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Breast cancer survivors (BCS) comprise the largest population of cancer survivors in the United States and often experience lingering physical symptoms that may affect their quality of life, with fatigue and pain the most commonly reported. This genetic research study was conducted within a larger R01 trial with the purpose of exploring associations between genetic variants and fatigue and pain symptoms and the Mindfulness-Based Stress Reduction for Breast Cancer (MBSR(BC)) program. The aims of this study were to: 1) identify specific genotypes involved in fatigue and pain symptoms, and 2) explore whether single nucleotide polymorphism (SNP) rs1800795 in gene IL6, SNP rs16944 in gene IL1B, and SNP rs4680 in gene COMT, moderate the effects of the MBSR(BC) intervention on fatigue and/or pain symptoms.

As part of a larger R01 trial, one-hundred-fifty-eight participants were randomized to either a 6-week MBSR(BC) intervention or Usual Care (UC). Data were collected at baseline, 6-week, and 12-weeks on subjective measures of pain, fatigue, along with demographic and clinical history information. In addition, DNA was collected for genotyping among the 158 participants using the PCR analysis method. For Aim 1, one-way linear trend analysis of variances (ANOVAs) were implemented to explore associations between the SNPs in genes with subjective symptom measures of pain and fatigue. For Aim 2, a comparison of mean scores along with a linear mixed model (LMM) analysis were used to explore if the patient’s SNPs moderated the effects of the MBSR(BC) intervention on fatigue and pain symptoms.

Cancer is an illness that knows no international boundaries. There are more than eight million global cancer deaths each year. A life-threatening diagnosis generates significant emotional problems for many patients across cultures. Death distress—consisting of death depression, death anxiety and death obsession—often results in poorer treatment adherence and lower overall health and quality of life. The purpose of this study was to determine whether religiosity has a moderating effect on the relationship between death distress and quality of life among patients facing a life-threatening cancer diagnosis.

The study sample consisted of 118 cancer patients: 82 cancer patients from a National Guard hospital in Saudi Arabia and 36 cancer patients from H. Lee Moffitt Cancer Center, Tampa, Florida. Three validated scales were used to obtain data from study participants: the Death Distress Scale, the Belief into Action Scale; and the Functional Assessment of Cancer Therapy Scale. After a Pearson correlation were conducted and results indicated a moderately strong inverse relationship between death distress and quality of life among both the Christian (r=-.45, p <.001) and Muslim (r=-.39, p <.001) patient samples. The degree of religiosity among study participants did not alter the effect of death distress on quality of life. Results reveal that the interaction term was not statistically significant (b=.005, p=.32). However, quality of life correlated with degree of religiosity in both the Christian(r=.39, p=.018) and Muslim patient groups ( r=.24, p=0.034)). This finding reinforces the importance of religious involvement among cancer patients found in earlier research.

The primary, descriptive aim of this dissertation was to describe the nighttime sleep quality of previously mechanically ventilated older adult patients within 24-48 hours of transfer out of the intensive care unit (ICU) to a medical-surgical floor. The secondary, exploratory aim was to examine the relationships between post-ICU sleep efficiency (SE) and wake after sleep onset (WASO) with grip strength in previously mechanically ventilated older adult patients within 24-48 hours of transfer out of the ICU.

The study included 30 adults ages 65 and older (11 women, 19 men; age 71.37 ± 5.35, range 65-86 years), who were functionally independent at home prior to hospitalization, mechanically ventilated during their ICU stay, and were within 24-48 hours of transfer out of ICU to a medical-surgical floor at Tampa General Hospital, a level 1 trauma center. Subjects wore an actigraph monitor on the dominant wrist (Actiwatch Spectrum) to monitor sleep over two consecutive nights. Parameters of post-ICU sleep quality included total sleep time (TST), sleep efficiency (SE), wake after sleep onset (WASO), sleep latency (SL), and number of awakenings (NA). The outcome measure of motor function was dominant hand grip strength, assessed by the National Institutes of Health Toolbox Motor Battery Grip Strength Test. Sleep data collected between nighttime hours (9:00 PM to 9:00 AM) on both nights were analyzed. For the descriptive aim, means for each sleep parameter and clinical characteristics were reported. For the exploratory aims, multiple regression analyses examined the individual associations between mean sleep parameters (SE and WASO) and grip strength.

Study subjects had a mean SE of 63.24 ± 3.88% and spent 135.39 ± 9.94 minutes awake after sleep onset. The mean TST among subjects was 7.55 ± 2.52 hours, ranging from 2.02 to 10.84 hours of sleep, out of the 12 hours of total time in bed. A total of 6 (20%) subjects slept less than 5 hours each night, and a total of 6 (20%) subjects slept greater than 10 hours each night. The mean SL among study subjects was 42.57 minutes, and ranged from 0.0 to 237.75 minutes. Overall, subjects’ average NA was 78.28 ± 26.39, ranging from 35 to 136 awakenings. In multiple regression analysis, SE was significantly and negatively associated with grip
strength, after adjusting for potential confounding factors. The model predictors explained 80.8% of the variance in grip strength, [R2 = .808, F(10, 15) = 6.324, p = .001]. Higher SE independently predicted worse grip strength (β = -0.326, p = .036). Further, among the tertiles of subjects with moderate or high TST (sleep duration ≥ 6 hours, n = 23), there remained a significant, negative association between SE and grip strength. The predictors explained 73.7% of the variance in grip strength, [R2 = .737, F(5, 15) = 8.416, p = .001]. Higher SE independently predicted worse grip strength among the subset of subjects with moderate or high sleep duration (β = -0.296, p = .046). Among the two quartiles of subjects with moderate-high or high WASO (≥ 120 minutes spent awake after sleep onset, n = 16), there was a significant, negative association between WASO and grip strength, after adjusting for covariates. The model indicated that the predictors explained 91.4% of the variance in grip strength [R2 = .914, F(6, 8) = 14.134, p = .001]. Greater WASO independently predicted worse grip strength (β = -0.276, p = .04). Finally, the effects of sex and preexisting obstructive sleep apnea (OSA) on grip strength were individually examined. Higher SE independently predicted worse grip strength among male subjects (β = -0.353, p = .039), as did preexisting OSA (β = -0.493, p = .033).

