandura's theory of self-efficacy framed the development of the instrument. Self-efficacy is the confidence to engage in persistent effort toward a behavioral goal.

Methods: The Healthcare Board Competency Survey for Nurses (HBCSN) was developed from the Center for Healthcare Governance board core competencies using a correlational design employing principal components analysis to identify latent factors underlying the set of items. Registered nurses (RNs) in the U.S. completed the online survey by snowball sampling. The HBCSN is an 18-item self-report survey arranged as a 5-point Likert-type scale to assess levels of confidence with items. Reliability of the data was analyzed via Cronbach's alpha (CA) and based on the varimax rotated component matrix.

Results: Analysis represents 223 RNs with completed data sets, females (93%), ages 40-69 (92%), with masters or doctorate education (89%). Seventy-two percent of respondents were not serving on boards at the time of survey completion and 66% lacked past board experience. Three components were derived from the data: Complexity/Analytic Skills (7 items) (CA=.91), Personal/Interpersonal Skills (6 items) (CA=.90), and Community/Organizational Awareness Skills (5 items) (CA=.83).

Conclusions/Implications: The pilot survey of the HBCSN shows promising results for assessing nurses' self-efficacy for board core competencies. The high CA scores for data on 3 derived components suggest the HBCSN is a reliable instrument for assessing nurses' readiness for board service. Nurses who serve on boards are well positioned to promote health and influence organizational policies to advance the quality of healthcare. The HBCSN is supportive of nurses who are preparing for governance leadership roles. Further development and psychometric testing of the HBCSN are recommended.

Learning Agility and Observed Leadership Ability in Nurse Managers: A Management Case Example

Jennifer Withall, New York University [black down pointing small triangle] Kimberly Glassman, New York University

Background/Purpose: Historically, nurses who have demonstrated clinical acumen are often rewarded through promotion to leadership positions. Organizations may lack a standardized method of distinguishing high performers/clinical experts from those who are high potentials/adaptable learners. The concept of learning agility, or "the willingness and ability to learn new competencies in order to perform under first-time, tough, or different conditions"(Lombardo & Eichinger, 2000, pg. 323), is considered to be a significant predictor of leadership ability. The purpose of this study was to measure nurse managers' learning agility and its relationship to role performance, and leadership talent predictions.

Theoretical Framework: The concept of learning agility provided the framework for the study. The domains of learning agility include: people, results, mental, change, and self-awareness.

Methods: An exploratory, descriptive pilot study was conducted in a multi-facility, academic medical center in NYC. Three instruments for analysis include: the learning agility assessment (both individual domains and overall score), a 9-box talent matrix, and annual performance review scores. There were forty-eight eligible nurse managers who were invited to participate. All were plotted on a 9-box talent assessment matrix, used to evaluate each individual's technical, management, and leadership skills. The final sample included the clinical nurse managers who had completed all parts of the study (N=17). The nurse managers completed the learning agility assessment survey by accessing a confidential, unique link. The aggregate results were correlated with the annual nurse managers' performance review. The director's 9-box rating of the nurse manager were compared to that of the nurse manager's individual learning agility assessment.

Results: SPSS was used to conduct the analysis on the five domains of learning agility, the overall learning agility score, and the performance review score. Spearman's rho correlation coefficients were calculated due to the small sample. The correlation matrix yielded significant relationships between performance rating with "overall" agility (r = .623, p< .05) and "people" agility (r=.549, p<.05). The "overall" agility scores were correlated with four of the five domains - mental (r=.784, p<.05), people (r=.537, p<.05), results (r=.700, p<.05), and self-awareness (r=.629, p<.05). "Change" agility was the noted exception. Additionally, the 9-box matrix scores and learning agility domain ratings were visually depicted using a star graphic, in which each of the points was colored to correspond with the percentile ranking (low, medium, high).

Conclusions/Implications: Learning agility is a concept that has not been explored in a nursing population. This pilot study and organization case example form the basis for further study in using learning agility to predict future leadership success in a prospective study of early-career nurses.

Obligation versus Opportunity: Qualitative Findings from a Mixed Method Study on Staff Nurse Perceptions of Peer Review

Kimberly Fenstermacher, York College of Pennsylvania [black down pointing small triangle] Deborah Lampo, WellSpan Health System [black down pointing small triangle] Barbara Buchko, WellSpan Health System [black down pointing small triangle] Paula Coe, WellSpan Health System [black down pointing small triangle] Theodore Bell, WellSpan Health System

Background: Peer review is defined as a process for RNs to systematically evaluate the quality of nursing as provided by their peers against professional standards of practice. The lack of a formal consistent peer review structure jeopardizes the professional environment and may impact success with Magnet re-designation.

Purpose: The purpose of this study was to explore staff nurses' perceptions of professional peer review (PR) and peer communication to inform the redesign of the PR process. This presentation will reveal findings from the qualitative arm of a mixed method study to describe the nurses' perceptions, identified barriers and experiences of participating in peer review.

Methods: After IRB approval, the 35 question Peer Group Caring Interaction Scale was distributed electronically to 1239 direct care registered nurses in a large teaching hospital in south central PA. Demographic data were collected. Between 157 and 294 responses were received to five open-ended questions that were posed to gather nurses' perceptions about the process and meaning of PR from their own participation experiences. Data were analyzed using content analysis to identify themes across the narratives.

Results: Nurses' perceptions of peer review were overwhelmingly negative. A central theme emerged, describing peer review as "Obligation versus opportunity." PR was viewed as time-consuming, difficult, and meaningless. Receiving and giving PR was only perceived as comfortable and constructive if the feedback being given was positive. Negative feedback was often perceived as bullying or threatening. Barriers included fear, insufficient knowledge, time, bias, and the process itself.

Conclusions/Implications: The purpose of peer review is often misunderstood by nurses. In spite of the challenges, nurses working in Magnet hospitals must practice in a professional environment that is conducive to giving meaningful peer review about clinical practice. Peer review must be thoughtfully designed to foster trust and encourage transparency in a non-threatening way.

Paper Session C4: Nursing Education: Faculty and Student Issues

Use of Standardized Patients with Disabilities in an Undergraduate Nursing Program: A Descriptive Qualitative Analysis of Student Perceptions

Serah Nthenge, Villanova University [black down pointing small triangle] Elizabeth Petit de Mange, Villanova University [black down pointing small triangle] Suzanne Smeltzer, Villanova University [black down pointing small triangle] Bette Mariani, Villanova University [black down pointing small triangle] Jennifer Ross, Villanova University [black down pointing small triangle] Colleen Meakim, Villanova University [black down pointing small triangle] Elizabeth Bruderle, Villanova University

Background: People with disabilities (PWD) report having negative encounters with nurses due to lack of knowledge, negative attitudes, and lack of communication skills needed to interact effectively with PWD. Undergraduate nursing programs and textbooks devote little attention to the care of PWD. To address this gap, simulation experiences, in which PWD were employed as standardized patients (SP), were implemented and evaluated in a BSN program.

Purpose: The purpose of this study was to examine the perceptions of BSN senior nursing students as related to PWD after completing simulation experiences which employed PWD as SP.

Methods: A mixed method design was used. This presentation will focus on an analysis of the three post-test qualitative questions using descriptive qualitative analysis. The questions addressed the students' 1) initial reaction to encountering a PWD as an SP, 2) reaction after having had an interaction with a PWD, and 3) opinion regarding the value of the experience. A purposive sample of 452 senior BSN students in a Catholic University in the U.S. Mid-Atlantic region. Post-test surveys were administered electronically in a proctored class room after completion of the final simulation in 2013 and 2014.

Results: Data were analyzed using descriptive qualitative methods and were read, reread, compared and contrasted by two investigators. Four categories identified were cognitive, emotional, behavioral, and interpretive. Cognitive themes included a) critical thinking, and b) experience. Emotional themes included a) confidence, b) surprise c) security, and d) comfort. Behavioral themes included a) assessment, and b) communication. Interpretive themes included a) normality, b) reality, c) social acceptance, d) opportunity, and e) respect.

Conclusions/Implications: Participants overwhelmingly indicated they valued the experience and recommended continuing the program. This study is a step in closing the gap in nursing education and research to improve the health care experiences of PWD.

The Description and Meaning of Clinical Competency: Perceptions of Acute Care Nurse Managers and Prelicensure Baccalaureate Faculty

Carolyn Meehan, West Chester University

Theoretical Framework: Transitions Theory is presented as a theoretical framework supporting the findings of this study. The application of the four themes described in this study to the Transitions Theory assists in further understanding the meaning of clinical competency in nursing.

Background: Clinical competency is a significant concept for nursing as it relates directly to the quality of patient care that nurses provide in the healthcare setting. Despite the vital nature of this concept, there is no widely accepted understanding of the term between the academic and clinical groups in nursing, in the literature. Consequently, there is a continuous struggle to set standards to measure clinical competency in undergraduate nursing students. This imprecise understanding of clinical competency widens the gap between education and practice. When prelicensure baccalaureate nursing faculty and acute care nurse managers share expectations of what constitutes clinical competency in nursing students, that gap may be bridged and assist in building unity in nursing, healthcare, and science.

Purpose: The focus of this study was to describe and gain an understanding of the concept of clinical competency from the perspective of acute care nurse managers and prelicensure baccalaureate nurse faculty.

Methods: This was an interpretive descriptive study. Participants included eight acute care nurse managers and nine prelicensure baccalaureate nurse faculty. Data were collected through semi-structured interviews with the participants, and analyzed through a constant comparative analysis until the data reached saturation.

Results: Four themes emerged from the data of this interpretive description study when acute care managers and baccalaureate nurse faculty described the meaning of clinical competency and what expectations managers have of the new graduate nurse in regards to clinical competency. The themes are applying metacognitive judgment, getting the big picture, providing safe care, and developing professional nursing behaviors. Implications of this study from the perspective of nursing science and research offered for the first time a shared view of the concept of clinical competency from the perception of the managers in practice and the faculty educating undergraduate nursing students in the clinical area.

Conclusions/Implications: Implications for nursing education included providing faculty a means to structure the clinical experience so that students may be better prepared to practice in the acute care setting as a new graduate nurse. In nursing practice, the benefits for the managers are an understanding of the level of clinical competency and preparation of the new graduate nurse, which enables them to further support their transition to clinical practice. Future research may include a tool for the objective measurement of clinical competency.

Test Anxiety and Academic Procrastination Among Pre-licensure Nursing Students

Nicole Custer, Indiana University of Pennsylvania

Background/Purpose: Test anxiety may cause nursing students to cope poorly with academic demands, resulting in lower academic performance levels, high attrition rates, and possibly failures on the NCLEX-RN^(R). Test-anxious nursing students may engage avoidance behaviors, such as academic procrastination, as a coping mechanism. The purpose of this study was to describe the relationship among test anxiety and academic procrastination among pre-licensure nursing students, determine the frequency of test anxiety and academic procrastination among undergraduate nursing program types, and identify factors that may predict academic procrastination.

Theoretical Framework: The Cognitive Avoidance Theory of Worry acted as the theoretical framework for this study. This theory suggests that cognitive avoidance (procrastination) is a coping mechanism to perceived actions that may cause anxiety or fear.

Methods: This research study utilized a quantitative descriptive correlational design. The Test Anxiety Inventory (TAI) and the Procrastination Assessment Scale for Students (PASS) were administered to a convenience sample of 202 pre-licensure nursing students from diploma, associate, and baccalaureate nursing programs in west central Pennsylvania. Descriptive statistics, Pearson's product-moment correlation, analysis of variance, and multiple regression were performed to examine the research variables of test anxiety, academic procrastination, and nursing education program type

Results: The study results identified a moderate correlation between test anxiety and academic procrastination among pre-licensure students, with associate degree nursing students experiencing significantly higher levels of test anxiety than those enrolled in diploma and baccalaureate nursing programs. Additionally, this study's results indicated that the majority of pre-licensure nursing students report procrastinating most on keeping up with weekly reading assignments, followed by writing term papers, and studying; however, nursing students with higher self-reported GPAs tended to procrastinate less on academic tasks.

Conclusions/Implications: This study's findings provide insight on the relationship of test anxiety and academic procrastination among pre-licensure nursing students across nursing education program types. The implications of this study may be used to aid nurse educators in the development and implementation of strategies to identify and decrease test anxiety and academic procrastination among pre-licensure nursing students.

Just in KASE: Evaluating Nursing Students' Knowledge, Attitudes and Self-Efficacy to Care for the Dying Patient

Emma Max, Villanova University [black down pointing small triangle] Meredith MacKenzie, Villanova University

Background/Purpose: Caring for the dying patient can be distressing for nursing students. End of life (EOL) care is an essential skill for the professional nurse and the nursing student must prepare to provide quality care to these patients, while maintaining their own emotional health. Little is known about current student nurse knowledge, self-efficacy or attitudes towards EOL care. The goal of this study was to describe the knowledge, self-efficacy, and attitudes towards EOL care among nursing students at a northeastern traditional baccalaureate program and examine correlations between student demographics and outcomes.

Theoretical Framework: We hypothesized that student life experiences and beliefs would influence their attitudes towards EOL care, while formal education would influence their knowledge and self-efficacy.

Methods: Nursing students from the sophomore to senior levels were sent an online survey consisting of demographic questions, the Frommelt Attitude Toward Care of the Dying (FATCOD), the Knowledge Assessment, and Self-Efficacy Assessment Instruments. The response rate was 25%. Multivariate modeling was used to identify correlates of student knowledge, self-efficacy and attitudes.

Results: Sixty-nine sophomore (22%), junior (52%), and senior (26%) nursing students completed the survey. The sample was 87% white, 98% female and 71% had cared for a dying person, either in clinical or personal life. On average, students scored 5.8 (out of 7) on knowledge, scored 35 (out of 48) on self-efficacy and held positive attitudes towards EOL care. Class year was the only correlate of knowledge, while student's attitudes and class year impacted their self-efficacy. Students' attitudes towards EOL care were correlated with ethnicity, previous experience with EOL care, age and self-efficacy.

Conclusions/Implications: Enhancing student exposure to EOL care in the clinical environment positively impacts their attitudes towards caring for the dying patient. Nursing schools should consider actively incorporating hospice and palliative care experiences into their clinical rotations.

Assessment of Nurse Faculty's Acceptance and Intent to Use Social Media Using the Unified Theory of Acceptance and Use of Technology 2 Model

Danielle Devine, Drexel University

Background/Purpose: Since its emergence, social media has been a popular online venue that has influenced how individuals communicate. It has also become a forum for users to discuss health issues. The ease of finding health information online has replaced the need for health consumers to contact their health providers. Although there are benefits such as immediacy and cost effectiveness, not all information is accurate and reliable. It is important the health discipline produce professionals efficient in navigating online health venues. Without, health recipients will be met with a potentially unprepared workforce. The purpose of this descriptive, quantitative study was to examine nurse faculty's use of social media and its impact on the intent to incorporate social media in curricula.

Theoretical Framework: The modified Unified Theory of Acceptance and Use of Technology 2 (UTAUT2) model assisted in examining faculty's use of social media and intent of using.

Methods: Data were collected from 137 nurse faculty members using an 87 item online survey. Data were analyzed using descriptive statistics, Pearson's correlations, and multiple regressions.

Results: Faculty reported that constructs of the UTAUT2 were positively related to both intent to use and current use of social media. They also identified social media as a form of nursing informatics and stated credible and non-credible health-related sites were included in teaching. Faculty who perceived social media as easy to use, beneficial, and pleasurable reported intent to use in the future.

Conclusions/Implications: Registered nurses are the largest health profession. Because of their scope of influence, it is imperative that nurses be versed in all aspects of care. Although not all patients use social media to get health information, expanded adoption seems certain because of growth in social media platforms. Faculty in this study viewed communication systems as an integral component to healthcare delivery and believed social media should be examined in nursing education.

Paper Session C5: Childbearing: Intra and Postpartum Periods

Maternal Morbidity and Mortality Awareness: Providing Consistent Post-Birth Education

Patricia Suplee, Rutgers University [black down pointing small triangle] Debra Bingham, Institute for Perinatal Quality Improvement [black down pointing small triangle] Lisa Kleppel, Association of Women's Health, Obstetric, & Neonatal Nurses (AWHONN)

Background: In the U.S., maternal morbidity and mortality rates are at their highest level since 2008. Black women are three times more likely to die from complications of pregnancy compared to White women and women who have chronic conditions are more at risk. More than 60% of maternal deaths occur in the postpartum period. However, not all risk factors for potential complications are identified prior to postpartum discharge and up to 40% of women never return for a postpartum visit, a missed opportunity to identify potential complications. Research focusing on identifying the best teaching approaches for nurses to take when educating women about potential warning signs, and what information should be provided to women during the postpartum period is sparse. Increasing awareness and providing consistent messaging may ultimately contribute to decreasing maternal morbidity and mortality rates.

Purpose: To explore what types of discharge information are being provided to postpartum women about the warning signs of postpartum complications.

Methods: Design: Exploratory qualitative Participants: Fifty-two nurses Setting: Six hospitals located in New Jersey and Georgia Data Collection: All postpartum nurses at six hospitals were invited to participate in one of six focus groups conducted to elicit data on how and what nurses taught women about maternal post-birth warning signs. Two instruments were used to collect data, a demographic survey and a semi-structured interview guide. Guided questioning was used to help the facilitator organize each discussion and facilitate data collection. Analytic Approach: Focus group discussions were audio-recorded and transcribed verbatim. Transcripts were reviewed independently by two of the authors and organized and coded using open coding strategies to identify key categories. An external audit ensured confirmability of the findings. Demographic data were analyzed in Stata 13 using descriptive statistics.

Results: The majority of nurses described the signs and symptoms of warning signs of pregnancy complications following birth; however, what they described was not always consistent or accurate. Some nurses based their teaching on the woman's medical diagnosis rather than their potential for other risk factors related to pregnancy. One to one teaching and booklets of information were the primary mechanisms for educating the women. Current teaching challenges reported by the nurses included: an increase in comorbidities, language barriers, and literacy issues.

Conclusions/Implications: Nurses who were interviewed were not consistent in the content and type of postpartum education they provided to women prior to discharge. Some of the postpartum nurses provided content that was not evidence-based which indicated that there are opportunities for improving the postpartum discharge education on post-birth warning signs that nurses provide.

Meta-Analysis of the Predictive Factors of Postpartum Fatigue

Hanan Badr, Case Western Reserve University [black down pointing small triangle] Jaclene Zauszniewski, Case Western Reserve University

Background/Purpose: Nearly 64% of new mothers are affected by fatigue during the postpartum period, making it the most common problem that a woman faces as she adapts to motherhood. Postpartum fatigue can lead to serious negative effects on the mother's health and the newborn's development and interfere with mother-infant interaction. The aim of this meta-analysis was to identify predictive factors of postpartum fatigue and to document the magnitude of their effects.

Theoretical Framework: Runquist's middle-range theory of "persevering through postpartum fatigue," which suggests there are key factors that influence the onset of postpartum fatigue, provided the foundation for this meta-analysis

Methods: Two search engines, PubMed and Google Scholar, were used to identity studies that met two inclusion criteria: 1) identification of a factor(s) that predicted postpartum fatigue; and (2) reliable and valid measurement of the predictive factor(s). Seven articles met these inclusion criteria. The direction and strength of correlation coefficients between predictive factors and postpartum fatigue were examined across the studies to determine their effect sizes. Research questions were: 1) What factors have researchers identified as predictors of postpartum fatigue; and 2) How strongly do these factors influence the onset of postpartum fatigue.

Results: Across the seven studies (published 1998-2014), 890 women with postpartum fatigue were sampled. Measurement of predictor variables occurred from 3 days to 6 months postpartum. Correlations reported between predictive factors and postpartum fatigue were as follows: small effect size (rrange =.10 to .29) for education level, age, postpartum hemorrhage, infection, and child care difficulties; medium effect size (rrange =.30 to .49) for physiological illness, low ferritin level, low hemoglobin level, sleeping problems, stress and anxiety, and breastfeeding problems; and large effect size (rrange =.50+) for depression

Conclusions/Implications: Postpartum fatigue is a common condition that can lead to serious health problems for a new mother and her newborn. Therefore, increased knowledge concerning factors that influence the onset of postpartum fatigue is needed for early identification of new mothers who may be at risk. Appropriate treatments, interventions, information, and support can then be initiated to prevent or minimize the postpartum fatigue.

Couples' Dismissal of Symptoms of Maternal Postpartum Depression

Alyssa O'Brien, University of New Hampshire [black down pointing small triangle] Janice Humphreys, Duke University [black down pointing small triangle] Catherine Chesla, University of California San Francisco

Theoretical Framework: This study used the sensitizing frameworks of family-stress and coping theories and the diathesis-stress model of depression.

Background: Depression in new mothers during the postpartum period is the most common complication of childbirth, with an etiology and course similar to depression in women during other life events. However, postpartum depression (PPD) deserves dedicated focus because of the critical role this period plays in family development. The partner relationship provides support for women during this time, yet little is understood about the associations between this relationship and PPD.

Purpose: Therefore, the purpose of this interpretive phenomenological study was to examine couples' experiences during the transition to parenthood within the context of a maternal PPD diagnosis.

Methods: An interpretive phenomenological method was employed. Data collection included narrative and thematic open-ended interviews, as well as observations within couples' homes. Ten couples were interviewed within three years of the mother's PPD diagnosis. Interpretive and narrative analysis of the data was completed.

Results: Findings indicate that couples experienced a range of responses to maternal PPD, including the process of dismissal of the symptoms of maternal PPD. Dismissal was influenced by multiple social and familial factors. The pattern of response influenced participants' experience of the transition to parenthood, their interpersonal relationship, and the functioning of their household. In-depth descriptions of this process and factors that influenced the couples' dismissal will be presented.

Conclusions/Implications: Couples co-create their experience of maternal PPD in early parenthood. These findings suggest a need for medical professionals, therapists and perinatal nurses to broaden their PPD assessments and interventions to include both the mother and her partner and for the development of guidelines for family-centered care of families experiencing maternal PPD.

Women in the World: A Metaethnography of Global Labor Pain

Carrie Eaton, University of Connecticut

Theoretical Framework: Noblit and Hare's (1988) approach for synthesizing qualitative data was used to conduct this metasynthesis on intrapartum labor pain.

Background: There is a dichotomy in labor pain; the event is often feared and poorly controlled, yet purposeful and needing to be understood. Exploring global themes related to labor pain holds promise for synthesizing knowledge that promotes an understanding of the significant impact intrapartum care has on women.

Purpose: The purpose of this metaethnography is to decipher the wide chasm between how various cultures envision labor pain management versus the clinical direction of healthcare providers.

Methods: This research utilized Noblit and Hare's (1988) approach to metaethnography. The rich qualitative data from 22 qualitative research articles representing 16 non-US countries were synthesized. The retrieval process yielded 22 qualitative research studies related to labor pain representing 16 countries including Iran, Finland, Africa, Scotland, Thailand, England, Switzerland, Iceland, Jordan, Japan, Ireland, Sweden, Brazil, Indonesia, Greece, and Australia. In evaluating the studies through an iterative hands-on process as well as NVivo exploration, extrapolating on the seven phases of Noblit and Hare's (1988) approach were maximized by the traditional and technological processes.

Results: In order to synthesize the 22 studies, I utilized Noblit and Hare's (1988) steps of reciprocal translation to integrate findings interpretively. The synthesis revealed four overarching themes that reflected perspectives involved with intrapartum pain: (a) beyond the bump: the paradox of pregnancy and control, (b) bound by fear and anxiety: the untold story inside, (c) entangled in transition: pain demands to be felt, and (d) cutting the cord: does the purpose exceed the pain? The research illustrated the ability of mothers to vacillate between perspectives. Birth is a time-limited event in the life of a woman, but the metasynthesis details how the birth journey creates an eternal mental imprint on women around the world.

Conclusions/Implications: Each culture has its unique language of pain expressed verbally and non-verbally and the pain of childbirth is no exception. Pain is a sensation that humans fear, but equally desire to conquer in light of the positive reward associated with childbirth. Utilizing themes extracted from this metaethnography and enhanced by the Middle Range Theory of Traumatic Childbirth: The Ever-Widening Ripple Effect, this research opens the door to maternal perspectives of intrapartum pain and its impact on the human psyche. In an effort to provide culturally competent care, it is imperative healthcare providers comprehend individual expressions of verbal and non-verbal intrapartum pain in order to recognize therapeutic care and/or give a voice to those who are suffering in silence as a result of their childbirth experiences.

When Food Control a Mother's Love: Experiences of Recovered Anorexic Mothers Feeding Their Children

Carrie Eaton, University of Connecticut

Theoretical Framework: This study utilized Colaizzi's (1978) descriptive phenomenological approach, allowing participants to describe their experience and researchers to describe the phenomena as participants experienced it.

Background: After delivery, mothers are flooded with messages from an image driven society blasted by myths of a stress free parenting experience. The reality of such a flawed perception is prevalent for countless mothers, but is exacerbated for mothers with a history of an eating disorder.

Purpose: This purpose of this phenomenological study to give a descriptive phenomenological voice to those mothers who have survived the cognitive prison of anorexia and are currently immersed in feeding their children everyday.

Methods: Design: This study utilized Colaizzi's (1978) descriptive phenomenological method underpinned by the philosophy of Edmund Husserl. Participants: Three recovered anorexic mothers with young children. Setting: Each participant met with the researcher in a private location of her choice. Data Collection: Purposive sampling was used to gather participants. Audio-taped in-depth interviewed with three recovered anorexic mothers with young children were conducted and transcribed. An unstructured interview process consisting of an open-ended question started the interview and helped to facilitate the collection of rich data and poignant experiences. Each participant reviewed the consent form and the IRB approval in advance. Participants agreed to be tape recorded and transcribed. Analytic Approach: Using Colaizzi's procedural steps of analysis, six themes of meaning were explicated.

Results: Mothers with a history of anorexia nervosa are enmeshed in the process of forging a healthy relationship with feeding their children everyday. At times, the cognitive prison of anorexia nervosa prevails over a healthy voice, creating doubt and ambivalence in their ability to create a healthy relationship with food for their children.

Conclusions/Implications: For moms with a history of anorexia nervosa it is imperative healthcare providers address the issue openly during prenatal visits by extending emotional support, dietary guidance, counseling referrals when needed, and most importantly, an educated and non-judgmental attitude.

Symposium Session C6: The Health of Sexual and Gender Minority Populations Across the Lifespan

The Health of Sexual and Gender Minority Populations Across the Lifespan

K. Jackman, Columbia University [black down pointing small triangle] Jordon Bosse, University of Massachusetts-Amherst

Integrative Summary: This symposium presents nursing research about the health of sexual and gender minority populations across the lifespan. It will address potential risk and resilience factors among these understudied populations, identify gaps in our knowledge, and suggest clinical interventions and next steps in research.

The first paper identifies risks faced by children who are nonconforming in gender expression, and proposes a model to help nurses understand sources of vulnerability and develop interventions to improve the health outcomes of this at-risk population. The second paper reports on original data about sexual orientation and gender identity among adolescents/emerging adults to increases nurses' understanding of the diversity of identities and how this affects their clinical practice. The third paper describes a novel approach for addressing the disproportionately high burden of mental health problems among LGBT adults living in rural areas. The fourth paper reviews the existing literature about patient and provider perceptions of LGBT older adults in long-term care. The final paper describes an interprofessional collaborative practice model to improve the health of older LGBT adults and presents outcomes from patients and health professionals. Each presenter will offer suggestions for next steps to reduce the health disparities and improve health outcomes among sexual and gender minority populations.

The Elder LGBT Interprofessional Collaborative Care Program (e-linc): Cultivating a Practice Environment for Emerging Nurse Leaders, Partnering Together, and Promoting Wellness to Improve LGBT Health

Sigrid Gabler, Columbia University [black down pointing small triangle] Jeffrey Kwong, Columbia University

Background: Research shows that Lesbian, Gay, Bisexual and Transgender (LGBT) individuals face considerable health disparities resulting in higher prevalence of isolation, depression, anxiety, tobacco use, less frequent use of preventative health services, higher rates of substance use, HIV infection, and a greater risk for certain cancers. LGBT older adults are often reluctant to access health care due to their perceptions of repercussions of disclosing their sexuality or gender identity. Lack of culturally sensitive health services result in delays in older LGBT persons receiving necessary primary and preventive health care. Until recently specific training in LGBT cultural competency has been lacking in nursing education.

Purpose: The Elder LGBT Interprofessional Collaborative Care Program (e-linc), is a novel interprofessional collaborative practice demonstration program with the goal of improving the health of LGBT older adults in New York City through the focused preparation of nurse leaders.

Methods: Utilizing an interprofessional collaborative practice model, e-linc provides a team of nurse practitioners, social workers, physical and occupational therapists, mental health providers, and a patient navigator who work together to provide LGBT culturally sensitive and competent care. To improve the capacity of the future workforce, health professional students from Columbia University Medical Center, and in particular graduate-level nursing students, work side-by-side with e-linc team members in order to gain experience and skills in both LBGT health care as well as interprofessional team work.

Results: This novel program has been well received by older LGBT participants and student participants alike. Findings suggest that students benefit from this approach by enabling direct patient interaction, collaborating with colleagues across the healthcare spectrum, and an opportunity to experience leadership roles early in their training. Participants benefit from better care coordination, falls risk assessment, systematic attention to preventative health screenings, and mental health referrals.

Conclusions/Implications: There remains an ongoing need for culturally competent and appropriate health services targeted to the unique issues of LGBT older adults to help them age in place.

A Concept Analysis of Gender Nonconformity in Children

K. Jackman, Columbia University [black down pointing small triangle] Jordon Bosse, University of Massachusetts-Amherst [black down pointing small triangle] Elizabeth Cohn, Adelphi University [black down pointing small triangle] Walter Bockting, Columbia University

Theoretical Framework: Social ecological model.

Background: Nurses in many clinical settings come into contact with gender nonconforming children and their families. Clinical nurses would benefit from having an understanding of nonconformity in gender expression in childhood in order to provide culturally sensitive care. However, the lack of inclusion of this population in nursing education and in the nursing literature leaves many nurses unprepared to understand gender nonconformity and its implications for health. Research has demonstrated that gender nonconformity in childhood is a risk factor for childhood abuse and victimization, which may lead to suboptimal physical and mental health outcomes that extend into adulthood. Nurse researchers would benefit from a conceptualization of gender nonconformity in childhood to explore risk and resilience factors in this population and develop interventions to promote long-term positive health outcomes.

Purpose: The purpose of this paper is to provide an analysis of the concept of nonconformity in gender expression among prepubertal children and propose a conceptual model to be used by nurses in practice, education, and research.

Methods: Walker and Avant's (2011) concept analysis method includes exploration of the concept and related concepts, describing the defining attributes of the concept, example cases, antecedents, consequences, and empirical referents.

Results: An innovative model of measurement is proposed to aid nurses in understanding gender expression nonconformity in children and the potential risks when expectations in the child's environment differ from the child's gender expression.

Conclusions/Implications: Clinical nurses may use the proposed model to understand factors contributing to gendered expectations in a child's environment and develop interventions with the potential to both improve the quality of care provided and support gender nonconforming youth and their families. Nurse researchers who are interested in topics related to children and families can employ this conceptual model of gender nonconformity in children to develop and test nursing-specific and interdisciplinary interventions to improve the physical and mental health of this at-risk population.

It's Complicated: Gender and Sexual Orientation Identity in LGBTQ Youth

Jordon Bosse, University of Massachusetts-Amherst [black down pointing small triangle] Lisa Chiodo, University of Massachusetts-Amherst

Background/Purpose: Identity development is a key task of adolescence. Among the multiple identities that young people navigate are sexual orientation and gender identity. Challenges with solidifying and integrating aspects of one's identity can contribute to poor physical and mental health outcomes. The purpose of this paper is to explore the variations of sexual orientation and gender identity as well as the intersections of those identities in a sample of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth.

Methods: A cross-sectional descriptive survey was completed by 175 LGBTQ young people who were recruited via collaborations with community organizations and Internet groups who provide information and services for LGBTQ youth under the age of 25.

Results: One third of the sample reported a gender identity that was not congruent with their sex assigned at birth. Those assigned female sex at birth, reported non-congruent gender identities as well as fluid and non-binary identities such as genderqueer and agender more frequently that respondents assigned male at birth. Individuals with non-congruent gender identities were more likely to identify with a sexual orientation other than lesbian, gay, or bisexual than individuals with gender identities congruent with their sex assigned at birth

Conclusions/Implications: Adolescent sexual orientation and gender identity is complex and nuanced. Nurse scientists and clinical nurses can contribute to understanding of these identities, their meaning to the young person, and the unique health implications by regularly inquiring about sexual orientation and gender identity in their practice. Nurses in clinical practice need to be aware of the sometimes complicated nature of adolescent identity and its related terminology so that they can ask relevant questions and provide culturally safe care.

Patient and Providers Perspectives on Lesbian, Gay, Bisexual and Transgender Issues in Long-Term Care: A Systematic Review

Billy Caceres, New York University [black down pointing small triangle] Jillian Primiano, New York University [black down pointing small triangle] Rachel Luscombe, New York University [black down pointing small triangle] Ab Brody, New York University

Background: Lesbian, gay, bisexual, and transgender individuals are virtually invisible in the gerontology literature. However, there is recognition of higher rates of disability and lack of informal caregivers for lesbian, gay, bisexual, and transgender elders compared to heterosexuals suggesting a greater need for long-term care services in old age. Lesbian, gay, bisexual, and transgender elders are expected to double by 2030, therefore, it is important for healthcare and service organizations to address the needs of this population.

Purpose: Thus, the purpose of this paper is to examine patient and healthcare providers perceptions of lesbian, gay, bisexual, and transgender issues in long-term care.

Methods: A comprehensive search of five electronic databases was conducted for peer-reviewed English-language studies. A total of 22 studies met inclusion criteria. The methodological rigor of each study was evaluated using the Crowe Critical Appraisal Tool, which informed data analysis.

Results: Healthcare providers recognized they lacked the adequate training and expertise to address the unique needs of lesbian, gay, bisexual, and transgender elders. Overall, patients expressed fear of being discriminated against and having to conceal their sexuality from providers. A lack of lesbian, gay, bisexual, and transgender-friendly long-term care services and dependence on formal caregivers were identified as sources of stress for lesbian, gay, bisexual, and transgender participants. Few of the included studies examined lesbian, gay, bisexual, and transgender elders currently receiving long-term care services as most researchers focused on younger lesbian, gay, bisexual, and transgender adults' perceptions of long-term care.

Conclusions/Implications: Future research should capture the experience of lesbian, gay, bisexual, and transgender elders currently receiving long-term care. This paper can inform the creation of models of care and provider training in long-term care to increase sense of belonging and alleviate fear of discrimination among lesbian, gay, bisexual, and transgender elders.

Poster Session II: Meet the Researchers

Quality of the Relationship (QOR) Between Family Members and Military Veterans with Traumatic Brain Injury (TBI); An Integrative Review

Faith Atte, Villanova University

Background: TBI, "the silent epidemic" among returning soldiers, may result in family disruption. Sequelae from TBI may impact the QOR between the patient and family members. Although often overlooked, QOR may be a factor related to family members' perception of burden. Mutuality and reciprocity are concepts commonly used to describe the QOR between caregivers and care receivers.

Purpose: The aim of this literature review was to examine studies of QOR in family members of veterans following a TBI and the association of QOR to caregiver burden.

Methods: A literature review search of published articles in CINAHL, MEDLINE and PsychInfo database from 1980-2016, was conducted. Additional references were obtained from bibliographies of these articles.

Results: Findings revealed that increased mutuality and reciprocity was related to reduced burden in four cross-sectional studies. Three longitudinal studies reported lower levels of burden in relationships historically characterized with mutual behaviors. Inconsistent findings were found in two studies examining QOR in the context of giving and receiving. One study revealed that family members who viewed their relationship as less balanced in terms of both giving and receiving had increased perception of burden. In the other study, increased burden was associated only with the receiving aspect of the QOR. Of the reviewed studies, only one examined family members of veterans with TBI.

Conclusions/Implications: The findings imply that QOR is an important factor influencing caregiver burden. Future studies should be conducted to investigate this phenomenon in families of civilians and veterans with TBI. Recognizing and understanding the role of QOR in determining burden will aid in identifying families at risk and development of effective interventions.

The Effects of Exercise Interventions on Depression Among Older Adults in the Community: A Systematic Review of Literature

Jin Young Seo, Hunter College [black down pointing small triangle] Ying-Yu Chao, Rutgers University

Background/Purpose: Depression is the most prevalent mental health problem among older adults. Identification and treatment of depression among older adults is difficult in the community because older adults have undesirable side effects of medications, and have less ability or willingness to participate actively in treatments. Exercise has been found to have a protective and treatable effect on depression among older adults. However, no systematic review of exercise interventions on depressive symptoms in older adults who live in communities in the U.S. has been found in the literature. Hence, the aim of this review is to assess the influence of exercise interventions on alleviating depressive symptoms in older adults who reside in a community setting in the U.S.

Theoretical Framework: Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement (PRISMA) guidelines provided the direction for this systematic review.

Methods: We conducted a systematic review of literature published during 2005-2015 regarding exercise intervention in reducing depressive symptoms among community-dwelling, older adults in the U.S. Online search of the electronic bibliographic databases CINAHL, PubMed, PsycINFO, and Medline (OVID), manual reviews of reference lists, and internet searches (Google Scholar) were conducted. For the quality appraisal, we used the Quality Assessment of Controlled Intervention Study to assess methodologic quality and risk for bias.

Results: Ten studies, which included 7 randomized controlled trials and 3 quasi-experimental studies, were selected for inclusion. Exercise interventions have positive short-term effects on depression and depressive symptoms among older adults. In addition, exercise interventions alleviated the depressive symptoms among older adults with a diagnosis of chronic disease. However, it is difficult to conclude that exercise intervention was effective, because the studies varied in their mode of intervention, intensity and duration of exercise, sample characteristics, measurement of depression, and length of follow-up.

Conclusions/Implications: Future studies should include a randomized control trial with a larger sample size, a longitudinal design, and a culturally-sensitive intervention. For long-term benefits, incorporating motivational strategies into community exercise programs and collaborating with community healthcare providers are recommended to enhance the maintenance of exercise behavior among older adults in communities.

