Equine-assisted service's effect on cartilage and skeletal biomarkers for adults and older adults with arthritis: A pilot study

OBJECTIVE

The object of this study was to determine the effect of EAS (Equine-Assisted Services) on arthritis conditions, as measured by the sTnT (Skeletal troponin) and COMP (cartilage oligomeric matrix proteins) biomarkers, compared to an exercise attention control intervention.

DESIGN

This was a secondary analysis of a randomized clinical trial comparing equine-assisted therapy to exercise education attention-control on cartilage and skeletal biomarkers in adults with arthritis. Twenty-one adults (Mage = 64 years) with arthritis who attended rheumatology clinics in the midwestern United States participated.

RESULTS

No changes were found in sTnT from baseline to week six within either intervention nor were there differences in changes between the two groups (p = 0.91). COMP increased from baseline to week six for both conditions, suggesting increased deterioration of cartilage and joints. Although the attention-control condition demonstrated larger increases in cartilage oligomeric matrix proteins level, compared to the EAS condition, these differences were not statistically (p = 0.58) or clinically significant (i.e., trivial effect, d = -0.16). When 3 outliers were removed, the differences in changes between EAT and attention-control group could be arguably of clinical significance (d = - 0.33), suggesting that the attention-control group demonstrated larger increases in levels of COMP than those in the EAS condition, though this difference was not statistically significant (p = 0.28).

CONCLUSION

Although equine-assisted therapy may reduce pain and improve quality of life for adults with arthritis, findings here are not fully corroborated with biomarkers.

Trust in the Transplant Team Associated With the Level of Chronic Illness Management-A Secondary Data Analysis of the International BRIGHT Study

A trustful relationship between transplant patients and their transplant team (interpersonal trust) is essential in order to achieve positive health outcomes and behaviors. We aimed to 1) explore variability of trust in transplant teams; 2) explore the association between the level of chronic illness management and trust; 3) investigate the relationship of trust on behavioral outcomes. A secondary data analysis of the BRIGHT study (ID: NCT01608477; https://clinicaltrials.gov/ct2/show/NCT01608477?id=NCT01608477&rank=1) was conducted, including multicenter data from 36 heart transplant centers from 11 countries across four different continents. A total of 1,397 heart transplant recipients and 100 clinicians were enrolled. Trust significantly varied among the transplant centers. Higher levels of chronic illness management were significantly associated with greater trust in the transplant team (patients: AOR= 1.85, 95% CI = 1.47-2.33, p < 0.001; clinicians: AOR = 1.35, 95% CI = 1.07-1.71, p = 0.012). Consultation time significantly moderated the relationship between chronic illness management levels and trust only when clinicians spent ≥30 min with patients. Trust was significantly associated with better diet adherence (OR = 1.34, 95%CI = 1.01-1.77, p = 0.040). Findings indicate the relevance of trust and chronic illness management in the transplant ecosystem to achieve improved transplant outcomes. Thus, further investment in re-engineering of transplant follow-up toward chronic illness management, and sufficient time for consultations is required.

A Descriptive, Correlational Study of Perceptions of Adult Kidney Transplant Recipients and Those Waiting for a Kidney Transplant About Managing Their Medications During a Pandemic

Introduction: Little is known about COVID-19 impact on patient medication management. Research Question: The aim was to describe medication management, healthcare team interactions, and adherence during the COVID-19 pandemic in kidney transplant patients and those on the kidney transplant wait list. Design: Using a descriptive, correlational design 340 adults from a midwestern US transplant program were recruited. The Managing Medications in the Midst of a Pandemic Survey measured healthcare team encounters and medication management. The Basel assessment of adherence to medications scale measured medication adherence. Results: The response rate was 35% (119/340). During the pandemic, 88% had practiced/were currently practicing socially distancing, 85% had worn/were currently wearing a face mask in public, 18% had been/were currently diagnosed with COVID-19 and 82% received the vaccine. Medication management: 76% planned and organized their own medications. Healthcare team interactions: 89% met in the office, 20% via phone, 12% telehealth, and 13% delayed seeing a healthcare provider because of COVID-19 concerns. Pharmacy interactions: 11% changed their method of obtaining medications from pharmacy due to social distancing. Medication adherence implementation was problematic with 19% missing a dose; results from the binary logistic regression suggested that those with higher levels of education were more likely to report missing a dose. Conclusions: Patients acted to prevent COVID-19 but some still contracted the virus. The pandemic changed healthcare team medication management interactions. Adherence implementation problems were nearly 20%. Findings are relevant to the transplant healthcare team to understand the impact of a pandemic on patient/team interactions and medication adherence.

Prevalence and Patient-Level Correlates of Intentional Non-Adherence to Immunosuppressive Medication After Heart-Transplantation-Findings From the International BRIGHT Study

After heart transplantation (HTx), non-adherence to immunosuppressants (IS) is associated with poor outcomes; however, intentional non-adherence (INA) is poorly understood regarding its international variability in prevalence, contributing factors and impact on outcomes. We investigated (1) the prevalence and international variability of INA, (2) patient-level correlates of INA, and (3) relation of INA with clinical outcomes. Secondary analysis of data from the BRIGHT study-an international multi-center, cross-sectional survey examining multi-level factors of adherence in 1,397 adult HTx recipients. INA during the implementation phase, i.e., drug holiday and dose alteration, was measured using the Basel Assessment of Adherence to Immunosuppressive Medications Scale© (BAASIS©). Descriptive and inferential analysis was performed with data retrieved through patient interview, patient self-report and in clinical records. INA prevalence was 3.3% (n = 46/1,397)-drug holidays: 1.7% (n = 24); dose alteration: 1.4% (n = 20); both: 0.1% (n = 2). University-level education (OR = 2.46, CI = 1.04-5.83), insurance not covering IS costs (OR = 2.21, CI = 1.01-4.87) and barriers (OR = 4.90, CI = 2.73-8.80) were significantly associated with INA; however, clinical outcomes were not. Compared to other single-center studies, this sample's INA prevalence was low. More than accessibility or financial concerns, our analyses identified patient-level barriers as INA drivers. Addressing patients' IS-related barriers, should decrease INA.