In summary, objectively measured sleep quality was disturbed among previously mechanically ventilated, hospitalized older adults, even after transfer out of ICU to a medicalsurgical floor. Longer TST and greater SE predicted worse grip strength among these frail patients who were previously independent, community dwelling older adults. Among the subjects with more severely fragmented sleep, WASO also independently predicted weaker grip strength. As poor grip strength is an indicator of ICU-acquired weakness, optimal sleep duration and less sleep disturbances may be crucial in prevention of worse functional outcomes and new
institutionalization. Additional research is needed to discern the temporality of associations between sleep quality and motor function among older adult survivors of critical illness.

Validation of the Electronic Kids Dietary Index
(E-KINDEX) Dietary Screening Tool for Early Identification of Risk for Overweight/Obesity (OW/OB) in a Pediatric Population: Associations with Quality of Life Perceptions in a Pediatric Population

Despite a worsening obesity epidemic and despite the American Medical Association (AMA) declaring Obesity a disease (2013), few assessment tools exist that assist practitioners who are charged with identifying risk for development of OW/OB in children. The Center for Health Statistics (2017) reported a 40% rate in obesity in the adult population and 18.5% in children in the U.S. Successful weight loss maintenance after 1 to 2 years of non-invasive treatment is less than 1%, indicating obesity is nearly incurable, making prevention imperative. Assessing risk for OW/OB in children has proven difficult given the lack of validated tools. The purposes of this study were to evaluate the predictive validity and estimate the reliability of the Electronic Kids Dietary Index (E-KINDEX) to measure risk for development of overweight and obesity OW/OB in children aged 10 to 18. In addition, the relationship between quality of life perceptions and OW/OB in children was assessed.

Methods. E-KINDEX, a 30-item questionnaire encompassing three dietary domains of food quality, dietary behaviors (attitudes), and dietary habits (Lazarou et al., 2011), was administered to 50 child participants who, with their parents’ consent, agreed to participate. The children also completed the quality of life questionnaire. The range for E-KINDEX scores was 1 (worst) to 87 (best) for assessment of the obesogenic environment that encompasses the immediate environment of the individual, factors that influence food quality, choices, and behaviors. Predictive validity was evaluated using multiple regression, factor analysis, and receiver operating curve statistics in SPSS; reliability was analyzed using Cronbach’s alpha. Pearson product-moment correlations were used to measure strength of relationships among OW/OB, E-KINDEX scores, and quality of life perceptions in the sample.

Results. E-KINDEX overall score was significantly correlated with OW/OB (r = -340, n = 50, p = .008), as was Dietary Behaviors (r = -.593, n = 50, p = <.001). These results were consistent with other statistical analyses, including regression and ROC curve analyses. Internal consistency for all subscales and the total ranged from .643 to .703. The correlation between OW/OB and IWQOL-Kids was strong (r = -.340, n = 50, p = <.016), as was E-KINDEX and IWQOL-Kids (r = .925, n = 50, p = <.001). Subscale structure was supported by factor analysis.

Discussion. Predictive validity of E-KINDEX subscales and overall were supported through achievement of aims of the study. Correlations between both E-KINDEX scores and child weights were significant and reliability supported by Cronbach’s alpha. Limitations included small sample size of 50 and accuracy of children self-report data in the presence of parents. Parental weight did not correlate with E-KINDEX, but should be studied further relative to the Obesogenic Environment. Physical activity was high in both OW/OB and lean groups. Validated Physical Activity tools are needed.

Implications. Although refinement and further study are needed, E-KINDEX is a useful tool for clinicians to identify children at risk for the chronic disease of OW/OB before it develops, perhaps before risk factors become difficult to modify.

Currently, between 21.9 and 23 million veterans have served in the United States armed forces. Of those, 2 million are women, and of those, only 6.5% use the Veterans Health Administration system. These females often suffer from physical and mental health disorders, and overall impaired quality of life (QOL), rendering their healthcare needs complex. Seeking, and providing care in this specialty area may become overwhelming not only for the women seeking the care, but also for healthcare systems that are unfamiliar with the specific needs of this population.

A retrospective medical records review was completed of 51 female veterans between the ages of 40 and 60 years, and who attended a women’s health specialty clinic in a women’s health center in the VA healthcare system. This center provides comprehensive women’s health services to female veterans. By attending this center, female veterans are having most if not all of their healthcare needs met in one location. Some of the services provided at the center include: primary care; gynecology; other gender specific health care needs; mental health care; and social assistance among other issues that may be associated with the overall QOL and depression.

Despite this study having a small sample size (n = 51), the participants were ethnically diverse: White (52.9%); African American (29.4%); Hispanic/Latino (15.7%); and Asian/Pacific Islander (2%). The overall results of this study reveal that female veterans who attend this clinic, have significantly lower baseline scores for QOL when compared to a North American population reference value. Means and standard deviation for total Menopause Rating Scale (MRS) score were; (n = 51, M = 21.2, SD = 9.2) compared to the North American women population reference values (n = 1,376, M = 9.1, SD = 7.6), z = 9.41, p < .0001, cohens d = 1.31. These results were significantly lower for all MRS subsets. The higher the means and standard deviation, the lower the QOL. A paired sample t-test indicated significant improvement in QOL after treatment in QOL (t = 7.80, p < .0001), and depression levels (t = 3.74, p < .0001) among female veterans attending the women’s health specialty clinic. Forward stepwise multiple linear regression models were fit to explore the association between the following variables and the outcomes of QOL and depression levels: low socioeconomic status (SES); number of deliveries; years of service; and military sexual trauma (MST). The only predictor that appeared to be significantly associated with higher MRS scores at baseline was a history of MST (β = .363; t = 2.44; p = 0.02). Higher MRS scores can be interpreted as lower QOL among female veterans.

Despite the complexities and unique needs of female veterans, the findings of this study suggest that timely, comprehensive and gender specific healthcare can significantly improve overall QOL and depression levels. In addition, further studies are need to assess what other variables may have a direct association with QOL, depression levels, and overall health of female veterans.

Denny, Janette

The Effectiveness of an Intervention Designed to Improve Chlorhexidine (CHG) Bathing Technique in Adults Hospitalized in Medical Surgical Units

Central line associated bloodstream infections (CLABSIs) are one of the most fatal types of healthcare associated infections (HAIs) and their economic impact is significant. Although some studies have found no signification reduction in CLABSI rates with chlorhexidine gluconate (CHG) bathing; good evidence exists to support the use of CHG bathing as an intervention to reduce CLABSIs (Bleasdale et al., 2007; Climo et al., 2009; Climo et al., 2013; Montecalvo et al., 2012). CHG bathing performance may influence the effectiveness of the CHG bathing protocol.