Examining the Effectiveness of a Modified E-mailed Delivered CBT-I on Sleep Outcomes in College Students with Insomnia

Terrika Pereira, SUNY Buffalo [black down pointing small triangle] Alexander Salinas, SUNY Buffalo [black down pointing small triangle] Marlene Morales, SUNY Buffalo [black down pointing small triangle] My Lan Le, SUNY Buffalo [black down pointing small triangle] Yu-Ping Chang, SUNY Buffalo

Background/Purpose: Cognitive Behavioral Therapy for Insomnia (CBT-I) has been established as an effective non-pharmacological treatment for adults with insomnia and is based on changing sleep-related behaviors and thoughts through patient education. There is limited research on CBT-I in college students. This study aims to examine the effectiveness of an e-mail delivered version of CBT-I on sleep outcomes in college students with insomnia.

Theoretical Framework: The 3P Model of Insomnia is used as a basis for this project in order to address the influential factors and consequences of irregular and insufficient sleep among college students.

Methods: A two-group pre-and-post design was used. College students were recruited from a University. Eligibility criteria include being a full time student between the ages of 18 and 24 with an Insomnia Severity Index score of 7 or greater, without symptoms or prescribed medication for another sleep disorder or psychiatric disorder. The intervention group receives a 6-week email-delivered CBT-I consisting of stimulus control, sleep restriction, sleep hygiene, relaxation training, cognitive restructuring, and relapse prevention. Measures for outcome include 16-Item Dysfunctional Beliefs and Attitudes about Sleep, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Sleep Hygiene Index. Assessments are administered at baseline, six weeks after baseline, and at after four weeks to evaluate effect of the intervention. Descriptive statistics and repeated measured ANOVA were used for data analysis.

Results: There are 61 college students currently enrolled in the study. Preliminary findings indicated that participants in the intervention group demonstrated more positive attitudes toward sleep, better sleep quality, less daytime sleepiness, and better sleep hygiene, compared to the control group.

Conclusions/Implications: Our findings suggest that email-delivered CBT-I might have the ability to improve sleep outcomes in college students. An e-mail delivered intervention is a simple, feasible, and cost-effective tool that clinicians can use to promote healthy sleep in college students.

The Association Between Alcohol Use and Sleep in College Students

Alexander Salinas, University At Buffalo [black down pointing small triangle] Yu-Ping Chang, University At Buffalo

Background/Purpose: Substance use and insomnia are common problems in college students primarily due to stress, lifestyle change, and peer influence in this age group. Substance use and insomnia can have negative impact on students' health and academic performance. The most common causes of sleep disturbances in college students are sleep deprivation (e.g. insufficient sleep because they go to bed late and wake up early) and inadequate sleep hygiene (e.g. eating before bed). Poor sleep practices coupled with stress, alcohol consumption, and technology use prior to bed can contribute to sleep deprivation and subsequently, daytime sleepiness. However, little is known about the association between alcohol use and sleep. This is an ongoing study aiming to describe the association between substance use, sleep hygiene, and daytime sleepiness in a sample of insomnia college students who have been enrolled in a sleep education study.

Theoretical Framework: The 3P Model of Insomnia will be utilized as the guiding framework of this study.

Methods: Participants' baseline data were used to examine the association between variables of interest. Measures used in the study include Alcohol Use Disorder Identification Test, Insomnia Severity Index, Sleep Hygiene Index, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Dysfunctional Beliefs and Attitudes about Sleep. Descriptive and correlational statistics were used to analyze data.

Results: A total of 55 college students have enrolled in the study. Preliminary findings indicate that about 60% of our current sample reported alcohol use and 16% of them reported drug use. Alcohol use is significantly correlated with daytime sleepiness and sleep hygiene.

Conclusions/Implications: Our preliminary findings suggest a high prevalence of alcohol use among college students. Drinkers were more likely to experience daytime sleepiness and poor sleep hygiene. It is important for healthcare workers to routinely screen for alcohol consumption and provide education and behavioral interventions to address the impact of alcohol use on sleep in college students.

The Use of the Project Veterans' After-Discharge Longitudinal Registry (VALOR) Conceptual Model

Chizoba Nwosu, University of Massachusetts-Boston [black down pointing small triangle] Teri Aronowitz, University of Massachusetts-Boston

Background/Purpose: The number of female veterans entering the military is expected to increase over the next ten years as women can now serve in front line combat assignments. Research shows that 10-18% of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) (conflicts in Afghanistan and Iraq) veterans suffer from PTSD upon return from deployment. About 20% of female OEF/OIF veterans suffer from PTSD. The purpose of the proposed study is to assess the role of social support in decreasing PTSD in women veterans.

Theoretical Framework: The conceptual model Project Veterans' After-Discharge Longitudinal Registry (VALOR) Conceptual Model is based on current evidence regarding psychosocial predictors of recovery and outcome domains in PTSD. The VALOR conceptual model has antecedent, mediating or moderating factors, and outcome domains. The antecedent factors are those that are present prior to deployment and cannot be changed or adjusted. The mediating or moderating factors include traumatic life events, psychological/cognitive factors and social and environmental support systems. The outcome domains include service utilization, mental health/neuropsychological outcomes, and psychosocial outcomes.

Methods: A systematic review of the literature of the phenomenon of interest and the conceptual model was completed.

Results: Using the Project Veterans' After-Discharge Longitudinal Registry Conceptual Model a middle-range nursing theory was developed to understand the role of social support and the most significant social network.

Conclusions/Implications: The Veterans Health Administration needs to be concerned about the effect of PTSD among female veterans. As the number of female veterans increase, it is imperative to meet the needs of this population. Future study should include policy changes that focus of women veteran's health as a first step in developing a research program to inform theory-guided practice.

The Variability of Nursing Attitudes Toward Mental Illness: An Integrative Review

Krystyna de Jacq, Columbia University [black down pointing small triangle] Allison Norful, Columbia University [black down pointing small triangle] Elaine Larson, Columbia University

Background: Mental illness are common worldwide and nurses' attitudes toward mental illness have an impact on the care they deliver. In the United States, 18.6% of the population have a mental illness diagnosis. Even though effective treatments exists, only 39% of people with mental illness receive treatment and among those who receive treatment, one in five terminates treatment prematurely.

Purpose: The aim of this integrative review was to explore nurses' attitudes toward patients with mental illness.

Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guided the conduct of this research. The following databases searched: Ovid MEDLINE, PsycINFO, CINAHL, and PubMed. The included studies were published in English between January 1, 1995, and October 31, 2015, and included nurses as participants. The outcome was nurses' attitudes toward patients with mental illness. Quality appraisal of each study was conducted using modified Quality Assessment for Observational Cohort and Cross-Sectional Studies.

Results: The initial search yielded 2,615 articles and fourteen studies, conducted across 20 countries, met the inclusion criteria and were included in the final review. Nurses' attitudes toward different aspects of mental illness were mixed and similar to those of the general public. There was no significant difference in attitudes between psychiatric and general nurses' attitudes. Nurses expressed more positive attitudes toward people with depression than schizophrenia, but most agreed that mentally ill people should have social restrictions imposed upon them. Respondents had mixed beliefs about the perceived dangerousness of the mentally ill.

Conclusions/Implications: Since no studies were conducted in the United States, it is crucial to assess nurses' attitudes toward mental illness in this country. Understanding the factors related to nurses' attitudes may help to identify strategies to improves nurses' attitudes and their delivery of care to those patients who suffer from mental illness.

Ceremonial Drug Use and Its Relationship to Recreational Drug Use: Results of a Pilot Study

Caroline Dorsen, New York University [black down pointing small triangle] Michele Shedlin, New York University

Background: There has been an explosion of articles in non-medical journals and newspapers documenting the surge in the ceremonial use of psychoactive/hallucinogenic drugs (including ayahuasca and psilocybin) in the United States (U.S.). Anecdotal evidence suggests that self-formed groups are using these drugs to promote physical and emotional healing. However, there has been little research documenting how many people are involved in this work, who the users are, what co-existing physical and mental health issues users may have, and what benefits/risks exist in the use of these drugs. This preliminary, qualitative study capitalized on a unique opportunity to investigate this emergent drug subculture.

Purpose: As part of larger study on ceremonial drug use, the purpose of this presentation is to describe study participant's perspectives on how ceremonial drug use relates to recreational drug use.

Methods: After approval from the (blinded) University Internal Review Board (IRB), this exploratory, qualitative study used individual, face to face or skype interviews with a convenience sample of 17 participants who are currently running and partaking in "plant medicine" ceremonies in the US. Inclusion criteria included: adults greater than 18 years old, who are currently using and running ceremonial 'plant medicine' ceremonies in the United States. Exclusion criteria included: age less than 18, ceremonial drug users not living in the US, non-ceremonial users of plant medicines or other drugs. Descriptive content analysis was performed with the assistance of Atlas.Ti software to discover themes and to inform the research questions, conceptual framework and methodology for a larger mixed method study focusing on the perceived physiological, psychosocial, spiritual and behavioral risks and potential benefits of ceremonial drug use.

Results: Participants in this study represent a diverse sample of plant medicine users. Salient themes emerged regarding the relationship of ceremonial drug use to past, present and potential future drug use. Participant's uniformly described ceremonial drug use as "the opposite" of recreational drug use and recounted stories of ceremonial drug use healing past traumas, including drug and alcohol addiction. However, participants had conflicting beliefs about whether ceremonial drug use may encourage or discourage recreational drug use.

Conclusions/Implications: It is critical that nurses be aware of emergent drug cultures. As the numbers of participants in ceremonial drug use continue to rapidly grow, more research is needed on pathways to membership in these communities, how and why people choose to participate, the potential risks/benefits of ceremonial drug use and the relationship of ceremonial drug use to recreational drug use. Results from this study will be used to inform the development of a larger mixed methods study.

Hearts and Minds Matter: Education = Health

Genevieve Chandler, University of Massachusetts-Amherst [black down pointing small triangle] Mary Jane O'Connor, Holyoke Community College [black down pointing small triangle] James Helling, University of Massachusetts-Amherst

Theoretical Framework: Resilience theory describes individuals as self-righting, using psychological and environmental resources to bounce back from stress. Highlighting strengths, respectful interaction and active decision-making in the Positive Youth Development (PYD) model facilitates protective factors. Resilience and PYD form the framework.

Background: Low income, first generation college students with the pressure of athletics and academic demands are vulnerable to mental health issues, unhealthy behaviors and academic disengagement. 35% of athletes have been exposed to levels of extreme childhood stress that may lead to elevated risk for physical and psycho-social symptoms leading to adult illness.

Purpose: Assess effectiveness of strength-based resilience intervention.

Methods: Mixed methods, two group pre-post test design, with intervention and control group, n = 23, male, 80% African American, 20% Caucasian. Content analysis of participant writings and measures of aggression, social support, resilience, stress and ACE. Repeated measures analysis of variance used to assess pre- versus post intervention scales. Empower Resilience Intervention, a five week, ten session strength-based course to build resilience, manage stress and create community. Centering, education, writing and reflection structure each session.

Results: Content analysis: Strength focus, mindfulness skills, fellowship & leadership capacity. "Sharing the very best things about us nourished our mind[horizontal ellipsis]the healthier my mind is, the less life's circumstances will take a toll on me." "Having everyone elucidate our backgrounds and dreams made us a small community." Participants actively participated, expressed vulnerabilities, encouraged each other and assumed leadership roles in and outside of class. Quantitative analysis indicated trends towards resilience with no pre post significant differences.

Conclusions/Implications: The ERI is a viable, effective intervention. Athletic scholarships bring low income diverse students with elevated stress loads into college. Yet, the dramatic differences between qualitative and quantitative outcomes questions the current measures. Recommend using well being measures. By fostering agency, managing stress, and building community across lines of difference, ERI supports resilience empowering vulnerable students to engage, thrive and graduate, potentially leading to adult success and lifelong health.

An Intervention to Improve the Catheter Associated Urinary Tract Infection Rate in a Medical Intensive Care Unit: Direct Observation of Catheter Insertion Procedure

Janet Galiczewski, Stony Brook University [black down pointing small triangle] Kathleen Shurpin, Stony Brook University

Background/Purpose: Healthcare associated infections from indwelling urinary catheters lead to increased patient morbidity and mortality. The purpose of this study was to determine if direct observation of the urinary catheter insertion procedure, as compared to the standard process, decreased catheter utilization and urinary tract infection rates.

Theoretical Framework: Chain of infection is a physiologic theory based on the principles of epidemiology. This theory explains processes required for the transmission of pathogens from their existing environment to a patient and for subsequent infection to occur

Methods: Case control study conducted in a medical ICU. It was carried out in two phases. During phase I (n = 74), a retrospective data review was conducted on utilization and urinary catheter infection rates when practitioners followed the institution's standard insertion algorithm. During phase II (n = 64), an intervention of direct observation was added to the standard insertion procedure. An independent t-test was used to determine if mean monthly catheter utilization and urinary catheter infection rates between the two samples were statistically significant.

Results: Results demonstrated no change in utilization rates, however, CAUTI rates decreased from 2.24 to 0 per 1000 catheter days.

Conclusions/Implications: This study has provided a beginning framework to understand the impact of direct observation during the insertion procedure as an intervention to prevent CAUTI. Findings from this study may promote changes in clinical practice guidelines leading to a reduction in urinary catheter infection rates and improved patient outcomes.

A Concept Analysis of Patient and Family Engagement in Clinical Genetics Services

Michelle Glowny, Brigham and Women's Hospital

Background: Patient and family engagement (PFE) has become increasingly recognized as a crucial component of a health care delivery model encouraging active participation which leads to improved health outcomes, better patient care, and lower costs. However, PFE is an ambiguous concept, often used interchangeably with related terms such as patient participation, patient involvement, and patient activation. Furthermore, the definition of PFE is often dependent on the context in which it is described or adapted, including a range of health care settings and specialties, and areas such as quality and safety, health care policy, and research. To date patient and family engagement has not been defined in the context of the use of clinical genetic services, which are becoming an integral part of health care as technology advances.

Purpose: The aim of the analysis is to clarify the meaning of patient and family engagement in the context of the use of clinical genetics services (CGS).

Methods: The 8 step method of Walker and Avant (2011) was used as a framework. A literature search was conducted within the PubMed, Scopus, and Google Scholar databases. Original articles, systematic reviews, and associated reference lists from multiple health care disciplines were included.

Results: PFE can be regarded as both an individual state and a relational process with cognitive and emotional components associated with actions. Defining attributes, antecedents and consequences are identified. Model, contrary, and related cases are provided to further delineate the concept. An operational definition in the context of clinical genetics services is developed. Engagement on the levels of direct care, organizational design and governance and policy making outlined by Carman et al. (2013) in clinical genetic services is described.

Conclusions/Implications: An operational definition of PFE may aid in the measurement of patient related outcomes associated with clinical genetic services and serve as a framework for interventions to increase uptake. Conceptual clarity in the context of the use of CGS is especially relevant in an era of rapidly evolving genetic and genomic technologies leading to personalized health care. Implications for research, practice and policy and ideas for future study are discussed.

The Relationship Between Patient Safety Climate and Standard Precaution Adherence: A Systematic Review

Amanda Hessels, Columbia University [black down pointing small triangle] Elaine Larson, Columbia University

Background/Purpose: Background: Standard precautions (SP) recommended by the Centers for Disease Control and Prevention are a core component of healthcare associated infection (HAI) prevention and health care worker (HCW) safety. Decades of literature indicate that HCW adherence to SP is grossly suboptimal. An emerging body of evidence suggests patient safety climate (PSC) factors are important to improve HCW behaviors. There is no systematic review of the literature that examines the relationship between PSC and SP adherence in HCWs in acute care hospitals.

Theoretical Framework: A systematic review was conducted and guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

Methods: Literature was searched using PubMed, CINAHL, and EMBASE for quantitative studies published between January 2000 and September 2014 and available in English language. Seven of 888 articles identified were eligible for final inclusion in review. Two reviewers independently assessed study quality using a validated quality tool.

Results: The seven articles were assigned quality scores ranging from 7 to 10 of 10 possible points. All seven studies reported a statistically significant relationship between better PSC and greater adherence to SP. These studies used data from self -report survey and different measures of PSC and SP were used. All seven used a validated PSC measure or measured management support and leadership. Five measured all aspects of SP, two solely measured needle-stick and sharps handling. Three included a secondary outcome of HCW exposure, none included HAIs.

Conclusions/Implications: Conclusion: While limited in number, studies identified were of high quality and confirmed that PSC and adherence to SP were correlated. Implications of this systematic review for administrators and clinical practice suggest efforts to improve PSC may enhance adherence to a core component of HAI prevention and HCW safety.

Guided by Roy Theory: Getting to Know You Project Improves Patient Satisfaction

Celine Reiner, Morristown Medical Center [black down pointing small triangle] Donna Watridge, Morristown Medical Center [black down pointing small triangle] Mildred Kowalski, Morristown Medical Center

Background/Purpose: Aimed at improving patient satisfaction, a review the literature was completed on communication. Little is written about communication with individual patients on a personal level, with some dated publications identifying relationships as important (Trygstad, 1886). Research shows that patients expect nurses to be competent, but having a relationship and showing compassion boosts patient satisfaction (Boev, 2012). Moreover, the human connection may decrease anxiety and improve reception of information. A publication done at on the West coast served as a springboard for our quality improvement project.

Theoretical Framework: Roy's Adaptation Model (RAM) was used as the theoretical basis for this project, as it guides our institutional nursing practice. A holistic model, RAM support the importance of "knowing" an individual to provide adequate care and build a trusting relationship.

Methods: This quality improvement project began with a blank poster with headings for patients and families to complete. Poster headings included: family members, hobbies, pets and favorite foods. The posters provide a starting place for a conversation to know the individual as a person, rather than focus on their patient-role. One patient stated: "I was treated as a person - not as a patient."

Results: Over 500 posters have been completed since August 2015. Patient satisfaction scores have steadily increased since the project started (Internal Composite of 71.4% to March 2016 of 76.3%). Admittedly, other initiatives aimed at increasing patient satisfaction may have influenced overall HCAHPS scores.

Conclusions/Implications: Challenges include the additional time to connect and actively listen to patients. But, given the increase in patient satisfaction, the time is well-spent. We see this theory guided initiative as a way to connect with patients and to build rapport and patient engagement. The Getting to Know You project worksheets have been used at staff and council meetings to strengthen professional relationships, and are now an option for orientation.

Registered Nurse Self-Efficacy with Evidence-Based Practice and a Nurse-Driven Telemetry Discontinuation Protocol

Patricia Bowen, Virtua

Background/Purpose: Utilization of evidence-based practice (EBP) by registered nurses (RNs) remains a significant challenge. While the benefits of EBP are universally acknowledged by RNs, their perceived self-efficacy with accessing and implementing EBP is low. This study was designed to examine the perceived level of self-efficacy for EBP and for a nurse-initiated protocol for medical-surgical RNs in an acute care setting and to compare the difference in EBP self-efficacy and a nurse-driven telemetry discontinuation protocol when evaluating various demographic characteristics.

Theoretical Framework: Bandura's Self-Efficacy Theory illustrates self-reflection of personal skills and knowledge.

Methods: Descriptive and comparative descriptive designs were used to examine perceived RN EBP self-efficacy and EBP self-efficacy with a nurse-driven telemetry discontinuation protocol and to compare both by various demographic characteristics. The sample was comprised of medical-surgical RNs (N = 64) from inpatient acute-care units at Virtua-Voorhees hospital that utilize the nurse-driven telemetry discontinuation protocol. An electronic survey provided the Evidence-Based Practice Self-Efficacy (EBPSE) scale by Tucker et al. (2009) to elicit perceived level of self-efficacy with EBP. Two items on EBP self-efficacy with a nurse-driven telemetry discontinuation protocol and demographic characteristics were also included in the instrument. Quantitative data were obtained from electronic EBPSE scale responses and descriptive and inferential statistics were used to analyze the data. Medical-surgical RNs reported confidence with routinely asking questions about their practice. However, there were significant gaps noted in RNs' proficiency with accessing and using research and implementing evidence-based patient care initiatives.

Results: Results from the EBPSE instrument inferred a lack of confidence with EBP among female RNs, non-specialty certified RNs, and RNs employed less than one year.

Conclusions/Implications: Use of the EBPSE instrument to measure self-efficacy with EBP and the Nurse-Driven Telemetry Discontinuation Protocol provided useful information regarding RNs' confidence and use of evidence-based research and practices. Critical to successful implementation of evidence-based nurse-driven protocols, it is essential to develop an effective EBPSE assessment, education, and implementation plan prior to execution of a nurse-driven protocol to ensure optimal RN acceptance and commitment.

A Survey of Nurses' Nutritional Care Practices

Rose Ann DiMaria-Ghalili, Drexel University [black down pointing small triangle] Elizabeth Miller, Drexel University [black down pointing small triangle] Christine Chen, Drexel University [black down pointing small triangle] Zachary Hathaway, Drexel University

Background/Purpose: Nutrition is an important nursing domain. In the US, nurses are primarily responsible for the nutritional screening of hospital patients (Patel et al., 2014). Early recognition of malnutrition is critical so that nutrition interventions can be implemented in a timely fashion. With the exception of Kalisch's (2009, 2012) work, little is known about nursing practices surrounding basic nutrition care in US hospitals. Identifying current nursing practices can lead to the development of evidence-based practices to enhance nutritional care. The purpose of this online survey was to identify current nursing practices related to nutrition care in US hospitals.

Methods: The Nursing Nutritional Practice Survey (NNPS), developed using a modified Delphi methodology, consists of 59 items in four nutrition domains (nutrition assessment, measuring and monitoring food and fluid intake, oral nutritional supplement practices, and mealtime factors). The NNPS was anonymously administered via Qualtrics to a convenience sample of nurses in an online RN-BSN or MSN program and recent alumni.

Results: A total of 235 acute-care nurses completed the survey, of which 174 were included in the analysis. Respondents were female (93.9%) with a mean age of 37.46 years, and 62% had a BSN. Most performed a nutritional screen upon admission (86.6%) and weighed patients upon admission (87.2%). Only 38.4% reported re-evaluating nutritional status at discharge and 25.9% weighing patients at discharge. In terms of monitoring intake, 55.6% reported the intake/output chart was used to determine treatment and 55% reported the intake/output to be accurate. Most nurses reported visually inspecting food trays (70.8%) and estimating the amount of food (70%) and fluid intake (66.7%) patients' consumed. 54.5% of nurses reported patients always received assistance with feeding when needed on their units.

Conclusions/Implications: While admission nutrition screening practices reported by respondents are aligned with national standards, the discharge nutrition screening is not. Further efforts are needed to implement policies for a repeat nutrition screen upon hospital discharge.

Using Motivational Interviewing to Increase Caregiver's Satisfaction of Hospice Patients at the Community Hospice Agency X

Denise Sennett, NYU Langone Medical Center [black down pointing small triangle] Christine Maloney, Thomas Jefferson University Hospital

Background/Purpose: In the spring of 2015, a community hospice agency (CHX) found that scores on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) did not meet either agency or national benchmarks on two parameters: providers' listening, and caregiver satisfaction. A comprehensive and critical assessment of evidence related to patient and caregiver satisfaction at the end of life supported the use of Motivational Interviewing (MI) as an appropriate communication strategy. The purpose of this quality improvement project (QIP) was to identify if MI communication techniques would improve perceptions of provider listening and increase caregiver's satisfaction at end of life in the hospice setting.

Theoretical Framework: The Evidenced Based Quality Improvement (EBPI) framework was used to guide the QIP.

Methods: A motivational interviewing pre- test was administered prior to implementation, followed by MI instruction to providers. An MI educational program was designed to instruct CHX providers on how to incorporate MI based communication into their daily practices. Plan-Do-Study-Act (PDSA) cycles were implemented to refine the QIP every two weeks. Providers used self-report checklists to document specific MI communications used during home visits. Facilitators reviewed this information and provided additional education in the form of role-playing scenarios to promote adoption of the new communication strategy. Additional improvement strategies include: home observational visits, definitions of clinical documentation, and retrospective chart audits. Finally, a post-test will be administered to document change from pre-test results.

Results: Primary outcomes of provider knowledge and use will be measured by results of the pre and post- testing. Final outcomes of CAHPS questions #14 and #39 will be evaluated by results of volunteer calls to patients involved in MI. Providers' satisfaction with MI protocol will be assessed through a focus group.

Conclusions/Implications: Final results, conclusions, and implications will be available at the time of presentation.

Using Content Validity to Shape Cardiac Patient Education

Mildred Kowalski, Morristown Medical Center [black down pointing small triangle] Kathleen Griffith, Morristown Medical Center [black down pointing small triangle] Betsy Pendexter, Morristown Medical Center [black down pointing small triangle] Michael Desiderio, Morristown Medical Center [black down pointing small triangle] Stephanie Chiu, Atlantic Center for Research [black down pointing small triangle] Nickolas Juliano, Morristown Medical Center [black down pointing small triangle] Darcie Demilt, Morristown Medical Center [black down pointing small triangle] Brian Forrestal, Georgetown University Hospital [black down pointing small triangle] Jordan Safirstein, Morristown Medical Center

Background/Purpose: Nurses and physicians understand the importance of discharge education following percutaneous coronary intervention (PCI). We created a survey to assess knowledge and educational preferences. Important knowledge categories include anatomy, medication, lifestyle changes, and healthcare surveillance.

Theoretical Framework: A content validity index (CVI) methodology, based on established researchers (Polit & Beck, 2012; Waltz & Bausell, 1981) was used to evaluate content and relvance of the survey developed for this study.

Methods: A team of advanced practice nurses and physicians created the initial evidence-based questions that were subsequently reviewed in a blinded and independent fashion by four masters prepared cardiac nurses. Relevancy was rated on a scale of 0 (not relevant) - 4 (highly relevant) for each question. Questions with low CVI were modified or omitted and changes in wording were also suggested. Three iterations were conducted which resulted in an overall CVI of 92% for the survey. Sixteen questions were related to knowledge about the intervention and after care; nine questions focused on preferences for education, including use of technology.

Results: The survey was given to 123 adults who received elective PCI discharge education from staff RNs. The mean age was 64 and 77% were males. More than half (56%) had a previous catheterization and may have received prior PCI-related education. The majority of patients (91%) used some form of technology; the most frequently used being computers (75%). The survey identified knowledge gained by most participants. Results also identified areas of education opportunity related to anatomy, medication adherence, and expected outcomes.

Conclusions/Implications: Use of subject experts and the CVI methodology enabled the researchers to adequately assess knowledge of patients, and provided a solid foundation for future educational interventions tailored to incorporate patient education preferences.

Applications of Geographic Information Systems to Cancer Research: A Review of the Literature from 2006 - 2016

Rachel Pozzar, Northeastern University

Background: The National Cancer Institute recognizes that spatial context plays an important role in health. Geographic information systems (GIS) allow investigators to statistically analyze relationships between geospatial variables and disease incidence, prevalence, and mortality. Yet despite the promise of GIS to inform cancer research in general and cancer nursing research in particular, examples of geospatial cancer research are limited.

Purpose: To provide an update on the ways in which GIS are used in cancer research, determine the extent to which GIS are used by cancer nurse scientists, and describe potential future directions for the use of GIS in cancer research.

Methods: The MEDLINE and CINAHL databases were searched using the major headings "geographic information systems" and "neoplasms." Results were limited to papers published in English in an academic journal on January 1, 2006 or later. Titles and abstracts were reviewed for publications that described a study in which GIS were used to conduct cancer research.

Results: Thirty-two unique papers met the criteria for inclusion. None of the included articles were published in nursing journals. Authors described four broad applications of GIS to cancer research: (1) analysis of cancer incidence and mortality; (2) evaluation of health systems; (3) environmental exposures and risk for cancer; and (4) intervention planning. Study authors generated new insights regarding where cancer occurs, who is affected by it, and what factors contribute to its occurrences and outcomes. Innovative approaches employed by study authors included the use of GIS to determine the influence of geography on health-promoting behaviors; identify community targets for cancer control interventions; analyze regional access to care; and evaluate trends in cancer rates by place over time.

Conclusions/Implications: The use of GIS in cancer research has grown in scope and popularity, yet its full potential has not been realized. The ability to integrate multiple layers of data represents an opportunity to uncover novel insights regarding the spatial determinants of health. This is particularly relevant to nurses, who are uniquely concerned with the interaction between person and environment. Future trends in the use of GIS may include their being used to investigate cancer disparities, inform recruitment and intervention planning, and analyze aspects of time and place as they pertain to cancer outcomes.

The Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) Questionnaire: A Critical Appraisal of the Literature

Lynn Macken, Maine Medical Center [black down pointing small triangle] Caitlin Coppenrath, Maine Medical Center

Background/Purpose: As America ages, the prevalence of patients with symptomatic Atrial Fibrillation (AF) is reaching epidemic proportions. Treatment failure is often evidenced by recurrent and unpredictable symptoms, negatively impacting patients' health-related quality of life (HRQOL). The Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) questionnaire was developed in 2011 for use in research studies and clinical practice. A critical appraisal of the literature of published studies using the AFEQT was undertaken to inform data collection in a pilot study investigating HRQOL outcomes in patients with AF who were offered cardiac rehabilitation.

Theoretical Framework: This ongoing pilot study is guided by the Conceptual Model of Health-Related Quality of Life proposed by Ferrans and colleagues in 2005. This model emphasizes the interrelationships of five health domains including biological function, symptoms, functional status, general health perceptions and overall quality of life. The interprofessional team chose a disease-specific instrument to measure HRQOL that was consistent with this conceptual framework.

Methods: A literature search in Medline, PsycINFO and CINAHL produced eight published articles in which the AFEQT was used to measure HRQOL. Three articles were eliminated because of extensive modification of the instrument, its use for discriminant analysis of another instrument and repetition in a review article. A critical appraisal of the remaining five articles summarizes the purpose, study design, methods, results and implications for using the AFEQT in research and practice.

Results: Development and psychometric testing of the AFEQT resulted in a 20-item questionnaire with four domains (Symptoms, Daily Activities, Treatment Concern and Treatment Satisfaction) and one global score. Internal consistency was excellent for all scales ([alpha] >0.88). Study patients in the reviewed articles were recruited primarily from the U.S., then Canada and China. Sample sizes were between 100 and 2000 subjects and follow-up ranged from 30 days to almost two years. HRQOL was either a primary or secondary outcome in studies investigating differences among ablation, cardioversion, and pharmacologic interventions. Patients who were younger, female and with comorbidities reported lower HRQOL.

Conclusions/Implications: Developed with patient input, the AFEQT is a disease-specific HRQOL instrument with very satisfactory psychometric properties. The reviewed studies provided additional metrics such as meaningful important difference, change and threshold scores. While the AFEQT has been used in observational research, its application to clinical practice needs further study.

Technology Interventions Among HIV-Infected Youth for Adherence Support and Retention in Care: An Integrative Review

Ann-Margaret Dunn Navarra, New York University

Background/Purpose: Human immunodeficiency Virus (HIV)-infected adolescents and young adults (HIV-infected youth) living in the US face staggering disparities including poor adherence to antiretroviral treatment (ART) with lack of sustained HIV viral suppression, and non-retention in care. Mobile and electronic technologies offer promise for increased reach. Yet among HIV-infected youth, little is known about the impact of technology supported behavioral interventions on HIV disease self-management. The objective of this integrative review is to summarize current published literature on technology interventions implemented for support of ART adherence and or retention in care, among behaviorally HIV-infected youth.

Theoretical Framework: Whittemore and Knafl's (2005) framework was used to guide the methodological development of this integrative review.

Methods: A comprehensive search strategy was executed across five electronic databases (PubMed, CINAHL, EMBASE, Ovid PsycINFO, and Web of Science). Inclusion criteria were HIV technology interventions conducted in the US (January 2005 - March 2016) with behaviorally HIV-infected youth (ages 16-29 years), and specific to the health outcomes of ART adherence and or retention in care. Identified studies were evaluated for content, methodology and quality. Data reduction, extraction and display using matrices were performed, and data compared to identify relationships and draw conclusions.

Results: Of the 1461 articles retrieved, nine studies met inclusion criteria representing a sample of 275 HIV-infected youth (mean age = 21.9 years) from diverse geographic locations, and characterized as predominantly black (71.3%) and male (80.0%). Seven of the nine studies were pilot studies, and five of these seven pilots included samples of <= 25 participants. HIV technology interventions were heterogeneous (texting, cell phone, and computers), and varied in dose and frequency. Post-intervention improvements in self-reported ART adherence and serum HIV viral load were observed in four, and one of the nine identified studies, respectively. Retention in care was not reported as an outcome in any of the nine studies.

Conclusions/Implications: The development of effective HIV technology interventions for support of ART adherence and retention in care in the US lags behind the health care needs of HIV-infected youth. Recruitment strategies are needed to increase representation of HIV-infected youth in intervention trials targeting HIV-disease self-management.

A Pilot Randomized Controlled Trial of Videoconferencing versus Telephone-Based Smoking Cessation Intervention for U.S. Women Living with HIV

Sun Kim, University of Massachusetts-Boston [black down pointing small triangle] Courtenay Sprague, University of Massachusetts-Boston [black down pointing small triangle] Rosanna DeMarco, University of Massachusetts-Boston [black down pointing small triangle] Sabreen Darwish, University of Massachusetts-Boston

Background/Purpose: Prevalence of cigarette smoking among people living with HIV is two to three times higher than that in the general population. In contrast to the general population where smoking prevalence in men is higher than that in women, the rates are similar among men and women living with HIV. Women smokers living with HIV (WLHIV) have higher risk for developing AIDS, and a higher mortality rate compared to non-smoking women with HIV. The main purpose of the study is to test the safety and feasibility of a videoconferencing cessation intervention for WLHIV.

Theoretical Framework: Bandura's theory of self-efficacy is the guiding framework of the study.

Methods: The study is a two-arm parallel-group randomized controlled trial that are conducted with 50 WLHIV. Participants are daily smokers who self-report having been smoking five or more cigarettes a day for at least the past 6 months. They are recruited from study fliers posted at HIV health care clinics. Both arms have eight weekly individualized counseling sessions each for 30 minutes in conjunction with active nicotine patches for 8 weeks. Data collection is scheduled at baseline and three follow-up points (1-, 3-, and 6-months from the target quit day). Self-reported abstinence at 3- and 6-month follow-ups are verified with a salivary cotinine test. Survival analyses are conducted to examine the relationship between the intervention condition and abstinence using the Kaplan-Meier survival plot and Cox proportional hazards model for possible covariates such as nicotine dependence and self-efficacy.

Results: Participant recruitment began in July 2016. The number of participants recruited per month and the rate of retention in each arm are reported. Seven-day point prevalence abstinence rates at post-quit 1 month, 3 and 6 months are compared between the two arms.

Conclusions/Implications: Recruitment strategies and lessons learned are discussed utilizing data through March 31, 2017.

Factors Associated with Fatigue in Family Caregivers of People with Dementia

Meg Phillips, University At Buffalo [black down pointing small triangle] Yu-Ping Chang, University At Buffalo

Background/Purpose: Fatigue is extreme tiredness resulting from mental or physical exertion or illness. Family caregivers often take primary responsibility and manage all aspects of the care for their care-recipients with dementia so are at high risk of experiencing physical and psychological health issues. Family caregivers with uncontrolled symptoms for long time might demonstrate poor health outcomes, low quality of life, and poor functional status. However, little is known about factors associated with fatigue in dementia family caregivers. The purpose of the study was to examine the association between fatigue and depression, sleep, social support, and care recipient's functionalities.

Theoretical Framework: Hill's model of family stress was used to guide the study.

Methods: This study used a cross-sectional design. A total of 43 family caregivers participated in the study. Measures used in this study included Lee Fatigue Scale (LFS), Pittsburgh Sleep Quality Index (PSQI), Actigraph (wore for 7 days), Center for Epidemiologic Studies Depression (CES-D), caregiver burden inventory (CBI), Social Support Survey Index (SSSI), and Physical Self-Maintenance Scale and Instrumental Activities of Daily Living Scale. Descriptive and correlational statistics were used for data analysis.

Results: Family caregivers reported a moderate level of fatigue. Our findings indicated that fatigue was significantly associated with depression, subjective and objective sleep quality, caregiver burden, and care-recipient's functionality. However, there was no significant relationship between fatigue and social support.

Conclusions/Implications: Fatigue is a common symptom in family caregivers of people with dementia. Sleep disturbance and depression often co-occur with fatigue. Due to the high inter-correlation among those symptoms, it is important that clinicians routinely screen for them and provide relevant interventions when working with family caregivers of people with dementia.

Pain and Sleep Characteristics in Stable Heart Failure

Samantha Conley, Yale University [black down pointing small triangle] Shelli Feder, Yale University [black down pointing small triangle] Andrea Knies, Yale University [black down pointing small triangle] Nancy Redeker, Yale University

Background/Purpose: Pain and sleep disturbance are common in stable heart failure (HF). However, little is known about the relationships between these symptoms in this population. To describe the associations between pain severity and interference and objective and subjective sleep characteristics among adults with stable HF.

Theoretical Framework: Our study is based on the Yale Center for Sleep Disturbance Framework.

Methods: Retrospective analysis of data from a cross-sectional study of 173 adults with stable HF. We measured pain severity and interference (SF36v2 Bodily Pain Scale); sleep quality (Pittsburgh Sleep Quality Index); insomnia symptoms (difficulty initiating or maintaining sleep and/or waking too early), and objective sleep characteristics (actigraphy). We conducted bivariate analyses (chi-square, t-test).

Results: The sample was 65% male (M age = 60 +16.1 years); 57.2% (n = 99) reported moderate to severe pain, and 47.4% (n = 82) reported pain interference. New York Heart Class (NYHA) was associated with pain severity and interference (p < .010), while comorbidity was associated with severity (p < .001). Both pain severity and interference were associated with insomnia severity (p < .01), decreased sleep quality (p < .01), sleep fragmentation (p = .027) snooze time (p = .023), napping (p < .05), and use of sleep medication (p < .01). Pain severity, but not interference, was associated with self-reported and objective sleep efficiency and nocturnal activity (p < .05). Pain interference was associated with prolonged sleep latency (p < .05). Neither of the pain characteristics were associated with sleep duration.