A concept analysis of routines for improving health behaviors

Objective

Chronic disease patients often have unhealthy routines, especially when away from health care professionals. These patients need clear guidance about establishing and maintaining routines. This study aimed to synthesize a definition of the concept of routines for improving health behaviors based on its uses in the literature.

Methods

We searched CINAHL, Medline, Scopus, and Google Scholar from January to May, 2022 for articles that included definitions of routines in the context of improving health behavior. We applied no date restriction. The systematic analytic method and Rodgers' evolutionary concept analysis method were used. We charted the attributes, antecedents, and consequences of routines for improving health behaviors, analyzed their uses in the literature, and synthesized the results in a definition of the concept.

Result

At total of 24 articles were included. Attributes of the concept were repeated patterns, controllable by the patient, goal-oriented health, and integration into an overarching lifestyle. Antecedents were individual characteristics and environmental factors. Consequences were psychological, physical, and social well-being at individual and environmental levels.

Conclusion

This clarified definition of routines for improving health behaviors will provide a starting point for future research and, eventually, a basis for clinical nursing interventions to support patients in developing and maintaining healthy routines to promote better patient outcomes.

Frequency of Medication Administration Timing Error in Hospitals: A Systematic Review

BACKGROUND

Medication administration timing error (MATE) leads to poor medication efficacy, harm, and death. Frequency of MATE is understudied.

PURPOSE

To determine MATE frequency, and characteristics and quality of reporting studies.

METHODS

A systematic review of articles between 1999 and 2021 was conducted using the Cumulative Index of Nursing and Allied Health Literature, ProQuest, and PubMed databases. Articles were scored for quality using the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) checklist.

RESULTS

Initially, 494 articles were screened; 23 were included in this review. MATE was defined as administration beyond 60 minutes before or after the scheduled time in 13 (57%) of the included studies. Measurement procedures included data abstraction, self-report, and observation. Frequency of MATE was 1% to 72.6%. Moderate study quality was found in 78% of articles.

CONCLUSION

Research on MATE is characterized by inconsistent definitions, measurements procedures, and calculation techniques. High-quality studies are lacking. Many research improvement opportunities exist.

Determinants of Length of Stay after Neonatal Cardiac Surgery Using Path Analysis

After neonatal cardiac surgery, families, and the health care team strive for exclusive oral feedings before hospital discharge. With the hypothesis that exclusive oral feedings would reduce the length of stay (LOS), a multidimensional path analysis was used to examine a cross-section of 280 neonates from 2009 to 2013. Buttigieg, Abela, and Pace's theoretical framework of structural and process-related determinants of LOS was modeled with hypothesis-driven correlation and directionality. The recursive path model had a good global and local fit with outcome variances of 26% for exclusive oral feeding and LOS. In the full cohort and model groups (single and biventricular), when controlling for covariances: sepsis, birth distance, necrotizing enterocolitis, genetic differences, specialty consults, the age at which neonatal cardiac surgery occurred (β = .23, p ≤ .001) and the duration of postoperative intubation (β = .47, p ≤ .001) more significantly influenced the LOS than intermediate mediation of exclusive oral feedings at discharge.

Managing Medications and Medication Adherence Among US Adults During the Early Phase of the COVID-19 Pandemic

PURPOSE

Before the COVID-19 pandemic and the disruptions it brought, medication adherence was already a challenging and complex health behavior. The purpose of this study was to describe patients' interactions in clinic, pharmacy, and home contexts and associated medication management and adherence during the early phase of the COVID-19 pandemic.

PATIENTS AND METHODS

A survey questionnaire was developed using the Medication Adherence Context and Outcomes framework and distributed via social media between May and July 2020 targeting adults taking a daily prescribed medication. Survey questions assessed sociodemographics, interactions with healthcare providers, clinics, pharmacies, medication management experiences, habit strength, and life chaos perceptions during the pandemic. Medication adherence was assessed by the self-report BAASIS© scale to measure implementation, discontinuation, and overall nonadherence.

RESULTS

A total of 134 adults from the United States, mean age 50.0 (SD 16.1) years were included in this analysis. Respondents took a median of 3.50 (interquartile range 4) daily medications. Delays in seeing a provider were reported by 47 (35.1%). Pharmacy encounters were impacted; 25 (18.7%) indicated their method for obtaining medication changed. Medication nonadherence was reported among 62 (46.3%) and was significantly greater among those who delayed prescription refills (p=0.032), pillbox users (p=0.047), and those who experienced greater life chaos (p=0.040) and lower habit strength (p<0.001) in the early phase of the pandemic.

CONCLUSION

Although the early phase of the pandemic affected access to care for nearly one-third of the sample, distance-accessible care options and strategies to obtain needed services without being in-person supported respondents medication management. Helpful strategies included provider accessibility, telehealth, home delivery/mail-order, drive-thru's, 90-day supplies, and online/automatic refills. Methods to develop and reestablish habits are critical. Care providers in clinic and pharmacy settings can educate and remind patients about services like distance-accessible technologies and online ordering of medications and establishing routines to support medication adherence.

Multi-level correlates of received social support among heart transplant recipients in the international BRIGHT Study: a secondary analysis

AIMS

Social support is critical in follow-up of patients after heart transplant (HTx) and positively influences well-being and clinical outcomes such as medication adherence. The purpose of this study was to (i) explore received social support variation (emotional and practical) in HTx recipients at country and centre level and (ii) to assess multi-level correlates.