The purpose of this study was to determine the effect of a targeted educational approach involving simulation on the delivery by nursing assistants of a CHG bathing protocol. The study aims were (1) to compare the effectiveness of removal of simulated skin microbes by nursing assistants who receive training for a CHG bathing protocol with simulation training to simulated skin microbe removal by nursing assistants who receive training for a CHG bathing protocol without simulation training and (2) to examine the influence of a demographic factor, years of practice as a nursing assistant on the percentage of simulated microbes present following performance of bathing.

Thirty nursing assistants volunteered for this study and were randomized to either the intervention group (training for a 2% CHG cloth bathing protocol with simulation training) or the control group (training for a 2% CHG cloth bathing protocol without simulation training). For aim (1)  an independent t-test (inferential tests of group differences) was used to examine if there was any difference between the intervention group and the control group on the percentage of microbes remaining on the mannequin post bathing. For aim (2) a Pearson correlation was computed to assess the relationship between years of practice as a nursing assistant and the percentage of microbes remaining post bathing.

Results showed no statistically significant differences between the two groups on demographic factors. For aim (1) the t-test revealed a statistically significant (p < .001) difference between the intervention group and the control group on the percentage of simulated microbes remaining on the mannequin post bathing. For aim (2) there was no correlation between the years of practice as a nursing assistant and the amount of microbes left on the mannequin post bathing (p=.709).

This study provided an innovative method of assessing the percentage of simulation microbes remaining on the mannequin and made it possible to quantitatively measure bathing performance. Monitoring the compliance with CHG bathing is an important component when evaluating the effectiveness of a CHG bathing protocol. The findings of this study suggest that simulation training was an added benefit to the nursing assistants who received it, as they performed better than those who did not receive simulation training.

The use of cardiovascular risk scores remains the foundation for risk stratification to guide clinical management. Clinicians have access to several cardiovascular risk scores in practice settings. While having several risk scores with different risk factors may provide more information, it does not imply accuracy of the cardiovascular risk score used to calculate individual patient cardiovascular risk. The objective of this study was to compare the Framingham Risk score, Reynolds Risk scores, and the Pooled Cohort Risk Equation (3 commonly used equations) scores with respect to ability to predict cardiovascular events in a diverse ethnic population. Additionally, the potential predictive utility of three novel risk factors (carotid intima media thickness, peripheral arterial tonometry and vasa vasorum) was examined in relation to ability to improve 10-year cardiovascular risk prediction.

A secondary analysis of the longitudinal prospective study cohort known as Heart Strategies Concentrating On Risk Evaluation (Heart SCORE) was conducted. The cardiovascular risk scores of study participants who did and did not experience a cardiovascular event composite index consisting of myocardial infarction, death, stroke, acute ischemic stroke, or revascularization were assessed using methods of calibration and discrimination overall and by race and gender. When examining performance of the 3 risk scores, the overall 10-year absolute predicted cardiovascular risk varied substantially (e.g. approximately 2-fold) and this wide variation in predicted 10-year cardiovascular risk was present across race and gender. Nonetheless, despite the wide variation in estimates of absolute risk, the 3 cardiovascular risk score equations were strongly associated with future cardiovascular risk overall and by race and gender. There was some indication that the Reynolds risk score was the most accurate measure of future cardiovascular risk. The 3 novel risk factors examined did not significantly improve 10-year cardiovascular risk prediction above and beyond the standard demographic and clinical variables used in these well-known equations.

Hardwick, Marian

Examination of the Use of Accelerated Resolution Therapy (ART) in the Treatment of Symptoms of PTSD and Sleep Dysfunction in Veterans and Civilians

Posttraumatic Stress Disorder (PTSD) is a prevalent anxiety disorder that is debilitating to both veterans and civilians following one or more traumatic events. Sleep disturbances are hallmark features of PTSD. Sleep disturbances and PTSD remain two significant PTSD-related issues that continue to plague veterans returning from active duty, thereby preventing full reintegration into society. The same problem exists for civilians. This research was conducted as a previously collected pilot study data and a secondary data analysis. The purpose of the study consisted of: 1) examining the impact of treatment with Accelerated Resolution Therapy (ART) on symptoms of PTSD and sleep disturbances; 2) examining the relationships and treatment response among both subjective and objective measures of sleep function; and 3) comparing the relationship between PTSD and sleep disturbances among military versus civilians, including the effects of treatment with ART.

The study represents one of only a few studies consisting of subjective measures of PTSD (PCL checklist) and sleep quality (Pittsburgh Quality Sleep Index (PSQI)), and objective measurement of sleep function by use of electroencephalography (EEG) testing and based on a 30-minute nap protocol. The aims of this study were to: 1) investigate the effects of ART on comorbid PTSD and sleep disturbances in U.S. veterans measured both subjectively (self-report) and objectively (sleep EEG data) from previously collected pilot study data; 2) assess the relationships between objective and subjective measures of sleep disturbances before and after treatment with ART for symptoms of PTSD in U.S. veterans from previously collected pilot study data; and 3) compare self-report PTSD and sleep disturbances symptoms between civilians and veterans before and after treatment with ART using a secondary analysis from two previously conducted studies.

For Specific Aims 1 and 2, the methods consisted of previously collected pilot study data of 8 veterans who were treated with ART at the University of South Florida, College of Nursing. For Specific Aim 3, data were pooled from two completed studies of ART directed by Dr. Kevin Kip that included civilians (n=75) and veterans (n=50) who were treated for PTSD. Data analysis for Aim 1 included the use of paired t tests to compare PSQI score and each stage of sleep measured from qEEG (Delta, Theta, Alpha, Beta, Gamma) before and after treatment with ART. For Aim 2, Pearson correlation was used to assess the relationship between objective measurement of sleep disturbances and subjective sleep quality before and after ART. For Aim 3, multiple linear regression models were fit with PSQI (sleep) score as the dependent variable, PCL (PTSD) score as the primary independent variable, along with a main effect term for military status (civilian versus military) and an interaction term (military status * PCL score).