Conclusions/Implications: Pain is associated with poor sleep continuity and strategies to accommodate for sleep loss (napping, sleep medication). Research is needed to examine the causal direction of the relationships between pain and sleep and the contributions of both pain and behavioral sleep interventions, given conflicting evidence from past studies of the causal nature of the relationships between sleep disturbance and pain.

Patient Perceptions of and Satisfaction with Treatment: Hypertension, Hyperlipidemia, & Diabetes

Jacqueline Dunbar-Jacob, University of Pittsburgh [black down pointing small triangle] Jeffrey Rohay, University of Pittsburgh

Background/Purpose: Good control of persons with metabolic syndrome remains a challenge. This secondary analysis examined the perception of and satisfaction with treatment recommendations among 331 patients in treatment for diabetes, hypertension, and hyperlipidemia who took part in a medication adherence study. Subjects were female (57%), married (59%), middle aged (64 + 10 years), white (82%), well-educated (14 + 3 years), and not working (62%).

Theoretical Framework: Self-management: successful management of chronic disease is dependent upon self-management of complex, multi-component treatment regimen. One element of interest is patient's satisfaction with treatment recommendations.

Methods: Data were collected at baseline by mailed paper and pencil self-report. Subjects were asked whether they had been advised to engage in a diet plan (91%), exercise (58%), skin care (64%), monitor BG (89%), monitor BP (28%), eye examinations (66%), visit a podiatrist (45%), multiple medical visits annually (93%), and how many medications they were taking (M=9.3+4). Patients reported receiving M=4.9 +1.6 recommendations. They rated their satisfaction with each recommendation and overall and the ease of carrying out treatment.

Results: Overall 85% were satisfied with their treatment. Satisfaction was unrelated to the number of recommendations (p=.17). Neither satisfaction nor number of recommendations was related to any medication adherence. Recommendations varied from 91% advised to follow a diet plan, 58% exercise, 64% engage in skin care, 88% monitor blood glucose, 23% monitor blood pressure, 66% have eye examinations, 45% see a podiatrist, and 93% to have more than one routine medical visit per year. Just 51% reported following the diet plan. Following recommendations were seen as easy for blood glucose (83%) and blood pressure (84%) monitoring, obtaining eye examinations (91%), seeing a podiatrist (86%), and completing multiple medical visits per year (94%). More difficult recommendations included following a diet (51%) and exercising (47%).

Conclusions/Implications: Overall patients were satisfied with treatment and satisfaction did not influence adherence to medication. The most commonly recommended treatment plan included medication, diet, blood glucose monitoring, and more than one medical visit per year. There are missed opportunities for patient education to support improved outcomes which would not impair patient satisfaction with care nor adherence to medications.

An Evidence Based Clinical Decision Support Tool to Improve the Detection, Evaluation and Referral Patterns of Adult Chronic Kidney Disease Patients in Primary Care

Mary Regan, York College of Pennsylvania

Theoretical Framework: Evidence Synthesis and Translation Model used for the project was the Johns Hopkins Nursing Evidence Based Practice Model.

Background: The incidence of chronic kidney disease (CKD) is progressively increasing in the United States. Causes of CKD include hypertension, diabetes, obesity, older age and family history of CKD. CKD can lead to increased cardiovascular risk, renal failure and mortality. The economic burden of CKD also has a huge impact on health care expenditures, especially in later stages of CKD. CKD is undertreated and under-recognized in primary care. As a result of this suboptimal care, there is an increase in health care spending and poor patient outcomes. The majority of primary care providers are not aware or knowledgeable of current CKD guidelines. However, the majority of clinicians are amenable to guided-care for CKD patients.

Purpose: The purpose of this project is to increase the awareness and knowledge of CKD for primary care providers (PCPs) through the delivery of evidence-based guidelines at the point of care. In doing so, patients can be properly identified, managed, treated and appropriately referred to nephrology. As a result, the risk of disease progression to renal failure can be decreased and the quality of life and clinical outcomes can be improved in this growing population. This project strongly aligns with the tenets of the Institute for Healthcare Improvement's Triple Aim - reducing costs while improving the health of populations and the patient experience through the delivery of quality care.

Methods: A clinical algorithm and CKD pathway based on the NKF-KDOQI guidelines and more recent evidence was developed in the electronic medical record for providers to access within one large organization comprising many primary care offices. Prior to this intervention a CKD pre-knowledge assessment was performed along with an educational tutorial on CKD and the pathway. A post-knowledge assessment on CKD is expected to be distributed at upon completion of the three month project in early December 2016.

Results: Forty-four of the 76 eligible PCPs (MDs, PAs, and NPs) completed the CKD pre-knowledge assessments. While the majority of providers felt confident in the diagnosis and management of CKD, baseline data showed 41% of patients who met laboratory criteria for CKD diagnosis did not have a diagnosis of CKD in the EMR and only 25% of CKD patients had the recommended annual urine microalbumin. In addition, only 4% of Stage 4 CKD patients had a completed nephrology correspondence letter. However, the majority of respondents welcomed a clinical decision support tool to aid in guided-care for CKD patients. The Clinical Decision Support CKD Tool went live Sept 1 and will end Dec 1, 2016.

Conclusions/Implications: TBD.

The Lifestyle Choices and Health Outcomes of Aging Parents of Adult Children with Intellectual and Developmental Disabilities

Karen Pounds, Northeastern University [black down pointing small triangle] Janet Rico, Northeastern University

Background/Purpose: The life expectancy and areas of functional ability of individuals with intellectual and developmental disabilities (ID/DD) have changed dramatically in the last 15 years (Coppus, 2013). Advances in health care have made it possible for even the smallest neonates and those with severe physical challenges to survive to adulthood. The burden of care for the life time of these individuals most often falls to the parents, as direct care givers and/or case managers for their adult children. Yet, little is known about the health of parents who are full time care givers for adult children with ID/DD. The purpose of this research is to identify the health maintenance and coping strategies of this population and their use of technology to monitor and maintain their health. The results will help to formulate an understanding of their lifestyle choices and needs. The goal of this program of research is to design interventions, including the technology to enhance the wellness of this vulnerable population.

Theoretical Framework: The theoretical framework for this study is care giver role burden and its impact on health outcomes.

Methods: This exploratory study will utilize the Zarit Burden Interview in surveying care givers of adult children with ID/DD. Additional demographics will be compiled as well as an additional study question asking whether the subject uses any type of technology to monitor or maintain their own health. There are 4 public/private agencies that will be involved in sending out the surveys via email. Statistical analyses will be conducted to answer the research questions.

Results: This research is ongoing.

Conclusions/Implications: The conclusions drawn from this research will be used to design interventions (including technology) that will assist the caregiver parents of adult children with ID/DD to improve and maintain their own health and wellness.

Non-Invasive Tools for Screening Undiagnosed Diabetes and Pre-diabetes: A Systematic Review

James Muchira, University of Massachusetts-Boston [black down pointing small triangle] Laura Hayman, University of Massachusetts-Boston [black down pointing small triangle] Eileen Stuart-Shor, University of Massachusetts-Boston

Background: Screening tests detect risk factors or diagnose diseases in the earliest stages and have a vital role in preventing future complications. Numerous risk prediction tools for diabetes have been developed in many countries but few tools screen for the current undiagnosed diabetes or pre-diabetes. The prevalence of undiagnosed diabetes and pre-diabetes is rising globally with the resource-limited settings reporting the highest rates of undetected diabetes (65%). Early detection of diabetes using simple and cost-effective tools is important in prevention of cardiovascular disease; however, many cases of diabetes go undetected and undiagnosed.

Purpose: To determine the availability and performance of non-invasive tools or instruments for screening undiagnosed type 2 diabetes or pre-diabetes.

Methods: A systematic review of the literature was conducted following guidelines of the preferred reporting items for systematic reviews and meta-analysis (PRISMA). This method sought to systematically identify prediction models, non-invasive instruments or devices that can be used for detecting undiagnosed diabetes and/or prediabetes in a community setting. The search was mainly conducted using online databases, CINAHL, MEDLINE, PubMed and Ovid databases.

Results: Seventeen articles with fifteen different screening tools met the inclusion criteria for qualitative synthesis. Of the 15 tools/models, seven were identified as high performing based on the sensitivity (>70 %) and specificity scores (>60%). The best performing tools were Diabetes Risk Calculator, Finnish Diabetes Risk Score, EZSCAN system device, Artificial Neural Network Algorithms, TOPICS Diabetes Screening Score, Leicester Risk Assessment Score and Support Vector Machine Models.

Conclusions/Implications: Simple non-invasive screening tools have been developed and they add value to the nurse-led prevention visits by providing a noninvasive and low-cost way to identify individuals with pre-diabetes and undetected diabetes earlier in the trajectory of the disease.

Barriers and Facilitators to Self-Care in Stroke Survivors

Lisa Babkair, New York University [black down pointing small triangle] Victoria Dickson, New York University

Background: Stroke is a major cause of long-term disability and loss of quality of life. People living with stroke face enormous challenges particularly after discharge from the acute care setting in adjusting to a new life. Stroke self-care is an important element in preventing stroke recurrence by directing survivors' attention to stroke secondary prevention. Self-care also helps survivors to recapture or learn new skills to manage their daily activities. Identifying the barriers and facilitators for stroke self-care is essential in developing effective patient interventions.

Purpose: To analyze the state of science to address the research question, 'What are the barriers and facilitators to self-care among stroke survivors?

Methods: The electronic databases PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycInfo were searched. Articles were included if they were peer reviewed (2005 to 2015), written in the English language and investigated at least one factor influencing self-care in stroke survivors > 18 years.

Results: From an original 794 studies identified, 23 met the inclusion criteria and were reviewed. Self-care and self-management concepts were used interchangeably. Barriers for self-care included: factors related to individual characteristics, such as lack of knowledge, decreased individual capacity, and lack of self-efficacy and motivation; factors related to psychological status, i.e., depression, anxiety, and cognitive impairment; and factors related to social and environmental conditions, i.e., lack of transportation, low socioeconomic status, and lack of resources. The facilitators for self-care included factors associated with social support, medication routine, personal beliefs, and motivational forces.

Conclusions/Implications: Overall, quality of the studies was limited by small sample sizes and inconsistent measurement. Understanding the barriers and facilitators to self-care will help in providing an appropriate guide for intervention strategies to improve self-care in stroke survivors

Challenges to Effective Self-Management of Type 2 Diabetes (T2D) in Adults: Results of a Phenomenological Study

Mary Elizabeth Teixeira, The College of New Jersey

Background: Research has established the association between obesity and T2D. However, patients' perspectives related to self-management are limited.

Purpose: This study's purpose was to explore the challenges encountered by adults living with T2D.

Methods: A convenient sample of 8 participants from one internal medicine practice completed the study. Inclusion criteria included a medical diagnosis of T2D for at least two years, between the ages of 20 and 60 age and able to provide informed consent. Individual interviews were conducted for an average time of 40 minutes. All interviews were recorded and later transcribed. Transcriptions were coded and analyzed by hand following techniques to identify themes by Ryan and Bernard (2003) such as identifying key phrases, repetitious concepts, metaphors, and transitions as well as phenomenological methods described by Munhall (2007). Follow-up phone calls to participants to clarify themes based on transcription excerpts are ongoing.

Results: Major themes centered on adherence to lifestyle modification. Timing of life circumstances was a predominant theme. Life events such as hospitalization, pregnancy, or aging prompted a new found seriousness. However, even with acceptance and readiness to change, the struggle to lose and maintain weight loss became evident. Other themes identified were motivation and support. Motivation was associated with either internal (personal goal attainment) or external (family/friends support) forces. Inhibiting factors were often related to work or family commitments.

Conclusions/Implications: This study further supports that patients struggle with weight and often "blame the weight" as a negative contributing factor to controlling their diabetes. Moreover, varied barriers exist that may be related to a person's individual life circumstances at any given time. Novel interventions are clearly indicated to assist patients with T2D to overcome weight-related challenges. Education for providers to develop population-based approaches may be helpful.

The Model of New Normal

Pamela Adamshick, Moravian College [black down pointing small triangle] Jennifer Specht, Aria Health School of Nursing

Background/Purpose: Parents of chronically ill children experience a variety of difficult emotions over long periods of time, placing them at risk for grief, depression, uncertainly and lessened ability to avoid crisis. The purpose of this exploration is to present a model based on the theory of chronic sorrow that captures parents' experiences of attaining a 'new normal' in response to the stress of living with a child with chronic illness.

Theoretical Framework: Concepts from chronic sorrow, crisis, and complexity theories are integrated into the model, providing a framework for parents to adopt a 'new normal' through the use of balancing factors and coping mechanisms.

Methods: Garnering data sources from a literature review of topics in CINAHL, PubMed, and PsychInfo (1962-2015), the authors analyzed theoretical, qualitative and quantiative studies. They developed a Model of New Normal that applies a new lens from which to frame and manage the experience of chronic sorrow.

Results: For parents experiencing chronic sorrow, a new normal can be achieved through the use of repatterning behaviors that can decrease the impact of stressors and increase the functionality of balancing factors.

Conclusions/Implications: The Model of New Normal depicts parents' experience of chronic sorrow and adaptation to their situation. Normalizing the experience of chronic sorrow should promote a nursing practice change toward more effective identification of chronic sorrow and proactive strategies to avoid crisis. Additional research on the Model of New Normal may forecast an avenue for health promotion applicable to others attempting to adapt to experiences of chronic grief, loss, or despair.

Cancer Beliefs: Their Impact on Perceptions of Patient Centered Communications

Thomas Hardie, University of Pennsylvania [black down pointing small triangle] Carolee Polek, University of Delaware

Background/Purpose: Cancer beliefs include fatalism where one possesses predetermined thoughts about the causes of cancer and its outcome, which can impact patients' perceptions of provider communication. These perceptions of provider communication are correlated to health promotion behaviors and literacy and future cancer risks. The purpose of this study is to identify groups of cancer beliefs that are associated with patient centered communication. Understanding the relationship between cancer beliefs and perceived provider communications is an important first step in the development of interventions to enhance cancer communication and health literacy.

Theoretical Framework: Theory of reasoned action.

Methods: A secondary analysis of data from the NCI's Health Information National Trends Survey 4 (HINT) cycle 4. Responses to nine cancer belief questions from 3,641 subjects (general public) were factor analyzed using an exploratory structural equation model in Mplus to define factors and factor scores. A model with patient centered communication scores as the dependent variable and the factor scores as the independent variable was evaluated using multiple regression.

Results: Three complex factors were defined which included fatalism, denial/doomed, and future treatment involvement. All three of the factors had a significant impact on the self-reported patient centered communication with the most impactful being the factor of fatalism.

Conclusions/Implications: Beliefs about cancer are formed both independently and through experiences with health care providers. Fatalistic beliefs have experiential and cultural origins and can influence patient's perceptions of their providers' communications and likely their health behaviors. Addressing errant fatalistic beliefs may enhance patient provider relationships and result in higher rates of screening early detection of cancers.

Meta-Synthesis: The Meaning of Self-Management

Mohammad Alkawaldeh, University of Massachusetts-Amherst [black down pointing small triangle] Cynthia JACELON, University of Massachusetts-Amherst [black down pointing small triangle] Jeungok CHOI, University of Massachusetts-Amherst

Theoretical Framework: The study was guided by the World Health Organization Classification of Impairment, Disability, and Handicap, and the Maintaining the Balance.

Background: Self-Management is a concept that has evolved over time, in many contexts, cultures and from varying perspectives. Despite this development, there are similarities in the antecedents, attributes, and consequences of self-management.

Purpose: To synthesize a definition of the concept of self-management of multiple chronic conditions from definitions presented in published concept analyses.

Methods: The process of meta-synthesis was guided by Nobilt and Hare (1988). The procedure of concept analysis developed by Rodgers and Knafl (2000) was used.

Results: Self-management is defined as a comprehensive approach by individual patients toward improving their health outcomes. Five critical attributes are identified: multidimensional process; activities; strategies; communication; and support for self-management. The identified attributes are mediated by a set of factors including: individual; family; social network; care provider; illness; and intervention factors. Outcomes of effective self-management include: improved well-being, quality of life, social function, freedom, independence, functional health, and physical health.

Conclusions/Implications: A synthesized definition of the concept of self-management provides a foundation for researchers, educators, policy makers, and clinicians to compare the effectiveness of interventions supports self-management across settings. Additionally, findings from this concept analysis could guide researchers to develop scales with which to assess an individual's propensity for self-management

Older Adult Participation with Neighborhood Walking Audits

Anne Mitchell, Thomas Jefferson University [black down pointing small triangle] Barbara Harrison, West Chester University of Pennsylvania [black down pointing small triangle] Eleanor Whittum, West Chester University of Pennsylvania [black down pointing small triangle] Kelsey O'Neill, West Chester University of Pennsylvania [black down pointing small triangle] Atiya Mahmood, Simon Fraser University

Background/Purpose: Increasing physical activity in older adults is an intervention to decrease morbidity from chronic disease. Walking is the most common form of physical activity for older adults, yet previous studies report that only 25% of older adults perform the recommended amount of 150 minutes or more per week. The purpose of this study was to determine the feasibility for older adults to use the Stakeholders Walkability/Wheelability Audit in Neighborhood (SWAN) instrument in two distinct urban areas to assess the ease of walking in the neighborhood.

Theoretical Framework: Lawton and Nehamow (1974) proposed The Ecological Theory of Aging often referred to as the "person-environment fit' theory. This theory was used to examine the features of the neighborhood that represented the environmental press on walking behavior as identified by the older adults of the neighborhood.

Methods: Student nurse researchers with pairs of older adults performed four block walking audits in two distinct neighborhoods, one small suburban city, and one large urban area. The target sample size is 60. The audit was performed using the SWAN instrument completed by both researchers and older adult residents. Residents took pictures of specific neighborhood features that ease or hinder walking. This study represents the first time the SWAN instrument has been used in cities in the United States. The instrument examines seven domains: street crossings, sidewalks, traffic, personal safety, maintenance, land use and social aspects of the neighborhood.

Results: Full statistical analyses using multiple regression and Spearman correlation are pending as to the differences in supportive features of the walking environment in each city. The smaller city has been identified as a World Health Organization Age Friendly City, and demonstrates features more supportive of walking such as highly maintained appearance, personal safety, and uncluttered sidewalks. Analyses are also being conducted as to the inter-rater reliability of the instrument, and how the ratings of the domains compare to other sites in Europe and Canada where the instrument has been used. Findings based on the age and gender of the residents and their association with ease of walking is also examined.

Conclusions/Implications: The benefits of the study are for older adults to identify barriers and facilitators to walking in their neighborhood. The goal for older adults in the recruited areas is to meet with political, transportation and community stakeholders to discuss their findings and perceptions. As more cities seek to achieve the WHO designation as an Age Friendly City, community participatory research methods represent the most accurate means to give voice to diverse members of the community. Thus, the community can be involved in promoting physical activity within their neighborhoods. Nurses along with community stakeholders can work to enhance opportunities to engage in this health promotion.

Tablet-Based Self-Management Intervention for Diabetes Mellitus Type II Patients: Usability and Efficacy of the ASSISTwell Tool

Mohammad Alkawaldeh, University of Massachusetts-Amherst [black down pointing small triangle] Jeungok CHOI, University of Massachusetts-Amherst [black down pointing small triangle] Cynthia Jacelon, University of Massachusetts-Amherst [black down pointing small triangle] Jenna Marquard, University of Massachusetts-Amherst [black down pointing small triangle] John Ridgway, University of Massachusetts-Amherst

Background/Purpose: The usefulness of technology and the powerful capabilities of technological applications have led to interest in developing novel approaches to support older adults' self-management. ASSISTwell is a tablet application for self- management of chronic health problems that has been designed with user feedback at every phase of development. Usability is the key to adoption and sustainability of such technologies. The purpose of this research is to assess the usability of the ASSISTwell application in an older adult population with Diabetes Type II (DMII) and explore whether the application can enhance DMII patients' self-management.

Theoretical Framework: The application development was guided by the self-management model of Maintaining the Balance (Jacelon, 2010), which states that individuals who manage and balance their activities, health, autonomy, attitudes, and relationships will be able to obtain optimal wellness. The usability evaluation was guide by the Technology Assistance Model

Methods: A purposive sample with 24 elderly patients with DMII will be recruited for the study. These individuals will use ASSISTwell for 1 month and report weekly on their experience. Semi-structured and audio taped interviews, observation, documentation, and standardized measures will be used in this study. Descriptive and inferential analysis will be used to analyze the quantitative data. Content analysis will be used to organize the emerging usability themes.

Results: This is an ongoing project this is an ongoing project with first results expected in February 2017.

Conclusions/Implications: A well designed application has the ability to improve quality of life, support informed decision making, improve communication with care providers, promote active collaboration with care teams, encourage self-care behaviors, problem solving, improving health status, and improve clinical outcomes.

The Feasibility of an Exergaming Program Among Underserved Older African Americans

Ying-Yu Chao, Rutgers University [black down pointing small triangle] Rita Musanti, Rutgers University

Background: Higher prevalence of insufficient levels of physical activity lead to poor health outcomes among older African Americans. Community health workers (CHWs) share cultural values and beliefs with the community and have been shown to play an integral role in facilitating residents' health behavior change.

Purpose: The study tested the feasibility of an exergaming program in this underserved older African Americans.

Methods: The study was a single-group with pre-and-post test design. Twelve older African-American (64.17 +/- 6.74 years old) engaged in a Wii Fit U exergaming program once or twice a week for 24 sessions over 14 weeks. CHWs implemented the program through coaching and supporting mechanism to motivate participants to exercise in the two public housing health centers. Outcomes included functional mobility (muscular strength, flexibility, dynamic balance), depressive symptoms, and quality of life. Descriptive statistics and Wilcoxon signed-rank test were used. Semi-structural individual interviews were also conducted.

Results: After the program, participants showed statistically significant improvements in lower-body flexibility (p = .012), and physical domain of health-related quality of life (p = .005). Participants had comparable outcomes of upper-body strength and flexibility, lower-body strength, dynamic balance, depressive symptoms, and mental domain of health-related quality of life before and after the program. Four themes emerged relating to the benefits of the CHW-led exergaming program: (1) improving health; (2) feeling enjoyment; (3) getting connected; and (4) knowing you.

Conclusions/Implications: CHWs played a significant role in influencing and improving health outcomes in the underprivileged communities. The CHW-delivered exergaming program provided an easy-to-implement and potentially effective intervention that could be used in the community-directed center to improve health and well-being in the underserved population.

Ecologic Assessment of Physical Activity Patterns of Elderly Patients with HIV

Natalie Voigt, Columbia University [black down pointing small triangle] Rebecca Schnall, Columbia University

Background/Purpose: People living with HIV (PLWH) experience comorbid conditions on average five years earlier than their uninfected counterparts, making the importance of physical activity (PA) more relevant in this population. In order to mitigate the effects of multimorbidity and inflammatory processes associated with long-term ART use, PA adherence is paramount. The benefits of PA have been demonstrated in the literature among this population, yet adherence over time is poor. The purpose of this study is to describe the PA patterns of a sample of PLWH over the age of 50 in New York City (NYC).

Theoretical Framework: This study was guided by the Social-Ecological Model.

Methods: We used a cross-sectional, descriptive study design comprising a sample of 72 adults aged 50 years or older, living in NYC, with a confirmed HIV diagnosis. Exclusion criteria included an inability to read or understand English, under 50 years old, and contraindication of PA. Study measures included self-reported demographics, PA recall, and a 6-minute walk test. Analysis was conducted using SAS university edition, version 9.4 and Microsoft Excel.

Results: Most participants were 50-60 years old (79%), female (54%), African-American (71%), non-Hispanic (72%), single (63%), had a high school education or less (56%), were disabled (53%), yet had a monthly income of $800 or more (56%). Most had health insurance (97%), permanent housing (79%), and identified as heterosexual (75%). On average, the participants engaged in 33, 13, and 2 minutes of light, moderate, and vigorous PA per week, respectively. Both men and women engaged in light PA per week most often, 32 and 34 minutes. Men spent more time on PA than women, 57 versus 41 minutes. Whites and African Americans engaged in the most PA per week, 53 and 49 minutes. Most participants (67%) walked between 1000 and 1400 feet in 6 minutes, more than 200 feet less than the norm.

Conclusions/Implications: This study describes the demographics and PA patterns of older PLWH in NYC and provides preliminary evidence for the need for PA interventions to support health promotion in this population.

The Association Between Body Mass Index (BMI), Cognition and Brain Volume in patients with Multiple Sclerosis (MS): An Integrative Review (IR)

Aliza Ben-Zacharia, Mount Sinai Hospital NYC

Background/Purpose: MS is a neurodegenerative and inflammatory disease affecting mostly young Caucasian women. Patients with MS are at high risk to develop cognitive, emotional, and physical deficits. Patients with MS develop cognitive dysfunction and brain volume loss early in the disease process affecting their quality of life. The purpose of this IR was to investigate the association between BMI, cognition and brain volume in patients with MS and analyze the current literature.

Theoretical Framework: The theory that guides the association between BMI, cognition and brain volume is the revised Scaffolding Theory of Aging and Cognition (STAC-R) developed by Park and Reuter-Lorenz. This theory can be adapted to young patients with MS due to the early manifestations of brain volume loss and axonal loss. The STAC-R includes life course experiences, which may enrich or deplete neural resources. Life course factors such as, obesity, contribute to neural resource depletion, thus obesity may accelerate cognitive and brain volume loss.

Methods: The IR was based on a literature search in PubMed, CINHAL, PsycInfo, Web of Science, Embasse, and Scopus. The inclusion criteria included quantitative clinical research studies. Other criteria required that the articles be peer-reviewed published after 2010 due to updated MS diagnostic criteria, written in English, and performed in Western countries consistent with MS standard of care. This review excluded animal experimental studies, systematic reviews, meta-analysis or dissertations. The initial electronic search identified 422 studies, but only six articles fulfilled the IR criteria.

Results: The mean age was 45.9 and the percentage of women ranged from 53%-80%. The range of Caucasians was between 84%-95%, while African-Americans was 3.7-5.1%. The prevalence of obesity ranged from 26%-29% and overweight from 26%-39%. Four studies analyses found no association between BMI and cognitive function among patients with MS. Significant results between lean body mass and symbol digit modalities test was demonstrated showing lower cognitive scores in obese and overweight patients. Overweight/obesity were associated with increased lesion volume, which signifies axonal loss correlated with neurological deficits. The combination of BMI with other risk factors and brain volume demonstrated statistically significant associations. Hypertension, smoking and overweight/obesity were associated with decreased gray matter, decreased parenchymal brain volume and increased ventricular volume in MS.

Conclusions/Implications: There was no association between BMI and cognitive function in MS based on the cross-sectional studies, which provide limited methodological value. In the presence of cardiac risk factors, notably hypertension and smoking, there was an association between BMI and brain volume loss in MS. Carefully designed studies are needed to determine the impact of BMI on cognition and brain volume in MS.

Assessment of Activity of Daily Living (ADL) Among Elderly Patients in Post-Acute Care (PAC) Settings

Zainab Toteh Osakwe [black down pointing small triangle] Mansi Agrawal, Columbia University [black down pointing small triangle] Elaine Larson, Columbia University [black down pointing small triangle] Jing Jing Shang, Columbia University

Background: Older adult's ability to self-manage their illness is dependent on their ability to perform activities of daily living (ADL). Forty-five percent of those older than 65 years will have ongoing clinical needs after hospital discharge and require post-acute care (PAC) services in settings such as home health care (HHC) and skilled nursing facilities (SNF). Current variations exist in the methods of assessing ADLs in SNF and HHC. The Improving Medicare Post-Acute Care Transformation Act (IMPACT) of 2014 requires PAC providers to begin collecting and reporting ADL data to build a coordinated approach to payment and standardize patient assessments and quality measurement.

Purpose: The aim of this integrative review was to compare the methods of assessing ADLs in HHC to SNF.

Methods: The authors followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement to ensure that the results were reported systematically. With the help of a university medical librarian, the first author conducted scientific literature searches without date restriction within the PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases. Search results were limited to "English-language," "humans" and "age +65 years". Study inclusion included (1) original research (2) observational study (4) sample age >= 65 (4) valid measure of activities of daily living (ADLs) (5) HHC or SNF setting. Two independent investigators assessed study quality using the quality appraisal instrument developed by Kmet and colleagues. Study quality ranged from 94.5% to 100%.

Results: Of the 18749 articles identified by the search, 8 met inclusion criteria: 1 quasi experimental study, 1 prospective cohort study, 1 retrospective cohort study, and 5 observational studies. 4 tools were identified that are used to assess ADLs in SNF and HHC.

Conclusions/Implications: Although SNF and HHC collect similar ADL information, the range of content covered, item definitions, scoring, and psychometrics are not comparable across settings Objective methods of assessing ADLs in HHC that include a patient's self-performance are warranted to ensure that clinician assessment accurately captures a patient's ADLs.

Mobile Technology for Assessing Balance and Symptoms During Sit to Stand Movement of Older Adults in Long Term Care

Deanna Gray-Miceli, Rutgers University [black down pointing small triangle] William Craelius, Rutgers University

Background: Loss of balance among older adults frequently occurs due to drops in blood pressure. We have isolated physical assessment findings and predictors of orthostatic hypotension among older adult's who fell, which can be dynamically measured using technology. Technological dimensions of human movement are critically important to further describe in accordance with symptom experiences in order to build strength and unity in the diversity of nursing science.

Purpose: The objective of this experiment is to quantify the body sway of older adults during a sit to stand movement using mobile technology, determine symptom experienced and if blood pressure dropped.

Methods: A cross sectional, mixed methods pilot study of older adults maximum change in velocity, jerkiness and blood pressure during sit to stand movement was conducted in one sub-acute rehabilitation facility located in New Jersey. A convenience sample of 6 older adults residing in a 100 bed sub-acute unit were recruited and screened for eligibility. A secondary convenience sample of 6 college students were also recruited to serve as a comparative sample. Eligibility included elders 65 years of age or older, receiving physical therapy on the sub-acute unit who were: English speaking; cognitively intact with Folstein Mini-Mental State Examination Scores > 21/30; able to independently perform a sit to stand position. Baseline demographic and falls history, symptoms during sit to stand maneuvers, Falls Efficacy assays were administered following administration of a 30 second sit to stand maneuver where participants wore 2 smartphones. Blood pressures were recorded. Analysis of acceleration and angular displacement patterns were determine by use of a tri-axial accelerometer and gyroscope.

Results: The mean age of the elderly sample was 86 years: 2/3 (n=4) were female and 1/3 (n=2) were male. All participants were cognitively intact. Subjects demonstrated a high degree of efficacy to perform activities without falling (16.33 out of 100). None experienced symptoms of loss of balance. One experienced a 15 mmHg drop in blood pressure with standing. Youths had a larger maximum change in velocity and maximum jerkiness than elders. The jerkiness had a larger mean in the Z-axis trials, which shows a greater body sway while moving back and forth than moving left and right (X-axis trails).

Conclusions/Implications: Youths demonstrated more body sway in the anterior and posterior sections of the body than elders. Due to a large variability among volunteer participants, a larger sample size is needed to reduce errors, especially one which is focused on elderly subjects with a known diagnosis of orthostatic hypotension. Design of a reliable and quantitative tool to help clinicians assess older adults balance from sit to standing and other activities are needed, especially for those at greatest risk to fall from known orthostatic hypotension or symptoms of loss of balance during movement.

How Do Younger Adults View Aging? A Pilot Study Examining the Impact of a Cross-Generational Arts Installation

Caroline McDermott, Penn State College of Nursing [black down pointing small triangle] Donna Fick, Penn State College of Nursing [black down pointing small triangle] Nikki Hill, Penn State College of Nursing [black down pointing small triangle] Jacqueline Mogle, Penn State College of Nursing [black down pointing small triangle] Andrew Belser, Pennsylvania State University [black down pointing small triangle] Amy Lorek, Pennsylvania State University

Background: Ageism is pervasive in American society and is expected to increase as our aging population grows rapidly. Younger adults are most likely to endorse negative aging stereotypes. Thus, it is imperative to reach younger adults through innovative interventions in order to reduce negative age-based stereotypes, challenge younger adults' negative attitudes towards aging and promote a view of healthy aging as part of the normal life course.

Purpose: The purpose of this pilot study is to demonstrate the impact of a cross-generational, multi-media installation, FaceAge, on younger adults' perceptions of aging.

Methods: We examined changes in younger adults' (18-25 years old) perceptions of aging from pre- to post-viewing of the installation using a mixed methods approach. Data collection included objective measures on age identity, social norms, aging stereotypes, and salience of age analyzed using paired t-tests. Semi-structured interviews about the participants' subjective experiences were conducted and compiled for thematic analysis.

Results: Results will be shared concerning younger adults' changes in perceptions of aging along with qualitative data about the participants' experience viewing the installation. Results will also demonstrate how to integrate artistic media in non-traditional and transdisciplinary intervention development as well as research more broadly.

Conclusions/Implications: By encouraging positive views of aging and older adults, younger adults are challenged to expand their own personal paradigms which may, in turn, affect their future career choices and contributions to society. This study investigates not only the potential change in younger adults' perspectives of aging but also the subjective experience of younger adults encountering a unique artistic installation. These findings can help to shape future transdisciplinary collaborations that create and translate artistic media into community interventions.

Walking Patterns Among African American Older Adults

Anne Mitchell, Thomas Jefferson University [black down pointing small triangle] Ann O'Sullivan, University of Pennsylvania [black down pointing small triangle] Pamela Cacchione, University of Pennsylvania

Background/Purpose: Current data cite that 22% of older adults walk the recommended amount of 150 minutes per week. In studies where racial differences were explored, Whites as a racial group were more likely to walk. In an investigation where Whites comprised only 27% of the study sample, Whites as a group still were more likely than non-White Hispanics or Blacks to walk in the neighborhood. Older adults who identify as African American have been an under-represented group in studies examining walking patterns. The purpose of this study was twofold: 1) to investigate the perception of health and the built environment in a group of older African American adults to identify possible associations that may exist as to the amount of walking achieved, and 2) to contribute to the findings on diverse communities that have been under-represented.

Theoretical Framework: The Ecological Theory of Aging (Lawton and Nehamow, 1974) served as the theoretical framework. The framework was used to examine the relation of competence of the individual and the environmental press of the neighborhood on the amount of walking.

Methods: The study was a descriptive, cross sectional, non-experimental survey with a sample of 132 African American community dwelling older adults. Four survey instruments measured the participants' demographic information, perception of health, perception of the neighborhood built environment and the amount of self-reported walking. Multiple regression models were used for analyses.

Results: Proximity to retail (p <.05) and access to services (p<.05) were the significant variables for transport walking. For transport purposes 85% of the sample preferred to walk alone. Driving a car was a significant variable for transport walking, and had a negative association resulting in 52 less minutes spent walking per week. In this particular sample for the cohort over age 85, 50% of the sample still drove a car. Pleasant neighborhood surroundings, was significant ( p = .016) for the amount of leisure walking performed accounting for 24 more minutes of walking per week. Perception of crime and traffic were not significant for either transport walking or leisure walking. The findings are for models that controlled for age, gender, BMI and health perception.

Conclusions/Implications: Contrasting with studies where older African Americans did not achieve much walking compared to older Whites, nearly half of this sample did achieve 150 minutes of walking per week. Similar to findings with other racial/ ethnic groups, access to services and proximity to retail were significant for transport walking, and pleasant surroundings was significant for leisure walking. This sample contrasts with the association of negative crime safety perception and walking in White populations and older Latino populations. The implications are for interventions on walking behavior based on studies that apply directly to a specific community may be a greater value than studies that compare diverse groups.

Fuel for Life: A Literature Review of Nutrition Education and Assessment Among Older Adults Living at Home

Melissa O'Connor, Villanova University [black down pointing small triangle] Carolyn Astrup, Villanova University

Background/Purpose: Nutrition is often considered the foundation of health and an important indicator of well-being. Older adults living at home are at particular high risk for poor nutrition due to the incidence of multiple chronic diseases such as diabetes, arthritis, heart failure and cognitive impairment, as well as the financial instability and social isolation that often plagues this population. Older adults living at home who receive skilled home health may still be at risk for poor nutrition as the Outcomes Assessment Information Set (OASIS), the Centers for Medicare and Medicaid mandated home health assessment, does not contain items specifically related to nutrition assessment, leaving this important aspect of health potentially neglected. An abundance of knowledge defining adequate nutrition for older adults exists. However, it is unclear how nutritional recommendations are provided to older adults or if nutrition status is consistently assessed. To address this gap, we conducted a literature review related to nutritional assessment and education for older adults living at home.

Theoretical Framework: NA

Methods: The PubMed, CINAHL, and MedLine databases were searched for relevant English language studies published between 1998 and 2016 using the search terms 'nutrition", "older adults", "assessment", and "education" with the two additional terms, "community" and "home health", generating eight studies eligible for inclusion.

Results: Five studies identified barriers to adequate nutrition and three tested interventions. Nurses are the professionals who provide nutritional education and assessment most often in the home; however both health professionals and family caregivers report feeling underprepared to assess, educate and meet the nutritional needs of older adults. Additional barriers included time constraints, lack of interprofessional communication and collaboration, poor teaching materials and that health professionals feel family caregivers do not consider nutrition a priority. Interventions such as individualized nutritional counseling and the development and testing of malnutrition screening tools have been tested to identify and mitigate risk for poor nutrition.

Conclusions/Implications: There is a paucity of research in the United States regarding the nutritional education and assessment of the older adults living at home. Additional interprofessional research and health care professional education could be important to improving this population's nutrition status.

De-Stressed in the Emergency Department: Music Therapy Reduces Anxiety

Mildred Kowalski, Morristown Medical Center [black down pointing small triangle] Richard Klemm, Morristown Medical Center [black down pointing small triangle] Erin Bolding, Morristown Medical Center [black down pointing small triangle] Filipa Molina, Morristown Medical Center

Background/Purpose: The purpose of this quality improvement project was to determine the potential impact of music therapy on pain and anxiety while in the Emergency Department (ED).