METHODS AND RESULTS

Secondary data analysis of the multi-level cross-sectional BRIGHT study was conducted in 36 HTx centres in 11 countries. Received social support related to medication adherence was measured with emotional and practical sub-scales. The Conceptual Model of Social Networks and Health guided selection of patient, micro (interpersonal and psychosocial), meso (HTx centre) and macro-level (country health system) factors. Descriptive statistics, intraclass correlations, and sequential multiple ordinal mixed logistic regression analysis were used. A total of 1379 adult HTx recipients were included. Patient level correlates (female sex, living alone, and fewer depressive symptoms) and micro-level correlates (higher level of chronic disease management and trust in the healthcare team) were associated with better emotional social support. Similarly, patient level (living alone, younger age, and male sex), micro-level and meso-level (patient and clinician-rated higher level of chronic disease management) were associated with better practical social support. Social support varied at country and centre levels for emotional and practical dimensions.

CONCLUSIONS

Social support in HTx recipients varies by country, centre, and was associated with multi-level correlates. Qualitative and longitudinal studies are needed to understand influencing factors of social support for intervention development, improvement of social support, and clinical outcomes.

Cross-sectional Study of the Relationship between Experiences of Incivility from Staff Nurses and Undergraduate Nursing Students’ Sense of Belonging to the Nursing Profession

AIM

This study examined the frequency of incivility for undergraduate nursing students and the relationship between staff nurse incivility and nursing students' sense of belonging. Factors between program semester and students' body mass index (BMI) to staff nurse incivility and students' sense of belonging were assessed.

BACKGROUND

Sense of belonging enhances belonging development to the profession. However, no studies address the relationship between incivility and nursing students' sense of belonging.

METHODS

A cross-sectional design assessed the relationship between staff nurse incivility and undergraduate nursing students' sense of belonging to the nursing profession. An online survey was administered to 123 pre-licensure junior and senior undergraduate nursing students from February 1, 2021, to May 5, 2021. Correlation coefficient, descriptive statistics, Fisher r-to-z transformation, 95% confidence intervals were calculated.

RESULTS

Staff nurse incivility inversely correlated with undergraduate nursing students' sense of belonging (rs=-.358; p <.001). American Indian or Alaskan Native students reported the highest mean frequency of incivility (1.25 ± .421). There were no significant differences in correlations based on semester or BMI.

CONCLUSION

Staff nurse incivility is inversely associated with sense of belonging in students. Further research is needed to test interventions mitigating the effects of incivility on belonging.

Women's Reports of Barriers to and Facilitators of Oral Medication Adherence During Ovarian Stimulation: A Mixed Methods Pilot Study

Background:

Adherence to lifestyle modification recommendations remains problematic for women undergoing fertility treatment, raising concerns about the extent to which women adhere to prescribed medication regimens. Limited data have shown suboptimal oral medication adherence rates of 19% to 74%. The objective of this study was to explore what women perceive as barriers to and facilitators of oral medication adherence during fertility treatment cycles.

Methods:

An exploratory mixed methods pilot study was conducted among a sample of 30 women who were actively taking one to two cycles of letrozole or clomiphene citrate for ovarian stimulation in conjunction with intrauterine insemination cycles. Medication adherence barriers were measured using a 20-item survey. Medication adherence facilitators and personal experiences with fertility treatment were assessed with structured interviews. Medication adherence was assessed with electronic event monitoring.

Results:

The overall medication adherence median was 0.97 with a range of 0.75 to 1.00, and nine women (50%) demonstrated perfect adherence. The most commonly reported barriers were recently feeling sad, down, or blue (53%), and taking medication more than once per day (40%). Women with higher barrier scores had significantly lower medication adherence scores (p=0.02) compared to women with lower total barrier scores. Facilitators included using physical aides as reminders (60%) and establishing a daily routine (50%). No significant correlation was found between medication adherence scores and facilitators.

Conclusion:

The dynamic interplay between perceived barriers and facilitators and women’s medication-taking patterns could influence whether or not medication regimens are followed correctly.

Prevalence and Correlates of Cost-Related Medication Nonadherence to Immunosuppressive Drugs After Heart Transplantation: The International Multicenter Cross-sectional Bright Study

BACKGROUND

Cost-related medication nonadherence (CRMNA) refers to not taking medications as prescribed because of difficulties paying for them.

OBJECTIVES

The aims of this study were (1) to assess the prevalence of CRMNA to immunosuppressants in heart transplant recipients internationally and (2) to determine multilevel correlates (patient, center, and healthcare system levels) of CRMNA.

METHODS

Using data from the cross-sectional international BRIGHT study, applying multistaged sampling, CRMNA was assessed via 3 self-report items in 1365 patients from 36 heart transplant centers in 11 countries. Cost-related medication nonadherence was defined as any positive answer on any of the 3 items. Healthcare system-level (ie, insurance coverage, out-of-pocket expenditures) and patient-level (ie, intention, perceived financial burden, cost as a barrier, a health belief regarding medication benefits, cost-related self-efficacy, and demographic factors) CRMNA correlates were assessed. Correlates were examined using mixed logistic regression analysis.

RESULTS

Across all study countries, CRMNA had an average prevalence of 2.6% (range, 0% [Switzerland/Brazil] to 9.8% [Australia]) and was positively related to being single (odds ratio, 2.29; 95% confidence interval, 1.17-4.47), perceived financial burden (odds ratio, 2.15; 95% confidence interval, 1.55-2.99), and cost as a barrier (odds ratio, 2.60; 95% confidence interval, 1.66-4.07). Four protective factors were identified: white ethnicity (odds ratio, 0.37; 95% confidence interval, 0.19-0.74), intention to adhere (odds ratio, 0.44; 95% confidence interval, 0.31-0.63), self-efficacy (odds ratio, 0.54; 95% confidence interval, 0.43-0.67), and belief about medication benefit (odds ratio, 0.70; 95% confidence interval, 0.57-0.87). Regarding variability, 81.3% was explained at the patient level; 13.8%, at the center level; and 4.8%, at the country level.

CONCLUSION

In heart transplant recipients, the CRMNA prevalence varies across countries but is lower than in other chronically ill populations. Identified patient-level correlates are novel (ie, intention to adhere, cost-related barriers, and cost-related self-efficacy) and indicate patient-perceived medication cost burden.