Results for aims 1 and 2 showed the mean age of the sample to be 37.6 years, 87.5% male, 87.5% White (non-Hispanic), 87.5% had experienced prior combat, 50% had experienced 5 or more traumatic memories that impacted their lives, and 87.5% had previous treatment for PTSD. Sample mean scores were above established screening criteria for PTSD (PCL-M = 63.7), sleep disturbance (PSQI = 14.5), and Center for Epidemiologic Studies Depression Scale (CES-D = 28.9). For Aim 1, after treatment with ART, the mean score on the PSQI dropped 4.88 points, mean score on the PCL-M dropped -30.13 points, thereby indicating significant reductions in sleep dysfunction and symptoms of PTSD. Mean Delta 1.5-3.5 Hz waves increased pre/post by 299.89 (p=.032), and Theta 4-6.5 Hz waves increased pre/post mean by 83.07 (p<0.001), both indicative of improved sleep quality. Results for Aim 2 showed statistically significant strong inverse correlations between PSQI and Theta 1.5-3.5 Hz waves (r=-0.79) and PSQI and Alpha 8-11 Hz waves (r=-0.89) at baseline. Post-ART, non-significant trends were observed for higher PSQI scores and higher Beta (conscious, alert) waves. For Aim 3, mean age of military participants (n=50) was 41.9 years versus 40.4 years among civilians (n=75, p=.439). For the military cohort, 18% were female compared to 80% among civilians (p<0.001), with lower Hispanic ethnicity among military compared to civilian participants (12% vs. 27%, p=0.04). In multiple regression analysis, change in PCL score was a strong predictor of change in PSQI score, regardless of military status PCL.

In summary, within the setting of PTSD, military participants tend to present with different traumatic exposures and worse sleep quality compared to civilian counterparts. In spite of these differences, the treatment protocol with ART demonstrated similar level of benefit (reduction in symptoms of PTSD and sleep disturbance) for both military and civilian personnel. Thus, nurses caring for individuals with PTSD, whether military or civilian, need to routinely assess sleep disturbances and initiate an open dialogue regarding these conditions. In return, nurses will be able to provide patients with resources to help them better understand and address these concerns, including after experiencing restless nights of sleep. Lastly, nurses should recognize the bi-directional temporal relationship between PTSD and sleep disturbances places. This places a premium on assessing these conditions collectively, rather than as discrete, independent clinical conditions.

Huang, Li-Ting

Investigating the Mutual Effects of Depression and Spiritual Well-Being on Quality of Life in Hospice Patients with Cancer and Family Caregivers Using the Actor-Partner Interdependence Model

The World Health Organization and the leading hospice organizations have emphasized the inclusion of family caregivers of hospice patients with cancer into end-of-life care, as these two dyad members may spiritually and emotionally influence each other. Given that depression and spiritual needs, which are prominent in these pairs, may impair quality of life (QOL) of hospice dyads, examining mutuality within dyads is imperative to develop a more accurate model that includes family caregivers. Therefore, the purpose of the study was to elucidate the importance of mutual effects within hospice dyads by examining the contribution of depression and unmet spiritual needs on their personal and their counterparts’ QOL. Structural equation modeling was used to integrate the feature of actor and partner effects in the Actor-Partner Interdependence Model. After eliminating outliers, the final sample was comprised of 660 hospice dyads in which the majority of hospice patients were white (97%) and male (56.6%) with a mean age of 73 years. Most of the family caregivers were white (95.9%) and female (73.5%) with a mean age of 65 years. On average, hospice patients reported a depression score of 4.00 (SD = 1.53), and their family caregivers had a significantly lower mean depression score of 3.65 (SD = 1.48). With respect to their spiritual needs, 25.5% of hospice patients indicated going to religious services was an unmet need, and about 13% of family caregivers also reported that going to religious services was an unmet spiritual need, followed by being with friends, laughing, thinking happy thoughts, and being around children. The results of structural equation modeling revealed that depression and spiritual needs in cancer patients and family caregivers exhibited significant actor effects on the individual’s QOL after controlling for the partner effects. Among the spousal pairs, depression in family caregivers exhibited a positive partner effect on hospice patients’ functional well-being (β = .15, p < .05), implying that as depressive symptoms increase, hospice patients’ functional well-being increases. This study supported the need for considering both as one unit and the mutuality inherent in dyads. The findings of the study suggest the importance of consistent assessment in emotional and spiritual well-being for hospice patients as well as family caregivers, as their concerns may be transmitted to each other due to mutuality existing within the dyads.

Masha'Al, Dina

The Change in Nutritional Status in Traumatic Brain Injury Patients: A Retrospective Descriptive Study

There is a high prevalence in malnutrition among traumatic brain injury (TBI) due to the hypermetabolism and hypercatabolism which develop post injury. Traumatic brain injury patients are different, even among themselves, in their energy requirements and response to nutritional therapy. This implies that there are other factors that affect the energy intake of these patients and enhance the incidence of malnutrition. 

This dissertation study examines the nutritional status of TBI patients upon admission to the intensive care unit (ICU) and during their hospital stay to describe baseline status, detect changes in nutritional status over 7 days, and identify the factors affecting the adequacy of energy intake and the change in nutritional status as a consequence. Anthropometric measurements, biomedical measurements, measures of severity of illness, daily health status,level of brain injury severity, and other data were collected from the medical records of 50patients, who were ≥ 18 years old, mechanically ventilated in the first 24 hours of ICU admission, and had a Glasgow Coma Scale score between 3-12. These data were used to examine the previous relationships. 

Although there was no statistically significant change found in body mass index and weight, there was a significant change detected in other nutritional markers, including hemoglobin, albumin, and total lymphocyte levels over the 7 days of ICU and hospital stay. No significant relationship was found between the adequacy of energy intake and total prescribed energy, severity of illness, level of brain injury severity, daily health status, patient age, intracranial pressure, or time of feeding initiation.

Findings may be used to develop and test interventions to improve nutritional status during the acute phase of TBI. This will lay a foundation for health care providers, including nurses, to establish standards for practice and nutrition protocols to assure optimal nutrition assessment and intervention in a timely manner.

Morse, Shannon

Exploring the Relationship Between Severity of Illness and Human Milk Volume in Very Low Birth Weight Infants and Extremely Low Birth Weight Infants Over Six Weeks

Very low birth weight and extremely low birth weight neonates have tremendous risk of mortality. This is a grave concern; however, survival alone is not the goal of neonatal intensive care. Survival, along with a reduction or elimination of life long morbidity is the aim of neonatal intensive care. 