Theoretical Framework: Building on the body of research related to music in hospital settings, this project served to quantify the impact of a music therapist on pain and anxiety perceived by patients in a busy emergency department. The expertise of one music therapist to identify the needs of individuals and the surroundings was explored.

Methods: Patients, family members and healthcare providers were asked to evaluate pain and anxiety before and after music therapy (N=60). Scales from 0 - 10, which are routinely used in the institution, were employed for this project.

Results: Sixty surveys were completed by patients (n=14), family member (n=13) or healthcare providers (n=33). Outcomes showed that for patients with pain (n=10) and/or anxiety (n = 14), scores decreased after music therapy, reflecting a decrease in both pain (5.53 +/- 3.35 to 2.45 +/- 2.47) and anxiety (7.21 +/- 2.08 to 2.51 +/- 2.09).

Conclusions/Implications: Findings from this quality improvement project showed a reduction in pain and anxiety was self-reported by patients in the ED. Both the absence of demographics, potential other contributing factors, a control group, and a small sample size are limitations. Music therapy continues in the ED. The findings from this project provide a basis to plan a larger more robust study to explore other potential values of music therapy, which may be expanded to other areas of the medical center.

Communication Experiences of Family Caregivers of Hospitalized Adults with Intellectual and Developmental Disabilities

Marie Charles, Pace University

Theoretical Framework: Theory of Caregiver Dynamics

Background: Several research studies indicated that research on persons with intellectual and developmental disabilities was not readily available and even less research was conducted on the family caregivers of this group. Their hospital experiences were generally complicated by their difficulties with communication and the need to have an advocate speak on their behalf. Furthermore, hospital staff, namely nurses, have little experiences with this population as adults in an inpatient hospital setting.

Purpose: The purpose of this study was to discover new insights regarding the lived experiences of family caregivers of hospitalized adults with intellectual and developmental disabilities. Communication is an important component of patient care; therefore, the communication experiences between patient, family, and hospital professionals have a significant impact on the care.

Methods: I used a hermeneutic phenomenological approach as the research method. I used open-ended questions and a number of potential probes to interview ten participants face-to-face. I audio-taped, transcribed, and coded the interviews. Subsequently, I collapsed the to determine emerging and broader themes. I consulted the family caregivers to ensure the family caregivers to ensure the information revealed their experiences.

Results: I noted four emergent themes from the interviews: need for advocacy, need for better communication, sense of abandonment, and lack of confidence.

Conclusions/Implications: The findings indicated the need to improve education at the prelicensure level as well as continuing education and support for staff to safely care for individuals with intellectual and developmental disabilities.

Fear of Cancer Recurrence in Young Adult Breast Cancer Survivors: An Integrative Review

Maurade Gormley, New York University [black down pointing small triangle] Marilyn Hammer, New York University [black down pointing small triangle] Mei Fu, New York University [black down pointing small triangle] Janet Van Cleave, New York University

Theoretical Framework: The Transactional Stress and Coping Theory served as a theoretical framework for this integrative review.

Background: Fear of cancer recurrence (FCR) is considered the greatest unmet psychosocial need among cancer survivors. Higher FCR has been associated with poorer quality of life (QOL), greater psychological distress and physical symptom burden. Implications of FCR may include the development of dysfunctional behaviors, and in extreme cases, lead to mental health disorders and functional impairment. FCR is more common among young adult breast cancer survivors (YABCS) with prevalence rates up to 70%. Although age is the most consistent predictor of FCR, little is known about why this population experiences higher levels of FCR.

Purpose: This integrative review explored the factors associated with FCR in YABCS (<45 years of age).

Methods: A literature search was conducted using PubMed, CINAHL, PsychInfo and Embase databases with specific MeSH terms delimited to FCR, diagnosis, sex and age range. The initial search yielded 54 studies, 10 of which met the inclusion and exclusion criteria for this integrative review.

Results: The themes that supported the association between younger age and FCR included motherhood status, health behaviors and decision making (surgery and surveillance), psychological morbidity and social support. Various cognitive behavioral factors including cognitive processing, metacognition, illness intrusiveness and self-efficacy were also identified.

Conclusions/Implications: These findings suggest that FCR in YABCS is a unique construct requiring further exploration and tailored interventions to improve the health-related QOL for this population. Healthcare providers should screen all cancer survivors for FCR, with special attention to the unique needs of young adults. Future research should address the role of age appropriate support and increased levels of FCR during surveillance periods.

Paper Session D1: Health Promotion

Sexually Transmitted Infection History, Childbearing Motivation, and Contraceptive Use Among Urban African American Adolescent and Young Women

Kamila Alexander, Johns Hopkins University [black down pointing small triangle] Nancy Perrin, Johns Hopkins University [black down pointing small triangle] Jacky Jennings, Johns Hopkins University [black down pointing small triangle] Jonathan Ellen, Johns Hopkins University [black down pointing small triangle] Maria Trent, Johns Hopkins University

Background/Purpose: This study examined relationships among prior STI history and positive childbearing motivation (CBM), current pregnancy desire, infertility beliefs, and contraceptive use among urban African American adolescent and young adult women (AYA).

Theoretical Framework: Miller's 1995 framework describing pathways through which attitudes and beliefs about CBM, desires, and intentions affect sexual behaviors.

Methods: This study is a secondary data analysis of the Neighborhood Influences on Adolescent and Young Adult Health (NIAAH) Study, a household survey conducted from 2004-2007. The sample included 318 women aged 15-24 years. Statistical models examined differences in CBM, childbearing desires, and condom/contraceptive use between women with and without STI histories. Age, pregnancy history, and infertility beliefs were evaluated as potential confounders.

Results: Mean age was 19.1 (SD 2.6) years. Twelve months prior to the survey, 94% reported doctor visit and 68% reported sex in previous month. In unadjusted analyses, STI history was not associated with CBM differences (3.27 vs 3.22; p<0.258). STI history did not predict current childbearing desire differences (24.0% vs 16.6%; p<.082). Women with STI histories were significantly less likely to use condoms (48.6% vs 61.8%; p<.001) at last sex. Regression models found developmental age and pregnancy history significantly predicted condom use (b=.472, p<.006; b=.570, p=.049). Women with STI histories were significantly more likely to be over 19 (72.9% vs 47.5%) and have prior pregnancies (75.0% vs 35.0). STI history became nonsignificant when adjusted for age and/or previous pregnancy.

Conclusions/Implications: STI history was not significantly associated with positive CBM among AYA women. Condom use behaviors were influenced by pregnancy history and developmental age. Older AYA with prior pregnancies were more likely to use condoms. This suggests potential new markers for nursing practice to promote family planning among this age group. Further research is needed to fully understand catalysts for childbearing attitudes and reproductive behaviors.

Nurse Practitioner Implementation of Increased Screening Intervals for Cervical Cancer Screening

Joyce Cappiello, University of New Hampshire [black down pointing small triangle] Maureen Boardman, Little Rivers Health Care, Inc., Bradford, VT

Background/Purpose: Cervical cancer screening guidelines have changed dramatically in the past decade with annual screening no longer recommended for low risk women. This study explored the rate at which nurse practitioners (NPs) have incorporated the new consensus guidelines on cervical cancer screening into their practice.

Theoretical Framework: Health Belief Model

Methods: We conducted a longitudinal survey of NP's incorporation of cervical cancer screening guidelines into practice in 2008, 2012 and 2015. E-Surveys were distributed through list servs of professional NP organizations in three New England states. Paper copies were distributed at annual meetings of the state professional organizations. IRB approval was secured through Dartmouth Medical School in 2008 and 2012 and the University of New Hampshire in 2015. SPSS was used for statistical analysis.

Results: By 2015, 88% of respondents were delaying cervical cancer screening until age 21. In 2012, 15% of NPs were screening every three years in 21-30 year olds. By 2015, 72% were screening every three years. In women over age 30, few NPs continue to screen annually (2.34%) with 94% of respondents screening every 3-5 years. However, in 2015 only half of NPs were incorporating the every 5 years interval guideline into practice. By 2015, 75% of NPs discontinued screening at age 65 and 14% by age 70. We assumed that more recent NP graduates would have incorporated the newer guidelines at a higher rate, however this assumption did not hold true. Practice specialty had some impact with NPs in family and women's health practices incorporating guidelines at a slightly higher rate than NPs in internal medicine practice.

Conclusions/Implications: The uptake of guidelines was high for all NP specialties at all experience levels especially when compared to reported rates for other health care disciplines. From 2008 -2015, lack of knowledge of guidelines, cost and insurance barriers decreased significantly. Office practice standards were cited as ongoing barriers to incorporating aspects of the guidelines and reflect the need for NPs involvement in office practice committees.

The Effect of a Brief Motivational Interviewing Training on Students' Skills, Knowledge, and Confidence in Managing Prescription Opioid Abuse in Older Adults: A Mixed Methods Approach

Jade Cassalia, Clifton Springs Hospital and Clinic [black down pointing small triangle] Yu-Ping Chang, University At Buffalo [black down pointing small triangle] Molli Warunek, University At Buffalo [black down pointing small triangle] Tammy Austin-Ketch, University At Buffalo [black down pointing small triangle] Yvonne Scherer, University At Buffalo

Background/Purpose: Prescription opioid misuse or abuse is a growing epidemic in the United States. Older adults are frequently prescribed opioids for their chronic pain. Misuse or abuse of prescription opioids can have very detrimental effects on older adults' health. Motivational interviewing (MI) has been widely used to promote healthy behaviors such as substance abuse and medication adherence. The study aimed to examine an educational intervention targeting doctorate of nursing practice (DNP) students on MI with the use of a standardized patient simulation on the outcomes of attitudes, knowledge, and confidence.

Theoretical Framework: Experiential Learning Theory, a cyclical model of learning, consisting of experience, perception, cognition, and behaviors was used to guide this study.

Methods: This study used a one-group with pre-posttest design that took place at a University campus. The sample consisted of 31 DNP students who received an educational intervention that included a didactic lecture, role-playing exercise, and standardized patient simulation scenario. Outcomes including MI knowledge and confidence were measured at baseline, after didactic lecture, and after standardized patient simulation. Three debriefing sessions were conducted after the simulation. Field notes were taken to record students' feedback regarding their learning experiences. Additionally, students provided written feedback in three open-ended questions regarding their learning experiences. Content analysis was used to analyze the qualitative data. Descriptive statistics and repeated measure ANOVA were used for quantitative data analysis.

Results: Findings indicated a significant increase in student's knowledge and confidence regarding MI at both post-test compared to baseline. Qualitative analysis indicated that students expressed the value of standardized patient in practicing MI skills and solidifying their knowledge of MI principles.

Conclusions/Implications: Our findings suggested that MI training with standardized patient simulation demonstrates promising effects on improving advanced practice nursing student's knowledge and confidence in using MI to manage prescription opioid misuse in the older adult with chronic pain. This study shows the potential to enhance care of older adults that abuse opioids to address this problem in practice.

The PACE Center for Health and Wellness: Using a Collaborative Practice Model to Address Variations in Utilization of Clinical Preventive Services by Community-Dwelling Elders

Marie Ann Marino, Stony Brook University [black down pointing small triangle] Dolores Cannella, Stony Brook University [black down pointing small triangle] Patricia Bruckenthal, Stony Brook University [black down pointing small triangle] Elinor Schoenfeld, Stony Brook University [black down pointing small triangle] Kathleen Monahan, Stony Brook University [black down pointing small triangle] Barbara Brathwaite, Stony Brook University [black down pointing small triangle] Lisa Snelling, Stony Brook University [black down pointing small triangle] Wei Hou, Stony Brook University [black down pointing small triangle] Mary Truhlar, Stony Brook University

Theoretical Framework: The Clinical-Community Relationships Model, which demonstrates the inter-relationships among providers, patients and community resources, provided the conceptual foundation for this study. This model provides a measurement framework for how to define, measure and evaluate programs that support the delivery of clinical preventive services through clinical-community relationships.

Background: The aging adult is the fastest growing segment of the population. Clinical preventive services are important resources to promote and maintain health of older adults, however, critical gaps exist in the number of older adults receiving recommended services. Only 50% of adults over age 65 years are up-to-date with core preventive measures. Disparities are greater for vulnerable populations who are affected by social, economic and environmental determinants.

Purpose: The purposes of this study were to: 1. Identify variations in clinical preventive services utilization among a sample of community-dwelling elders, and 2. Determine whether use of a collaborative practice model, The PACE Center for Health and Wellness, would improve clinical preventive services utilization by community-dwelling elders.

Methods: The project utilized a mixed methods design to identify variations in clinical preventive services utilization (survey; N=522) and inform strategies and processes to effectively deliver clinical preventive services to community-dwelling adults (focus group; N=7). This data was used to inform development of a collaborative practice model to improve clinical preventive services utilization by community-dwelling elders.

Results: Survey data revealed status of prevention services utilization and factors associated with variations in utilization. The percentage of PACE Center patients (N=300) referred to a community resource who received appropriate preventive services increased. Leveraging clinical-community relationships improved access to and use of clinical preventive services.

Conclusions/Implications: The PACE Center has shifted the current practice paradigm by embedding a collaborative practice model, focused on assisting older adults to meet their health promotion and clinical prevention needs, into an existing dental care practice. Leveraging clinical-community relationships has provided an opportunity to identify and mitigate factors associated with variations in clinical preventive services utilization and address social, physical and environmental barriers to successfully achieving health promotion recommendations.

TABS: The Development and Testing of a Nicotine and Tobacco Research Tool

Shai Lev, Binghamton University [black down pointing small triangle] Strianie Louis, Binghamton University [black down pointing small triangle] Rosemary Collier, Binghamton University [black down pointing small triangle] Geraldine Britton, Binghamton University

Background: While the negative effects of tobacco on health are well-recognized, and cigarette use has decreased among college students, use of electronic nicotine delivery systems (ENDS) and hookah has increased in this population. In order to assess behaviors and perceptions about tobacco and ENDS on a large public university campus in the Northeast, our Interdisciplinary Tobacco Use Research Program (ITURP) team developed a survey. The tool was designed for use on this campus and other campuses nationwide.

Purpose: This study reports a process evaluation of the development of the Tobacco Attitude and Behavior Survey (TABS) as well as testing measures of reliability and validity.

Methods: The first version of TABS was created by ITURP students and faculty in 2012, with initial content validity established through consulting experts in the field and incorporating their recommendations. The survey has been modified based on students' input regarding ENDS and hookah. Six survey administrations over 4 years allowed ITURP members to examine issues of survey location, timing, and method of administration, as well as collection, transcription, entry, and management of data. The process evaluation was conducted through student and faculty discussion. Chronbach's alpha and Spearman's Rho analyses will be used to test reliability of TABS items over time, and a factor analysis will identify commons themes to establish construct validity.

Results: The process evaluation revealed strengths and challenges to the method of survey development and revision. By consulting experts in the selection of initial questions, content validity was established. Involving students in the creation and ongoing revision of TABS ensured face validity. The factor analysis and reliability testing of the survey are pending at this point.

Conclusions/Implications: This process evaluation shows that involving students in developing TABS allowed the ITURP team to rapidly assess the evolution of ENDS use on a large campus. By maintaining certain questions, and changing others, the team was able to track specific measures over time, while allowing for assessment of emerging trends. A challenge of this method was merging data between survey versions. Recommendations include continued survey administration to increase sample size, as well as using the survey at outside universities to assess reliability and validity in other populations.

Paper Session D2: Older Adult: Inpatient Focus

Factors Associated with Resident Influenza Vaccination in a National Sample of Nursing Homes

Jasmine Travers, Columbia University [black down pointing small triangle] Patricia Stone, Columbia University [black down pointing small triangle] Ragnhildur Bjarnadottir, Columbia University [black down pointing small triangle] Monika Pogorzelska-Maziarz, Thomas Jefferson University [black down pointing small triangle] Nicholas Castle, University of Pittsburgh [black down pointing small triangle] Carolyn Herzig, Columbia University

Background/Purpose: The Centers for Medicare and Medicaid Services requires certified nursing homes (NHs) to offer influenza vaccinations to residents and HealthyPeople 2020 set target vaccination rates at >=90%. The purpose of this study was to examine associations between resident influenza vaccination prevalence and facility and resident characteristics and employee policies.

Theoretical Framework: The parent study was guided by Donabedian's conceptual framework of healthcare quality.

Methods: A survey of 2,550 randomly sampled US NHs was conducted in 2014. Data on influenza vaccination policies for staff and residents and perceived infection challenges were obtained. Results were linked to Certification and Survey Provider Enhanced Reporting, which contains NH facility characteristics, aggregate resident characteristics, and number of residents who received influenza vaccination within the previous year. The outcome of interest was resident influenza vaccination prevalence for each facility: high (>=75%) vs. low (<75%). Descriptive statistics and multivariable logistic regressions were computed.

Results: Completed surveys were received from 990 NHs (39% response); a complete case analysis of 874 surveys was performed. Only half of participating NHs (48%) had >=75% influenza-vaccinated residents. On average, 70% of residents were vaccinated. Less than half of NHs (38%) required staff to receive the seasonal influenza vaccine and influenza was ranked as one of the top three infection challenges in 13% of NHs. Staff vaccination policies or perceiving influenza as a challenge were not associated with resident vaccination. NHs with high vaccination prevalence were more likely to be small (0-85 beds vs. >120 beds; OR=1.48; P<.05), government/nonprofit (vs. for-profit; OR=1.58; P=.01), located in the Northeast (vs. in the Midwest; OR=1.73; P=.01), and had higher proportions of dementia residents (OR=1.43; P=.02).

Conclusions/Implications: The proportion of influenza-vaccinated NH residents remains below target. Because facility characteristics are associated with resident vaccination, understanding facility needs may improve vaccination coverage. Implementing organized vaccination programs in facilities with low coverage and/or offering incentives for vaccination administration may be efficacious in meeting national goals.

Assessing Quality of Pain Management of Older Adults in Emergency Care

Sharon Rainer, Thomas Jefferson University

Background/Purpose: The crisis of the opioid epidemic in America has focused attention on safe and effective pain care. However, adequately treating pain is important to patients and families worldwide. Pain negatively affects physical, psychological, social, and financial well-being. Unrelieved pain interferes with sleep and increases falls, anxiety, depression, morbidity and mortality. The purpose of this study was to evaluate quality of pain care older adults in moderate to severe pain receive in the emergency department (ED).

Theoretical Framework: Donabedian's Quality Framework (DQF) guided the exploration of the relationships among patients, providers and EDs.

Methods: Design- A quantitative, non-experimental, descriptive correlational design was used to explore the relationships among structure, process and outcome variables that have been linked to quality ED pain care. Sample/Setting- A convenience sample of 143 patients in an urban, academic medical center ED. Measures- 1) Numeric Rating Scale (NRS) 2) Emergency Severity Index (ESI) 3) National Emergency Department Overcrowding Score (NEDOCS) Analysis- Descriptive statistics, one-way, two-way ANOVA, and Hierarchical Linear Regression were used to analyze the data.

Results: Forty percent of patients with moderate to severe pain did not receive analgesia. Of those not receiving analgesia, 53.6% were 65 years or older. Of those who did receive analgesia, the average wait from time seen by a provider to medication administration was 1.2 hours. The average length of the ED visit was 5.3 hours and the average number of pain reassessments was one. ED crowding, gender and age were not statistically significant contributors to delayed pain care.

Conclusions/Implications: Pain care of older adults in a complex system such as the emergency department (ED) is challenging and deserves further investigation. "Opioid -Free" policies that are on the rise in EDs to combat the growing opioid crisis are a one-size-fits-all approach to a serious and complex problem. Evidence shows that effective pain management must be patient-centered.

Apathy Assessment Discrepancy Among Family and Clinicians for Long-Term Care Residents with Dementia

Ying-Ling Jao, Penn State College of Nursing [black down pointing small triangle] Madeline Verbeke, Penn State College of Nursing

Background/Purpose: Nearly half of nursing home residents live with dementia and 25-88% of people with dementia live with apathy. Apathy is a neurobehavioral symptom of dementia, demonstrated as lack of initiative, lack of interest, and flat mood. Apathy is associated with faster cognitive and functional decline and higher caregiver burden. However, apathy is often unrecognized or misdiagnosed in long-term care. Apathy assessment is a challenge because it is a subjective and inconspicuous symptom. Family and various clinicians have different levels of understanding about the residents' underlying personality and clinical judgments when conducting apathy assessment. This study aimed to examine agreements in apathy assessment among family, certified nurse assistants (CNAs) and nurses or activity coordinators for residents with dementia in long-term care.

Theoretical Framework: This study was guided by the Person-Environment Fit Theory.

Methods: This was a descriptive study, recruiting residents with dementia from two long-term care facilities in Pennsylvania. For each resident participant, one family member and two clinicians were also recruited. The two clinicians were one CNA and one nurse or activity coordinator who had provided direct care at least 4 times in the past month. The Apathy Evaluation Scale (AES) was used to rate the resident's apathy level. The AES consists of 18 items where each item is rated on a 1-4 scale. The total score ranges from 18 to 64 with a lower rating indicating more apathy. Family and clinicians rated the residents' apathy level independently based on the residents' condition over the past 4 weeks. Repeated measures analysis of variance (ANOVA) was used to examine the rating agreement among three raters.

Results: A total of 15 residents were enrolled. The AES ratings were significantly different among three raters (p<.0001). Specifically, nurses and activity coordinators rated participants the least apathetic (Mean=40.5, SD=14.2), followed by CNAs (Mean=34.0, SD=8.4). Family rated participants the most apathetic (Mean=30.2, SD=7.6).

Conclusions/Implications: This is one of very few studies that examine apathy assessment agreement among family and clinicians. Our findings suggest that nurses and activity coordinators tend to underestimate apathy level compared to CNAs and family. Input from CNAs and family may facilitate apathy assessment. Findings will guide apathy assessment and evaluation of apathy treatment in long-term care.

Patient and Family Caregiver Experience During the Transition of Care into the Preoperative Environment for Joint Replacement

Ann Malley, Massachusetts General Hospital [black down pointing small triangle] Meg Bourbonniere, Massachusetts General Hospital [black down pointing small triangle] Mary Naylor, University of Pennsylvania

Theoretical Framework: The Quality Health Outcomes model provides a framework to consider patient, environmental factors and interventions related to post-operative outcomes.

Background: Joint replacements represent an opportunity to improve a patient's quality of life. Quality and cost of joint replacements can vary and the complication rate can be significantly higher at some facilities resulting in re-hospitalizations. Recognizing this, CMS has initiated Bundled Payment for Joint Replacements with the episode of care starting the day a Medicare beneficiary is admitted for joint replacement. It is critical for stakeholders to engage patients and their family caregivers in the preoperative care transition. High risk patients who perceive their care is based on their needs and preferences are more likely to adhere to therapies and have better post hospital outcomes.

Purpose: To understand what older patients with multiple chronic conditions and family caregivers experience as they transition to the preoperative care environment.

Methods: Qualitative descriptive design was used. Convenience sampling was used to recruit adults > age 75 scheduled for hip or knee replacement in a large academic hospital. Semi structured interviews were conducted preoperatively and 21 days postoperatively. Descriptive coding was performed to extract themes.

Results: 11 patients and 5 family caregivers participated. Themes (1)Joint replacement is often not elective(2)Lack of preoperative care coordination(3)Standardization of preoperative interventions(4)Variability in outcome

Conclusions/Implications: Joint replacement represents an opportunity to improve quality of life. Preoperative interventions are often standardized to maximize organizational efficiency and less often patient centered. There is a lack of transitional care in the preoperative environment and family caregivers often become care coordinators. There can be large variability in patient experience after joint replacement surgery. Nurse led patient centered preoperative care reflecting attempts to engage patients and their family caregiver can improve perioperative transitions and perhaps impact postoperative outcomes and resource utilization.

Inpatient Middle-Age Falls

Donna Guillaume, UMass Memorial Medical Center [black down pointing small triangle] Sybil Crawford, University of Massachusetts Medical School [black down pointing small triangle] Patricia Quigley, VISN 8 Patient Safety Center

Background/Purpose: Inpatients continue to fall at a high rate each year. Although it is well documented that the older adult is at risk for falls and injury, recent studies have identified that there is an increase in middle-age adult inpatients falls. Purpose: Nursing and the multidisciplinary team need to understand the acuity needs of this population in order to develop fall prevention interventions. The purpose of this study was to describe the characteristics of inpatient middle-age adults (45-64 years of age) who are at risk for falls. (Characteristics of the middle-age adult inpatient fall, Guillaume, D., Crawford, S., Quigley, P., 2016)

Theoretical Framework: Risk Factor Model For Inpatient Falls was adapted from the 'Risk factor model for fall in older age' with permission from the World Health Organization (WHO)(WHO), 2007. This model is supported by the metaparadigm of health, patient, environment and nursing with the multidisciplinary team.

Methods: A quantitative approach performing a retrospective chart review of 439 middle-age inpatient falls, at an academic medical center was done.

Results: The data showed that this population had a mean age of 55.75 years (SD 5.26) and 28.7% of total falls (n=126) had an injury. Those that fell had an average of four comorbidities. When comparing fall rates per 1000 patient days, inpatients ages 45-64 (2.54) and ages 65-90 (2.62) had similar fall rates (p=.637).

Conclusions/Implications: Middle-age inpatients risk to fall should not be overlooked because of age. This population often overestimates their abilities, not appreciating that they are in a different environment and are compromised because of acute and chronic disease conditions that places them at risk for falls. For this age group education and shared decision-making are challenges for the clinical team in fall prevention.

Paper Session D3: Organizations and Workforce Issues

Using the CCC Coding in the Electronic Health Record to Estimate Nursing Action Costs for Select Interventions: A Delphi Study

Veronica Feeg, Molloy College [black down pointing small triangle] Lyris Greenidge-Adams, Molloy College

Background/Purpose: There are decades of research on the development and use of the CCC. Recent activities have been published using the CCC for costing out nursing care such as observing nurses performing nursing activities and using the coded interventions to calculate actual time. These flat per-diem values must be assessed with a reliable formula of relative value units (RVUs) that should be based on nurses' reported assessments of complexity. The purpose of this study was to explore how expert nurses describe nursing actions by time and complexity using the standardized terminology of the CCC.

Theoretical Framework: The clinical classification coding system (CCC) developed by Virginia Saba is an evidenced-based, standardized, atomic, coded data terminology that can be readily used to incorporate documentation of clinical nursing practice into the EHR. Using a clear terminology, the CCC coded data could be used to track the time it takes and the cost of providing nursing care.

Methods: A preliminary focus group of four nursing experts reviewed and discussed selected CCC nursing interventions from previous studies that estimated time. Their consensus resulted in a list of 26 nursing actions that served as the instrument. Using the Delphi technique, 20 participants from four hospitals who are clinical staff nurses were invited to join a panel of experts for 3 rounds of the Delphi survey. A Delphi study is a hybrid survey design which consists of several rounds with the aim of reaching a consensus on central questions by the participants. The experts were instructed to estimate the average nursing time to perform each of the actions. The quantitative results from round 1 were tabulated and redistributed to participants in round 2. Following the second set of responses, the same nursing interventions were used with questions to capture the complexity estimated and the cost calculated from prior rounds. Relative value units (RVUs) were developed to capture the algorithm that can be used in cost estimates of new nursing actions identified from the CCC terminology.

Results: The results of the 3 rounds yielded a descriptive table for the estimated costs related to nursing time and relative value for 26 selected nursing actions (assess, perform, teach, manage). These interventions are graphically displayed to estimate the potential reasonable and fair charges that could be captured for nursing care.

Conclusions/Implications: Placing an economic value on selected nursing interventions is the first step in overall cost estimates on real-time nursing care. Future research to validate using the CCC terminology and RVUs can begin to build a cost table for individualized nursing actions.

The Influence of Implementation Fidelity in Health Outcomes Research

Pamela DiNapoli, University of New Hampshire

Theoretical Framework: Implementation Science guides the improvement in prevention program quality and health care outcomes. Implementation fidelity refers to the degree to which prevention programs are delivered as intended by program developers.

Background: There is little research that links fidelity implementation to program outcomes and fewer studies that identify barriers and challenges to implementation fidelity. Fidelity is a multidimensional construct and not simply self-report of faithfulness to or reporting a strict observation of program components.

Purpose: It was hypothesized that fidelity is influenced by systems and process issues that need to be better understood. An increased understanding of the construct of fidelity has the potential to reexamine if challenging situations such as high risk and low family functioning, reliably impact fidelity later influencing family outcomes.

Methods: This secondary analysis of qualitative data seeks to better understand challenges to implementation fidelity of an evidence based maternal and infant early home visiting program. The primary qualitative data was collected during staff interviews and focus groups as part of a rigorous program evaluation to answer a series of nested research questions. The secondary analysis of these transcripts provided qualitative evidence of perceptions of implementation and intervention fidelity.

Results: Themes that emerged included: social determinants of health, regulatory reporting competing with service delivery, lack of referral networks and workplace safety issues.

Conclusions/Implications: The results of this study underscore that the dissemination of health outcomes research must be considered in the context of populations being served. Health outcomes researchers must monitor implementation fidelity when reporting effectiveness of evidence based prevention programs.

The Use of the Communication Wheel to Enhance Interprofessional Healthcare Communication

Majeda El-Banna, The George Washington University [black down pointing small triangle] Lisa Schwartz, The George Washington University [black down pointing small triangle] JoAnn Conroy, The George Washington University [black down pointing small triangle] Julia Browne, The George Washington University

Background/Purpose: Today's complex healthcare environment requires collaborative teams to provide safe, effective care, but ineffective communication is often a barrier. The Inter-professional Education Collaborative Expert Panel stressed the importance of academic preparation of healthcare practitioners using an interactive approach in which students learn together. The purpose of the study was to examine how an interactive workshop based on Myers-Briggs communication style would enhance interprofessional communication among Accelerated Bachelor of Science in Nursing (ABSN) and Post-baccalaureate Pre-medicine (PBPM) students.

Theoretical Framework: Peplau's Interpersonal Relations Theory, which includes four stages of the relationship (orientation, identification, exploitation, and resolution) to achieve a common goal, guided this study.

Methods: A two-hour communication workshop was conducted with 76 ABSN and 10 PBPM students. After administering the Communication Preference Questionnaire (a self-assessment based on the Myers-Briggs Type Indicator), a presentation was provided by an industry coach, followed by discussion of communication styles and impact on clinical practice within small interprofessional groups with heterogeneous communication styles. All students completed a demographic data survey, pre and post assessments (immediately before and after training and after one month) on their knowledge and attitudes towards interprofessional communication. Descriptive statistics and Repeated Measure ANOVA were conducted.

Results: 74 students (84% women, 69% single, 89% without children, 60% White) completed the assessments. There was a significant increase in familiarity working in interprofessional teams and identifying different communication styles immediately after the workshop from pre- to post-workshop, which was maintained one month later. Also, students' ability to apply communication strategies across different styles increased significantly. Seventy-three percent agreed or strongly agreed that the workshop was a valuable learning experience, and this remained true after one month.

Conclusions/Implications: This pilot study integrated interprofessional education into two pre-health professional programs. The experience supported the development of discipline-based and interprofessional core competencies among students of both programs and may ultimately contribute to the success of their careers as health professionals and improve patient outcomes.

Building a Global Network of Nurse and Midwifery Research

Carolyn Sun, Columbia University [black down pointing small triangle] Jennifer Dohrn, Columbia University [black down pointing small triangle] Elaine Larson, Columbia University

Background/Purpose: Background: Building a solid evidence base for nurses and midwives requires a robust research program, but with a global nursing shortage and dearth of clinically focused nursing and midwifery research, such objectives require a united, global endeavor. Purpose: Therefore, in a two year program, we have partnered with collaborators in the Southern and Eastern African (year 1) and Eastern Mediterranean (EMR, year 2) regions to build a network of nursing and midwives, who through sharing of resources, brainstorming, peer-mentoring and collaboration can produce sustainable research output.

Theoretical Framework: The Global initiatives Model has been the theoretical framework for this research, which focuses on the intersection between education, service and practice and research. By collaborating with academicians who are nurse leaders, actively training and educating clinicians, research priorities can be identified from the ground up, shifting the research agenda and creating an evidence based practice, global research networks, and serving under-served and resource-limited populations.

Methods: In each region, we undertook a scoping review of existing evidence and a Delphi study of clinical nursing and midwifery experts to determine regional gaps in the evidence and research priorities. We then invited participants to attend a regional Research Summit to foster networks, build mentoring partnerships and formulate long-term plans for research.

Results: Both Research Summits yielded focused, directed action plans and nascent research networks. Current projects underway include Linked-In networks for continued partnerships, a third Research Summit in which the two regions will extend their global collaborations, and manuscripts of regional success stories in research.

Conclusions/Implications: By replicating the process developed in year one in a new region in year 2 (EMR), we have demonstrated the potential reproducibility of this program. This program suggests the potential for increasing nurse engagement in clinical research by increasing research capacity through shared knowledge and resources.

Organizational Attributes of NP Practices: Implications for NP Modernization Act in New York State

Lusine Poghosyan, Columbia University [black down pointing small triangle] Allison Norful, Columbia University [black down pointing small triangle] Grant R. Martsolf, RAND

Background/Purpose: In 2015, New York State passed the nurse practitioner (NP) Modernization Act to allow experienced NPs, those with more than 3,600 hours of clinical practice, to deliver care without a collaborative agreement with physicians. Policy change alone is not adequate for optimal NP practice. We examined the organizational structures reported by NPs with less than three (new) and more than three (experienced) years of experience in their current position and job satisfaction and turnover intentions.

Theoretical Framework: Theories on organizational climate indicating that organizational structures within employment settings affect employees' job performance and outcomes including their job satisfaction and turnover guided the study.

Methods: Online survey NY Nurse Practitioner Association members was conducted in 2012; 278 NPs completed measures of job satisfaction, turnover intentions, and organizational structures including the relation they have with physicians and administrators, the support they receive for care delivery, and the infrastructure available in their practices for care delivery. Descriptive statistics were computed.

Results: About 29% of both experienced and new NPs reported being dissatisfied with their jobs. Significantly, almost twice more new NPs (25.5%) reported planning to leave their job compared to experienced NPs (14.3%) (p = .03). About 28% of experienced NPs reported that their role is not understood in their practice settings compared to 42.9% of new NPs. About 30% of new and experienced NPs reported lack of ancillary staff to prepare their patients during the visits, such as measuring height and weight of patients.

Conclusions/Implications: Both new and experienced NPs faced organizational challenges such as poor relations with administration and lack of support and infrastructure for care. New NPs were twice more likely to have turnover intentions. For the NP Modernization Act to achieve its maximum promise of addressing the primary care shortage in New York State, these organizational barriers should be addressed by administrators.

Paper Session D4: Child Health: Focus on Advocacy and Prematurity

Health and Educational Characteristics of Children Born Prematurely

Michelle Kelly, Villanova University

Background/Purpose: Preterm birth is a significant public health issue, with children born prematurely experiencing educational and health difficulties throughout childhood. The specific aim of this study was to compare the educational experience and health implications in children born prematurely compared to children born at term. Preterm birth was determined by parent report of birth more than 3 weeks early.

Theoretical Framework: The guiding framework for this research is the Institute of Medicine conceptual model of Child Health which depicts child health as a kaleidoscope of overlapping circles (social environment, behavior, physical environment, biology) interacting within the context of policy and services.

Methods: A secondary data analysis was conducted to evaluate the health and educational outcomes of children born prematurely compared to the sample of children born at term. The 2011/2012 National Survey of Children's Health is a nationally representative survey of parents/caregivers of children 0 to 17 years of age. Selected variables include Individualized Family Services Plan / Individualized Education Plan (IFSP/IEP), grade repetition and chronic health conditions.

Results: A sample of 95,675 children ages 0 to 17 years were eligible for analyses, with 11.2% born premature. Preterm birth negatively affects the educational experience of children born prematurely as measured by increased report of IFSP or IEP and repeated grades across all age categories. The 6 most frequently occurring chronic health conditions disproportionally affected children born prematurely: ADD/ADHD (OR 1.59), anxiety (OR 1.63), asthma (OR 1.7), learning disability (OR 2.07), speech problems (OR 2.27) and developmental delay (OR 3.17).

Conclusions/Implications: Collaboration between primary health care providers, school health providers, educators, behavioral specialists and families is recommended to improve care coordination and address educational needs for children born prematurely. Early screening and intervention is recommended in children born prematurely.

The Role of Chronic Pain in Modulating Preterm Infants' Gut Microbiome

Wanli Xu, University of Connecticut [black down pointing small triangle] Xiaomei Cong, University of Connecticut [black down pointing small triangle] Wendy Henderson, National Institute of Nursing Research (NINR)

Background/Purpose: Premature infant experiences numerous painful/stressful procedures in the NICUs. Recent evidence has reported that stress can alter epithelial barrier integrity, increase intestinal permeability, which leads to translocation of gram-negative bacteria across the mucosal lining, and alter the composition of gut microbiome. The purpose of the study was to determine the impact of early life pain/stress in the first 4 days of life on microbial colonization and diversity in preterm infants.

Theoretical Framework: Gut-brain axis, the bidirectional interaction between the central nervous system and peripheral gastrointestinal functions plays a key role, in the regulation of stress and early programming of the gut microbiome community.

Methods: A prospective longitudinal study was conducted. Thirty-nine preterm infants (26 0/7 - 32 6/7 weeks gestational age) were recruited at birth and followed-up for 4 weeks. Accumulative pain/stress were collected daily using Neonatal Infant Stress Scale. DNA extracted from daily stool samples was used to sequence the 16S rRNA gene using Illumina Miseq. Operational taxonomic units and Simpson Diversity Index, which measures the richness and evenness of species in a community were determined using QIIME software. Predictions for Simpson Diversity Index were analyzed with linear mixed effect models. Indicator species analysis was performed to identify the species that reflect the difference in gut microbiota among preterm infants with different levels of pain/stress.

Results: On average, preterm infants experience 4.3 +/- 6.0 hours chronic pain/stress per day. Preterm infants with higher accumulative chronic pain/stress have lower Simpson Diversity Index, after controlling for gender, postnatal age, feeding type, antibiotics use and birth gestational age (p<0.001). The abundances of Granulicatella, Anaerobacillus and Staphylococcus were found significantly increased in infants with higher level of chronic pain/stress, p<0.05.