SystemCHANGE™ Solutions to Improve Medication Adherence in Kidney Transplant Recipients: A Secondary Data Analysis

The SystemCHANGE™ intervention has led to great improvements in medication adherence, which is a challenge for nearly one-third of kidney transplant recipients. This secondary data analysis sought to measure the frequency of individual solutions utilized by participants in a previously conducted randomized controlled trial of the SystemCHANGE™ intervention and to determine which classes of solutions had greatest impact on improved medication adherence. Solutions that were significant predictors of improving medication adherence to the 85% or higher level included alarm cues (p ≤ 0.0001), time cues (p = 0.006), restructuring the physical environment (p = 0.048), and social support (p = 0.023). Alarm and time cues, restructuring the environment, and social support were successful solutions largely influenced by personal routine and environment consideration that might be prioritized in future studies when implementing SystemCHANGE™.

Critical Care Nurses' Physical and Mental Health, Worksite Wellness Support, and Medical Errors

BACKGROUND

Critical care nurses experience higher rates of mental distress and poor health than other nurses, adversely affecting health care quality and safety. It is not known, however, how critical care nurses' overall health affects the occurrence of medical errors.

OBJECTIVE

To examine the associations among critical care nurses' physical and mental health, perception of workplace wellness support, and self-reported medical errors.

METHODS

This survey-based study used a cross-sectional, descriptive correlational design. A random sample of 2500 members of the American Association of Critical-Care Nurses was recruited to participate in the study. The outcomes of interest were level of overall health, symptoms of depression and anxiety, stress, burnout, perceived worksite wellness support, and medical errors.

RESULTS

A total of 771 critical care nurses participated in the study. Nurses in poor physical and mental health reported significantly more medical errors than nurses in better health (odds ratio [95% CI]: 1.31 [0.96-1.78] for physical health, 1.62 [1.17-2.29] for depressive symptoms). Nurses who perceived that their worksite was very supportive of their well-being were twice as likely to have better physical health (odds ratio [95% CI], 2.16 [1.33-3.52]; 55.8%).

CONCLUSION

Hospital leaders and health care systems need to prioritize the health of their nurses by resolving system issues, building wellness cultures, and providing evidence-based wellness support and programming, which will ultimately increase the quality of patient care and reduce the incidence of preventable medical errors.

Experiences of Military Veterans in a Therapeutic Horseback Riding Program

Posttraumatic stress disorder commonly occurs among U.S. military veterans. Therapeutic horseback riding (THR) has emerged as an adjunct therapy. We explored 20 veterans' perceived benefits, drawbacks and views of a 6-week THR program. Participants had confirmed diagnoses of posttraumatic stress disorder, traumatic brain injury, or both. Veterans rode the same horse weekly, the same day, at the same time. Data were collected as part of a randomized clinical trial testing the effects of THR on Post-Traumatic Stress Disorder. Veterans responded to an open-ended questionnaire. Content analysis was used for data analysis. Benefits were "Connection to the Horse," "Relaxing," "180 Degree Change," and "Meeting New People." Drawbacks were "None," "Struggle to Get There," "Pain," "Too Short," and "It is Structured." Overall perceptions were "I Absolutely Loved It," "Feel Again," "The Horse," "The People," and "No Worries." Participants viewed THR as positive. Findings may elucidate why THR may be clinically beneficial.

Defining a new normal: A qualitative exploration of the parent experience during the single ventricle congenital heart disease interstage period

AIM

To explore parents' experience of transition in the period between the palliative cardiac surgeries (i.e., the interstage period) of an infant with single ventricle congenital heart disease.

DESIGN

We conducted an exploratory naturalistic inquiry using a qualitative descriptive approach.

METHODS

A purposive sample of 11 parents of children with single ventricle disease was selected among families that participated in an interstage-period parental home monitoring program during the past 2 years. Interviews and field observations were conducted September-October 2019, and data were analyzed for themes. Analysis of data was inductive, although study questions and the interpretation of results were informed by Meleis' transition theory.

RESULTS

Parents described the experience of transition in interstage as a striving for normality, a theme that was clustered in subthemes of home, self, and infant.

CONCLUSION

Parents' experiences of striving for normality indicated a need for more targeted efforts to address parents' psychosocial needs during the highly stressful interstage transition.

IMPACT

This research underscored the complexity of parents' psychosocial support needs on returning home after their child's first palliative surgery. The findings also suggest need for examination of the transition following the second palliative heart surgery, when the home monitoring program is withdrawn. Understanding parent needs will help guide healthcare teams in developing ways to support parents as they adjust to home, self, and child.

Parental mobile health adherence to symptom home monitoring for infants with congenital heart disease during the single ventricle interstage period: A concept analysis

PURPOSE

Single ventricle heart disease is fraught with risk for infant mortality and morbidity. During the interstage period, or the time between palliative cardiac surgeries, mobile health (mHealth) technology improves the ability of registered nurse coordinators to monitor infant symptoms through parental monitoring and reporting. The concept of parental mHealth adherence to symptom home monitoring of infants with single ventricle congenital heart disease has not been defined, despite increasing use of mHealth technology.

METHODS

Rodger's concept analysis method was used to derive a unified definition of parental mHealth adherence to symptom home monitoring of infants with congenital heart disease during the single ventricle interstage period. A literature review included a search of databases for studies that addressed interstage home mHealth monitoring. Thematic analysis was applied to selected articles to derive a unified definition based on attributes, antecedents, consequences, related terms, and an illustrative case example. Sixteen publications were selected. Attributes, antecedents, and consequences of the concept were derived from the literature leading to a definition of parental mHealth adherence for infants with congenital heart disease during the single ventricle interstage period. The definition is the degree of adherence to which parents' transfer mHealth data for their infant meet healthcare providers' recommendations for symptom home monitoring. Consequences were improved infant symptom home monitoring through parental mHealth adherence measured by initiation, implementation, and discontinuation.

CONCLUSION

The unified definition of the concept will provide a firmer ground for research in mHealth and interstage pediatric care and a guide for clinicians in developing new mHealth interventions for symptom home monitoring.