Human milk is known as the best nutrition for babies and a growing body of evidence supports that human milk is critical in helping these fragile neonates mitigate the overwhelming risks they face. Therefore, the purpose of this study was to examine the relationship between neonatal severity of illness and human milk, specifically mothers own milk (MOM), donor human milk (DHM), and total human milk (THM) intake in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants over the first six weeks of life. Although there is a growing body of evidence that supports the use of human milk in this fragile neonatal population, information is lacking about the relationship between human milk and neonatal illness severity. 

The current study was a secondary data analysis from a National Institutes of Health (NIH) funded R21 study in a level three NICU in Florida. Multilevel modeling was used for data analysis to examine relationships between maternal dyad characteristics and severity of illness, operationalized by the Score for Neonatal Acute Physiology-II (SNAP-II), at 12 hours of life and at the end of each week of life for six weeks. 

Growth models (linear, quadratic, piecewise) were examined to determine the best model fit for the data, then predictor variables were added and model fit was tested. Birth weight was added to final models as a control as it is seen as a proxy for severity of illness in the literature. Model six demonstrated a significant inverse relationship between MOM(mL) (γ_MOM(mL)) = -.000079, p < .05) and SNAP-II scores (Deviance = 287.862, Dc²(df)= 31.38(1), p < .001, AIC = 303.862, BIC = 336.930). Model 11 demonstrated a significant inverse relationship between THM(mL) (γ_THM(mL)  = -.000127, p < .001) and SNAP-II scores (Deviance = 279.280, Dc²(df)= 30.859(1), p < .001, AIC = 295.280, BIC = 328.347). No relationships were noted between severity of illness and DHM(mL), MOM(%), DHM(%), or THM(%). Therefore the relationships noted between MOM(mL) and THM(mL) and neonatal severity of illness should be interpreted with caution. 

Gordon, Jessica

Basal Salivary Oxytocin and Skin to Skin Contact among Lactating Mothers of Premature Infants

This dissertation research explored mechanisms of human milk (HM) expulsion by describing the effects of skin to skin contact (SSC) on maternal basal oxytocin (OT) secretion among 20 premature mothers with hospitalized premature infants. This one-group, repeated measures design consisted of: 1) daily SSC with covariant data via self-report diary and 2) maternal salivary OT with and without SSC at 4 time points were collected over a 7 day time frame. Results indicate that mean levels of basal OT increase over time (M 234 pg/ml, SD 108 pg/ml time point 1; M 257 pg/ml, SD 125 pg/ml time point 3). Through multilevel model data analysis basal OT was found to have a meaningful amount of dependence on SSC frequency (t(16) = 6.389, p = < 0.001) and SSC duration (t(17) = 6.867, p = < 0.001) with coefficient estimates that indicate that basal OT exposed to 75-85 minutes of SSC per day are 92 pg/ml higher. These findings provide preliminary data that suggest that lactating mothers with premature infants sustain positive effects of SSC that increase basal OT secretion over time. Continued research comparing maternal cortisol and OT will determine if SSC physiologically deregulates maternal stressors that influence OT secretion and HM volume.

Perron, Sara

The Cognitive Load of Registered Nurses during Medication Administration in an Electronic Health Record Environment

Over 4 million avoidable hospital admissions result from medication errors (IMS Insitute for Healthcare Informatics, 2013). Human error accounts for 80% of all medical errors (Palmieri, DeLucia, Peterson, Ott, & Green, 2008). Medication administration is a complex process. It is important to understand the cognitive load (CL) of Registered Nurses (RNs) working in an electronic health record environment to identify the risk factors of medication errors. The purpose of this study is to investigate the factors that influence the CL of RNs during medication administration who are working in an electronic health record environment. Simulated medication administration scenarios with varying degrees of multi-tasking were completed with 30 participants. When RNs multi-task during medication administration their CL increases. Furthermore, RNs who have poor sleep quality cannot process high-level tasks as well as those RNs who report a good sleep quality. Future work can limit EEG lead placement to the frontal channels of the EEG. Furthermore, replication of this study with a larger sample and a broader range of competing tasks is indicated.

Belote, Marisa

A Comparative Evaluation of the Learner Centered Grading Debriefing Method in Nursing Education

The nursing discipline lacks a consensus on a best practice method for debriefing students following simulation-based training. A recognized, standardized method does not exist and various methods are utilized within the domain. The similarities between aviation and healthcare are well documented. Training members of both disciplines require standardization and methods of best practice. The aviation industry through the Federal Aviation Administration has found Learner Centered Grading (LCG) to be a successful educational format. The utilization of the LCG Debriefing method in simulation-based training is the standardized debriefing format for a technologically dynamic industry.

The aim of this research was to examine the LCG debriefing approach and determine the added value of the approach using a scenario-specific behavioral checklist as an instrument for the nursing faculty and the learner to assess the learner’s performance. A repeated measure was conducted to evaluate whether there were differences between the control and treatment groups across the pre and post-test. The test statistic demonstrated no statistical significance between the control and treatment groups. Results of Pearson’s correlations showed that self-efficacy was not significantly correlated with change in performance by debriefing method.

A number of factors contribute to this finding, one of which is the small sample size. The small sample size led to insufficient power to detect an effect if one did exist. Other factors included time allotted for data gathering, simulation space availability and participant’s prior exposure to the control debriefing method.

This study served as a pilot for future research. Implications for the next study include extending the time allotted for gathering data to allow for a larger sample size, utilizing the Certified Healthcare Simulation Educator (CHSE) designees to function as facilitators as well as evaluators and to design the study to evaluate performance immediately after the debriefing session and once again at a different interval of time. A second simulation session conducted one week after the initial participation would be beneficial to evaluate if knowledge acquisition occurred.

Brewster, Glenna

Sleep, Depressive Symptoms and Cognition in Older Adults and Caregivers of Persons with Dementia

Summary as no abstract for whole dissertation available:

This dissertation used the theory by Vitaliano et al. (2011) which attempts to explain how mediators of caregiver stress can increase the risk of cognitive impairment in spousal caregivers of persons with dementia to guide my dissertation which aimed to understand the relationships among sleep, depressive symptoms and cognition in caregivers of persons with dementia. Using adults 60 years and older as a comparative population for caregivers, I concluded that in the first section of the dissertation, the current literature is inconclusive about the association between subjective sleep parameters and cognition in older adults and there is insufficient literature to determine whether a relationship exists between objective sleep parameters and cognition. Therefore, more research studies incorporating measures to capture sleep variability and similar cognitive measures, are needed to clarify the relationships both in older adults and caregivers of persons with dementia.