Conclusions/Implications: Chronic pain/stress has a negative effect on the diversity of preterm infants' gut microbiota.

Use of the Premature Birth Knowledge Scale with Pediatric Nurse Practitioners

Michelle Kelly, Villanova University [black down pointing small triangle] Spencer Dean, Villanova University

Background/Purpose: Prematurity affects a significant portion, 10-12%, of America's children, with potential for physical, psychological, neurodevelopmental and behavioral impairments continuing long past the neonatal period. National Survey of Child Health 2011/2012 data indicates that 17.5% of US children born prematurely have special health care needs. The specific aims of this project are to assess the current knowledge of pediatric providers in providing health care to children born prematurely throughout childhood.

Theoretical Framework: The guiding framework for this research is the Institute of Medicine conceptual model of Child Health which depicts child health as a kaleidoscope of overlapping circles (social environment, behavior, physical environment, biology) interacting within the context of policy and services.

Methods: Members of the National Association of Pediatric Nurse Practitioners participated in an online survey utilizing the 33 item Premature Birth Knowledge Scale (PB-KS) to assess knowledge of current neurodevelopmental outcomes of children born prematurely (N=399).

Results: Mean scores on the PB-KS total scale was 17.8, (total possible score range 0-33) with a mean accuracy of 53.9%. Higher scores on the PB-KS were correlated with higher perceived preparation to care for children born prematurely. Neither years of practice as a registered nurse or as a PNP predicted performance on the PB-KS total scale.

Conclusions/Implications: This is the first study to measure primary care providers' knowledge of neurodevelopmental outcomes of children born prematurely. Characteristics of premature birth matter to children's future health, not because premature birth presents an insurmountable challenge, but because it establishes the basis for adult well-being (NRC / IOM, 2004). Primary care providers are uniquely situated to educate and support families facing the long-term consequences of premature birth, to do so they must maintain accurate understanding of current outcomes.

Pediatric Nurses and Nurse Practitioners as Patient Advocates

Donna Hallas, New York University

Theoretical Framework: Watson's theory of caring guided this qualitative study. The fourth carative factor, developing and sustaining a helping-trusting relationship, was viewed as essential to the role of the nurse as a patient advocate.

Background: It was believed that stories from pediatric nurses and pediatric nurse practitioners (PNPs) concerning their 'lived experiences' advocating for their patients and families would provide rich data to articulate the role of pediatric nurses and PNPs as patient advocates.

Purpose: The purpose of this qualitative, narrative, phenomenological study was to articulate the role of pediatric nurses and PNPs as advocates for their patients and families.

Methods: IRB approval to conduct the study was obtained from the University and permission to use the e-mail list was obtained from the Pediatric Nursing Certification Board. E-mail requests were sent out once a month for 6-months, but each individual on the list only received one e-mail request to participate in the study survey. Pediatric registered nurses and nurse practitioners were asked to write a narrative describing a 'lived experience' in which they acted as an advocate for pediatric patients or their families. Participant stories were analyzed using Colaizzi's phenomenological methodology. The stories were read by the PI several times searching for themes related to advocating for patients or families. Atlas Ti was used for generation of themes.

Results: Fourteen pediatric nurses and 11 PNPs participated in this study. Several themes emerged from the data that inform the Role of the PNP and pediatric nurse as an advocate for children and the families. Five themes emerged: Theme 1: Recognition of signs from child/adolescent behaviors that compel the pediatric nurse or PNP to advocate for the child. Theme 2: Recognition of signs from parents that compel the pediatric nurse or PNP to advocate for the parent. Theme 3: Role of NP is to empower parents and children to act on their behalf when confronted with challenging behaviors from others. Theme 4: Outcomes for pediatric nurses and PNP who are Child and Parent Advocate: Feels Warm and Satisfied as an Advocate: Just Feels Right. Theme 5: Barriers to the role of Child and Parent Advocate: Lack of experience as a nurse or PNP.

Conclusions/Implications: These themes may provide the foundation for preparing pediatric nurses and PNPs to be patient advocates.

Employment & Work Competence of Former Premature Infants at Age 23 Years

Mary Sullivan, University of Rhode Island [black down pointing small triangle] Mary Roberts, Memorial Hospital of Rhode Island, Center for Primary Care and Prevention [black down pointing small triangle] Suzy Winchester, University of Rhode Island

Background/Purpose: Each year, 15 million infants worldwide and more than 450,000 infants (11.5%) in the United States are delivered prematurely. An estimated 50-70% of premature infants have later dysfunctions that effect later age-appropriate competencies. Yet, we know little about how medical risk of prematurity affects a key milestone of young adulthood - employment and work performance. Our purpose was to examine young adult competency in employment, job skill, and work stress in former preterm infants characterized by birth weight and neonatal illness at age 23 years.

Theoretical Framework: The Developmental Origins of Health and Disease theory proposes that prenatal/perinatal stress provokes endocrine and metabolic system change affecting adult outcomes.

Methods: This is a 5-group, prospective, longitudinal study of 213 infants classified by neonatal morbidity and followed to age 23 years. Subjects completed current demographic information and the Job Content Questionnaire. Neonatal and cumulative risk were indexed from physical assessment and medical records. Descriptive statistics and ANOVA were used.

Results: Of 215 recruited infants, 180 [n=45 FT, n=24 healthy preterm (HPT), n=53 medical preterm (MPT); n=31 neurological preterm (NPT); n=27 SGA preterm (SPT)] participated at age 23 years (85% retention). The majority (n=152, 92%) graduated high school and 58% completed some post-secondary education. Half (42%-67%) were employed full-time. Of those employed, 33%-69% former preterm infants worked in unskilled to semiskilled occupations, X2(12)=23.3, p=.03. Six former preterm infants (1 MPT, 4 NPT, 1 SPT) had disabilities precluding work. Neonatal risk did not impact self-reported job demand and stress (F (4,133) =.90, p =.46), however cumulative medical risk did (F (1,133) = 6.86, p =.01).

Conclusions/Implications: Young adult developmental expectations bring an additional level of complexity for those who were born prematurely and have physical and/or coordination difficulties, learning/academic problems, and limited social skills. Ongoing medical risk impacts work competence at early adulthood.

Symposium Session D5: Center in Self-Management of Symptoms: Building Science and Research Teams for the Future System

Centers in Self-Management of Symptoms: Building Science and Research Teams for the Future

Cynthia Jacelon, University of Massachusetts-Amherst [black down pointing small triangle] Angela Starkweather, University of Connecticut [black down pointing small triangle] Barbara Guthrie, Northeastern University [black down pointing small triangle] Nancy Redeker, Yale University [black down pointing small triangle] Suzanne Bakken, Columbia University

Integrative Summary: The National Institute of Nursing Research (NINR) funds Centers of Excellence for Symptom Science Research (P30) and Centers to Build Research Teams for the Future (P20). The NINR Centers focus on symptom science, self-management, and self-management of symptoms. The individual studies of each Center focus on related themes in the context of a highly collaborative, interdisciplinary research environment. The purpose of this symposium is to share the organizing framework, methods, and progress of the currently funded NINR- P20 and P30 Centers in the Northeastern United States.

Presentations will address the following 1) the theoretical framework of self-management employed by the UManage Center to Build the Science of Symptom Self-Management (University of Massachusetts Amherst); 2) standardized measures and methods for data collection and database development at the Center for Accelerating Precision Pain Self-management (University of Connecticut); 3) strategies to promote quality of life among underserved urban ethnically diverse aging populations and lessons learned related to technology use (Northeastern Center for the Integration of Technology with Self-Management); 4) The implementation of the organizing framework and themes in the of Yale Center for Sleep Disturbance in Acute and Chronic conditions; and 5) How informatics and data science-based approaches support precision symptom self-management. (Precision in Symptom Self-Management (PriSSM) Center at Columbia). The new NINR strategic plan will be used as the organizing framework for this symposium.

Common Data Elements: Utilization to Improve Data Sharing and Generalizability

Angela Starkweather, University of Connecticut

Background/Purpose: Common data elements used in symptom and self-management science are measures of a clearly defined symptom or self-management phenomenon. Common data elements have been recommended by various Institutes, including the National Institute of Nursing Research.

Theoretical Framework: Most recently, recommended common data elements for self-management studies were published, including measures of patient or caregiver activation, self-regulation, self-efficacy for managing common conditions and global health.

Methods: The objectives of this presentation are to: (1) describe the need for common data elements in nursing research; (2) examine a process for selecting common data elements and data collection platforms based on the focus of the study; and (3) explain the process for integrating datasets across studies that include common data elements. Each objective will be discussed within the context of the National Institute of Nursing's 2016 Strategic Plan. This presentation will provide an overview of the recommended common data elements for symptom and self-management science, where to find the information about common data elements and how to obtain the instruments.

Results: In addition, we will provide a framework used by the Center for Accelerating Precision Pain Self-Management for integrating common data elements across pilot projects and the process for selecting common data elements. We will compare different strategies for using common data elements across data collection platforms. Using one of the pilot studies as a model, we will explain how the common data elements are threaded across projects and the anticipated deliverables of a de-identified database that will be used to compare and contrast self-management processes and outcomes across studies.

Conclusions/Implications: Using common data elements across studies from one Center and across Centers will speed the understanding of these common phenomena

The Precision in Symptom Self-Management (PriSSM) Center

Kathleen Hickey, Columbia University [black down pointing small triangle] Mary Byrne, Columbia University [black down pointing small triangle] Walter Bockting, Columbia University [black down pointing small triangle] Lena Mamykina, Columbia University [black down pointing small triangle] Suzanne Bakken, Columbia University

Background/Purpose: Latinos are the fastest growing ethnic group in the US and by 2060 are estimated to represent 29% of the population. Although often treated as a homogeneous population in research, Latinos vary in culture as well as in genetic ancestry admixture. The former may influence symptom experience and responses as well as self-management needs. The latter influences disease risk and treatment responses and Ancestry Informative Markers have been developed to quantify admixture for Latinos in the Americas. However, little is known about how these cultural and genetic factors interact in the context of symptom science. The goal of the PriSSM Center is to advance the science of symptom self-management for Latinos through a social ecological lens that takes into account variability in individual, interpersonal, organizational, and environmental factors across the life course.

Theoretical Framework: For Center pilot studies, the overarching lens of the Social Ecological Model is complemented by the NIH Symptom Science Model.

Methods: To achieve the goal of the PriSSM Center, the Administrative and Pilot Projects (n=6) Cores are complemented by a Precision Medicine Core. The Precision Medicine Core integrates expertise and resources related to variety of data sources (genomic and other biomarkers, clinical, symptom self-reports, quantified-self, environmental) and analytic approaches (biostatistics, statistical genetics, data science). A federated information architecture supports instantiation of the Social Ecological Model with multiple data sources and tools to enable precision in characterization of genotype and phenotype, precision in identification of intervention targets, and precision in intervention. The formative and summative evaluation plan applies novel data science methods including network analysis and topic modeling to measure changes in collaboration patterns and research topics over time.

Results: Funded in August, 2016, the Center has two pilot studies in progress, one focused on fatigue in the home health care setting and another that is adapting and pilot testing a fatigue intervention for older PLWH. Core services and infrastructure include a common data element repository.

Conclusions/Implications: Funded through the Centers of Excellence in Self-Management of Symptoms Program, the PriSSM Center is contributing to NINR's goal of advancing symptom science through complementary, synergistic research activities.

Self-Management of Sleep Disturbance in Acute & Chronic Conditions

Nancy Redeker, Yale University [black down pointing small triangle] Henry (Klar) Yaggi, Yale University

Background/Purpose: Chronic conditions are the leading causes of death, including 70% of U.S. deaths. Half of American adults have one chronic condition and a quarter have two or more. An acute condition may be the first stage, predictor, or an unstable phase in the trajectory of chronic conditions. Seventy million Americans have chronic sleep disturbance that often contributes to the development and exacerbation of chronic conditions (e.g., diabetes, cardiovascular disease, depression); daytime symptoms (e.g., fatigue and sleepiness); and decrements in function, quality of life, and injury risk. Sleep disturbance is dynamic across the trajectory of chronic conditions; influenced both positively and negatively by treatment; and contributes to long term negative consequences. There is a critical need for better understanding of the relationships between sleep disturbance and chronic conditions and effective strategies for self-management of sleep disturbance across populations and settings.

Theoretical Framework: The organizing framework is based on the 2-Process Model of Sleep Regulation, predisposing, precipitating, and perpetuating factors for sleep disturbance, the Trajectory Model of Chronic Illness, and the Framework for Self- and Family Management of Chronic Conditions.

Methods: The purposes of this presentation are to describe the organizing framework for the Yale Center for Sleep Disturbance in Acute and Chronic Conditions, an NINR-Exploratory (P20) Center, examples of research using this framework, and discuss implications for future research and future model development.

Results: The Center funded 4 pilot studies and supported other projects that addressed sleep disturbance in a number of acute and chronic conditions, providing the foundation for self-management of sleep disturbance.

Conclusions/Implications: The Center's Organizing Framework presents a useful heuristic for conceptualizing the nature of sleep disturbance in acute and chronic conditions and self-management of sleep disturbance and formulating future research in this area.

NUCARE Disparity Framework: Framework Guiding the Integration of Technology with Self-Management Strategies with Ethnically Diverse Older Urban Adults

Barbara Guthrie, Northeastern University [black down pointing small triangle] Elizabeth Howard, Northeastern University

Background/Purpose: There is a growing need to develop self-management strategies that promote quality of life among ethnically diverse, urban dwelling older adults. The center's purpose is to develop, implement and evaluate the integration technology with self-management strategies with this vulnerable subpopulation.

Theoretical Framework: The Center faculty developed a Diversity framework to be the center's overarching guide for funded pilot studies to generate their specific frameworks. Adapted from Warnecke, et al. (2008), the framework provides a broad and integrated lens for understanding the multi-dimensional nature of health disparities among this subpopulation.

Methods: To utilize the framework's three interrelated determinants, proximal, intermediate, and distal that are fluid, interrelated, and interactive to guide pilot studies. Interwoven throughout these dimensions is the use of technology as a medium for health professionals, individuals, families, and communities to interconnect and interact with each other in real time to promote quality of life and self-management strategies for chronic conditions.

Results: The presentation will describe how the Disparity framework was used to guide a specific pilot study titled "Vitalize 360 program." This program includes a comprehensive assessment system and a wellness coaching model. The framework's three determinants within the intervention were designed to promote self-management and to improve quality of life and well-being of older adults.

Conclusions/Implications: The psychosocial, environmental and economic challenges related to integrating technology with self-management with this vulnerable population will be addressed.

A Functional Approach to Building the Science of Symptom Self-Management

Cynthia Jacelon, University of Massachusetts-Amherst [black down pointing small triangle] Annette Wysocki, University of Massachusetts-Amherst [black down pointing small triangle] Rebecca Spencer, University of Massachusetts-Amherst [black down pointing small triangle] Jenna Marquard, University of Massachusetts-Amherst [black down pointing small triangle] Deepak Ganesan, University of Massachusetts-Amherst

Background/Purpose: More than 90% of individuals over 65 in the United States have health issues that require daily maintenance and more than 33% of older individuals have functional impairments that affect their self-management abilities. Many of these individuals experience fatigue and impaired sleep as symptoms of these chronic conditions. Interventions focused on symptom management and functional capacity hold promise for chronic disease management.

Theoretical Framework: Our framework of self-management is based on the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The ICF describes function as "[horizontal ellipsis]a dynamic interaction between health conditions and contextual factors, both personal and environmental." Based on this approach, the symptoms of chronic disease and the effect of those symptoms on daily function are the focus of research.

Methods: The UManage Center for Building the Science of Symptom Self-management is designed using a functional approach to improve self-management using wearable and hand held technologies. The long-term goal is to increase the capacity of individuals and families to self-manage chronic disease symptoms, to reduce healthcare costs, improve quality of life, and prevent admission to healthcare facilities. We will accomplish this through nurse-led interdisciplinary teams conducting research on self-management using wearable or hand held devices.

Results: Our functional approach is aimed using wearable and handheld devices to provide information to the individual about their symptoms of chronic conditions. This approach improves the versatility of the devices and self-management strategies by expanding the range of chronic conditions for which the technology is useful as symptoms of many chronic conditions are similar. Focusing on self-management actions, regardless of the underlying disease process, is a significant innovation in self-management science. The first two pilot research projects

Conclusions/Implications: Approaching self-management from a functional perspective provides a way to identify cost-effective strategies for self-management of symptoms and promotion of personal health across disease processes. The functional approach is unique in that few scientists have considered chronic diseases and symptom-self-management from this perspective.

Symposium Session D6: From Assessment to Implementation: A State-Wide Cultural Competency Initiative

From Assessment to Implementation: A State-Wide Cultural Competency Initiative: Integrative Summary

Rita Adeniran, Drexel University [black down pointing small triangle] Sarah Haxem, National Nurse-Led Care Consortium (NNCC) Philadelphia [black down pointing small triangle] Monica Harmon, University of Pennsylvania [black down pointing small triangle] Elizabeth Gonzalez, Drexel University

Integrative Summary: Changing demographics and multiculturalism has elevated the importance of cultural competency in the delivery of health care services. Nurses, the single largest segment of healthcare professionals are positioned to lead the practice of culturally competent healthcare services in their organizations. Cultural competence is a process in which the provider continuously strives to achieve the ability to effectively work within the cultural context of the patient (individual, family, community). The National Quality Forum (NQF) Comprehensive Framework that underscores data collection about the practice of cultural competency as essential to driving quality improvements guided this study.

To support nurses in advancing culturally competent healthcare services across the state of Pennsylvania, a state wide assessment (Cultural Competency Education and Awareness Survey) of Pennsylvania Registered Nurses was conducted with the following objectives:

* Identify PA RNs desire and interest to provide culturally competent care

* Discover the sources and availability of education, training, and other information that support PA RNs to provide culturally competent care

* Assess the extent to which culturally competent care is provided by RNs practicing in the state of PA.

This symposium encompasses three abstracts; each focus on the findings of the Cultural Competency Education and Awareness Survey (CCEAS) among PA RNs. The first abstract focuses on the descriptive results of the CCEAS. The second abstract is a comparative analysis of CCEAS survey between Magnet and non-Magnet facilities in PA. The third abstract presents the qualitative findings of CCEAS, echoing the voice of the nurses who participated in the study. Each presenter will address strategies that have been implemented to date to bolster cultural competency among RNs in the state of PA.

The Cultural Competency Factor: A Comparison of PA Magnet and Non-Magnet Facilities to Advance 21st Century Health Care Delivery

Monica Harmon [black down pointing small triangle] Rita Adeniran, Drexel University [black down pointing small triangle] Elizabeth Gonzalez, Drexel University [black down pointing small triangle] Sarah Hexem, National Nurse-Led Care Consortium (NNCC)

Background/Purpose: Magnet Designation is a performance driven recognition from the American Nurses Credentialing Center (ANCC). Magnet designated healthcare organizations are known for providing high-quality care, safer environments, and improved outcomes for patients. Nurses in Magnet organizations are reported to have greater autonomy, more satisfied and engaged in their work. Higher engagement correlates directly with improved quality, and increased patients' and organizational outcomes. As of date, only 8% of U.S. hospitals have earned the Magnet designation. The purpose is to determine if difference exists in nurses' engagement with cultural competency between Magnet and non-Magnet designated facilities in PA.

Theoretical Framework: The National Quality Forum (NQF) Comprehensive Framework that underscores data collection about the practice of cultural competency as essential to driving quality improvements guided this study.

Methods: RNs from both Magnet and Non Magnet Facilities across the state of Pennsylvania participated in the state-wide CCEAS to appraise the level of desire, participation in cultural competency professional development opportunities, and organizational resources that enable the delivery of culturally competent care. Independent t-tests were used to determine differences between the magnet and non-magnet facilities. The level of significance was set at alpha = 0.05.

Results: RNs in both magnet and non-magnet facilities expressed an equivalent level of desire to provide culturally competent care and to engage in ongoing professional development opportunities. However, RNs in Magnet facilities reported significantly higher level of educational preparation, superior organizational resources, and support for cultural competency.

Conclusions/Implications: Opportunity exists for all nurses regardless of area of practice to strengthen their cultural competency skills. Nursing leadership and healthcare organizations have a role to enhance culturally competent practice in both magnet and non-magnet facilities.

Cultural Competence: Voices of Practicing Registered Nurses

Rita Adeniran [black down pointing small triangle] Sarah Hexem, National Nurse-Led Care Consortium (NNCC) Philadelphia, PA [black down pointing small triangle] Elizabeth Gonzalez, Drexel University

Background: The increasing cultural diversity of patients in the United States pose many challenges and opportunities as nurses continuously strive to achieve the ability to effectively work within the cultural context of the patient and families. This paper is part of an initiative that includes a Cultural Competence Education and Awareness Survey among registered nurses in the State of Pennsylvania.

Purpose: The purpose of this paper is to describe perspectives on cultural competence captured in the narratives of RNs.

Methods: 171 RNs provided a narrative on cultural competence based on their encounter in the clinical field. Thematic analysis was used. Data were coded on recurring themes.

Results: Themes identified include the following needs: 1) cultural awareness i.e., being prepared for geographical, cultural, and ethnic backgrounds of patients; 2) need for cultural knowledge and skills; 3) Openness to differences in beliefs, values, and attitudes of patients, and 4) respect for cultural diversity and motivation to engage in providing cultural competent care. Themes identified as challenges include: 1) Providing cultural competent care requires time with patients; 2) resources are not available in patient's languages and if available, it is not available 24 hrs; 3) and the healthcare system does not provide sufficient time for provider-patient interaction; and 4) provider's values, beliefs and attitudes are barriers.

Conclusions/Implications: The themes derived from the nurses' narrative reflect the desire to be culturally competent and the need for more educational training program in cultural competence.

Where Do We Go from Here? Pennsylvania Registered Nurses' Desire and Preparedness to Provide Culturally Competent Care

Rita Adeniran, Drexel University [black down pointing small triangle] Monica Harmon, University of Pennsylvania [black down pointing small triangle] Sarah Hexem, National Nurse-Led Care Consortium (NNCC) [black down pointing small triangle] Elizabeth Gonzalez Gonzalez, Drexel University

Background/Purpose: Nurses or any clinician's ability to provide healthcare services that are congruent with a patient's cultural health values and beliefs constitute cultural competency. Evidence suggests that clinician's struggle with operationalizing cultural competency, as they may lack the knowledge, skills and/or attitudes necessary to bridge the patient - provider cultural gaps. Healthcare services that are valued by patients in one culture may be inept to patients from other cultures. Nurses' risks being incompetent when they subconsciously or unintentionally disregard a patient's cultural values. The purpose is to discuss the descriptive results of the Cultural Competence Education and Awareness Survey (CCEAS)

Theoretical Framework: The National Quality Forum (NQF) Comprehensive Framework that underscores data collection about the practice of cultural competency as essential to driving quality improvements guided this study.

Methods: Registered Nurses (RNs) in the state of Pennsylvania (PA) participated in the CCEAS online. CCEAS is a 41item instrument that collected participant's demographics, quantitative and qualitative data about the state of cultural competency in the state of PA. Data was collected over a 5-months period, using snowball technique. Quantitative data was analyzed using IBM SPSS Statistics, version 22.

Results: The final sample consisted of a total of 1, 209 participants. Demographics findings closely mirror PA's RNs demographics. Over 70% of the participants were staff nurses working in acute care settings. 73% have received some form of education about cultural competency within previous five years of the study. The majority of study participants expressed a desire for continued professional development, emphasizing specific topics and preferred methods of receiving education and training.

Conclusions/Implications: PA registered nurses recognize the value of cultural competency. They expressed interest to acquire additional skills to meet the unique needs of their increasing diverse patient's population. The desire to gain more knowledge and expertise has implications for society. Findings of this study are being used to guide new programs and to advance cultural competency in the state of PA and beyond!

Poster Session III: Meet the Researchers

The Developmental Screening Behaviors, Skills, Facilitators and Constraints of Family Nurse Practitioners in Primary Care: A Preliminary Look

Patricia Gellasch, Villanova University

Theoretical Framework: Constructs from Fishbein's Integrative Model of Behavioral Prediction guided the development of this study.

Background: Primary care settings are responsible for conducting periodic developmental screening. The average age when children are identified as having a developmental delay is 5.9 years, which is too late and is cited as a missed opportunity. Children entering school with unidentified developmental delays are at greater risk for morbidities, poor health choices, delinquency, and criminal activity. Many studies have been conducted to explore the developmental screening behaviors of providers in primary care, but only 5 studies have included nurses.

Purpose: The purpose of this research was to explore and describe the developmental screening behaviors, skills, and environmental facilitators/constraints of primary care family nurse practitioners (FNPs) who care for children from birth to five years of age.

Methods: A qualitative descriptive design allowed for an in-depth exploration of the developmental screening behaviors, skills, and environmental facilitators/constraints of FNPs. Demographic and semi-structured questions were developed and reviewed by nurse experts. An online demographic questionnaire was completed by participants. A secure digital conference room was used to conduct individual interviews, which were recorded and transcribed. Elo & Kyngas' inductive approach of content analysis was used to interpret the data. A doctorally prepared nurse researcher confirmed the analysis.

Results: Twenty-four interviews were completed. Preliminary data analysis revealed informal methods of screening are more commonly employed than validated developmental screening instruments. FNPs are uninformed about validated developmental screening instruments and current developmental screening recommendations. Support staff, templates within electronic health records, and assessments that are brief and easy to use are identified as environmental facilitators to conducting developmental screening with a validated tool, while time and lack of standardized practice in the clinic setting are considered constraints. Analysis will continue until a general description of the phenomenon is created.

Conclusions/Implications: This study serves as a foundation to devising developmental screening recommendations for FNPs in primary care. The findings will inform FNPs and nurse educators of the areas in clinical practice and nursing education that require further research to improve the identification of children with developmental issues.

Factors Influencing the Non-Medical Use of Prescription Medications in U.S. High School Adolescents

Cynthia Ayres, Rutgers University [black down pointing small triangle] Nancy Hurley Pontes, Rutgers University [black down pointing small triangle] Manuel Pontes, Rowan University

Background/Purpose: The non-medical use of prescription medications has been escalating progressively among adolescents, particularly among prescription anti-anxiety medications, pain relievers, steroids and stimulants. While it is clear that non-medical use of prescription medication among adolescents is problematic, examining the factors that may be associated with this behavior is important to gain a better understanding of how to help prevent this phenomenon. The study purpose was to examine relationships between sleep insufficiency, depressive symptoms, demographic factors, and the non-medical use of prescription medications in U.S. high school students.

Theoretical Framework: This study used theoretical propositions and empirical literature to examine the associations between sleep, depressive symptoms, and the non-medical use of prescription medications in adolescents.

Methods: This research is a secondary analysis of YRBS health behavior-related survey data collected from a nationally representative 3-stage cluster sample design of US high school students. The binary dependent variable for this study was non-medical use of prescription medications (yes/no). The binary independent variables were sleep insufficiency (yes/no) and presence of depressive symptoms (yes/no). Additional independent variables included race/ethnicity, grade level, and gender. Data were analyzed using multivariate logistic regression with SPSS 24 Complex Samples(TM).

Results: Significant bivariate relationships were found between the non-medical use of prescription medications and sleep (p < .01), feeling sad (p < .001), grade level (p < .001) and race/ethnicity (p < .01). Logistic regression analyses found that all of the independent variables were significant in predicting the likelihood of the non-medical use of prescription medications. The overall predictive model was statistically significant (Wald adjusted chi-square =498.238 (10) p < .000).

Conclusions/Implications: This study's findings further contribute to the knowledge base around adolescents' non-medical use of prescription medications. Findings underscore the potential impact of preventing non-medical use of prescription medications in high school adolescents by improving the sleep behaviors and assessing adolescents for depressive symptoms. Testing theory-based propositions in a large nationally representative data set affords for a more robust understanding of the associations among sleep insufficiency, depressive symptoms, non-medical use of prescription medications in the adolescent population.

Does Scheduling a Primary Care Follow-Up Appointment After a Pediatric Emergency Department Visit for Asthma Improve Outcomes? A Systematic Review and Quantitative Synthesis

Ashley Gyura, Columbia University [black down pointing small triangle] Brittany Kronick, Columbia University [black down pointing small triangle] Nadia Elgoghail, Hana Health [black down pointing small triangle] Nathaniel Saintus, Northwell Health [black down pointing small triangle] Arlene Smaldone, Columbia University

Background/Purpose: Pediatric asthma exacerbation continues to be a major public health issue associated with many negative health outcomes. Despite national programs to improve primary care asthma management, this condition is commonly treated in EDs or urgent care centers, resulting in more than two million visits annually in the United States. The purpose of this systematic review was to determine the impact of facilitated follow-up appointment scheduling in the ED on subsequent ED readmission rates and overall asthma care within the pediatric population.

Theoretical Framework: Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines

Methods: The databases PubMed, Embase, CINAHL, and Cochrane Library were searched for relevant studies. Inclusion criteria were pediatric population, ED setting, asthma exacerbation, and an intervention involving facilitated follow up appointment at discharge. Exclusion criteria included patients with status asthmaticus, hospital admission, or urgent care settings. Of 1,790 studies retrieved, seven RCTs met inclusion criteria. Study quality and bias were assessed using the Cochrane Collaboration tool. Data regarding sample size, patient population, study design, and outcomes were extracted and evaluated to determine similarities across studies. Outcomes of interest were synthesized by group, and data were analyzed using descriptive and chi square statistics. Data analyses were conducted using SAS 9.3 statistical software.

Results: The seven RCTs included data from 2,093 patients aged one year to eighteen years of age who presented to the ED for acute asthma exacerbations. Study follow-up ranged from two weeks to one -year post ED discharge. Facilitated follow-up appointments in the ED improved adherence with subsequent visits to the PCP (p<0.0028), and pooled data showed that inhaled corticosteroid use was higher in the intervention group compared to controls (67.6% versus 50%; p<0.0001); however, this did not impact 30-day ED readmission rates (p=0.72) or overall ED visits within a one-year period.

Conclusions/Implications: Facilitated ED follow-up appointments improved PCP follow-up and inhaled corticosteroid use at 30 days. These encouraging results support the implementation of this intervention in the ED setting. More research is needed on PCP follow up appointments after an asthma exacerbation to determine the post-exacerbation treatment and education necessary to continue to improve overall asthma care and reduce ED readmission.

Examining Perceptions of Communication Regarding Diabetes, Sex, Family Planning, Pregnancy, and Preconception Counseling Among Diabetic Young Latinas, Their Mothers and Healthcare Providers

Hiba Abujaradeh, University of Pittsburgh [black down pointing small triangle] Ellen Olshansky, University of Southern California [black down pointing small triangle] Frances Peterson-Burch, University of Pittsburgh [black down pointing small triangle] Keirsten Montgomery, Children's Hospital of Orange County [black down pointing small triangle] Dara Sorkin, University of California, Irvine [black down pointing small triangle] Robynn Zender, University of California, Irvine [black down pointing small triangle] Patricia Schmitt, University of Pittsburgh [black down pointing small triangle] Denise Charron-Prochownik, University of Pittsburgh

Background: Diabetic adolescent Latinas are at risk for major reproductive health (RH) complications. Current recommendations emphasize starting preconception counseling (PC) at puberty which requires communication among girls, mothers, and healthcare providers (HCPs).

Purpose: To examine the perceptions of communication regarding diabetes (DM), sex, family planning, pregnancy, and PC among diabetic young Latinas (13-21 yrs; with type 1 and 2 DM), their mothers and HCPs caring for this population.

Methods: Qualitative, descriptive study: used written open-ended questions with Latina mothers and daughters (M-D: M=13, D=21); and focus group of 8 HPs experts on Latinas, DM, adolescents, PC and/or RH. HCPs discussion was recorded verbatim and transcribed. Analysis was guided by qualitative descriptive methods where three members of the research team coded and discussed themes and consensus was reached.

Results: The following 9 themes were identified: M-D: 1) Lack of discussion about RH/PC from HPs. 2) Cultural and religious norms (e.g., 'delaying sex' and 'pregnancy till marriage'). 3) Mothers and HCPs focused on DM management. 4) Lack of Latina M-D communication about sex and pregnancy. 5) Importance of safe sex, but difficult to discuss between M-D. HCPs: 1) Cultural norms (e.g., parents' staying in examination room prevents discussing RH/PC). 2) Language barriers (e.g., parents speak Spanish; provide information using English or Spanish). 3) Promoting trust by listening and respecting teens' autonomy. 4) Discuss RH/PC within larger context for cultural sensitivity (e.g. couched in general health, planning for future sexual relationship when "married").

Conclusions/Implications: Several communication issues regarding RH/PC were reported among M-D and HCPs. Each group of the triad raised concerns about each other's problems and lack of communication. Future research should be directed toward developing culturally sensitive RH/PC programs for this population and empowering teens to initiate discussion about RH/PC with their mothers and HPs.

Pain Assessment in the Special Education Classroom

Brenna Quinn, University of Massachusetts-Lowell [black down pointing small triangle] Richard Serna, University of Massachusetts-Lowell

Background/Purpose: Approximately 15% of the 50 million public schoolchildren in the United States have intellectual and developmental disabilities (IDDs) and are at risk for experiencing undertreated pain while at school due to inadequate pain assessments. Although special educators are primarily responsible for the well-being of students with IDDs, these professionals lack training in determining whether a child with IDDs is experiencing pain. Pain that is not assessed or managed restricts student access to learning. This systematic review describes potential challenges or barriers to adequate pain assessment in the special education classroom.

Theoretical Framework: The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines directed the systematic review process.

Methods: Searches of databases, reference lists, and journals were conducted to identify sources for inclusion in the review. Electronic databases searched included Cumulative Index to Nursing and Allied Health Literature (CINAHL), Education Research Complete, Education Resources Information Center (ERIC), MedLine/PubMed, and PsycARTICLES. Search terms were acute pain, chronic pain, pain, classroom, educat*, intellectual disabilit*, developmental disabilit*, and special education. Research articles relevant to the area of interest available in the English language, published in peer-reviewed scholarly journals, and published between 2005 and 2016 were included.

Results: A total of 383 non-duplicate articles were found through the database search. Forty-five additional sources were identified by hand search. The majority of articles (325) identified were excluded following a review of the title and abstract, as information relevant to pain in students with IDDs was not addressed. Of the remaining 58 sources, 22 articles were excluded following full-text review, as data relevant to the study was not included. A sample of 36 sources was included for review. Following a content analysis of extracted data, five themes relevant to barriers and challenges to adequate pain assessment in the special education classroom emerged: (1) pain and maladaptive behavior, (2) teaching students in pain, (3) teacher and nurse role, (4) teacher and nurse knowledge, and (5) collaboration challenges.

Conclusions/Implications: This review identifies a critical need for an educational program for special educators related to pain occurrence, identification, and assessment in students with IDDs. Although teachers, specialists, and school nurses are providing the best care under current conditions, more research in this area is needed to inform the development of educational interventions for school staff. Changes in practice are needed to help ameliorate barriers to interdisciplinary communication and collaboration.

Toxic Stress and Yoga Practice in Pre-School Children: A Pilot Study

Patricia HIndin, Rutgers University [black down pointing small triangle] Barbara Caldwell, Rutgers University

Background/Purpose: According to the 2014 report by Robert Wood Johnson Foundation, the mental health challenge is to shift policy and practice to promote wellness, improve mental health behaviors and prevent disease at multiple levels of individual and family life. A toxic stress response can occur when pre-school children are exposed to gun violence, gang wars, unsafe public housing, discrimination, deficient dietary options, and unsafe play environments. Prolonged toxic stress can cause immunosuppression and may be associated with autoimmune and inflammatory diseases, interfere with restful sleep patterns, and impact behavior and attention spans. There is a growing body of literature that identifies yoga as having positive effects on stress reduction by decreasing the sympathetic arousal of the autonomic nervous system and eliciting the parasympathetic response. The purpose of the study is to test the hypothesis that pre-school children will experience a decrease in toxic stress when exposed to a 20-week yoga routine compared to children who experience a standard play time routine.

Theoretical Framework: The bio-ecological systems theory of childhood development will examine the behavioral and physical health of the pre-school children

Methods: The study will use a pretest-posttest crossover design with a sample size of 30 male and female children enrolled in a pre-school program. The participants will be randomized to either a yoga group or waitlist group. Measure: The Child Behavior Checklist (CBCL) and the Children's Behavior Questionnaire will be given to the parents. Biomarkers will be collected on the children to include B/P, BMI and pulse rate. Descriptive statistics will illustrate the characteristics of the children. T-test will analyze the difference between the two means and liner regression will be conducted.

Results: Preliminary data analysis will be available for the poster presentation

Conclusions/Implications: The researchers theorize a reduction in toxic stress as demonstrated by changes on CBCL, Children's Behavior Questionnaire and biomarkers.

Factors that Influence Decision Making Engagement for Mothers of NICU Infants

Melissa Kurtz, Johns Hopkins University

Theoretical Framework: The Roy Adaptation Model (RAM), which describes adaptive processes to stressful stimuli, guides this research. Variables representing all four concepts of the RAM (Stimuli, Coping Process, Adaptive Modes, and Adaptive Responses) were identified for this study. Sr. Callista Roy, the developer of the RAM, is a consultant on this research.

Background: In the U.S., congenital anomalies impact 1 in 33 infants and frequently result in neonatal intensive care (NICU) hospitalization. While the American Academy of Pediatrics (AAP) states that NICU parents must be involved in shared decision making (SDM) with health care providers, various factors associated with a NICU hospitalization may limit parent engagement in decision making. Research to date has not explored the many factors that can influence parent engagement in NICU decision making.

Purpose: To explore factors that influence decision making engagement for NICU mothers.