PRACTICE IMPLICATIONS

This concept analysis hypothesizes that infants with a single ventricle during the interstage period, whose parents are mHealth symptom home monitoring adherent, will have timelier symptom identification with resultant superior outcomes compared with infants with a single ventricle during the interstage period whose parents are not mHealth adherent.

A Pilot Randomized Controlled Trial Using SystemCHANGE™ Approach to Increase Physical Activity in Older Kidney Transplant Recipients

BACKGROUND

Cardiovascular disease is the leading cause of death in kidney transplant recipients. Physical activity after transplant is the most modifiable nonpharmacological factor for improving cardiovascular outcomes. Few studies have tested walking interventions to enhance daily steps and health outcomes in older kidney recipients.

METHODS

Using a pilot feasibility randomized clinical trial design, we tested the feasibility and efficacy of a 6-month SystemCHANGE™ (Change Habits by Applying New Goals and Experience) + Activity Tracker intervention for recruitment, retention, daily steps, and health outcomes (blood pressure, heart rate, body mass index, waist circumference, and physical function). The SystemCHANGE™ + Activity Tracker intervention taught participants to use a multicomponent intervention that connects person-centered systems solutions combined with visual feedback from a mobile activity tracker to achieve daily step goals.

RESULTS

Fifty-three participants (mean age 65 years, 66% male, and 57% white) participated with 27 in the intervention and 26 in the control group. The study protocol was feasible to deliver with high adherence to the protocol in both groups. The intervention group increased daily steps at 3 months (mean difference, 608; standard error = 283, P = .03) compared to the control group. The secondary outcome of heart rate decreased for the intervention group (baseline [mean] 74.4+ 10.8 [standard deviation, SD;] vs 6 months [mean] 67.6+ 11.3 [SD]; P = .002) compared to the control group (baseline [mean] 70.67+ 10.4 [SD]; vs 6 months [mean] 70.2 + 11.1 [SD]; P = .83).

CONCLUSIONS

SystemCHANGE™ + Activity Tracker intervention appears to be feasible and efficacious for increasing daily steps in older kidney recipients.

Recruitment of Older Kidney Transplant Recipients to a Longitudinal Study

BACKGROUND

Currently, limited information is available regarding selection of the most successful strategies for recruitment of older adult kidney transplant recipients as research participants.

OBJECTIVE

The aim of this study was to explore multiple modes of recruitment strategies to enroll older kidney transplant recipients in a 1-year longitudinal study.

METHODS

We used a feasibility design to explore the following recruitment methods: face-to-face contact in the transplant clinic, paper flyers placed in the transplant clinic, Facebook, an online transplant newsletter, and a university website listing of research studies.

RESULTS

Enrollment was open for 9 months, during which time websites and the Facebook portal were active, 142 newsletters were e-mailed, and 424 patients were approached in the transplant clinic. Among patients approached in the clinic, 12 did not own a smartphone required for the study. The sample consisted of 60 participants (39 men, 21 women), with a mean age of 64.5 ± 4.7 years. Of the participants who enrolled in the study, the largest number (75%, n = 45) was recruited using the face-to-face method in the transplant clinic. The online transplant newsletter was the second-best recruitment source (18%, n = 11).

DISCUSSION

Recruitment strategies using face-to-face contact and the online newsletter associated with the transplant clinic organization appeared to be more effective than strategies not associated with the transplant clinic (Facebook and university website). Findings suggest that using a familiar organization communication method to recruit older chronic disease population may be the most beneficial.

The ELFIN Mission

The Electron Loss and Fields Investigation with a Spatio-Temporal Ambiguity-Resolving option (ELFIN-STAR, or heretoforth simply: ELFIN) mission comprises two identical 3-Unit (3U) CubeSats on a polar (∼93^∘ inclination), nearly circular, low-Earth (∼450 km altitude) orbit. Launched on September 15, 2018, ELFIN is expected to have a >2.5 year lifetime. Its primary science objective is to resolve the mechanism of storm-time relativistic electron precipitation, for which electromagnetic ion cyclotron (EMIC) waves are a prime candidate. From its ionospheric vantage point, ELFIN uses its unique pitch-angle-resolving capability to determine whether measured relativistic electron pitch-angle and energy spectra within the loss cone bear the characteristic signatures of scattering by EMIC waves or whether such scattering may be due to other processes. Pairing identical ELFIN satellites with slowly-variable along-track separation allows disambiguation of spatial and temporal evolution of the precipitation over minutes-to-tens-of-minutes timescales, faster than the orbit period of a single low-altitude satellite (T_orbit ∼ 90 min). Each satellite carries an energetic particle detector for electrons (EPDE) that measures 50 keV to 5 MeV electrons with Δ E/E < 40% and a fluxgate magnetometer (FGM) on a ∼72 cm boom that measures magnetic field waves (e.g., EMIC waves) in the range from DC to 5 Hz Nyquist (nominally) with <0.3 nT/sqrt(Hz) noise at 1 Hz. The spinning satellites (T_spin ∼ 3 s) are equipped with magnetorquers (air coils) that permit spin-up or -down and reorientation maneuvers. Using those, the spin axis is placed normal to the orbit plane (nominally), allowing full pitch-angle resolution twice per spin. An energetic particle detector for ions (EPDI) measures 250 keV - 5 MeV ions, addressing secondary science. Funded initially by CalSpace and the University Nanosat Program, ELFIN was selected for flight with joint support from NSF and NASA between 2014 and 2018 and launched by the ELaNa XVIII program on a Delta II rocket (with IceSatII as the primary). Mission operations are currently funded by NASA. Working under experienced UCLA mentors, with advice from The Aerospace Corporation and NASA personnel, more than 250 undergraduates have matured the ELFIN implementation strategy; developed the instruments, satellite, and ground systems and operate the two satellites. ELFIN's already high potential for cutting-edge science return is compounded by concurrent equatorial Heliophysics missions (THEMIS, Arase, Van Allen Probes, MMS) and ground stations. ELFIN's integrated data analysis approach, rapid dissemination strategies via the SPace Environment Data Analysis System (SPEDAS), and data coordination with the Heliophysics/Geospace System Observatory (H/GSO) optimize science yield, enabling the widest community benefits. Several storm-time events have already been captured and are presented herein to demonstrate ELFIN's data analysis methods and potential. These form the basis of on-going studies to resolve the primary mission science objective. Broad energy precipitation events, precipitation bands, and microbursts, clearly seen both at dawn and dusk, extend from tens of keV to >1 MeV. This broad energy range of precipitation indicates that multiple waves are providing scattering concurrently. Many observed events show significant backscattered fluxes, which in the past were hard to resolve by equatorial spacecraft or non-pitch-angle-resolving ionospheric missions. These observations suggest that the ionosphere plays a significant role in modifying magnetospheric electron fluxes and wave-particle interactions. Routine data captures starting in February 2020 and lasting for at least another year, approximately the remainder of the mission lifetime, are expected to provide a very rich dataset to address questions even beyond the primary mission science objective.