One in three caregivers report depressive symptoms (Schoenmakers et al., 2010). If the instrument used to evaluate depression among different groups is measurement non-invariant and comparisons are then made across these groups, the conclusions will be incorrect. An instrument widely used to measure depression is the Center for Epidemiologic Studies Depression Scale (Radloff, 1977). The second section of the dissertation demonstrated evidence for configural and partial measurement invariance in Afro-Caribbean Americans, African-Americans, Hispanic Americans, and European-Americans. While being aware that some of the items are non-invariant, researchers and healthcare providers can use a composite score for the CES-D to make comparisons across the four groups of older adults.

Finally, caregivers report sleep problems, higher depressive symptoms and are at risk for impaired cognition (Alspaugh, Stephens, Townsend, Zarit, & Greene, 1999; McCurry, Logsdon, Teri, & Vitiello, 2007; Norton et al., 2010; Schoenmakers et al., 2010). In the third section of the dissertation, in caregivers of persons with dementia, subjective sleep parameters did not predict depressive symptoms or cognition. There is a possibility that depressive symptoms can moderate some sleep parameters but the suppression effects make it challenging to interpret the moderating influence. With the knowledge that there are potential associations among sleep parameters, depressive symptoms and cognition in caregivers, healthcare providers should collect baseline assessments on sleep, depressive symptoms and cognition from caregivers and monitor them on an ongoing basis to identify changes and intervene in a timely manner.

Kutash, Mary

The Relationship between Nurses’ Emotional Intelligence and Patient Outcomes

Heart Failure readmissions (HFR) significantly contribute to all cause hospital readmissions rates. Current evidence on the effectiveness of interventions for reduction of HFRis inconclusive. Recent research suggests that nurses’ emotional intelligence (EI) may be associated with better patient outcomes.

The purpose of this study was to examine if nurses’ EI is significantly related to HFR and if that relationship is mediated through patient satisfaction with care. One hundred and thirty six Registered Nurses were recruited from 11 in-patient units at a large teaching hospital in the southeastern United States. Two surveys were mailed to eligible participants; the Bar-On Emotional Quotient Inventory 2.0 and a demographic survey. Patient satisfaction was measured with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The unit of observation for the analysis of the current study was the individual nursing unit with monthly measures for 14 months. Nurses EI was assessed at a single point in time and served as the basis for the data collected.

Results of one-way ANOVA showed a non-significant small trend of higher total EI being associated with lower rates of HFR. The generalized estimating equation model was used to account for correlated observations and revealed a greater non-significant likelihood for higher total EI to translate to no HFR. Results of Pearson’s correlations found non-significant positive correlations between nurses total EI and the patient satisfaction items of rate hospital, nurses’ courtesy and respect, nurse listening, nurse explaining, and nurse communication. The linear mixed model to account for correlated observations showed small non-significant trends for total nurse EI and all patient satisfaction items. Results of one-way ANOVA showed no association between patient satisfaction and HFR. When accounting for correlated observations, increases in total nurse EI were not significantly associated with the predicted odds of no HFR. In conclusion, the examination of the aims in this study demonstrated results that were in the expected direction but not at the level expected. The findings of this study indicate that there is a need to further examine how nurses’ EI may influence patient outcomes.

Tinsley, Sara

A Comparison of Quality of Life between Intense and Non-Intense Treatment for Patients with Acute Myeloid Leukemia and High Risk Myelodysplastic Syndrome

Acute myeloid leukemia (AML) and high-risk myelodysplastic syndrome (MDS) are hematologic malignancies that occur most frequently in the sixth and seventh decades of life. Both disorders are associated with a poor prognosis, with median survival of one year or less. An overall five-year survival rate for both disorders, regardless of treatment, is less than 10%. A primary goal of treatment is to improve quality of life (QOL) because cure is improbable. The purpose of this longitudinal cohort study was to compare QOL between groups, intensive, non-intensive therapy, and supportive care. The sample consisted of 85 patients with high risk MDS and AML recruited from Moffitt Cancer Center. Functional Assessment of Cancer Therapy-Leukemia (FACT-Leu) was used to measure QOL. The aims for the study were to: 1) To compare the difference in QOL scores measured by the Functional Assessment of Cancer Therapy –Leukemia version for intensive chemotherapy, non-intensive therapy and supportive care within 7 days of new treatment and one month after initiation of treatment; 2) To determine QOL predictors of AML and high risk MDS from age, comorbidity, fatigue, and diagnosis; 3) To test the moderating effect of treatment with age, comorbidity, and fatigue on QOL.

The first aim was analyzed with repeated measures analysis of variance (ANOVA). The supportive care group was not included in the analysis because of low accrual. Results indicated that there was a significant group by time interaction (with p=.040). Follow up tests revealed that the intensive treatment group had a significant improvement in their QOL scores at 1 month post treatment (p=.020). The second aim was conducted using Pearson’s correlations with age, comorbidity, fatigue, and diagnosis with significant correlations found between fatigue and QOL (r=-.693, p< .001). These findings identify an important relationship between fatigue and QOL. This was a negative correlation, showing that as fatigue increases QOL decreases. The third aim was explored using regression with Hayes (2013) application for moderation analysis. Scores for QOL for age, comorbidity, and fatigue were not moderated by treatment.

These findings suggest that the most intensive treatment approach improves QOL. In addition, fatigue is a significant predictor of QOL. As fatigue increases, QOL scores decrease. Additional studies with a larger, more diverse sample is needed to explore the relationship between treatment approaches and QOL. In addition, intervention studies can be developed in AML and high risk MDS focused on fatigue management. It is anticipated that the results of this study will be used to inform patients and health care providers when making decisions concerning treatment based on QOL outcomes.

Daugherty, Julie

The Relationship between Hearing Status and Cognitive Performance and the Influence of Depressive Symptoms in the Older Adult

Hearing loss and cognitive impairment are significant health problems, threatening the independent function of older adults. While there appears to be a strong relationship between the two conditions, the mechanisms underlying this association are complex and are not fully elucidated.

The purpose of this secondary analysis was to explore the relationship between hearing ability and cognitive performance in older adults. In addition, this study attempted to examine the role of depressive symptoms in the relationship between hearing loss and cognitive performance. Comprehensive measures of peripheral hearing, central auditory processing and cognitive performance were utilized to examine these relationships in a sample (N = 30) of adults aged 60 years and older. The Geriatric Depression Scale (GDS) was used to assess depressive symptoms.