Methods: A cross-sectional, convergent parallel mixed methods design will be used to collect quantitative surveys from a convenience sample of 60 mothers of infants with a congenital anomaly hospitalized in the Johns Hopkins NICU. Mothers' survey measures include: (1) Perception of infant illness severity, (2) General and religious coping, (3) Depressive symptoms, (4) Decision engagement, and (5) Ranking of 'good parent' elements. Additionally, a purposive sampling technique will be used to deliberately sample ~20 mothers who participated in quantitative surveys for participation in semi-structured qualitative interviews (i.e. 50% with engaged and 50% with unengaged decision making will be selected). Interviews will expound on factors that influence decision making engagement. Chi Square/Fisher's exact analyses will test categorical relationships. Multivariate logistic regression will test relationships among study variables and the dichotomous outcome (decision making engagement). A content analysis approach will be applied to qualitative interviews. Mixing of quantitative and qualitative data will be facilitated through data displays and matrices to identify profiles of NICU mothers according to decision making engagement.

Results: Preliminary findings of this ongoing dissertation research will be presented.

Conclusions/Implications: Findings will contribute to the development of decision support interventions aimed at facilitating parent engagement in the context of NICU health care decision making.

A Community Approach to Decreasing Youth Violence

Felesia Bowen, Rutgers University

Background/Purpose: Youth violence (YV) is a serious health disparity issue which disproportionately affects minorities, especially African American males. From a health perspective, youth violence is a complex and multifactorial disease with no easy cure. YV typically affects youth between the ages of 10 and 24 years and like most diseases of childhood, has an insidious onset beginning with conduct problems during the preschool years and poor school performance in elementary and middle school. When misdiagnosed or inadequately treated, YV exacerbates the problem of juvenile delinquency and can result in serious sequela during adolescence such as gang behavior or membership, violent delinquency and even death. Treatment often involves incarceration which is expensive and often ineffective; costing an average of $240.99 per youth per day thus, resulting in billions of dollars spent annually with little benefit to public society. Despite improvements throughout New Jersey, the incidence of YV in Newark Public Schools increased. During 2011-2012 school year more students were involved in violent behavior and substance use while on school property. Violent behavior among Newark school children increased 16% with weapons related incidents at school increasing 35% and substance abuse issues on school property increasing 25%.

Theoretical Framework: Bronfenbrenner's Ecological Systems theory provided the framework for this descriptive exploratory study.

Methods: This project used a descriptive and exploratory approach. Students from a local high school who were suspended from school were given an opportunity to participate in a restorative program called Brick City Synergy. Participants received an extensive evaluation upon enrollment; and based on the findings a success plan was developed with the participant and guardian. The participants attended a series of four classes with peers and parents were also provided support. Follow up assessments were completed post intervention to evaluate the program effects in terms of health and academic outcomes.

Results: 20 youth have participated in the program with positive results. Participants have not progressed in terms of further violent or disruptive behaviors and school attendance is improved. Other outcome measures including referral and treatment for depression screen, PTSD and unmet learning needs are ongoing.

Conclusions/Implications: This low cost community based intervention demonstrates that when given an opportunity high risk, urban youth can identify and learn to build upon their protective factors. Realizing the seriousness of the long term physical and psychological impacts of trauma, nurses should take the lead to coordinate community partnerships to support these youth in their environments.

Improving the Transition from Hospital to Home for Clinically Complex Pediatric Patients

Danielle Altares Sarik, Nemours/Alfred I. duPont Hospital for Children [black down pointing small triangle] Mary Pat Winterhalter, Nemours/Alfred I. duPont Hospital for Children [black down pointing small triangle] Christina Calamaro, Nemours/Alfred I. duPont Hospital for Children

Background/Purpose: Clinically complex pediatric patients with multiple follow up appointments and high acuity are at increased risk of poor outcomes as they transition from hospital to home. Patient navigation programs help patients and families through these transitions, but little exploration of the outcomes for clinically complex pediatric population exist. This study 1) describes the pediatric population utilizing these services, and 2) evaluates the outcomes of the program.

Theoretical Framework: This work draws from the Transitional Care Model (Naylor et al.), which highlights the importance of an approach that ensures collaboration, continuity of care, and strong communication in order to improve health outcomes for vulnerable older adults.

Methods: A retrospective review of deidentified patient data from January 1-December 31, 2015 was completed. The patient population studied received inpatient care at a mid-Atlantic, stand-alone, Magnet^(R)-designated, pediatric hospital. Patients 0-20 years who were admitted for a minimum of one night between January 1, 2015 and December 31, 2015, and were subsequently provided patient navigation services either in person or via follow up telephonic communication within two days of discharge, were included in the study. The primary outcomes of interest included patient demographic information, 30-day all-cause readmission rate, "no show" appointment rate, and source of patient referral. Basic descriptive statistics were used for analysis. The study was reviewed and approved through the Nemours IRB (#784888).

Results: A total of 398 unique patients comprised the study sample, with a total of 422 inpatient encounters reported during the study period. The average age of patients was 7.4 years, with patients from 0-1 years comprising 34.1% of the sample. The majority of the sample was female (52.5%) and white (52.0%), with English most commonly identified as the primary language. The top five diagnoses leading to admission were convulsions, dyspnea/respiratory abnormality, pneumonia, fever, and asthma. The mean 30-day readmission rate was 15.9% and the post-discharge appointment "no-show" rate was 12.9%. The majority of patients referred to the Patient Navigation service from all settings came from hospital-affiliated outpatient practices (56%), followed by family-initiated referrals (27%).

Conclusions/Implications: A robust patient navigation program may provide support and scheduling services needed by patients and families to help with the transition of care from the hospital to home.

Learning Lessons and Navigating Challenges in Building Successful Community-Academic Partnerships

Sheila Grigsby, University of Missouri-St. Louis [black down pointing small triangle] Annie Vandermause, University of Missouri-St. Louis [black down pointing small triangle] Jennifer Cordia, Christian Hospital [black down pointing small triangle] Rick Zimmerman, University of Missouri-St. Louis

Theoretical Framework: The Community Coalition Action Theory (CCAT) is our organizing theoretical framework. Fourteen major constructs of this theory are addressed in this presentation as a tool for evaluating our and others' partnership projects.

Background: Our combination of partners-a university, 3 clinics, a hospital, multiple community organizations and two school districts-and the rare inclusion of patients/families and adolescents into working groups to develop a sustainable consortium will help to boost collaboration among healthcare providers. This collaboration will create a solid foundation for patient-centered comparative effectiveness research (PCCER) towards the care for asthma and an undetermined health issue defined by the community.

Purpose: The inclusion of patient and other stakeholder voices is required in patient-centered outcomes research (PCOR). The purpose of this project is to increase healthcare delivery to a vulnerable group of under-served youth in our community. We will discuss lessons learned in the preparatory phases of our research.

Methods: The following project aims will be implemented and evaluated using the CCAT framework. 1) Fully develop a patient-centered partnership among our community collaboration; 2) Initiate discussions about collaborations, systems, and processes needed to provide greater health care access to under-served youth in St. Louis; 3) Educate community partners toward the development of a PCOR program to reduce health disparities and; 4) Develop models, materials and resources for use by patient-centered community partnerships to reduce health disparities.

Results: Building coalitions for this project has resulted in successful and challenging outcomes. The use of the CCAT is a way toward evaluating and adjusting partnership activities to achieve long term goals. Propositions in the CCAT framework will be exemplified to describe our progress.

Conclusions/Implications: The use of a relevant theoretical framework can grow a sustainable community partnership that provides strong roots for conducting PCOR.

Urban Versus Rural Barriers to Healthcare Accessibility: A Systematic Literature Review

Melissa Cyr, Northeastern University [black down pointing small triangle] Barbara Guthrie, Northeastern University [black down pointing small triangle] James Benneyan, Northeastern University

Theoretical Framework: Systematic literature review, patient-centred access to health care conceptual framework

Background: Healthcare is an affirmed, fundamental human right; therefore, health promotion and attainment are essential to equity. Access to healthcare is a poorly defined construct, but is key to effectively reaching and utilizing services essential for attaining optimal health outcomes. This is even more critical for improving the health of vulnerable populations residing in urban or rural geographical areas.

Purpose: To provide an integrated summary of the recent literature on barriers to healthcare access among vulnerable urban and rural populations.

Methods: A conceptual healthcare access framework with ten dimensions (approachability, acceptability, affordability, appropriateness, and ability to perceive, seek, reach, pay, and engage) was used to guide the critical review. A systematic review of the CINAHL, PubMed, and ProQuest Social Sciences databases were utilized using search terms (health services accessibility) AND (urban OR rural), initially yielding 27,262 cumulative results. The inclusion criteria were: US based articles that included full text; peer-reviewed; English language articles; published from 2012 to 2016; that contained original research; with clear delineation between urban and rural data; and knowledge on patient access and utilization barriers in healthcare. The exclusion criteria were duplicate and dental health articles.

Results: The conceptual framework was used to generate ten pervasive themes. Despite geographical and societal variability, many of the same themes such as: 'health literacy, information, and provider trust', 'clinician culture and language acceptability', 'individual culture and language', 'distance and transportation', 'accommodation and hours of opening', 'uninsured and underinsured', 'cost and socioeconomic status', 'adequacy of services' were central to both populations

Conclusions/Implications: The majority of barriers for either urban or rural populations were found to be overall similar with few differences. Barriers to healthcare accessibility are ubiquitous obstacles to achieving health equity in both urban and rural populations.

The Associations of Relationship Mutuality, Relationship Connection, Sex Risk Behaviors, and Engagement in Substance Dependence Treatment Among Black Women

Siobon Barrett, Northeastern University

Background/Purpose: The Centers for Disease Control and Prevention estimates 20 million new sexually transmitted infections (STI) in the United States annually with young Black women disproportionately infected. Substance dependence, found to increase STI risk behaviors among all groups increases STI risks for Black women. Thus substance dependent Black women represent a population at high risk for STIs. Engagement in substance dependence treatment is associated with decreases in sex risk behaviors. Presently this decrease in sex risk behaviors is aggregated by gender or race, with the effects of treatment on Black women poorly understood. Further it is unknown if engagement in treatment changes how Black women perceive relationships with their sex partners.

Theoretical Framework: Relational Cultural Theory posits that relationships are essential to women's physical and psychological health, and can only be understood within a social and cultural context. Healthy relationships contain five elements of mutuality: increased energy, clarity of self, the other, and the relationship, sense of personal worth, the capacity to be creative and productive, and a desire for increased connections. Paradoxically women may still value maintaining relationships that lack mutuality and may use compensatory strategies to maintain those relationships. Drug use and sex risk behaviors are examples of compensatory strategies used to maintain connection with sex partners.

Methods: Design: Cross-sectional Sample/setting: Black women currently engaged in a substance treatment program Measures: Relationship mutuality, relationship connection, treatment engagement, addiction severity, sex risk behaviors, demographics Proposed Analysis: Multiple regressions

Results: Ongoing

Conclusions/Implications: Currently there are gaps in substance treatment science in regard to understanding the effects of treatment among Black women. This proposed framework will answer two questions: (1) how does engagement in substance treatment influence sex risk behaviors among Black women and (2) does engagement in substance treatment change how Black women perceive relationships with their sex partners?

Integrative Review of Barriers to Cervical Cancer Screening in Sub-Saharan Africa

Ditsapelo McFarland, Adelphi University [black down pointing small triangle] Sarah Gueldner, Case Western Reserve University [black down pointing small triangle] Keitshokile Mogobe, University of Botswana

Background/Purpose: Cervical cancer is the leading cause of mortality and morbidity among women in sub-Saharan Africa despite the despite the demonstrated efficacy of the Papanicolaou (Pap smear) screening in developed countries. The purpose this study is to review published studies to identify and describe barriers to Pap smear screening among women in sub-Saharan Africa

Theoretical Framework: Cooper's (1998) Integrative review methodology guided this review.

Methods: Studies published between 2006 and 2015 were identified by searching electronic databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, MEDLINE, ProQuest, and PsycINFO, using specified search terms. Using this strategy, 224 articles were identified and screened for duplication and by reading titles, abstracts, and full texts. Seventeen articles met the inclusion criteria and were appraised using relevant tools for qualitative and quantitative designs. No relevant articles published in 2006, 2007, and 2014 were found.

Results: All 17 articles had good methodological quality and were included in the review. The studies were from 10 sub-Saharan countries and from different settings. Content analysis of the data revealed three major themes coded as client, provider, and system barriers. The most common client barriers were lack of knowledge and awareness about Pap smear screening, fear of cancer, belief of not being at risk for cervical cancer, and that Pap smear is not important unless one is ill, and cultural or religious factors. Provider barriers were failure to inform or encourage women to screen. Major system barriers were unavailability and inaccessibility of the Pap test

Conclusions/Implications: Although there were some variations from country to country, sub-Saharan countries share similar constraints to Pap smear screening. These findings have important implications for practice and policy.

The Theories of Reasoned Action and Planned Behavior Applied to Understanding the Phenomenon of Gun Violence

Mary Francis, Widener University

Theoretical Framework: It was a qualitative study with no theoretical framework. Following analysis of the data, The Theories of Reasoned Action (Fishbein, 1980) and The Theory of Planned Behavior (Ajzen) helps to explain an individual's intention to engage in a behavior at a specific time and place. The theories when applied to gun violence narratives adds understanding to the behavioral i intent of gun violence.

Background: Gun violence is a major social and health care crisis in the United States. The statistics are alarming. In 2013, the most recent year for which complete statistics are available, over 33,363 Americans were killed by firearms. An average of 92 people die from gun violence each day and over 92,000 Americans were treated in hospital emergency departments and trauma centers for non-fatal gunshot wounds (Center for Disease Control and Prevention, National Center for Health Statistics (CDCP) (NCHS), 2013). The statistics are alarming. Gun violence is affecting a great deal of victims, survivors, and witnesses who are all impacted by the prevalence of gun violence. The medical costs and the financial impact on society for criminal proceedings and loss of income are astronomical. Gun violence is a significant public health concern to all aspects of society. Americans are now concerned about safety in their homes, neighborhoods, and schools. The voice of the gun victims has not been prevalent in the literature.

Purpose: The purpose of this study was to describe and gain an understanding of gun violence from the perspective of the victim.

Methods: A Narrative inquiry was utilized for this study with purposive sampling. Interviews were conducted with sixteen victims of gun violence. Open-ended interview questions were utilized in order to allow the participant to tell their story about gun violence.

Results: The data was analyzed into four themes. The four themes that emerged from the interviews was: prevailing nature of everyday violence; feeling abandoned by the institutions of society; living in a context of reactive violence fueled by poverty, lack of employable skills and education; evolving psychological effect following gun violence.

Conclusions/Implications: The victims of gun violence willingly shared their story of gun violence. The study provided insight into the personal experience of being a victim of gun violence. Victims of gun violence are struggling with many challenges, poverty, deficient educational preparation and community neglect have been identified as impacting the daily violence experienced in their communities.

Meta-Analysis of HIV Prophylaxis Among Sexually Assaulted Patients in the United States

Meredith Scannell, Brigham and Women's Hospital

Background/Purpose: Individuals who have been sexually assaulted are at risk for sexually transmitted diseases (STDs). The gold standard of medical treatment for sexually assaulted individuals is to receive comprehensive care which includes prophylaxis to prevent STDs, including the human immunosuppressant virus (HIV). However, not all patients receive prophylaxis medications and even fewer who complete a course of medications. A meta-analysis was conducted examining the rates of non-occupational post exposure prophylaxis (n-PEP) to patients that have been sexually assaulted and presented to an emergency department in the United States.

Theoretical Framework: The meta-analysis was conducted in three phases. Stage one involved searching CINHAL, Pub Med, Web of Science, and Google Scholar databases. Stage two was screening the 280 found studies. Stage three was extracting data from each study for analysis.

Methods: This meta analysis examined four different aspects: 1.) Individuals that reported a sexual assault, presented to an emergency department, met the criteria for n-PEP, and were offered non post-exposure prophylaxis to HIV. 2.) Individuals that reported a sexual assault, presented to an emergency department, met the criteria for n-PEP, offered non post-exposure prophylaxis to HIV, and accepted treatment. 3.) Individuals that reported a sexual assault, presented to an emergency department, met the criteria for n-PEP, offered non post-exposure prophylaxis to HIV, accepted treatment, and completed at least one follow-up appointment. Individuals that reported a sexual assault, presented to an emergency department, met the criteria for n-PEP, offered non post-exposure prophylaxis to HIV, accepted treatment, completed.

Results: Pooled results of the meta-analysis indicated that approximately half of the patients who are offered n-PEP will accept the medication, however, only 25.7% of those who accept the medication will complete the full course. Further research is needed to examine factors that may impact sexually assaulted patients' ability to complete n-PEP therapy.

Conclusions/Implications: The result of the meta-analysis indicate need for better adherence rates of n-PEP among sexually assaulted patients. One limitation of this meta-analysis is the ability to generalize the findings to other patient populations. Most studies conducted were within urban hospitals and healthcare services may be very different in urban areas compared to rural areas where access to healthcare services and resources are often a concern which then may impact rates of n-PEP being offered and patients' ability to complete n-PEP.

Usability Study of a Web-Based interactive CPAP Self Management Program for Newly Diagnosed Persons with Sleep Apnea

Suzanne Dickerson, University At Buffalo

Theoretical Framework: The Empowerment Informatics Framework notes that patents living with a chronic disease such as obstructive sleep apnea can use health enabling technologies such as web-based interactive formats to manage their care thus improving well-being and treatment adherence.

Background: Obstructive Sleep apnea (OSA) is a condition where individuals have repeated episodes of upper airway obstruction during sleep. Continuous positive pressure (CPAP) is the most effective treatment for OSA yet adherence is low, ranging from 27-54%. A self-management program book entitled "Practical Advice for CPAP Users" was developed and demonstrated moderate effectiveness for improving adherence. Patient-centric approaches were used to develop the program's components which include: educational modules, self-monitoring tools, cognitive restructuring exercises, provider communication guides, and peer accounts and testimonials regarding treatment problems and solutions. This program was transitioned to web-based format to facilitate interactivity, availability and accessibility.

Purpose: The purpose is to conduct usability study of the CPAP self-management program in a web-based format.

Methods: Usability testing with 10 patient participants recruited from a sleep medicine site, using cognitive interviews and think-aloud techniques. The patient would be asked to talk out loud as they navigate through the components of the program noting what they like, dislike and make suggestions to improve the program. Thematic analysis of the taped and transcribed transcripts identified component descriptions and suggestions for improvement focusing on language and meaning of the components.

Results: Ongoing.

Conclusions/Implications: This study addresses the need for comprehensive, easily and readily accessible self-management support that can be implemented in real life settings of primary care. This would facilitate and optimize provider-patient communications to support self-care and promote living with and adjusting to CPAP use. This program will ultimately improve patient-centric outcomes by facilitating patient self-tailoring of components that meet their current needs while using CPAP.

Screening for Urinary Symptoms Among a National Sample of Nurse Practitioners

Kimberly Angelini, Boston College

Background/Purpose: Overactive bladder (OAB) and urinary incontinence are a common public health problem with reported rates higher than that of other chronic conditions (diabetes and asthma.) Symptoms often go underreported and undertreated due to embarrassment and the false normalcy. Many national organizations encourage the importance of routine screening in order to identify symptoms and offer behavioral modification as first line recommended treatment. Studies show that patients need to be asked directly about symptoms before sharing. The purpose of the study was to describe nurse practitioner's self-reports of screening for urinary symptoms including urinary incontinence and overactive bladder. The current study is a secondary data analysis of data collected as part of a cross-sectional study of nurse practitioners from across the United States.

Theoretical Framework: The practice implications of the proposed study are influenced by The Public Health Prevention Model (Wallace, 2008) which stresses the importance of primary and secondary prevention strategies, which is applied to early identification of OAB symptoms.

Methods: Design: The current study is a secondary data analysis of data collected as part of a cross-sectional study of nurse practitioners from across the United States. Sample/Setting: The original study recruited nurse practitioners that were members of the American Association of Nurse Practitioners (AANP). A random selection of 1,000 mailing addresses from across the U.S. was provided by AANP. The participants were nurse practitioners who were members of AANP. Measures: A 4-part consecutive mailer was sent to the provided addresses following the Dillman method of an introductory postcard, followed by the survey, and two reminder postcards. The postcards also had links to a web-based version of the survey. Providers were asked about their screening practices for urinary symptoms as well as the structure of their work setting.

Results: The mean response rate was 19%. The final sample consisted of 177 providers. Less than half reported screening all female patients for any changes in urination (n=76) and only 40.1% (n=71) reported screening young women (ages 16-30) for urinary symptoms.

Conclusions/Implications: Many national organizations encourage the importance of routine screening in order to identify symptoms and offer behavioral modification as first line recommended treatment. This study demonstrates a missed opportunity for providers in screening for urinary symptoms. Future research is needed to understand barriers to screening in this population. This study demonstrates a missed opportunity for providers in screening for urinary symptoms.

College Students' Knowledge and Use of Nicotine-Tobacco Products

Ann Feeney, University of Scranton [black down pointing small triangle] Josef Kampfe, University of Scranton [black down pointing small triangle] Emily Calderone, University of Scranton [black down pointing small triangle] Stefanie McGowan, University of Scranton [black down pointing small triangle] Jacqueline Nugent, University of Scranton [black down pointing small triangle] Jacqueline Vindici, University of Scranton [black down pointing small triangle] Sarah Finn, University of Scranton

Background/Purpose: The purpose of this study is to assess the knowledge and behaviors associated with use of nicotine-tobacco products among students attending a northeastern private university. Results will be compared to results of a study conducted at a larger, public university in a comparable geographic region. The use of alternative nicotine-tobacco products is increasing among adolescents and young adults and the use of these products has been linked to a greater risk of trying cigarettes and nicotine addiction.

Theoretical Framework: The Theory of Planned Behavior suggests that an individual's knowledge about risks of nicotine and tobacco products may be associated with their use. Recent studies have shown that college students who perceive that hookah and e-cigarettes are less harmful than tobacco cigarettes may be more likely to use these products.

Methods: Data collection was recently completed on a 23 question survey distributed in the student center of the university. A preliminary analysis of descriptive statistics was done on 20% of the total respondents. Data entry and analysis is continuing.

Results: A total of 225 college students completed the survey. A preliminary description of 20% of the respondents include: 95% were between the ages of 18 and 22. Thirteen percent reported rare or occasional use of cigarettes, 22.8% reported rare or occasional use of hookah, and 9.1% reported frequent or daily use of smokeless tobacco. A majority of the respondents reported not knowing the ingredients of e-cigarettes (80%) and hookah (70%), and 16% believe there are no ill health effects associated with use.

Conclusions/Implications: This intercollegiate project conducted by undergraduate students from both a private and a public university working together to identify the current knowledge and use of nicotine-tobacco products campuses. Preliminary findings suggest a knowledge deficit regarding these products that could lead to an increase in use. Results will be used in development of appropriate interventions to educate students about nicotine-tobacco products.

Maintaining Fidelity in a Student Peer Educator (SPE) Sexual Health Intervention

Teri Aronowitz, University of Massachusetts-Boston [black down pointing small triangle] BoRam Kim, University of Massachusetts-Boston [black down pointing small triangle] Jennifer Mardin-Small, University of Massachusetts-Boston [black down pointing small triangle] Rosanna DeMarco, University of Massachusetts-Boston [black down pointing small triangle] Phil Gona, University of Massachusetts-Boston

Theoretical Framework: The SPE intervention is part of a larger grant that employs Neuman's Systems Model addressing individual, group and community Sexual Transmitted Infection (STI) primary prevention needs. The SPE addresses the group level aspect of the intervention.

Background: A large proportion of college students in the US are sexually active, and risk behaviors are common in this population. For example, 31% of college students report to not using condoms, and 12% report using no birth control the last time they had sex, which increases the risk of unplanned pregnancies and STIs. Unprotected sex is a major HIV and Hepatitis C (HCV) risk factor on campus, however many students have never had an HIV or HCV test.

Purpose: To describe the steps of training and maintaining fidelity in the development of an SPE Sexual Health Intervention for incoming freshmen students.

Methods: Forty hours of face-to-face group training sessions were completed, materials were developed to include a color-coded manual and all materials for each session were laminated. After each session the SPE dyads will individually complete a fidelity report, the project coordinator will randomly join the sessions and complete a fidelity worksheet.

Results: This is an ongoing project with the continuation of training and sessions twice a year prior to the beginning of the semester for the length of the grant period. One SPE intervention was completed and the second is underway. Focus group data will be presented from the perspective of the SPEs and their preparation to deliver the intervention. Additionally, pre- post-intervention survey data will be presented from the first freshmen group.

Conclusions/Implications: Maintaining fidelity is critical to the assessment of the adaptation of a CDC-approved Evidenced Based Intervention. Ongoing assessment of this aspect of the grant will provide further information on the adequacy of this adaptation.

Engendering Hope: A Descriptive Study of Patients and Nurses

Debra Stavarski, Reading Health System

Background/Purpose: Hope may improve well-being (Duggleby, et al., 2010), and assist patients experiencing chronic illness (Duggleby et al., 2012). Nurses engender or hinder hope through their interactions with patients. Purpose: To explore patients' and nurses' perceptions of hope-engendering nurse interventions (HENI), patients' perception of hope, differences between patients' and nurses' perceptions of HENI, and the relationship between patients' perceptions of HENI and patients' perceptions of hope. The research questions were: What are patients' and nurses' perceptions of hope-engendering nurse interventions and the four attributes as they experience a health/illness transition? What are patients' perceptions of hope and its three factors as they experience a health/illness transition? What are the differences between patients' and nurses' perceptions of hope-engendering nurse interventions and the four attributes? What is the relationship between patients' perceptions of hope-engendering nurse interventions and patients' perceptions of hope?

Theoretical Framework: Meleis' Transitions Theory

Methods: Design: Descriptive comparative, correlational. Sample: Convenience sample of 97 patients and 91 nurses. Setting: Five hospitals, medical-surgical units, in the Northeast. Measures: The Hope-Engendering Nurse Intervention - Patient and Nurse (HENI - PT, HENI - RN) Instruments, Herth Hope Index (HHI), and demographic questionnaires. Analysis: Descriptive and inferential statistics were computed using Statistical Package for Social Sciences.

Results: Patients' scores were significantly higher than nurses' scores (143 points; HENI Total, t = -4.95; p < .001); hope scores were high, and a weak relationship existed between HENI - PT and HHI (r = .27; p = .008). Instrument Cronbach's alphas: .97 HENI - PT, .96 HENI - RN, and .88 HHI.

Conclusions/Implications: Findings suggest a need for nursing education; establishing expectations of nurse promoting activities; and a need to understand patients' perceptions about and sources of hope, to implement appropriate nursing interventions.

Impact of Parental Health Literacy on Pediatric Care: Conceptual Analysis of Literature

Mia Waldron, Children's National Health System

Theoretical Framework: There are two major frameworks for HL: the Conceptual Framework of Health Literacy & Health Action and the Health Literacy Skills Framework

Background: Health literacy (HL) is a multifactorial communication process, determined by the unique characteristics within each of the four literacy domains: fundamental, science, civic and cultural. HL represents the interaction between the individual and the health information stimulus in concert with environmental and cognitive factors produces the synthesis of health information into actions or behaviors.

Purpose: The purpose of this review and summary of the literature is to explore the concept of parental health literacy in the context of the pediatric acute care setting. The concept of parental health literacy is significant to nursing because nurses have primary responsibility for patient and parent education and as such must have a valid and reliable means of ensuring that health information is understood by the target population.

Methods: The method of concept analysis was the eight stages described by Walker & Avant. Search of available sources of information to determine uses, scope, related terms and concepts for PHL included the electronic databases CINAHL, Medline, PubMed, Google and EBSCO.

Results: Parental Health Literacy (PHL) is a leveled concept of skill and ability that is predicated on the level of individuals ability to learn, read, comprehend and act on health information specifically related to the care and condition of their children with high levels correlated with higher outcomes and low PHL associated with poorer outcomes. The antecedents of PHL are: Parent Educational Level; Parent/ Family Socio-Economic Status; Parent/ Family Cultural/ Religious Environment & Influence. Characteristics of the concept of PHL fall within three domains of behavior: Functional Literacy; Health Information and Parenting.

Conclusions/Implications: PHL is an important conceptual derivation of HL as it directly involves the impact of parents' abilities to process health information in order to facilitate their effective decision making, advocacy and health promotion behaviors for their children within and outside health care settings. PHL is an important concept for study as a guide for information sharing relative to informed consents, discharge teaching, prevention education and minimizing disparities in health outcomes for population health in the U.S.

Compassion Satisfaction: A Concept Analysis in Nursing

Tara Sacco, St. John Fisher College

Background: Compassion satisfaction, as a concept related to the nursing workforce, has not been fully developed by nursing scholars. Although this topic has been explored using quantitative means, the current working definition of compassion satisfaction and measurement tool have been borrowed from the social work field. Thus, there is a gap in both theory and knowledge.

Purpose: The aim of this concept analysis is to provide clarity to the concept of compassion satisfaction in nursing practice.

Methods: The Walker and Avant (2011) model was utilized to complete this concept analysis. A literature search in the fields of nursing and social work was undertaken. Further, papers focusing on educational processes in both professions were sought. Search terms included "compassion satisfaction", "nursing", "social workers", "teachers", and "educators" in combination. No limitations on publication date or population served were applied. Papers included in this review were both research reports and topical in nature. A final yield of thirteen nursing, four social work, and three educational articles were included. A comprehensive review and critique of the selected articles was then conducted to identify assumptions, antecedents, characteristics, and consequences of compassion satisfaction in nursing. Utilizing these findings, a theoretical definition of compassion satisfaction was developed.

Results: As a result of this process, the following theoretical definition was developed: Compassion satisfaction is the pleasure, purpose, and gratification received by a professional caregiver through their contribution to the well-being of patients and their families. A conceptual model, including the antecedents, consequences, and characteristics of compassion satisfaction has been created. Utilizing both the conceptual model and theoretical definition, a model case, a borderline case, and a contrary case have been developed.

Conclusions/Implications: There is a need to for nurse researchers to identify the positive aspects of caregiving. Defining compassion satisfaction is an initial step in strengthening nursing science surrounding the rewards of caregiving in the nursing workforce. The theoretical definition and conceptual model presented can be used to inform further studies on this topic, including both qualitative and quantitative methods as well as tool development.

Integration of a Conceptual and a Theoretical Framework to Explore Complex Phenomena

Anna Etchin, Veterans Affairs

Theoretical Framework: Neuman's Systems Model (NSM) provides a holistic and comprehensive framework for investigating multifaceted, interdependent, and concurrent concepts of complex phenomena. Within NSM, stressors and resilience influence successful reintegration. The Resiliency Model conceptualizes the resilience process, with a focus on reintegration.

Background: Theory-guided research is fundamental, yet underutilized or inconsistently documented in nursing research. Complex phenomena, such as military to civilian reintegration, are poorly understood from a theoretical basis. Approximately 25-56% of veterans report "some" to "extreme" difficulty with social functioning, productivity, community engagement, and self-care. Roughly 40% report stress-related symptoms that interfere with reintegration. Nurses and other healthcare professionals are challenged to provide comprehensive care for veterans with complex health needs throughout reintegration.

Purpose: This paper explored an example of theory integration, using NSM and the Resiliency Model to conceptualize and operationalize complex concepts of reintegration, resilience, and stressors among U.S. veterans.

Methods: A literature review, using inductive and deductive processes and guided by concepts from NSM and the Resiliency Model, was completed with a focus on military to civilian reintegration among U.S. veterans of the current war era.

Results: Reintegration and resilience were conceptualized using models, and veteran-specific stressors from NSM. Various domains of stressors influence reintegration success. Successful reintegration, operationalized in this example by the Military to Civilian Questionnaire, is theoretically moderated by resilience. Resilience acts as a protective resistance against combat-related stressors while optimizing successful reintegration and overall wellness. Resilience is multi-dimensional, demonstrated by multiple scales of the Deployment Risk and Resiliency Inventory.

Conclusions/Implications: Integration of NSM and the Resiliency Model is feasible and fitting to explore complex phenomena, such as veteran reintegration. Nurses, alongside inter-professional colleagues, are better positioned to appreciate and comprehensively treat complex health phenomena if guided by theory.

Theory Integration to Examine the Influence of Rurality on Ventricular Assist Device Patient Outcomes

Windy Alonso, Penn State College of Nursing [black down pointing small triangle] Judith Hupcey, Penn State College of Nursing [black down pointing small triangle] Lisa Kitko, Penn State College of Nursing

Background/Purpose: Ventricular assist device (VAD) therapy is becoming more common in the treatment of heart failure. VAD care is complex and the therapy is not without risk of declining quality of life, medical complications, and increased mortality. Access to health services for routine care and in times of emergent need are important to achieve positive outcomes. VAD patients that reside in rural locations, with limited access to health services, may have poorer outcomes compared to their urban counterparts. Theory-driven research in rural VAD populations is limited. Therefore, a theory integration was undertaken to develop a model that will be used to identify outcome disparities related to rurality.

Theoretical Framework: The Theory of Fundamental Social Causes (TFSC) and the Behavioral Model of Health Services Use (BMHSU) were integrated.

Methods: In depth examination of each theoretical framework was accomplished through literature review and analyses of theoretical concepts. Areas of theoretical overlap and divergence were identified. The theories were integrated through the assimilation of overlapping concepts. Consideration was given to areas of divergence with those areas identified as critical to examining rural health disparities incorporated into the final study framework.

Results: Both theories recognized the importance of context and access to resources. However, the theories diverged when considering the proximity of the root cause to an outcome; the TFSC contended that distal influences should be the focus of inquiries into health disparities compared to the BMHSU which focused on causes more proximal to the outcome. The concepts of the BMHSU serve to operationalize the four tenets of the TFSC that may establish rurality as a fundamental cause of disparate outcomes for rural VAD patients.

Conclusions/Implications: Integration of these two theories provides a comprehensive framework to identify outcome disparities in rural VAD patients. Theory integration should be considered when examining complex, multi-faceted health outcomes.

Challenges and Benefits of Research Participation

Judith Erlen, University of Pittsburgh [black down pointing small triangle] Jennifer Lingler, University of Pittsburgh [black down pointing small triangle] Susan Sereika, University of Pittsburgh [black down pointing small triangle] Lisa Tamres, University of Pittsburgh

Background/Purpose: Research participants are essential when conducting a study that involves patient populations; however, when invited to participate, their answer is not always 'yes'. There is limited literature discussing research participation including its challenges for participants and its benefits to participants. Thus, to address this gap this study examined challenges and benefits of research participation.

Theoretical Framework: Decision theory provided the framework for examining the choices of the participants.

Methods: At the end of the study, we surveyed caregivers of patients with memory loss residing in the community who completed a longitudinal intervention study designed to enhance the caregiver's problem solving abilities to promote improved patient medication management. Caregivers completed an investigator developed exit questionnaire that asked about their satisfaction with the study, whether they thought they received benefit from being in the study, and challenges they encountered related to time and study assessments. Descriptive statistics were used.

Results: The sample included 53 caregivers (70% female, 87% white, and on average 67 years of age) who completed the exit questionnaire. Caregivers expressed satisfaction with this study (n=48, 90%) and willingness to participate in a future similar study (n=49, 94%). They were satisfied with the explanation received about the study (n=50, 94%). Two-thirds (n=35) said that they did not change their health habits because of study participation. All but one caregiver was satisfied with study staff interactions (n=52, 98%). They (n=42, 82%) indicated that enough time had been spent addressing the management of the treatment plan. Only four (8%) said that it took too much time to participate in the study program. Twenty-five (49%) said that their ability to manage the patient's medication regimen had not changed. The responses on the exit questionnaire were not significantly different between the intervention and the control groups.

Conclusions/Implications: Overall, this sample expressed high satisfaction with being in the study, despite the finding that nearly half did not change their health habits or patient's medication management as anticipated. Future research needs to continue to gather participant feedback. Knowing the perspectives of study participants provides knowledge that will aid in developing subsequent studies that focus on similar populations.

Development and Psychometric Testing of the Nipple Shield Satisfaction Survey (NSSS)

Kathleen Black, Thomas Jefferson University [black down pointing small triangle] Ilana Chertok, Ohio University [black down pointing small triangle] Colette Acker, Breastfeeding Resource Center

Theoretical Framework: According to Ajzen's Theory of Planned Behavior (1991), perceived behavioral control influences intent to perform a behavior. The theory guided development of the NSSS to reflect maternal perception of an effective resource to facilitate breastfeeding.

Background: Whether recommended by health care professionals or independently purchased by mothers, nipple shields are widely used by breastfeeding mothers for their nipple-related breastfeeding difficulties. The evidence is conflicting regarding nipple shield usefulness in extending breastfeeding duration when mothers face breastfeeding challenges related to latch. Additionally, maternal satisfaction with the breastfeeding experience may influence breastfeeding behaviors.

Purpose: To date, no instrument exists to measure mother's satisfaction with the use of nipple shields. To this end, a new 9-item scale, the Nipple Shield Satisfaction Survey was developed to measure maternal satisfaction with the use of nipple shields for breastfeeding challenges related to latch.

Methods: Twenty-one items were constructed from a review of the literature investigating both women's and providers' statements about their satisfaction with nipple shield use for latching-related breastfeeding difficulties. These items were evaluated by 7 lactation experts to determine content validity. A sample of 128 women using nipple shields or had used nipple shields within the previous 6 months were recruited online through a breastfeeding resource network to test the instruments reliability and validity through item to total analysis and exploratory factor analysis.

Results: Scale Content Validity Instrument (CVI) was originally 72% with 8 items having agreement scores less than the accepted level of 80%. Of the 8 items below 80%, 7 were eliminated and one was retained, for an acceptable overall Scale CVI of 91.5%. Item reduction through item to total reliability analysis resulted in a 10-item scale. Exploratory factor analysis yielded a single 9-item scale with an eigenvalue of 5.3, explaining 59% of the variance. Reliability of this 9-item scale is 0.9. NSSS scores range from 9 to 45 with higher scores indicating greater satisfaction with use of the nipple shield.

Conclusions/Implications: The NSSS, demonstrating initial validity and reliability, may be useful in examining the satisfaction of women with the use of nipple shields both in practice and research settings.