Variability in practice patterns regarding protective isolation measures after heart transplantation: A secondary analysis of the international BRIGHT study

BACKGROUND

Infection control is a cornerstone of post-heart transplantation (HTx) in-hospital management when immunosuppression is highest. The use of protective isolation persists despite its questionable effectiveness. We describe and compare practice patterns internationally and assessed correlates of protective isolation.

METHODS

Using the BRIGHT-study data, a cross-sectional intercontinental study, we assessed 12 protective isolation measures in 4 continents, 11 countries, and 36 HTx centers. Data were summarized descriptively, as appropriate. Comparisons between countries and continents and association testing between center characteristics and number of isolation measures used were also explored by general linear modeling.

RESULTS

A total of 89% (32/36) of HTx centers used protective isolation measures with an average of 4.5 protective isolation measures per center (SD, 2.6; range 1-10). Most often applied were disinfecting high-touch surfaces (n = 27/34; 79.4%), use of private room (n = 27/36; 75.0%), and changing linen daily (n = 25/36; 69.4%). Least applied were wearing a cap (n = 6/35; 17.1%) and high-efficiency particulate air filtration (N = 5/32; 15.6 %). Larger centers and those with dedicated beds for HTx applied more isolation measures.

CONCLUSIONS

Protective isolation measures are still widely applied within heart transplant centers across the world persists notwithstanding its doubtful effectiveness. Future clinical guidelines for heart transplant management should include a statement of the need for strict adherence to standard infection prevention measures.

Improving medication adherence and outcomes in adult kidney transplant patients using a personal systems approach: SystemCHANGE™ results of the MAGIC randomized clinical trial

This study determined if a SystemCHANGE™ intervention was more efficacious than attention control in increasing immunosuppressive medication adherence and improving outcomes in adult kidney transplant recipients during a 6-month intervention phase and subsequent 6-month (no intervention) maintenance phase. The SystemCHANGE™ intervention taught patients to use person-level quality improvement strategies to link adherence to established daily routines, environmental cues, and supportive people. Eighty-nine patients (average age 51.8 years, 58% male, 61% African American) completed the 6-month intervention phase. Using an intent-to-treat analysis, at 6 months, medication adherence for SystemCHANGE™ (median 0.91, IQR 0.76-0.96) and attention control (median 0.67, IQR 0.52-0.72) patients differed markedly (difference in medians 0.24, 95% CI 0.13-0.30, P < .001). At the conclusion of the subsequent 6-month maintenance phase, the gap between medication adherence for SystemCHANGE™ (median 0.77, IQR 0.56-0.94) and attention control (median 0.60, IQR 0.44-0.73) patients remained large (difference in medians 0.17, 95% CI 0.06-0.33, P = .004). SystemCHANGE™ patients evidenced lower mean creatinine and BUN at 12 months and more infections at 6 and 12 months. This first fully powered RCT testing SystemCHANGE™ to improve and maintain medication adherence in kidney transplant recipients demonstrated large, clinically meaningful improvements in medication adherence. Clinical Trial Registration: NCT02416479.

The Feasibility of a Using a Smart Button Mobile Health System to Self-Track Medication Adherence and Deliver Tailored Short Message Service Text Message Feedback

BACKGROUND

As many as 50% of people experience medication nonadherence, yet studies for detecting nonadherence and delivering real-time interventions to improve adherence are lacking. Mobile health (mHealth) technologies show promise to track and support medication adherence.

OBJECTIVE

The study aimed to evaluate the feasibility and acceptability of using an mHealth system for medication adherence tracking and intervention delivery. The mHealth system comprises a smart button device to self-track medication taking, a companion smartphone app, a computer algorithm used to determine adherence and then deliver a standard or tailored SMS (short message service) text message on the basis of timing of medication taking. Standard SMS text messages indicated that the smartphone app registered the button press, whereas tailored SMS text messages encouraged habit formation and systems thinking on the basis of the timing the medications were taken.

METHODS

A convenience sample of 5 adults with chronic kidney disease (CKD), who were prescribed antihypertensive medication, participated in a 52-day longitudinal study. The study was conducted in 3 phases, with a standard SMS text message sent in phases 1 (study days 1-14) and 3 (study days 46-52) and tailored SMS text messages sent during phase 2 (study days 15-45) in response to participant medication self-tracking. Medication adherence was measured using: (1) the smart button and (2) electronic medication monitoring caps. Concordance between these 2 methods was evaluated using percentage of measurements made on the same day and occurring within ±5 min of one another. Acceptability was evaluated using qualitative feedback from participants.

RESULTS

A total of 5 patients with CKD, stages 1-4, were enrolled in the study, with the majority being men (60%), white (80%), and Hispanic/Latino (40%) of middle age (52.6 years, SD 22.49; range 20-70). The mHealth system was successfully initiated in the clinic setting for all enrolled participants. Of the expected 260 data points, 36.5% (n=95) were recorded with the smart button and 76.2% (n=198) with electronic monitoring. Concordant events (n=94), in which events were recorded with both the smart button and electronic monitoring, occurred 47% of the time and 58% of these events occurred within ±5 min of one another. Participant comments suggested SMS text messages were encouraging.