Correlational analyses revealed a statistically significant relationship between centralauditory processing and executive function. Statistically significant relationships were alsoobserved between speed of processing and peripheral hearing as well as central auditoryprocessing. No significant relationships were noted between depressive symptoms, hearingacuity and cognitive performance. While the correlation coefficients (r) for several of the hearingand cognitive performance measures were not statistically significant, medium effect sizes weredetected, suggesting a moderate association may exist between these variables. 

Paterson, Carly

Sexual Functioning and Body Image in Younger Breast Cancer Survivors

Younger breast cancer survivors often report problems related to sexuality following surgical and adjuvant treatment that often lead to sexual distress and body image distress. This research was conducted as an exploratory study within a larger R01 trial with the purpose to evaluate sexual distress and body image related-distress in younger women with breast cancer and to examine the extent to which the Mindfulness-Based Stress Reduction-Breast Cancer (MBSR(BC)) was efficacious in improving distress related to sexuality, i.e. sexual distress and body image related-distress. The aims of this study were to: 1) evaluate the efficacy of the MBSR(BC) program in improving the psychological symptoms of sexual distress and body image related distress; and 2) evaluate whether positive effects achieved from the MBSR(BC)program are modified by specific patient characteristics measured at baseline.

Ninety-one participants were randomized to either the MBSR(BC) intervention or Usual Care (UC) and assessments were conducted at baseline, 6-week and 12-week follow-up for sexual distress, body image related distress, demographic data as well as clinical history. For aim 1, analysis of covariance (ANCOVA) and linear mixed model (LMM) analysis were the methods used to evaluate the efficacy of the MBSR(BC) program. For aim 2, ANCOVA and stepwise multiple linear regression were used to evaluate the patient characteristics at baseline that modified the effects achieved from the MBSR(BC) program.

Results showed the mean age of the sample was 57 years and 74% were White, non-Hispanic. Chi square analyses found that there were no significant differences between the MBSR(BC) and UC groups on baseline demographic or clinical characteristics. For Aim 1, results of the ANCOVA analyses found that there was no significant difference between the MBSR(BC) and UC groups at the 6-week follow-up on sexual distress or body image related distress (both p > .05). However, ANCOVA analyses found that there was a significant relationship between baseline scores and scores at the 6-week follow-up for both sexual distress (p < .0001) and body image related distress (p < .0001). Further ANCOVA analyses for Aim 1found that there was a trend towards a statistical significance for the difference between the MBSR(BC) group and UC groups at the 12-week follow-up for both sexual distress (p = .09) and body image related distress (p = .06). Results of the Linear Mixed Model (LMM) analyses, implemented to assess sexual distress over time, showed a significant main effect (ME) of time (p < .000) and a trend towards significance for the time by assignment interaction (p = .104). The LMM analyses for body image disturbance resulted in a significant ME of (p < .000) and an interaction that approached significance (p = .071). For aim 2, ANCOVA results found that age at baseline was a significant predictor of change at 6 weeks in levels of body image related distress (p = .007), but no relationship was observed for sexual distress. Further, analysis using a stepwise multiple linear regression analysis found age at baseline to be the only significant predictor of both baseline sexual distress (p = .004) and baseline body image related distress (p = .008).

Although the MBSR(BC) program was not tailored for integrating sexuality content, results of this stress reducing program (MBSR(BC)) program, adapted for breast cancer survivors, appeared to benefit these young women. The findings of this study identify that there is a need for stress reducing interventions addressing problems related to sexual distress and body image related distress. In addition, these results identified that clinically, BCS should be assessed for sexual distress and body image disturbance post-treatment, and interventions to assist with this distress should be incorporated into their plan of care.

Jasper, Brenda R.

Knowledge and Acceptance of HPV and the HPV Vaccine in Young Men and Their Intention to be Vaccinated

Sexually active young men are at high risk of contracting HPV and developing genital warts and penile/anal cancers. They contribute significantly to the incidence of HPV in women. The HPV vaccine, Gardasil, was approved in 2009 for use in preventing HPV 6 and 11 in young males ages 9 to 26. Knowledge and awareness of the virus and the vaccine is limited among young men. Promoting education and prevention measures regarding HPV and reducing personal risks to HPV is significant in narrowing the gap between acquisition of the HPV virus and cancer sequelae. A correlational design utilizing cross-sectional survey methodology was used for this study. Seventy participants completed a HPV vaccine survey at a university in Southwestern United States. The survey measured their knowledge and acceptance of the HPV vaccine and their intention to be vaccinated. Male participants were likely to accept or consent to receive the vaccine however they reported low intent to actually get the HPV vaccine. Acceptance of the vaccine was greater among minorities and participants who reported regular doctor visits. Knowledge of HPV and HPV prevention was low. Young men may benefit from HPV vaccine educational marketing strategies that include enhancing their communication skills on HPV, the HPV vaccine and reducing risky sex behaviors.

Parnell, Lisa (Huhn)

Examination of Possible Protective Effect of Rhesus D Positive Blood Factor on Toxoplasma-Related Depressive Symptoms in Pregnancy

Toxoplasma gondii infects approximately one third of the population worldwide. There is strong evidence that a relationship between T. gondii titer and depressive symptoms exists. There is also evidence suggesting a protective effect of RhD positive blood factor on toxoplasma-induced behavioral and personality changes. This protective effect may influence the relationship between T. gondii and prenatal depressive symptoms. The purpose of this secondary data analysis was to examine the possible protective effect of RhD positive blood factor on prenatal depressive symptoms in 56 pregnant women with T. gondii infection. The cross-sectional design was utilized to answer the question “Does positive RhD blood factor provide a protective effect on prenatal depressive symptoms of patients infected with T. gondii when controlling for ethnicity, race, income, marital status, age and stress?” The conceptual model hypothesized that there was a relationship between socio-demographic variables (age, income, marital status, race, and ethnicity), stress, positive T. gondii titers, RhD positive blood factor, and prenatal depressive symptoms. Pearson correlations and multiple regression were utilized to explore the aims of this study demonstrated in the four statistical models. Significant relationship between stress and positive T.gondii seropositivity on prenatal depressive symptoms was identified. There was no significant relationship identified between RhD positive blood factor on the pregnant women infected with T. gondii which could be attributed to the small sample size.