The Effect of Alternative Therapies on Psychosocial Factors in Women Undergoing IVF: A Systematic Literature Review

Jenna LoGiudice, Fairfield University [black down pointing small triangle] Jenna Massaro, Fairfield University

Background/Purpose: Infertility services are utilized by 11.3% of reproductively aged women. Undergoing in vitro fertilization (IVF) as a means to achieve pregnancy is often stressful, with potential negative consequences to a woman's psychosocial health including distress, anxiety, and depression. High levels of these psychosocial stresses can negatively affect the success rates of IVF. Alternative therapies to address these areas of mental health in women undergoing IVF can be utilized. This systematic review aims to evaluate the effect of alternative therapies on decreasing psychosocial factors such as depression, stress, and anxiety in women undergoing IVF treatment.

Theoretical Framework: The General Adaptation Theory (GAS) - Theory of Stress frames the need undertaking this systematic literature review.

Methods: Inclusion criteria was that the study examined women undergoing in vitro fertilization (IVF) as well as some form of alternative therapy intervention (i.e. yoga, acupuncture, mind-body therapy, and/or counseling/coping). Additionally, the study had to measure the effect of the alternative therapy on decreasing psychosocial measures (i.e. stress, distress, anxiety, depression). An exhaustive search of the literature was conducted utilizing CINAHL and PubMed databases. The searches included articles from 2010 to 2016, using the keywords: IVF AND mind body therapy, yoga, diet, acupuncture. A hand-search was also conducted using the reference lists of identified articles to locate any primary sources.

Results: The search revealed 10 research studies published between 2010 and 2016 from a variety of countries, which met inclusion criteria. Six of the studies were randomized controlled trials (RCT), two were non-randomized controlled trials, and two were cohort studies. Forms of the alternative therapy intervention varied: N=2 each for acupuncture and Positive Reappraisal Coping Intervention, N=1 each for emotional support, integrative mind-body-spirit intervention, mind-body therapeutic program, auricular acupressure, hatha-yoga, and self-administered cognitive coping and relation intervention. The psychosocial factors measured also varied: N=8 anxiety, N=4 depression, N=2 stress, N=1 distress.

Conclusions/Implications: The results of this literature review highlight the overall positive effect various forms of alternative therapies have on reducing psychosocial factors in women undergoing IVF. Specifically, utilizing alternative therapies such as yoga, acupuncture, coping and mind-body therapies during the IVF process appears to be a positive way of decreasing stress, anxiety and depression. The results of this review inform both women's healthcare providers, as well as women undergoing IVF treatment about the need to incorporate alternative therapies into the plan of care for improved health outcomes.

Factors Influencing First-Time Fathers' Positive Responses to Pregnancy

Gladys Vallespir Ellett, NYU Langone Medical Center/NYU College of Nursing

Background/Purpose: Maternal and infant and health is recognized as a cornerstone of healthy families. Traditionally, maternal-child health interventions have focused on interventions for women and children to the exclusion of men. There is an increased awareness among governments and clinicians worldwide of the benefits of men's involvement in perinatal health, and closer examination of factors influencing men's involvement in pregnancy is warranted. It is important to understand the motivations for fathers' involvement in order to elucidate the benefits of paternal involvement on perinatal outcomes. Despite the implied importance of men's involvement in perinatal health, little is known about first-time fathers' responses to pregnancy. The purpose of this integrative review is to examine first-time fathers' experiences, thoughts, and perspectives on pregnancy.

Theoretical Framework: Integrative Review

Methods: This integrative review is conducted using guidelines offered by Whittemore and Knafl (2005). An electronic database search of PubMed, PsychInfo, and the Cumulative Index of Nursing and Health Literature captured studies published from 2000-2016 and yielded 795 results. Of these studies, fifty-six were screened and ten studies were chosen for the final analysis. Matrix tables and the Critical Skills Appraisal Program (CASP) are used to assess rigor and identify themes.

Results: Analysis of all ten articles revealed a broad range of men's responses as they worked to redefine their roles and identities from partner to expectant father. Initial emotional reactions included both positive and negative feelings, i.e. excitement and worry that began from the time of announcement of pregnancy up until preparations for labor and birth. Men also adopted different behaviors including seeking information, support, and connection during pregnancy to help them manage their transitions to becoming fathers.

Conclusions/Implications: This review examined a range of first-time father's responses to pregnancy. Although variations of men's responses are found, the overarching element of upheaval is evident. The first-time paternal experience of pregnancy is one of emotional, social, and psychological upheaval. However, these findings are limited to a small number of studies conducted outside of the United States. As increasing global trends of perinatal paternal involvement is recognized as beneficial to pregnancy outcomes, further research of American men's involvement in pregnancy is needed.

Efficacy and Acceptability of Antenatal Breast Expression of Colostrum

C. Melissa Morelli-Walsh, NYU Langone Medical Center/NYU College of Nursing

Background/Purpose: Antenatal breast expression of colostrum is the removal of colostrum during pregnancy. The removal of colostrum during pregnancy and its storage for future use upon birth of the baby provides an alternative to artificial baby milk (formula) usage when a baby's nutritional needs are not being met by the mother's initial available supply of colostrum. Expectant mothers may be advised by nurses and other prenatal care providers to perform antenatal breast expression in anticipation of the need for supplementation during the immediate postpartum period. An integrative review was conducted to explore the state of the science of antenatal breast expression of colostrum and its potential usage in the immediate postpartum period. Aspects of safety, acceptability of the practice and effects on perinatal breastfeeding outcomes are explored.

Methods: The integrative review includes 14 studies from around the world. Due to the historical nature of antenatal breast expression and its paucity in the research literature, no time limits or design limitations are imposed upon the sample criteria. Critical appraisal and synthesis of studies was facilitated by the CASP tool

Results: Qualitative findings included themes of improved breastfeeding self-efficacy, maternal security and satisfaction with antenatal breast expression. Antenatal breast expression's relationship to outcome measures of infant well-being, infant feeding method, breastfeeding rates and time to establish full lactation were also explored. Although an increase in initial breastfeeding rates were noted, a concerning trend of negative impact on infant well-being was noted.

Conclusions/Implications: Antenatal breast expression is a potentially innovative method of supporting breastfeeding during the first few days of a newborn's life. Additionally, the usage of stored colostrum may improve exclusivity rates for babies at higher risk of formula supplementation. However, a concerning trend of increased neonatal intensive care unit admissions for hypoglycemia management and slightly lower gestational age among babies whose mothers practiced antenatal breast expression warrants immediate further research.

Postpartum Experiences of Intended Parents in a Surrogacy Arrangement

Lauren Thorngate, Women & Infants Hospital of Rhode Island [black down pointing small triangle] Jean Salera-Vieira, Kent Hospital

Theoretical Framework: Ramona Mercer's (2004) middle range theoretical work on becoming a mother will set the stage for the time frame chosen for the interviews.

Background: Artificial reproductive techniques and surrogate pregnancies can produce long awaited offspring for what were formerly unsuccessful pregnancies attempted through natural conception. However, once the arrangement between the surrogate or gestational carrier and intended parents is complete, little is known about the lived experience or adjustment during the postpartum period for intended parents. Although there is literature and research on the characteristics of gestational carriers and surrogates, and children of surrogacy arrangements, we found limited literature discussing the psychological health or physical needs of the intended parents. The expected outcomes of this project are to achieve an understanding of the lived experience for intended parents, through the exploration of themes that emerge from family interviews.

Purpose: The purpose of this study is to discover the postpartum experiences of the intended parents after the birth of the baby or babies to the surrogate or gestational carrier.

Methods: This descriptive study will employ a qualitative design and engage narrative analysis to discover themes. After informed consent, intended parents will be invited to participate in the study, including a single semi-structured in-home interview, within the 2nd-4th week after the birth, scheduled at the convenience of the family. The interviews will then be transcribed and analyzed using narrative analysis for the detection of emerging themes. Sampling will continue until saturation of themes are achieved, estimated to be greater than 5 and less than 15 family interviews.

Results: Ongoing research, results are pending at time of submission.

Conclusions/Implications: We expect this work to inform future study, to generate testable hypotheses and ultimately to direct the development of postpartum hospital or community supports for new families choosing surrogacy or gestational carriers for childbearing.

Maternal Experiences of Racism and Child Health: Implications for Health Disparities via the Toxic Stress Response

Eileen Condon, Yale University

Background/Purpose: An extensive body of research has demonstrated that racism and racial discrimination significantly contribute to the perpetuation of racial and ethnic health disparities across the life course. While experiences of racism are challenging to measure in young children, research on maternal experiences of racial discrimination may provide important insight into the mechanisms through which racism impacts the health of young children. The purpose of this integrative review is to explore pathways though which maternal experiences of racism contribute to racial and ethnic disparities in child health.

Theoretical Framework: Toxic stress results from exposure to persistent stressors in early childhood, and leads to physiological disruptions that impact long-term health and development. The ecobiodevelopmental (EBD) model provides a framework for explaining the link between exposure to chronic stressors and lifelong health via the toxic stress response. In this review, the EBD model is used as a framework to examine the pathways though which maternal experiences impact children's environment, biology, health, and development.

Methods: 1673 articles were reviewed using Whittemore and Knafl's integrative review methodology. Empirical studies were included if they assessed maternal experiences of racial discrimination and an outcome pertinent to the EBD model (children's environment, biology, or health/development). 55 full text articles were selected for inclusion, and data were extracted (sample description, study design, findings) and evaluated for patterns and themes.

Results: Maternal experiences of racism may impact child health through a number of pathways associated with toxic stress. The child's environment is affected by impacts on maternal mental health, maternal physical health, pregnancy and birth outcomes, parenting practices, and healthcare interactions. Child outcomes associated with maternal experiences of racism include increased cortisol reactivity, obesity, increased childhood illnesses, lower cognitive abilities, and behavioral problems.

Conclusions/Implications: The results of this review have important implications for understanding some of the ways in which health disparities are rooted in early childhood experiences. These results suggest the need for future research on the health effects of exposure to racism in early childhood, and highlight the need for the development of interventions to support ethnic minority families at risk for discrimination.

Neuro-Imaging Markers for Postpartum Depression: A Systematic Review

June Horowitz, University of Massachusetts-Dartmouth [black down pointing small triangle] Bobbie Posmontier, Drexel University [black down pointing small triangle] Pamela Geller, Drexel University [black down pointing small triangle] Meltem Izzetoglu, Drexel University [black down pointing small triangle] Vicky Grunberg, Drexel University

Background/Purpose: Postpartum depression (PPD) affects 10% to 15% of women following delivery with significant negative health effects for mothers and their infants. Despite its prevalence, PPD's neurological signature remains largely unexamined. This systematic review explored evidence of neuro-imaging markers of PPD from studies utilizing functional magnetic resonance imaging (fMRI) and functional near-infrared spectroscopy (fNIRS).

Theoretical Framework: Higher cortical areas regulate attention, impulse control, affect, and decision making that affect maternal goals, standards, mores, and intention Subcortical areas regulate reward, affect, motivation, emotion, memory, pleasure, anxiety, and fear. These functions drive maternal care, responsiveness to the infant, and affection. Documenting neuro-imaging markers of PPD could map processes involved in and/or affected by PPD, and also provide objective treatment-related improvement indicators

Methods: A systematic review was conducted following PRISMA guidelines utilizing Ovid/Medline, PubMed, CINAHL, and PsychInfo search engines. Inclusion criteria were: PPD determined by self-report symptom severity or diagnostic interview and examination of maternal neurological indicators by fMRI or fNIRs. Abstract and full-text reviews were conducted with consensus reached among the researchers for inclusion.

Results: Thirteen studies were selected and examined. Relevant fMRI studies revealed similarities and minor differences between PPD and general depression that showed: reduced prefrontal cortex activity and cortical- amygdala connectivity in depressed mothers (via fMRI); reduced ventral striatum activity (motivation, reward via fMRI); and increased insula activity (affiliative behavior via fMRI). We found no fNIRS studies for PPD; however, findings for non-depressed mothers showed increased orbitofrontal cortex (OFC), i.e., the area associated with cognitive processing of decision-making, activation in mothers and their infants in response to own infant and own mother with positive affect.

Conclusions/Implications: Neurological indicators of PPD remain understudied. Evidence to date stems primarily from inferences concerning general depression. Limitations include: small sample sizes (N= 8-37) and limited comparisons for participants with PPD to participants with major depression. Findings precluded identification of a distinct neurological signature for PPD. Additional research exploring neuro-imaging signatures for PPD is needed. Non-intrusive neuro-imaging technology, particularly fNIRs, has great promise for more wide-scale use to determine a neuro-imaging signature of PPD. Such Information could assist with screening and serve as a potential objective marker in research and practice for tracking PPD symptom improvement to complement self- report of symptom change.

Acculturation and Birth Weight in Women of Mexican Origin in the U.S.: An Integrative Review

Stacia Birdsall, New York University

Background: Low birth weight (LBW) is a significant contributor to infant mortality and morbidity, as well as to long-term health complications. Women of Mexican origin, a large and growing segment of the U.S. childbearing population, currently have a rate of LBW lower than the national average. Acculturation, the process of change within an individual or group as they interact with another culture, may play a role in perinatal health outcomes.

Purpose: This integrative review examines the state of the science of LBW in relation to acculturation in Mexican-origin women.

Methods: A search was conducted in PubMed, CINAHL, and PsychInfo using the terms "acculturation," "low birth weight," "birth weight," "perinatal outcome," "birth outcome," and "Hispanic," "Latino/a," and "Mexican." Twelve articles published between 2006 and 2016 met inclusion criteria of peer-reviewed empirical studies conducted in the U.S., use of an independent variable identified as a measure of acculturation, inclusion of Mexican women in the sample, and a measurement of birth weight.

Results: Measurement of acculturation across the studies was heterogeneous and dominated by relatively simplistic unidimensional and proxy measures. Study populations were often poorly defined. The categories of "Hispanic" and "Mexican," were frequently conflated and potentially salient variables such as nativity were often absent. The majority of studies found a statistically significant relationship between acculturation and birth weight, such that more acculturated women gave birth to smaller babies.

Conclusions/Implications: Findings suggest that processes related to greater exposure to or orientation towards American culture may have an adverse effect on birth weights of infants born to Mexican-origin mothers. However, the relationship remains poorly understood. More robust measurement of acculturation and more clearly delineated study population data are needed to better understand the contribution of acculturation to birth weight.

Factors Associated with Genetic Testing Among Relatives of Individuals with Hereditary Breast and Ovarian Cancer Syndrome (HBOC): An integrative Review

Kathryn Robinson, Northeastern University [black down pointing small triangle] Meghan Underhill, Dana-Farber Cancer Institute

Background: Risk assessment through genetic counseling and testing to promote cancer early detection and prevention is the gold standard of care for individuals at high risk for hereditary breast and ovarian cancer syndrome (HBOC), most commonly associated with gene mutations in BRCA1/2. First-degree relatives of individuals with a BRCA1/2 gene mutation have a 50% chance of inheriting the mutation from a parent and there are also implications for risk in more distant family members. However, literature suggests that many family members (26%-82%) aware of the potential for high cancer risk may choose not to undergo genetic testing. To understand how and why individuals make the decision to undergo genetic testing, it is important to define factors associated with HBOC genetic testing decisions.

Purpose: The purpose of this integrative review was to explore factors associated with genetic testing decisions in at high-risk family members of those with identified HBOC risk.

Methods: Reviewed databases included EBSCOhost, CINAHL, PsychoInfo, and Medline from 2008 to 2015. Articles were written in English, individuals had a family history of HBOC, and included articles were from the self-reported perspective of at high-risk family member's personal experience.

Results: 823 articles were identified, 596 abstracts were reviewed, and twenty-one articles were included. Articles meeting inclusion criteria consisted of 6 qualitative, 11 quantitative, and 4 mixed methods. The overall 'big picture' theme associated with individuals at high risk for HBOC deciding whether or not to undergo BRCA genetic testing was seen as a family decision. Additional factors such as social support, family dynamics, cancer risk status, perceived level of knowledge; cost and insurance played a crucial role in the decision-making process.

Conclusions/Implications: Through this review gaps in knowledge were identified. Findings will be used to develop a further research to understand and facilitate the genetic testing decision making process in individuals with high risk for HBOC.

Breast Cancer in Saudi Arabia: A Narrative Review

Ahdab Eskandar, Northeastern University [black down pointing small triangle] Tiffany Kim, Northeastern University [black down pointing small triangle] Barbara Guthrie, Northeastern University

Background: Breast cancer is the most common type of cancer among women worldwide. Early detection of breast cancer increases chance of survival and treatment. However, there is limited documented research on breast cancer prevention in Saudi Arabia.

Purpose: The purpose of this narrative review was to summarize the literature on breast cancer in Saudi Arabian women. The review aimed to bridge the gap in the literature related specifically to breast cancer prevention.

Methods: A narrative systematic review was conducted in September 2016. CINAHL, Medline, PyscINFO, and PubMed were searched using keywords "breast neoplasms", "Saudi Arabia", and "screening". After excluding pharmacological, pathological, genetic and radiology focused studies, a total of 50 articles out of 198 were identified.

Results: Breast cancer is the most common type of cancer among Saudi women. Saudi Women presents with breast cancer a decade younger (from 30 to 50 years) and at advanced stage of malignancy than women in Europe and the United States. Late diagnosis at advanced stage of malignancy has been associated with poor prognosis, invasive treatment and economic burden. Several research studies measured women's awareness of breast cancer. Results highlighted an insufficient level of knowledge among Saudis of breast cancer signs, risk factors, treatment and screening methods. Additionally, healthcare providers also had insufficient levels of knowledge and screening practices. Furthermore, there is lack of national guidelines for breast cancer screening and population-based screening program.

Conclusions/Implications: Breast cancer is a major women's health issue in Saudi Arabia. As a result, there is a critical need to develop an intervention that focus on increasing both women's and general public awareness. Also, health professionals can play a major role in educating Saudis on breast cancer and encouraging screening. Future research should focus on examining barriers related to participation in breast cancer screening among Saudi Arabian women ages 30 to 69.

Feasibility of Comparing Cortical Hemodynamic Response Between Postpartum Depressed and Non-Depressed Mothers and Their Infants

Bobbie Posmontier, Drexel University [black down pointing small triangle] June Horowitz, University of Massachusetts-Dartmouth [black down pointing small triangle] Pamela Geller, Drexel University [black down pointing small triangle] Meltem Izzetoglu, Drexel University [black down pointing small triangle] Vicky Grunberg, Drexel University

Background/Purpose: Postpartum depression (PPD) has adverse effects on maternal and infant health. Extensive research suggests that effects of PPD on the child are largely mediated by impairments in mothers' abilities to respond sensitively and contingently to their infants. The purpose of this pilot study is to determine the feasibility of using functional near infrared spectroscopy (fNIRS) to compare cortical hemodynamic response (CHR) between mother-infant dyads with and without PPD and determine whether or not fNIRS can be used as an objective neuro-imaging marker of PPD and the quality of mother-infant interaction (MII).

Theoretical Framework: We propose to elucidate an underlying neurophysiologic mechanism (CHR) that may account for the relationship between PPD and impaired MII and subsequent negative infant effects.

Methods: We are testing the procedure on 10 eligible mother-infant dyads from 4 to 52 weeks postpartum. Socio-demographic and obstetric health variables are collected by the Socio-demographic and Health Status Questionnaire. The Edinburgh Postnatal Depression Scale measures PPD symptom severity. The Coding Interactive Behavior (CIB) measures quality of observed MI. fNIRS is a non-invasive and affordable technique to measure brain activity indicated by CHR. fNIRS sensors that fit like a headband and are soft, flexible and comfortable are placed on the mother and the infant right above their eyebrows and the recordings are collected during computerized tasks and MI.

Results: Data collection is ongoing. To date two mother-infant dyads have been tested. The mothers found the procedure acceptable and easy. One 12-month old struggled to remove the fNIRS headband but a 1-month old easily tolerated it.

Conclusions/Implications: Preliminary data suggest that using fNIRS with mother-infant dyads is possible. During additional testing, we will establish feasibility, refine our protocol and examine maternal and infant patterns for depressed vs. non-depressed mothers and their infants, and MI.

Paper Session E1: Nursing Education: Clinical and Staff Nurse Issues

Randomized Controlled Trial Assessing the Impact of an Innovative Approach to Educating Nurses to Clinical Competence

Evelyn Lengetti, Villanova University

Background/Purpose: Catheter associated Urinary Tract Infections (CaUTI) are preventable, and hospitals receive no additional reimbursement for these infections. The purpose of this study was to evaluate the effect of Mastery Learning compared to Traditional Learning on new nurses' competence and self-regulation practices for indwelling urinary catheter insertion

Theoretical Framework: Mastery Learning posits that all learners can achieve mastery when given with deliberate practice, repetition and feedback. Traditional Learning, a more rote instructional approach, emphasizes memorization with a single summative assessment. Self-regulation reflects actions practiced by the learner to obtain knowledge

Methods: This RCT was conducted in an acute care healthsystem and collected outcome data at two points (initial and one month later). Participants, who were new to practice nurses, were randomized into the experimental (Mastery Learning, n = 19) and control (Traditional Learning, n = 20) groups. All received baseline education on indwelling urinary catheter insertion before completing the procedure in the simulation lab. The experimental group was offered multiple attempts for insertion with deliberate practice, repetition, and feedback. The control group was offered one attempt for insertion with feedback at the end. An independent t-test compared the mean change in Performance Assessment Tool (PAT) scores between groups at one-month. A paired t-tests compared self-regulation practices for both groups using the Survey of Academic Self-Regulation (SASR) questionnaire at one month

Results: The experimental group scored significantly higher than the control group, p = .013, on those procedural steps deemed critical (potential to cause harm). The mean SASR scores between groups was significant, p = .035. The experimental group SASR score (M = 308.58, SD = 15.09) was greater than the control group (M = 292.70, SD = 28.05).

Conclusions/Implications: Findings indicate that nurses given the opportunity for repeated practice, repetition, and feedback retain and self-regulate more frequently to maintain knowledge related to catheter insertion. This model may be valuable in educating nurses by improving learning and retention of clinical skills

The Relationship Between New Nurses Who Volunteer and the Caring Behavior New Nurses Exhibit in the Practice Setting, One Year Post Graduation

Nicolette Fiore-Lopez, St. Charles Hospital

Background/Purpose: Nurses comprise a significant portion of the millions who volunteer world-wide. Nurses who have engaged in volunteer activities anecdotally describe personally transforming experiences gained through their efforts. To date there has been a paucity of research on nurses who volunteer. The purpose of this study was to describe the characteristics of novice nurses who volunteer and determine the influence of volunteering and associated characteristics on their caring behaviors and their satisfaction with career choice.

Theoretical Framework: The sixth Caritas Process of Watson's Theory of Transpersonal Caring (2012) requires the creative use of self.

Methods: This was a quantitative survey study using a descriptive, correlational design to determine the effect of spirituality, altruism and prosocialness on nurse volunteerism and how volunteerism mediates caring behavior and satisfaction with career choice in the new nurse.

Results: Those in the final data set (n= 1023) were mainly young, White non-Hispanic female novice nurses who attained baccalaureate degrees as their basic nursing education. The majority reported as having volunteered. Significant findings include that volunteering is positively influenced by participation in non-school related, volunteer activity and negatively influenced by required volunteer activity. Caring behavior was positively influenced by local volunteer activity that was non-school related, volunteer activity. Volunteering did not influence satisfaction with career choice. Spirituality, altruism and prosocialness were each positively correlated with caring behavior and satisfaction with career choice. Volunteerism in nursing was not found to mediate the relationship between spirituality, altruism and prosocialness and either caring behavior or satisfaction with career choice.

Conclusions/Implications: The findings of this study reveal that the novice nurse who engages in purely voluntary volunteer activity may be able to nurture caring behaviors through that interaction. Education may need to revisit how undergraduate service learning is done. Practice should not only consider previous volunteer experience of prospective RN staff but also provide ongoing opportunities to engage in volunteer activities. Further research should focus on other outcome variables of volunteering in nursing such as job satisfaction, career mobility and mentoring.

The Relationship of Metacognition to Perceived Clinical Decision Making by Registered Nurses

Mary Yost, Drexel University

Background/Purpose: In a profession where errors have adverse consequences on patients' lives, it is important to examine all processes that affect quality and safety of patient care, including clinical decision making. There is a gap in the literature about the thinking behind the thought processes RNs use when they make clinical decisions. The term for this is metacognition.

Theoretical Framework: The relationship of metacognition to RNs' perceived clinical decision making was examined using the theoretical framework of metacognitive theory.

Methods: A descriptive correlational design was used to explore the relationship of metacognition to perceived clinical decision making by RNs. The instruments included a demographic questionnaire, the Metacognitive Awareness Inventory (MAI) and the Clinical Decision Making in Nursing Scale (CDMNS). Data were collected using a web-based survey distributed through the Academy of Medical Surgical Nurses Association. Data were analyzed using descriptive statistics, Pearson's correlations and step wise multiple regression analysis. The sample consisted of 240 RNs from the nine geographic regions of the United States.

Results: Participants demonstrated high levels of metacognition and moderate to high levels of perceived clinical decision making. There was a positive significant relationship between metacognition and perceived clinical decision making by RNs. The two components of metacognition, knowledge of cognition and regulation of cognition, predicted perceived clinical decision making. Regulation of cognition accounted for more of the variance in scores, while an MSN was positively correlated to perceived clinical decision making. Finally, experience was not correlated to knowledge of cognition, regulation of cognition, or perceived clinical decision making.

Conclusions/Implications: Registered nurses need to not only possess knowledge to make informed decisions, but as this research demonstrated they also must regulate their thinking when making clinical decisions. Implementing strategies to enhance RNs' ability to monitor and evaluate their thinking may lead to more effective decision making abilities among RNs.

Reflective Journaling to Increase Critical Thinking for RNs

Susan Zori, Adelphi University

Background: Critical thinking (CT) is thought to be foundational to the development of clinical judgment in RNs. Exploring the development and use of CT dispositions using reflective journaling supported it as a useful strategy for the education of nurses in a Critical Care and Emergency Department Fellowship Program (CCEDFP). The American Philosophical Association (APA, 1990), through a former Delphi study, identified the seven dispositions used for this study.

Purpose: To explore RNs in a CCEDFP perspectives of using CT dispositions through reflective journaling.

Methods: This descriptive qualitative study analyzed journal entries about CT dispositions written by RNs (N= 56) who were in the first 7 weeks of a 6 month fellowship program. A short descriptor of one of the CT dispositions was provided weekly for 7 weeks to participants who then journaled about their experiences with that CT disposition. The 7 CT dispositions were: inquisitiveness, systematicity, open-mindedness, analyticity, truth-seeking, CT maturity and CT confidence Line by line content analysis was used to develop first themes for each disposition and then through reduction, to two overarching themes that best described their repossess to these dispositions.

Results: The two overarching themes from their perspectives were: development of CT is a process that develops over time and purposefully using CT behaviors prevents negative patient outcomes. There was positive feedback from the participants regarding developing their critical thinking skills. The study was limited by being conducted in one healthcare system and by the variety of teaching strategies used, the development of CT could not be attributable solely to reflective journaling.

Conclusions/Implications: Nurse educators can incorporate the perspectives of RNs on the importance and development of CT skills. The use of reflective journaling as a method holds promise for strengthening CT in RNs in a residency or fellowship program. Further study is warranted to determine the effects of this method on patient outcomes.

Cultural Competency: Measuring the Sustainability Following an Immersion Program For Undergraduate Nursing Students

Maureen Roller, Adelphi University [black down pointing small triangle] Helen Ballestas, Long Island University

Background/Purpose: Study abroad programs offer students an experience in working with individuals from other cultures. Short-term study abroad programs for undergraduate nursing students, whose purpose is to engage students with diverse populations in health care, have been demonstrated to improve the students' cultural competence. Little is known about whether that competence, usually measured immediately after such experiences, is sustained. The purpose of this research was to determine the effect of a study abroad program on cultural competence one-year post experience compared to scores from the immediate post experience.

Theoretical Framework: The Campinha-Bacote theoretical model: The Process of Cultural Competency in the Delivery of Healthcare Services developed in 1998, was chosen as the framework for this study.

Methods: The quantitative study design compared post- tests at two points in time utilizing the instrument: Inventory for Assessing the Process of Cultural Competency among Healthcare Professionals-Revised (IAPCC-R) with permission of the author. Scores one-month after initial immersion experience in Costa Rica were compared to scores one-year post experience with the same students, who were either still undergraduates or recently graduated RN's from a suburban private university. The sample was purposive. Cultural competency was measured utilizing the IAPCC-R instrument, which was completed at conclusion of program (N=18) and one-year after participating in the immersion program (N=15).

Results: Cultural competence scores were maintained. The overall scores for the highest category (culturally proficient) were compared. Using a t-test for comparison, the initial score for this category immediately post experience was 78.83 and the post one-year score was 78.80. No significant difference was revealed. The group's overall cultural competency was maintained one-year post immersion course.

Conclusions/Implications: Cultural competency that increased at the conclusion of a study abroad program was maintained one-year post immersion experience. Short-term immersion programs can influence cultural competency, important for nurses caring for diverse populations and their health care needs.

Paper Session E2: Older Adult: Community Focus

Prevalence and Factors Related to Controlled Medication Prescription Among Medicare Home Health Recipients

Brandi Cotton, Department of Psychiatry, Geisel School of Medicine at Dartmouth [black down pointing small triangle] Matthew Lohman, Department of Psychiatry, Geisel School of Medicine at Dartmouth [black down pointing small triangle] Jessica Brooks, Department of Psychiatry, Geisel School of Medicine at Dartmouth [black down pointing small triangle] Karen Whiteman, Department of Psychiatry, Geisel School of Medicine at Dartmouth [black down pointing small triangle] Yuhua Bao, Weill Cornell Medical College [black down pointing small triangle] Rebecca Greenberg, Weill Cornell Medical College [black down pointing small triangle] Martha Bruce, The Dartmouth Institute of Health Policy and Clinical Practie Geisel School of Medicine at Dartmouth

Background/Purpose: High rates of controlled prescription drugs are associated with cognitive impairment, falls, and misuse and dependence. Yet little is known about the prevalence of controlled medication among older adults receiving home health care, a population at increased risk of medical burden, functional impairment, and multiple comorbidities. The purpose of this study is to determine the frequency of and the factors related to opioid analgesics, benzodiazepines (BNZ), and non-benzodiazepine (NBNZ) hypnotics among a national sample of older adults entering home health services.

Theoretical Framework: Anderson's behavioral model of health service use provided the theoretical framework for this study.

Methods: The data came from administrative records of 133 Certified Home Health Agencies located across 32 states. Patients (age > 65) receiving Medicare home health services and who received a start-of-care Medicare OASIS assessment between Jan. 1, 2013 and Dec. 31, 2014 were included in the study (n= 87,780). Rates of controlled medication use were compared across patient-level demographics, health, and functional variables. Multivariable logistic regression models were fit with predictor variables and demographic covariates and fit separately for each class of controlled medication.

Results: The prevalence of controlled medication within the sample was high with 58% prescribed at least one class of controlled drug, 44% were prescribed an opioid, 19% were prescribed a BNZ, and almost 7% were prescribed a NBZDH. Factors independently associated with higher levels of controlled medication usage include younger age, white race, post-surgical status, injuries, referral from inpatient settings and rural location.

Conclusions/Implications: The prevalence of controlled medication among older adults beginning home health services was high in spite of well-documented adverse effects and strong potential for misuse and dependence. Nurses providing home health care are well positioned for medication review and reconciliation.

Medication Discrepancies and Community Dwelling Older Adults with Diabetes Mellitus in Primary Care

Dawn Lea, 3M Health Information Systems [black down pointing small triangle] Wendy Henderson, National Institute of Nursing Research (NINR) [black down pointing small triangle] Jennifer Lingler, University of Pittsburgh [black down pointing small triangle] Dianxu Ren, University of Pittsburgh [black down pointing small triangle] Lisa Morrow, University of Pittsburgh [black down pointing small triangle] Judith Erlen, University of Pittsburgh

Background/Purpose: Medication management issues in persons with diabetes (PWD), are well documented. However, few studies have examined community-dwelling older PWD in primary-care. A significant unmet need exists to determine medications prescribed, those actually taken, and potential correlates of medication discrepancies (MD), such as undiagnosed cognitive impairment. We examined medication discrepancies in community-dwelling older PWD in order to: (1) characterize the sample, (2) characterize the discrepancies associated with prescribed medications, and (3) identify potential MD correlates.

Theoretical Framework: Donabedian's structure-process-outcome framework guided the research.

Methods: Secondary analysis of baseline data investigated a subset of PWD (n=142), 45.1% men and 93.7% white from a nested case control study (n=533) funded by NIH/NIA AG023129 examining the utility of cognitive function testing in community-dwelling adults >=65 years of age without history of cognitive impairment recruited from primary care practices in Southwestern Pennsylvania. Descriptive statistics, Spearman's rho correlation coefficient, and multivariate logistic regression were used to analyze sociodemographic data, health information, neuropsychological test results, and medication review data.

Results: MD were present in 95% of subjects. Subjects with the same number of health problems and those with a higher number of medications were more likely to exhibit MD compared to the subjects with fewer medications. Subjects with the same number of medications who had a higher number of health problems were less likely to have MD compared to the subjects with fewer health problems. Polypharmacy and number of health problems were significant correlates for MD. Despite high MMSE mean scores (27.9 +/- 1.9) and positive correlations with neuropsychological scores, mild cognitive impairment was present in 44% (p=0.056).

Conclusions/Implications: The pervasiveness of MD in older PWD at risk for cognitive impairment has significant health care implications that deserve further study.

Short-Term Lifestyle Strategies for Sustaining Cognitive Status

Elizabeth Howard, Northeastern University [black down pointing small triangle] John Morris, Institute for Aging Research, Hebrew SeniorLife [black down pointing small triangle] Knight Steel, Hackensack University Medical Center [black down pointing small triangle] Kelley Strout, University of Maine, Orono [black down pointing small triangle] Brant Fries, University of Michigan [black down pointing small triangle] Alice Moore, Professional Resources [black down pointing small triangle] Vjenka Garms-Homolova, Hochschule fur Technik und Wirtschaft

Background/Purpose: Cognitive decline impacts older adults, particularly their independence. The goal of this project was to increase understanding of how short-term, everyday lifestyle options, including physical activity, help an older adult sustain cognitive performance.

Theoretical Framework: Hettler's Dimensions of Wellness served as the organizing framework for the study. We examined cognitive decline from the perspective of independent variables arising from the dimensions that included measures relative to physical, intellectual, emotional, social, occupational/leisure, and spiritual wellness.

Methods: Using a secondary analysis of lifestyle choices, we drew on a data set of 4,620 community-dwelling elders in the US, assessed at baseline and one year later using two valid and reliable tools from the interRAI assessment suite (http://www.interRAI.org), the Community Health Assessment and the Wellness tool. Decline or no decline on the Cognitive Performance Scale (CPS) was the primary outcome. We examined sustaining one's status on this measure over a one-year period in relation to key dimensions of wellness through intellectual, physical, emotional, social, and spiritual assessment items. Baseline independent variables in each wellness domain were first assessed against the CPS-based cognitive decline dependent measure. Stepwise logistic regression was used for significant independent variables in each wellness domain to identify the resident characteristics within that domain that best identified older adults who are unlikely to experience cognitive decline. This step indicates whether each item in a wellness domain played a protective role or whether there was an underlying single latent factor at work.

Results: Engaging regularly in physical activity, formal exercise programs and specific recreational activities had a favorable effect on short-term cognitive decline. Involvement with computers, crossword puzzles, handicrafts and formal education courses also were protective factors.

Conclusions/Implications: The physical and intellectual domains of wellness are prominent aspects in protection from cognitive decline. Inherent in these two domains are mutable factors suitable for targeted efforts to postpone or slow the progression of cognitive decline and promote older adult health and well-being.

Chronic Musculoskeletal Pain Slows Foot Reaction Time in Older Adults

Yurun Cai, University of Massachusetts-Boston [black down pointing small triangle] Suzanne Leveille, University of Massachusetts-Boston [black down pointing small triangle] Jeffrey Hausdorff, Tel-Aviv Sourasky Medical Center [black down pointing small triangle] Jonathan Bean, Boston VA Medical Center [black down pointing small triangle] Brad Manor, Hebrew SeniorLife [black down pointing small triangle] Robert McLean, Hebrew SeniorLife [black down pointing small triangle] Tongjian You, University of Massachusetts-Boston

Background/Purpose: Older adults who report chronic musculoskeletal pain experience decline in mobility and are more likely to fall. Pain may interfere with mobility in part through a cognitively mediated pathway. The aim of this study was to examine the association between pain characteristics and foot reaction time in the MOBILIZE Boston Study II.

Theoretical Framework: The theoretical framework for this study is the Nagi Disablement Pathway Model.

Methods: In this cross-sectional study involving 307 community-dwelling participants (109 men, 198 women) aged 71y and older, pain characteristics including pain severity and pain location were measured by Brief Pain Inventory scale and a joint pain questionnaire. Musculoskeletal pain distribution was categorized by no pain, single site, multisite pain, and widespread pain. With participants seated, simple foot reaction time (SRT) measured participant's self-selected foot response time to an intermittent light, and choice foot reaction time (CRT) involved either foot in response to an intermittent light on either side of the mat, using a GaitRite^(R) gait mat. We used multivariable linear regression adjusted for age, gender, education, race, BMI, and in additional models, adjusted for cognitive function (MMSE or Trail Making).

Results: Global pain severity was positively associated with SRT (p=0.03) and CRT (p=0.04). Having >=2 lower body pain sites was positively associated with CRT (p=0.04). Among individual sites of pain, knee pain, but not back, hip or foot pain, was positively associated with CRT (p=0.02). Adjustment for cognitive function had little impact on these associations.

Conclusions/Implications: In conclusion, chronic musculoskeletal pain is associated with slower foot reaction time. The cognitive and neurological aspects of foot reaction time require further investigation. Improving our understanding of the impact of pain on physical functioning and risk for falls can inform nursing care of community dwelling older adults living with chronic pain.