CONCLUSIONS

It was feasible to recruit participants in the clinic setting for an mHealth study, and our system was successfully initiated for all enrolled participants. The smart button is an innovative way to self-report adherence data, including date and timing of medication taking, which were not previously available from measures that rely on recall of adherence. Although the selected smart button had poor concordance with electronic monitoring caps, participants were willing to use it to self-track medication adherence, and they found the mHealth system acceptable to use in most cases.

Impact of a SystemCHANGE™ Intervention on Medication Adherence in Older Adults With Heart Failure: A Feasibility Study

The purpose of the current study was to examine the feasibility and acceptability of a SystemCHANGE™ intervention in improving medication adherence in older adults with heart failure (HF). Adults age ≥50 years with HF who self-administered diuretics were screened for 2 months using electronic monitoring to determine baseline adherence scores. Participants were randomized into the SystemCHANGE™ or attention-control group if adherence scores were <88%. The SystemCHANGE™ intervention focuses on changing the individual's environment by including medication taking into existing routines, receiving support from individuals who impact routines, and using small experiments with feedback. Challenges were noted by participants in using the electronic medication monitor technology during the screening phase. Lessons learned from this study emphasize the need to revise recruitment procedures and include multiple sites. Education and counseling should be adapted to the cognitive level of the participant and address technology challenges. [Journal of Gerontological Nursing, 45(4), 15-19.].

Prevalence of Medication Nonadherence to Co-medication Compared to Immunosuppressants in Heart Transplant Recipients: Findings From the International Cross-sectional BRIGHT Study

PURPOSE

To assess and compare the prevalence of medication nonadherence (MNA) (implementation and persistence) to immunosuppressants and co-medications in heart transplant recipients.

METHODS

MNA prevalence was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale (self-report) and compared using logistic regression in a 4-continent sample of 1397 heart transplant recipients from 36 heart transplant centers in 11 countries.

FINDINGS

MNA was significantly (α = 0.05) higher to co-medications than to immunosuppressants (taking nonadherence: 23.9% vs 17.3%; odds ratio [OR] = 1.5; 95% CI, 1.30-1.73; drug holiday: 5.7% vs 1.9%; OR = 3.17; 95% CI, 2.13-4.73; dose alteration: 3.8% vs 1.6%; OR = 2.46; 95% CI, 1.49-4.06; and discontinuation: 2.6% vs 0.5%; OR = 5.15; 95% CI, 2.36-11.20).

IMPLICATIONS

The observed MNA necessitates adherence-enhancing interventions encompassing the entire post-heart transplant medication regimen. ClinicalTrials.gov identifier: NCT01608477.

An Exploratory Correlational Study in the Use of Mobile Technology Among Adult Kidney Transplant Recipients

INTRODUCTION

Rapidly growing use of mobile technology provides a platform for self-management of care support for those with chronic conditions. Few studies have explored the characteristics or access patterns of kidney transplant recipients who use mHealth applications (apps) for self-management of care.

RESEARCH QUESTIONS

The primary aim of this study was to describe demographics, use, barriers, and perceptions of mobile apps for self-management of care among adult kidney transplants recipients. The secondary aim was to compare blood urea nitrogen, glomerular filtration rate, and number of hospitalizations among mHealth app users, other app users, and non-app users.

METHODS

A cross-sectional design was used to administer the Mobile Application Use among Kidney Transplant Recipients Questionnaire. Descriptive statistics, χ² statistics, and analysis of variance were used for the primary aim and linear regression was used for the secondary aim.

RESULTS

The sample included mostly African American males (n = 123, 75.5%) with a mean age of 50 (13.2) years. Knowledge was the greatest barrier reported by the non-app users (mHealth app users 9%, other app users 12%, non-app users, 49%, P < .001). Significantly fewer hospitalizations were found in the mHealth app users compared to other app users (regression coefficient b = -1.2, standard error [SE] = 0.5) and non-app users ( b = -0.9, SE = 0.6), adjusting for patient demographic and clinical characteristics.

DISCUSSION

Findings suggest a relationship may exist between mHealth app use and a decrease in the number of hospitalizations following kidney transplantation.

Report from the American Society of Transplantation Psychosocial Community of Practice Adherence Task Force: Real-world options for promoting adherence in adult recipients

Starting in 2015, the American Society of Transplantation Psychosocial Community of Practice, with representatives of the Transplant Pharmacy Community of Practice, convened a taskforce to develop a white paper that focused on clinically practical, evidenced-based interventions that transplant centers could implement to increase adherence to medication and behavioral recommendations in adult solid organ transplant recipients. The group focused on what centers could do in their daily routines to implement best practices to increase adherence in adult transplant recipients. We developed a list of strategies using available resources, clinically feasible methods of screening and tracking adherence, and activities that ultimately empower patients to improve their own self-management. We limited the target population to adults because they predominate the research, and because adherence issues differ in pediatric patients, given the necessary involvement of parents/guardians. We also examined broader multilevel areas for intervention including provider and transplant program practices. Ultimately, the task force aims to foster greater recognition, discussion, and solutions required for implementing practical interventions targeted at improving adherence.

Testing the efficacy of a scaffolded writing intervention with online degree-completion nursing students: A quasi-experimental design

Writing should receive dedicated time in the nursing classroom for students to become competent writers, offering practical experiences for them to critically think and organize their ideas into meaningful messages. The purpose of this pre-post quasi-experimental study was to compare implementation of a scaffolded sequence of writing assignments (intervention) to typical writing assignments (comparison) in final coursework for baccalaureate nursing (BSN) completion students. Student writing self-efficacy and writing competency were measured pre and post coursework using the Post Secondary Writerly Self-Efficacy Scale, 6 + 1 Trait scale and Holistic scale. A convenience sample of 78 BSN-completion students at two Midwestern universities in the US were recruited to participate. The sample was primarily female (83%) and Caucasian (81%). There were no significant differences between the two groups on self-efficacy scores (p = 0.594). Significant group differences were noted on writing competency as assessed by the 6 + 1 Trait scale (p = 0.004) but not the Holistic scale (p = 0.024). No significant correlation between writing self-efficacy scores and writing competency were apparent (Holistic scale, p = 0.601; 6 + 1 Trait scale, p = 0.615). Writing skill-building needs attention to assure student competency. Educational interventions implemented in BSN education must be tested for efficacy and effectiveness.