Hernandez, Ivonne

Acculturation, Self-Efficacy and Breastfeeding Behavior in a Sample of Hispanic Women

Breastfeeding confers immunological, physiological and psychological benefits for the infant and mother as well as social and economic benefits to the nation. The United States Department of Health and Human Servcies (HHS), Healthy People 2020 has established national objectives for the initiation and duration of breastfeeding at 82% initiation, 61% at six months and 34% at one year. In addition, they have set goals for exclusive breastfeeding at 3 months to be 46% and 25% at 6 months of infant’s age. Currently breastfeeding initiation is at the highest recorded level of 76.9%, yet significant disparities exist (CDC, 2012). The purpose of this study was to examine the association of acculturation and self-efficacy on breastfeeding behavior of a sample of Hispanic women. Initially the plan was to focus on women from Mexican, Cuban and Puerto Rican countries of origin. However recruitment goals for only the Mexican population were reached. Two valid and reliable bidimensional instruments were used in addition to collecting contextual information to foster a more comprehensive understanding of the acculturation process. The roles of self-efficacy and social support and their relationship with acculturation measures and breastfeeding behavior was explored. The Non-Hispanic domain subscale of the Bidimensional Acculturation Scale scores were significantly different for those breastfeeding compared to those formula feeding, indicating higher levels of Non-Hispanic domain acculturation associated with not breastfeeding. Acculturation and self-efficacy (general and parental) were not found to be related. Breastfeeding outcomes and parental self-efficacy were found to have a significant negative correlation, a finding that was in an unexpected direction, with higher parental self-efficacy associated with decreased breastfeeding intensity.

Mixed feeding or Las Dos, is a common finding among Hispanic women especially for the Mexican origin community and exclusivity may not have been perceived as higher value then mixed feeding or formula feeding (Bunik et al., 2006). Rates for exclusive breastfeeding at three months are 33% for both the US as well as for Hispanic/Latino ethnicity (National Immunization Survey, 2007). At six weeks the practice of exclusively breastfeeding (not giving formula) was 17%  and this is about half of the 46% goal set for exclusive breastfeeding at three months by (HHS) Healthy People 2020. Of those that were exclusively breastfeeding in the hospital only three were still exclusively breastfeeding at the six week follow up call. This presents a unique opportunity in which targeting Hispanic mothers after discharge may assist in increasing further the rates of exclusive breastfeeding and recommendations are provided.

Marcolongo, Ellen

The Relationships between Sleep Disturbances, Depression, Inflammatory Markers and Sexual Trauma in Female Veterans

The purpose of this secondary data analysis was to assess for the relationships among sleep disturbances, depressive symptoms, inflammatory markers, and sexual trauma in female veterans. This may contribute to an understanding of the physical and mental health effects of sexual trauma in female veterans. Correlational analyses were conducted to evaluate the strength of these relationships. A reported history of sexual trauma was significantly correlated with longer sleep latencies, poorer sleep efficiency, shorter sleep durations, more daytime dysfunction, and poorer overall sleep quality in female veterans. A reported history of sexual trauma was also significantly correlated with depressive symptoms including anhedonia and a negative affect in female veterans. No significant correlations were noted between inflammatory markers and a reported history of sexual trauma in female veterans. Female veterans with a reported history of sexual trauma had more trouble falling and staying asleep, had more trouble functioning during daytime hours, and had total poorer sleep quality. These veterans also appeared depressed and they found normally pleasurable activities unenjoyable. Disturbed sleep and depressive symptoms may be risk factors in the development of chronic health diseases. By assessing and treating the sleep disturbances and depressive symptoms experienced by sexually traumatized female veterans, nurses may help to prevent the development of costly and deadly chronic diseases.

McKenzie McNair, Chauntel

Factors Influencing Vaccination Decisions in African American Mothers of Preschool Age Children

Rates and coverage levels of immunizations of African-American children are reduced compared to other races. Few studies have identified factors that influence vaccination decisions of African-American mothers. This study assessed the mothers’ vaccination decisions using a self-administered questionnaire and a screening instrument for determining health literacy. This instrument is called Rapid Estimate of Adult Literacy in Medicine (REALM). The sample was92 African American mothers, recruited from a large metropolitan church in Jacksonville, Florida, who had at least one child under the age of seven. A cross-sectional research design was used to administer survey instruments to identify and interpret parental barriers and decision-making regarding childhood vaccination. The results of this study showed that the there was a decrease in scores across the levels of education which indicated that education had a significant impact on the parental perception for the vaccination of their children. Interventions can now be tailored to improve the childhood immunization rates and provide a foundation for developing effective childhood vaccination educational materials for this population.

Shelby, Debra

Knowledge, Attitudes, and Practice of Primary Care Nurse Practitioners Regarding Skin Cancer: Validity and Reliability of a New Instrument

Background: Despite the rise in the occurrence of skin cancer, primary care nurse practitioners are reluctant to perform skin cancer assessments during patient visits. Melanoma is almost always curable if detected in the early stages, but invasive disease accounts for 9,000 deaths per year (American Cancer Society, 2013). Changing knowledge, attitudes and practice regarding skin cancer assessments potentially leads to early detection and treatment of skin cancers and impacts patient outcomes. However, in order to change knowledge and attitudes, we must first assess them.

Purpose: The purpose of this research was to validate a new skin cancer assessment tool instrument called KAP-SCA to measure knowledge, attitude, and practice in primary care NPs.

Methods: Sequential mixed methods were used. First, focus group interviews with 14 primary care nurse practitioners were conducted during Phase I. Interviews were audio-recorded then transcribed verbatim and imported into ATLAS.ti. Phase II involved instrument development from a blueprint and calculation of content validity indexes (CVI) for items and subscales. Phase III of this study included testing the validity and reliability of a KAP instrument using quantitative methods. This new instrument assesses primary care nurse practitioner knowledge, attitudes, and practice regarding skin cancer assessment.

Results: Content validity for the subscales was evaluated by CVI ranged from .90 to .95. The Cronbach's alpha was highest for the practice subscale (alpha =.89) while the lowest was seen with the knowledge subscales (alpha =.50). Construct validity assessed by exploratory factor analysis indicated the presence of three underlying factors, confidence in practice, confidence relating to education and NP role in practice.

Implications for Practice: Interventions need to be developed based on the knowledge deficits and barriers to practice identified by these NPs including educational programs that focus on increasing primary care NPs' knowledge and confidence levels regarding skin cancer assessments and identification of malignant lesions.

Conclusion: Beginning evidence of validity and reliability were found for the Knowledge, Attitudes and Practice-Skin Cancer Assessments (KAP-SCA), however further studies are warranted.