Paper Session E3: Acute and Critical Illness

Decreasing Postoperative Urgency Following Ureteroscopy: A Randomized Controlled Trial

Susan Fetzer, Southern New Hampshire Medical Center [black down pointing small triangle] Linda Goodwin, Southern New Hampshire Medical Center [black down pointing small triangle] Matthew Stanizzi, New England Urology

Background/Purpose: Postoperative recovery immediately following ureteroscopy can be painful or extremely uncomfortable. The urgent need to void, despite an empty bladder, arises from bladder spasms often resistant to narcotic interventions. One in ten urological surgery patients experience post anesthesia emergence agitation with voiding urgency a major complaint. Agitation leads to tachycardia, hypertension and the demand or attempt to go to the bathroom even when not fully recovered from anesthesia; such behaviors create safety risks. A standard postoperative intervention, using belladonna and opium (B+O) suppositories, requires 15 to 30 minutes for opium and 1 to 2 hours for belladonna to act, longer than many ureteroscopy procedures. Preemptive treatment of bladder spasms may improve patient outcomes. The study aimed to determine the effectiveness of a preoperative B+O suppositories on postoperative bladder comfort, narcotic requirements and length of stay of ureteroscopy patients.

Theoretical Framework: The Theory of Unpleasant Symptoms guided the study methods.

Methods: A double blind randomized controlled study was conducted. Fifty adult outpatient ureteroscopy patients were randomized to receive routine care or a B+O suppository prior to insertion of the surgical scope. Post-anesthesia nurses, blinded to group, provided routine post-operative care including assessment of urinary urgency (0-4) and pain (0-10) every 15 minutes and prior to discharge.

Results: The experimental group reported lower mean urgency scores than the control group (p = .018). All control group subjects expressed urgency during the post-operative period compared to 22 of 25 patients who received a preoperative B+O suppository. Mean pain scores, administration of narcotic equivalent medications or length of stay were no different. Both groups required rescue interventions.

Conclusions/Implications: This is the first study to test the effectiveness of preemptive B+O administration on outpatient ureteroscopy patients. Preemptive B+O suppositories were associated with a reduction in bladder spasms as reflected in patients' reports of urgency. Patients in this study discriminated urgency from post-operative pain, an indication that the constructs differ. Urinary urgency can be discriminated from surgical pain and should be assessed post operatively. The efficacy of preemptive B+O suppositories on other urological procedures warrants further research. The addition of the order for a preemptive B+O suppository on pre-operative ureteroscopy order sets is recommended.

Evolution of Nursing Case Management for Wounded Services Members Injured in Iraq and Afghanistan

Patricia Watts Kelley, Duquesne University [black down pointing small triangle] Deborah Kenny, University of Colorado at Colorado Springs [black down pointing small triangle] Patricia Benner, UCSF retired [black down pointing small triangle] Deborah Gordon, University of San Francisco

Background: The scope of rehabilitative care has dramatically changed from the perspective in the 19th and 20th Century. The difference is directly related to the advances in technology in the 21st Century that have resulted in the survival of patients with more life altering disabilities than those experienced in previous wars. Additionally, the unprecedented complexity of poly-trauma wounds from the wars in Iraq and Afghanistan coupled with the fact that these wounded service members will live longer with injuries that once were lethal, requires a change in the delivery of rehabilitative healthcare services (Darkins, 2008).

Purpose: Purse was to gather first person near accounts of experiential learning of nurses caring for wounded service members and first accounts of service members' memories of all levels of care and transition from point of injury in the combat zone into the Military and Veterans Heath Care Systems, in order to develop and sustain nursing competencies, and examine the rehabilitative factors (recovery, rehabilitation, and reintegration).

Methods: Qualitative ethnographic design. Two hundred and thirty-five (235) nurses were interviewed, including Case Managers (CMs) from nine military treatment facilities (MTFs) and Veterans Administration (VA), on actual patient care experiences and new knowledge development, and 67 Wounded Service Members (WSMs) were interviewed about their experiences of care.

Results: Seven key functions of an effective case manager were identified 1)Meeting, Knowing, and Tracking Past, Present, and Future, 2) Simplifying the Point of Contact Within and Between Institutions, 3) Knowing the patient, and Integrating and Coordinating Care 4) Case Manager as Patient Advocate: Patient-Focused Relational Work,5)Supporting and Integrating the Family Into the Health Care Team, 6) Advocating for Adequate Supportive Living Environment, and 7) the Case Manager as Life and Health Coach.

Conclusions/Implications: New military and VA nurse case management roles are essential for the effective functioning of the evolving, highly specialized, and transport-based health care system. Working effectively with WSMs requires that the CM role be expanded beyond healthcare management to include family support, re-entry, and life coaching for the extremely altered life circumstances of WSMs. There still remains many new questions for research and health policy development in caring for WSMs. The primary roles of the CM could be evaluated and improved through quality improvement research. The life coach role is taken on informally but for effective case management possibly case management might be improved with additional and explicit training in life coaching for WSMs with TBI and PTS/PTSD. At the policy level, it is crucial for planning and funding, that CM role be considered long term for WSMs with poly-trauma, TBI, and mental health.

Teaching Emergency Preparedness: Using Large Scale Simulation to Enhance Disaster Nursing Education

Linda McAndrew, The Pennsylvania State University [black down pointing small triangle] Donna Volpe, The Pennsylvania State University [black down pointing small triangle] Justina Ferguson, The Pennsylvania State University [black down pointing small triangle] Milton Evans, The Pennsylvania State University [black down pointing small triangle] Theresa Baker, The Pennsylvania State University [black down pointing small triangle] Michael Evans, The Pennsylvania State University

Background: The WHO recommended nurse educators adopt disaster nursing education into their curricula (2008). Nurses as the largest group of healthcare providers and, therefore, have a major role in disaster response. Simulation has proven to be an effective pedagogy to improve active learning and allow nursing students to apply critical thinking skills and problem-solving when exposed to a disaster scenario.

Purpose: The purpose of this project was to determine the current state-of-the science related to simulation and disaster nursing education to identify an innovative method of providing student nurses with a meaningful learning experience.

Methods: A literature search was conducted by identified student leaders and faculty to determine the current state-of-the-science. Community emergency preparedness experts were recruited to provide guidance to students related to the scenarios and the roles students were assigned. Students were provided just-in-time training on incident command, triage, and patient movement by faculty and student leaders. Students rotated through incident command teams, triage teams, treatment teams, and victims. Two scenarios were used; fire in the Intensive Care Unit and an explosion on campus. Victim cards were used by explosion victims to provide information related to injuries, vital signs, and acting instructions. A brief history and current condition of the patients were used for the ICU patients pre-fire followed by the changes which occurred post-fire. Students had to assess the situation, triage the victims, move victims to a safe location, and provide austere treatment.

Results: Students felt the scenarios were realistic as well as the victim presentations. They recognized the stress they would experience in a real disaster situation. Using the assessment skills learned in class, students were faced with making rapid decisions and using the limited resources available for treating victims. They recommend this simulation be conducted annually to provide future students this valuable learning experience.

Conclusions/Implications: Nursing faculty are challenged to include disaster nursing education in the curricula. By simulating disaster scenarios and using community experts, nursing students can have a meaningful learning experience and be better prepared to respond to real life disasters.

Relationship Based Care: Exploring the Manifestations of Health as Expanding Consciousness Within a Patient and Family Centered Medical intensive Care Unit

Lillian Ananian, Massachusetts General Hospital

Theoretical Framework: Newman's Health as Expanding Consciousness (HEC)

Background: Admission to the intensive care unit (ICU) represents a crisis for both patients and loved ones. Families are burdened by emotional distress, including anxiety, depression, PTSD and complicated grief. Relationship based care is thought to buffer these emotional burdens and has been operationalized in a tertiary facility in the Northeast as including early and ongoing family meetings, family presence on rounds and family presence during resuscitation. However, little is known about both the experiences of family members receiving relationship based care when a loved one is critically ill and the experiences of meaning among nurses and families when practicing within a model of relationship based care.

Purpose: The purpose of this study was to employ HEC and its praxis methodology to explore meaning embedded in experiences of relationship based care among ICU family members and registered nurses within a medical intensive care unit experience.

Methods: The HEC praxis methodology was employed, including engagement, narrative development, pattern formulation and diagrammatic representation, and reflection/insight.

Results: Family member experiences were thematically represented as 1) reassessment of life goals 2) lifting of emotional burdens through patient/family presence 3) consciousness expansion occurred by remaining true to love ones' end of life choices and wishes. Registered nurses experiences were thematically categorized as 1) knowing patients more fully by interfacing with the family's unique way of being 2) the impact of the family's unique way of being on professional nursing practice development and 3) the enhanced meaning offered by a relationship based model of care through the harmonization of critical care and palliative care nursing practices.

Conclusions/Implications: Family member burdens are eased and meaning is illuminated through relationship based care. Profound impacts are possible through the application of relationship based care.

Family Surrogates in Critical Care: The Ethical Basis for Their Decisions

Barbara Birriel, Penn State College of Nursing [black down pointing small triangle] Lisa Kitko, Penn State College of Nursing [black down pointing small triangle] Judith Hupcey, Penn State College of Nursing [black down pointing small triangle] Michelle McGowan, Cincinnati Children's Hospital Medical Center, University of Cincinnati [black down pointing small triangle] Susan Loeb, Penn State College of Nursing

Background: Critically ill patients are often unable to make independent decisions about their care, requiring a family member to serve as surrogate decision-maker. The majority of work on surrogate decision-making has been related to chronic or slow progressing illness. Critical illness is different, requiring more rapid decisions in life-threatening situations. Decisions made by surrogates affect not only their individual situations, but have implications for the health care system and society as a whole. Little is known about how family surrogates make decisions in critical care settings.

Purpose: The purpose of this study was to explore the process of surrogate decision-making during critical illness, focusing on the ethical basis for surrogates' decisions.

Methods: A prospective qualitative approach based in grounded theory was used. The setting included four intensive care units (ICUs) in a large university medical center. Eighteen family surrogate decision-makers of critically ill patients who were unable to make independent health care decisions were interviewed on enrollment and at discharge from the ICU. The semi-structured interviews explored participants' cognitive and bioethical decision-making processes. Thematic and content analysis was completed to identify the ethical thought process underlying participants' decisions.

Results: Two themes emerged from analysis - 'value of life' and 'when to stop'. None of the participants described a decision-making process that could be associated with a specific ethical theory. All 18 described basing decisions on some aspect of the value of life. All participants also voiced acceptance of an endpoint to medical interventions.

Conclusions/Implications: Though not consistent with any traditional ethical theory, respect for the value of life forms the ethical basis of surrogate decision-making during critical illness. While valuing life, surrogates acknowledge the importance of the quality of that life and anticipate that they would decide to stop medical intervention if those goals could not be met. This represents a shift in thought from the historical perspective of continuing futile interventions at the end of life. Understanding the family's ethical basis for decisions (value of life, including quality of life) informs clinicians aiming to provide family-focused care. These results may be affected by the lack of diversity in the sample. Further study in varied critical care populations is recommended.

Paper Session E4: Health Promotion: Focus on Cardiac Risk Reduction

The Effects of Acculturation and Environment on Lifestyle Behaviors and Body Mass Index in Korean Immigrants

Chorong Park, New York University [black down pointing small triangle] Soohyun Nam, Yale University [black down pointing small triangle] Robin Whittemore, Yale University

Background/Purpose: Due to genetic predisposition and acculturation, Korean immigrants (KIs) are at-risk for developing obesity and cardiovascular complications. However, little is known about the effects of acculturation on lifestyle behaviors and body mass index (BMI), while incorporating the environmental changes that KIs experience in the U.S. The purpose of this study was to examine the pathways between acculturation, environment (physical activity environment, healthy food environment, sleep environment), lifestyle behaviors (physical activity, sedentary behavior, healthy eating, and sleep duration), and BMI in middle-aged KIs

Theoretical Framework: Based on the Ecological Model of Obesity, Diet and Physical Activity with supportive empirical evidence, we developed four independent behavioral models (physical activity, sedentary behavior, healthy eating, and sleep duration). All models had the same directional relationships; a manifest variable of environment (i.e. physical activity environment) and a latent variable of acculturation (measured by Korean and American acculturation, age of immigration to the U.S., length of residency in the U.S., and English proficiency) that were hypothesized to have direct effects on lifestyle behavior (i.e. physical activity), and the lifestyle behavior was hypothesized to have a direct effect on BMI, while controlling for gender and age.

Methods: We conducted a cross-sectional study and recruited KIs aged 30 to 65 years online and at Korean community centers and churches in the Northeastern U.S. All data was collected by self-report measures that have established reliability and validity. Data were analyzed using structural equation modeling. The sample included 367 KIs (mean age=41.82+/-10.82 years, 48.5 % female, and 46.6% overweight or obese).

Results: In the physical activity model, acculturation was not related to physical activity, but a physically active environment was related to higher physical activity, which led to lower BMI. In the healthy eating model, a latent variable of acculturation and healthy food environment were related to KIs' healthy eating, but healthy eating was not related to BMI. In both the sedentary behavior and sleep models, sedentary behavior and sleep duration were not related to acculturation, environment variables, or BMI.

Conclusions/Implications: Acculturation and environment play a role in the lifestyle behaviors of middle-aged KIs. Physical activity appears to be a critical behavior to prevent obesity in KIs.

Predictors of Physical Activity Among Black Women

Wanda Williams, Rutgers University [black down pointing small triangle] Lola MacLean, University of Portland [black down pointing small triangle] Amber Vermeesch, University of Portland

Background/Purpose: Only 20% of Black women living in the United States meets the weekly physical activity guidelines (PAG) recommended by the Department of Health and Human Services. This lack of being sufficiently physically active places Black women at increased risk of cardiovascular disease, stroke, diabetes and some forms of cancer.

Theoretical Framework: The social ecological model (SEM) was the guiding framework in this analysis. When considering predictors of physical activity in Black women, multiple factors should be examined when informing interventions for this population. The SEM considers multi-level influences and connections between individuals and their environment.

Methods: Secondary analysis of data from the National Health Interview Survey (NHIS) 2008-2014 was explored to identify predictors of physical activity among Black women (N=23,162) between the ages of 18 and 47. NHIS is a cross-sectional household interview survey, drawn from each State and the District of Columbia. Logistic regression models were used to predict adherence to the PAG recommendation for moderate- or vigorous- aerobic activity and muscle-strengthening activities.

Results: Three factors were identified as predictors of Black women meeting PAG: a) living with a partner (cohabiting), b) higher educational levels and c) increased income.

Conclusions/Implications: These findings suggest that physical activity programs aimed at Black women should consider income and educational levels, as well as including partners. It is essential that efforts are made to promote physical activity among Black women to improve health outcome, and mitigate risks factors more prevalent in this population.

Achieving Cholesterol Management Goals at a Large Academic Medical Center: A Comparison of the ACC/AHA Guidelines to NLA Guideline

Jihane Hajj, Widener University [black down pointing small triangle] Douglas Jacoby, University of Pennsylvania [black down pointing small triangle] Daniel Soffer, University of Pennsylvania [black down pointing small triangle] Sharayne Mark, University of Pennsylvania [black down pointing small triangle] Eric Hossain, University of Pennsylvania

Background/Purpose: Nurse practitioners have contributed historically to quality care outcomes. Guidelines are suggested to influence clinical decision-making, behavior, and outcomes of care. The advances of science contributed to optimal management of cardiovascular diseases resulting in decreases in cardiovascular events. However, the 2015 heart disease and stroke statistics revealed that less than half of individuals with hypercholesterolemia are treated and approximately 2/3 are not optimally controlled. The purpose of this study was to examine the practices of clinicians at a large university hospital in Eastern United States, to determine the clinicians' adherence to nationally recognized guidelines to decrease cardiovascular risk.

Theoretical Framework: Abiding by the American Heart Association/ American College of Cardiology (AHA/ACC) and National Lipid Association (NLA) guidelines will result in decreased cardiovascular risk and optimization of cardiovascular health.

Methods: A descriptive design examining a large database was conducted on patients, seen within all outpatient clinics of a large health system, and had indications for statin therapy by either the 2013 ACC/AHA guidelines (N= 101,604) or the 2014 NLA guidelines (N = 172,962).

Results: A total of 172,962 patients and 101,604 patients met the NLA and ACC/AHA criteria for statin therapy; of those 36% and 38% respectively achieved the guideline recommendations. A sub analysis was performed by specialty: 36% of patients met the guidelines in the internal medicine department, followed by 40% and 50% in the cardiology and preventive departments. A sub analysis of patients by risk profile demonstrated that 83% of diabetics and 50% of patients with clinical atherosclerotic cardiovascular diseases (ASCVD) did not meet the national guidelines. Of the high and very high risk patients who did not meet the guidelines, the mean LDL-c levels were 135 and 106 mg/dl respectively, higher than the nationally recognized optimal goal of < 70 mg/dl.

Conclusions/Implications: This data analysis suggests a suboptimal adherence to the guidelines, which may lead to less than optimal patient outcomes. This was consistent with the PINNACLE registry, which demonstrated that patients with ASCVD were less likely to achieve lipoprotein goals. Lowering the LDL-c level to goal contributes to a fall in the HR from 0.46 to 0.37 reducing event rates from 16.7% to 10.9%. The identification of suboptimal adherence rates is an opportunity for public health efforts to improve patient outcomes and clinicians particularly nurse practitioners should lead the effort in the area of cardiovascular risk reduction.

Increasing Access to Physical Activity for Children and Their Families: Dance for Health

Terri Lipman, University of Pennsylvania [black down pointing small triangle] Cory Bowman, University of Pennsylvania [black down pointing small triangle] Rebecca Snyder Phillips, University of Pennsylvania [black down pointing small triangle] Janet Deatrick, University of Pennsylvania

Background/Purpose: Social determinants of health contribute to inactivity- a major risk factor for obesity, type 2 diabetes and cardiovascular disease. Physical activity is a leading health indicator in all age groups (Healthy People, 2020). Children and their families living in areas of poverty have limited opportunities for physical activity due to unsafe outdoor spaces, lack of access to exercise facilities, and minimal funding for organized sports. Thus alternative physical activity strategies are needed. The purpose of this study was to partner with the community to evaluate the effect of a program to increase access to safe physical activity on overall health and fitness levels of inner city children and their

Methods: Children were surveyed to determine their interest in a variety of free, safe programs to increase activity. Children chose dance, and requested that their families be included. From 2012-2016, weekly dance events were held at a local recreation center for 3 months. At each event, height, weight, and calculated body mass index were measured by nurse practitioner and high school students. Activity was measured by tracking participants' steps using pedometers. Heart rates were recorded pre-activity and after 30 minutes of dance. Pedometer readings were measured after the one-hour dance class. Participants completed the BORG scale of perceived exertion and PACES survey reflecting the level of enjoyment experienced as a result of the activity.

Results: 358 participants - 120 children- 3.7-16.7yr (x= 10.4 yr); 238 adults- 26-76 yr (x= 53.5 yr); 91.5% female, all African American. Adult women weighed significantly less at the conclusion of the program (weight loss x= 1.12 kg, range 0-2.2 kg, P= 0.05). Children's heart rates were significantly higher mid activity (P< 0.0001). The odds of reaching the 50%+ target heart rate zone increased by 3-fold for every 1000 steps taken. Assessment of activity enjoyment demonstrated that 48.8 % of PACES score across all weeks were rated at the highest score of 35.

Conclusions/Implications: This initiative provided members of a low income, inner city community with an innovative and enjoyable method to increase activity and achieve weight loss. Implementing a community-based dance program increased physical activity among urban children and their families, an important contributor to overall health. Dance is a safe, free, and easily accessible form of physical activity.

What Barriers and Facilitators Do School Nurses Experience When Implementing Obesity Interventions?

Krista Schroeder, University of Pennsylvania [black down pointing small triangle] Arlene Smaldone, Columbia University

Background: There exists calls for greater school nurse involvement in school-based obesity interventions. However a recent evaluation of a school nurse-led obesity intervention in New York City schools demonstrated a low implementation rate, suggesting that nurses face obstacles to involvement in these interventions.

Purpose: The purpose of this study was to explore school nurses' perceived barriers to and facilitators of implementing a school nurse-led obesity intervention in order to inform further intervention dissemination within the New York City school system.

Methods: Semi-structured individual interviews were conducted with school nurses. Interview discussion and data analysis were guided by RE-AIM, a framework for evaluating an intervention's translation into practice. Data were analyzed using content analysis and heat mapping.

Results: Nineteen nurses participated; eight themes were identified. Parental and administrative gatekeeping and heavy nurse workload were barriers to intervention implementation. Nurses also noted the impact of obesogenic environments, obesity stigma, and cultural considerations. Teamwork with parents and school staff was a key facilitator of program implementation. Despite barriers, some nurses creatively adapted the intervention to their school environment and student population.

Conclusions/Implications: School nurses may be able to play a key role in school-based obesity interventions, but barriers must be identified and addressed to optimize implementation.

Symposium Session E5: Why Do I Need to Know? Collecting Data to Improve the Health of Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) Populations

Why Do I Need to Know? Collecting Data to Improve the Health of Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) Populations

Jordon Bosse, University of Massachusetts-Amherst [black down pointing small triangle] K. Jackman, Columbia University

Integrative Summary: The purpose of this symposium is to disseminate information on collection of sexual orientation and gender identity (SO/GI) data in research and practice, highlighting best practices, barriers to implementation, and utilization of Electronic Health Record (EHR) to identify health disparities and improve health equity.

The first two papers in the symposium provide methodological perspectives for the collection of SO/GI data that can be utilized by interdisciplinary teams as well as improve the ability for nurse scientists to identify and develop innovative solutions to promote health in LGBTQ populations. The third paper speaks to nursing perspectives for knowledge development by highlighting barriers to collecting SO/GI data in the clinical setting through qualitative interviews with staff nurses. The final paper will demonstrate the use of EHR data as a method of data collection to identify outcomes in the LGBTQ populations with implications for interdisciplinary treatment teams.

Inclusion of measures to accurately capture sexual orientation and gender identity data in clinical practice and in research contribute to an increased understanding of the nature of health disparities in the LGBTQ population; allow for the provision of high-quality, patient-centered care; inform the development of population-specific interventions; and monitor progress toward improved health equity.

Investigating Barriers to Documentation of Patient Sexual Orientation and Gender Identity: A Qualitative Analysis of Inpatient Nurse Experiences

Miles Harris, Mount Sinai Hospital [black down pointing small triangle] Andie Gersh, Dell Children's Medical Center of Central Texas [black down pointing small triangle] Caroline Dorsen, New York University

Theoretical Framework: This study explored the main variables of Theory of Reasoned Action to help understand RNs' motivations and behaviors in asking patients about sexual orientation and gender identity.

Background: Collection of SOGI (sexual orientation and gender identity) data has been identified as major factor in reducing lesbian, gay, bisexual and transgender (LGBTQ+) health disparities. As a result, many healthcare facilities have incorporated SOGI data collection into routine assessments. Harris & Gersh (2013) studied the effect of a brief educational intervention for RNs on SOGI completion rates. The intervention significantly increased rates of SOGI question completion, yet post-intervention completion rates remained low, at about 25%.

Purpose: Authors hypothesised that nurses avoid completing SOGI questions due to multiple complex factors including: lack of familiarity with LGBTQ+ terminology, discomfort with discussing SOGI, and lack of time to complete the task. Building on previous quantitative research, this qualitative study explored and evaluated nurses' experiences and attitudes on completing nursing admission assessment questions on SOGI.

Methods: This IRB-approved qualitative study used one-on-one interviews with nurses working on inpatient medical units of a teaching hospital in a large Mid-Atlantic city. Participants were recruited using email communication and posted fliers. Participants were RNs working on adult med/surg inpatient units; RNs working in management or administration were excluded. Interviews were coded using Dedoose software and analyzed for consistent themes and experiences.

Results: Five themes were identified from interviews: 1) All participants could identify concrete reasons to ask about SOGI, 2) Many participants could also identify abstract reasons to ask about SOGI, 3) Participants express resistance to asking about SOGI, 4) Participants fear that asking about SOGI will offend straight and cisgender (non-transgender) patients, and 5) Participants use a variety of strategies to infer SOGI without asking patients directly.

Conclusions/Implications: Nurses understand why SOGI is included in inpatient nursing admission assessment, but this knowledge coexists with resistance to asking about SOGI. Heterosexism and cissexism frame nurses' concerns and resistance to asking patients about SOGI. Nursing education must go beyond "LGBT 101" if nurses are expected to routinely ask about SOGI in a meaningful and sensitive manner.

Making Your Questions Count: Measurement Issues Related to Sexual Orientation and Gender Identity

Jordon Bosse, University of Massachusetts-Amherst [black down pointing small triangle] K. Jackman, Columbia University

Background/Purpose: There are limited data available on large samples of lesbian, gay, bisexual, transgender, and queer (LGBTQ) individuals, making it difficult to understand the extent of health disparities and health inequities experienced by these populations. Lack of inclusion sexual orientation and gender identity (SO/GI) data in research contributes to the invisibility of the unique characteristics and health needs of these vulnerable populations. Failure to collect SO/GI data in the clinical setting leads to missed opportunities to provide culturally relevant care and patient education, which contributes to health disparities in these populations. The purpose of this presentation is to provide an overview of sampling, recruitment, and measurement challenges related to LGBTQ populations in research, and implications for clinical practice.

Theoretical Framework: Model of Multiple Dimensions of Identity (Jones & McEwen, 2000)

Methods: A literature search of WorldCat, Cumulative Index for Nursing and Allied Health Literature (CINAHL), PubMed, Academic Search Premier, and Health & Psychosocial Instruments was conducted utilizing the key words: sexual orientation, gender identity, data collection, measurement, sampling, and data analysis in various combinations. Existing recommendations for collection and analysis of SO/GI data were reviewed.

Results: When and how to collect data about SO/GI depends on the context and purpose of the clinical visit or research question. Two current recommendations from interdisciplinary experts emerged, but these still have some limitations. Combining sexual and gender minority individuals in data analysis should be done with caution, as it has the potential to mask within- and between-group differences.

Conclusions/Implications: Nurses and nurse scientists have the ability to directly impact health disparities in LGBTQ populations. Collecting SO/GI data can increase our knowledge about the unique health experiences and health needs of these populations, develop a foundation for identifying best practices in the clinical setting, and inform health policy that can improve the health and well-being of LGBTQ populations.

Measuring Biological Sex in Health Sciences Research

Madelyne Greene [black down pointing small triangle] Marilyn Sommers, University of Pennsylvania

Background: Biological sex in health sciences research generally refers to the primary sex characteristics, secondary sex characteristics, or the genotype of sex chromosomes present in an individual, or some combination of the above. Measuring biological sex is a broad topic encompassing studies of the physiology of the reproductive system, the role of the brain and endocrine organs in reproduction, chromosomal and phenotypic differences between sexes, and the effects of gendered experience on the corporeal body" (Oliffe & Greaves, 2012). The vast majority of health sciences research uses dichotomous variables of sex and/or gender that categorize participants into discrete groups. Researchers whose work focuses on exploring biological sex have much more nuanced views of what makes a human being male, female, or something else, how sex differences develop, and what differences biological sex may or may not make.

Purpose: The overall aims of this paper are to deconstruct the category of biological sex for health sciences research, and to encourage deliberate and careful decisions about how to measure sex and sex differences. Additionally, we aim to develop recommendations for researchers as they interpret findings related to sex and gender differences.

Methods: The analysis of measurement strategies for biological sex relies on a review of literature related to biological sex measurement, including literature on disorders of sex development (DSD), where most of this analysis has been done. The paper then uses two common sex measurement strategies (karyotyping and anatomical assessment) to demonstrate the assumptions researchers commonly rely on about biological sex and its impact on people's lives.

Conclusions/Implications: For those researchers and studies that do measure one or several physiologic aspects of sex, researchers should choose their measure of sex carefully; that is, the outcome's theoretical connection to biological sex should dictate the measurement strategy employed. Additionally, health science researchers should consider whether biological sex is a useful variable in their work, or if a measure of gender might be more applicable. Relatedly, researchers should be meticulous in their use of the terms "sex" and "gender" and specify which of these constructs they aim to measure and analyze. When interpreting the results of studies, researchers should ask how much of the "sex" difference could be explained by decades or centuries of specific socialization into male and female genders. These recommendations also have many implications for the study of trans and gender nonconforming as well as intersex populations; these populations may teach us more about "sex differences" or sex-related variation, and about the distinct effects of gender and biological sex.

Symposium Session E6: Criminal Justice, Violence and Trauma RIG Symposium: Nurse Strategies to Build Nursing Science in Violence and Trauma Research

Criminal Justice, Violence and Trauma RIG Symposium: Nurse Strategies to Build Nursing Science in Violence and Trauma Research

Donna Zucker, University of Massachusetts-Amherst

Integrative Summary: The purpose of this symposium is to illustrate nurses' role in developing leadership through violence and trauma research studies. The five papers in this symposium are unified by their focus on the role of nursing in trauma/violence research, the focus on vulnerable populations and the discovery of new strategies to address determinants of heath. The overarching framework for this collection of papers is Trauma Informed Care (TIC), and addresses the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist re-traumatization.

The papers address the conference theme, "Leading the Way" by demonstrating a rich understanding of trauma as seen in paper one that focuses the symposium by describing trauma providers' level of knowledge, attitudes and practice of TIC. The relationship between mental health risks and teen driving behaviors will be described in paper two. Paper three will report the impact of intimate partner violence on HIV testing among WIC eligible women. Papers four and five will provide findings on the relationship between risk related behaviors and internet related behaviors s in high school students, and the relationship between sexting and high risk behaviors in adolescents. In the aggregate these studies conclude that TIC care is a necessary component of nursing practice, that trauma is highlighted in vulnerable groups such as at risk adolescents, those who are impoverished and those who have mental health challenges. These papers bring together nursing research findings that emphasize the crucial work of TIC in advancing nursing science and nursing practice.

Trauma Providers' Knowledge, Attitudes and Practice of Trauma-Informed Care

Marta Bruce, University of Pennsylvania [black down pointing small triangle] Nancy Kassam-Adams, Children''s Hospital of Philadelphia [black down pointing small triangle] Mary Rogers, Hospital of the University of Pennsylvania [black down pointing small triangle] Karen Anderson, Hospital of the University of Pennsylvania [black down pointing small triangle] Kerstin Prignitz Sluys, Red Cross University College [black down pointing small triangle] Therese Richmond, University of Pennsylvania

Background/Purpose: Trauma-informed interventions have been implemented in various settings, but translation of trauma-informed care (TIC) into the treatment of adult patients with traumatic injuries is unknown. This cross-sectional study examined health care provider knowledge, attitudes, practices, perceived competence, and perceived barriers with regard to implementation of TIC.

Theoretical Framework: Traumatic experiences are associated with long-term physical and psychological effects, which can affect patients' healthcare experiences and influence their engagement with the health system. TIC offers a framework for providing health care that accounts for individuals' history of exposure to traumatic experiences and adversity, as well as potentially traumatic aspects of illness, injuries and medical treatment experiences, in order to avoid re-traumatization and promote optimal health outcomes.

Methods: We recruited a convenience sample of trauma providers from an urban academic medical center with a regional resource trauma center. Trauma providers (nurses, physicians, therapists [physical, occupational, respiratory]) working in trauma resuscitation, trauma critical care and trauma care units completed a web-based survey assessing attitudes, knowledge, perceived competence, and practice of TIC, as well as demographic variables (years of experience, provider role, educational level). We used regression to examine factors predicting use of TIC in practice.

Results: 147 trauma providers completed the web-based survey. Respondents were nurses (65%), therapists (18%), and physicians (17%), with a median 3 years of experience. The participants answered a majority (75%) of the knowledge items correctly. The vast majority of participants (89%) held favorable opinions about TIC. 18.9 % rated themselves as less than "somewhat competent" on specific aspects of TIC. All participants rated the following as significant barriers to providing basic trauma-informed care: time constraints, need of training, confusing information about trauma-informed practices, and worry about further upsetting or re-traumatizing patients. Self-rated competence-not years of experience, knowledge, or favorable opinions of TIC-was the most consistent predictor of providers' reported use of specific TIC practices.

Conclusions/Implications: TIC training for trauma providers is needed, and should aim to build providers' perceived competence in providing TIC.

Self Exploitation Behaviors and Sexting Among High School Students

Elizabeth Burgess Dowdell, Villanova University

Background/Purpose: Self exploitation, specifically the creating and distributing of explicit or inappropriate pictures of oneself or peers is an emerging high-risk Internet behavior. This practice known as "sexting," is increasing among high school students. The purpose of this study was to examine the relationship between sexting and a range of risk taking behaviors.

Theoretical Framework: This study was supported by the Trauma Informed Model of Care.

Methods: This descriptive correlational study used the willingness model of adolescent risk behavior to explore Internet risk and surveyed 5,437 high school students. Forty-seven percent (2,655) reported sexting (53% girls and boys, 47%) and 30% reported receiving a sext message.

Results: Students who were sexting had higher levels of electronic aggression towards others, physical aggression (fights), online harassment, contact with persons unknown when on the Internet, and viewing sexually explicit material online (p < .0001). A third of sexting students reported trouble at school and physical aggression with more sexting students (22.9% vs 10.8%; p < .0001) reported having bullied or beat up others. Students who received sexting were twice as likely to have been cyber bullied (25.3% compared to 12.7%; p < .0001), and four times as likely to report having been sexually harassed via Internet (17.9% vs 4.8%; p < .0001). Additionally, these students were more likely to be threatened by aggressive emails (36.1% compared to 12.8%; p < .0001) and to have been threatened via the Internet (21% vs 8.8%; p < .0001).

Conclusions/Implications: Findings from this study suggest that high school students who participate in sexting have additional online risk taking behaviors. Nurses and other professionals are in key roles to screen, identify, and assess online risk behaviors in adolescents. Focused nursing interventions and educational programs that emphasize prevention, risk reduction and safety in addition to long term impact are imperative.

Mental Health Risks and Driving Behaviors in Adolescents

Catherine McDonald, University of Pennsylvania [black down pointing small triangle] Eileen Regan, University of Pennsylvania [black down pointing small triangle] Marilyn Sommers, Retired [black down pointing small triangle] Thomas Power, Children''s Hospital of Philadelphia

Background/Purpose: We recruited 60 newly licensed adolescents (<=90 days of licensure) to enroll in a randomized controlled trial (results not presented here). At baseline, participants completed a series of self-report questionnaires online including the Conners-3 for ADHD, Conduct Disorder, and Oppositional Defiant Disorder; Center for Epidemiologic Studies Depression Scale; and the Behavior of Young Novice Drivers Survey (BYNDS). We evaluated baseline survey data with descriptive statistics and bivariate correlations to examine relationships between ADHD, conduct disorder, depressive symptoms, and risky driving.

Theoretical Framework: We used theories of adolescent risk to guide our study.

Methods: MVCs are the leading cause of death for US adolescents and each year an additional 350,000 adolescents ages 15-19 are treated for non-fatal MVC-related injuries. Little is known about how mental health factors may affect teen driving behaviors. The purpose of this analysis was to examine the relationships between attention deficit/hyperactivity disorder (ADHD), conduct disorder, oppositional defiant disorder, depression and a scale of risky driving.

Results: The 60 adolescents were 67% female; 78% White, 15% Black/African American; mean age was 16.98 (16.5-17.92, sd 0.35), mean length of licensure was 50.77 days (11-90, sd 23.68). Mean risky driving score of BYNDS was 82.8 (sd 17.8) (possible range 44-220). Higher total scores on risky driving behavior were associated with self-report of ADHD Inattentive Total Symptom Count (r=.31, p<0.05), ADHD Hyperactive-Impulsive (r=.29, p<0.05), Conduct Disorder Total Symptom Count (r=.52, p<0.01) and Oppositional Defiant Disorder (r=0.26, p<0.05). Higher depressive score were also associated with higher risky driving (r=0.31, p<0.05).

Conclusions/Implications: These data highlight how teens with symptoms of ADHD, conduct disorder and depression may be especially prone to engaging in risky driving. Further research is needed to develop and test interventions for high risk teens with mental health problems.

The Impact of Intimate Partner Violence on HIV-Testing Among WIC-Eligible Postpartum Mothers

Elizabeth Novack, University of Pennsylvania [black down pointing small triangle] Yukiko Washio, Treatment Research Institute [black down pointing small triangle] Annet Davis-Vogel, University of Pennsylvania [black down pointing small triangle] Jesse Chittams, University of Pennsylvania [black down pointing small triangle] Claire Anagnostopulos, Main Line Home Care and Hospice [black down pointing small triangle] Linda Kirby, NORTH, Inc. [black down pointing small triangle] Anne Teitelman, University of Pennsylvania

Background/Purpose: Low-income minority women are disproportionately represented among women living with HIV in the U.S and also at increased risk for violence & HIV/AIDS), which may impact HIV testing. The purpose of this research is to explore the relationship between IPV and HIV-testing among low-income minority post-partum women.

Theoretical Framework: The Theory of Planned Behavior, which examines beliefs attitudes, norms and self-efficacy on the impact of health behaviors, was used to guide this study.

Methods: As part of a larger study, a survey focused on health, relationships and HIV testing behavior and theoretical variables was developed using prior focus groups to identify salient beliefs. The survey was administered to women ages 18-30 who attended a Women, Infant, and Children (WIC) supplemental nutrition program in a large city in the northeastern US. In this present analysis, we examined the IPV questions, based on the Conflict Tactic Scale, from this survey which assessed physical, psychological and sexual IPV in the past year and HIV testing history among the participants (n=100). Chi-Square Test for Independence and Fisher's Exact test were used to examine self-reported IPV between women who had HIV testing within 6 months and those who did not

Results: Among participants, 86% were black/African American with 64% reporting an HIV test in the past 6 months. Seventy-two percent 72% perceived themselves at no risk for HIV. majority of the sample had a main partner but 1/3 were unaware of partner's HIV status. Fifty-three percent reported experiencing any IPV from a partner in the past year and 13% reported any physical IPV from a partner in the past year. Physical IPV was the only IPV variable significantly associated (p=.021) with not being tested for HIV in the past 6-months with33.3% of people reporting physical IPV had recent HIV testing compared to 69.8% who did not experience IPV being tested in past 6 months.

Conclusions/Implications: These findings highlight the need for further study to understand how the context of physical violence impacts health behaviors and intentions such as HIV testing. IPV may impede HIV testing due to fear of consequences from an abusive partner. Providing safe and accessible HIV testing sites in spaces like WIC may increase HIV testing rates overall and specifically among women experiencing IPV.