Multilevel factors are associated with immunosuppressant nonadherence in heart transplant recipients: The international BRIGHT study

Factors at the level of family/healthcare worker, organization, and system are neglected in medication nonadherence research in heart transplantation (HTx). The 4-continent, 11-country cross-sectional Building Research Initiative Group: Chronic Illness Management and Adherence in Transplantation (BRIGHT) study used multistaged sampling to examine 36 HTx centers, including 36 HTx directors, 100 clinicians, and 1397 patients. Nonadherence to immunosuppressants-defined as any deviation in taking or timing adherence and/or dose reduction-was assessed using the Basel Assessment of Adherence to Immunosuppressive Medications Scale^© (BAASIS^© ) interview. Guided by the Integrative Model of Behavioral Prediction and Bronfenbrenner's ecological model, we analyzed factors at these multiple levels using sequential logistic regression analysis (6 blocks). The nonadherence prevalence was 34.1%. Six multilevel factors were associated independently (either positively or negatively) with nonadherence: patient level: barriers to taking immunosuppressants (odds ratio [OR]: 11.48); smoking (OR: 2.19); family/healthcare provider level: frequency of having someone to help patients read health-related materials (OR: 0.85); organization level: clinicians reporting nonadherent patients were targeted with adherence interventions (OR: 0.66); pickup of medications at physician's office (OR: 2.31); and policy level: monthly out-of-pocket costs for medication (OR: 1.16). Factors associated with nonadherence are evident at multiple levels. Improving medication nonadherence requires addressing not only the patient, but also family/healthcare provider, organization, and policy levels.

Improvement of Immunosuppressive Medication Adherence Using a SystemCHANGE Intervention: Case Study of an Older Adult Kidney Transplant Recipient

This article reports a case study of an older adult kidney transplant recipient with poor medication adherence enrolled in an innovative six-month SystemCHANGE intervention that seeks to systematically improve medication adherence by identifying and shaping routines, involving others in routines, and using medication-taking feedback through small, patient-led experiments. Medication adherence increased immediately and was sustained throughout the intervention and maintenance phases. This is the first case study to demonstrate effectiveness of the SystemCHANGE intervention for promoting medication adherence in a kidney transplant recipient. The intervention improved the timing of doses by linking them to a regularly occurring behavior and providing feedback. The SystemCHANGE intervention represents a systems-thinking approach for both provider and patients, and gives healthcare providers the tools needed to assist patients in using habits and routines, and feedback to improve medication taking and timing.

Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans

BACKGROUND

Large numbers of post-deployment U.S. veterans are diagnosed with post-traumatic stress disorder (PTSD) and/or traumatic brain injury (TBI), leading to an urgent need for effective interventions to reduce symptoms and increase veterans' coping. PTSD includes anxiety, flashbacks, and emotional numbing. The symptoms increase health care costs for stress-related illnesses and can make veterans' civilian life difficult.

METHODS

We used a randomized wait-list controlled design with repeated measures of U.S. military veterans to address our specific aim to test the efficacy of a 6-week therapeutic horseback riding (THR) program for decreasing PTSD symptoms and increasing coping self-efficacy, emotion regulation, social and emotional loneliness. Fifty-seven participants were recruited and 29 enrolled in the randomized trial. They were randomly assigned to either the horse riding group (n = 15) or a wait-list control group (n = 14). The wait-list control group experienced a 6-week waiting period, while the horse riding group began THR. The wait-list control group began riding after 6 weeks of participating in the control group. Demographic and health history information was obtained from all the participants. PTSD symptoms were measured using the standardized PTSD Checklist-Military Version (PCL-M). The PCL-M as well as other instruments including, The Coping Self Efficacy Scale (CSES), The Difficulties in Emotion Regulation Scale (DERS) and The Social and Emotional Loneliness Scale for Adults-short version (SELSA) were used to access different aspects of individual well-being and the PTSD symptoms.

RESULTS

Participants had a statistically significant decrease in PTSD scores after 3 weeks of THR (P ≤ 0.01) as well as a statistically and clinically significant decrease after 6 weeks of THR (P ≤ 0.01). Logistic regression showed that participants had a 66.7% likelihood of having lower PTSD scores at 3 weeks and 87.5% likelihood at 6 weeks. Under the generalized linear model(GLM), our ANOVA findings for the coping self-efficacy, emotion regulation, and social and emotional loneliness did not reach statistical significance. The results for coping self-efficacy and emotion regulation trended in the predicted direction. Results for emotional loneliness were opposite the predicted direction. Logistic regression provided validation that outcome effects were caused by riding longer.

CONCLUSION

The findings suggest that THR may be a clinically effective intervention for alleviating PTSD symptoms in military veterans.

Practice patterns to improve pre and post-transplant medication adherence in heart transplant centres: a secondary data analysis of the international BRIGHT study

BACKGROUND

As medication non-adherence is a major risk factor for poor post-transplant outcomes, we explored how adherence is assessed, enhanced and integrated across the transplant continuum.

AIM

The aim of this study was to study practice patterns regarding pre- and post-transplant medication adherence assessment and interventions in international heart transplant centres.

METHODS

We used data from the Building Research Initiative Group: chronic illness management and adherence in heart transplantation (BRIGHT) study, a cross-sectional study conducted in 36 heart transplant centres in 11 countries. On a 27-item questionnaire, 100 clinicians (range one to five per centre) reported their practice patterns regarding adherence assessment and intervention strategies pre-transplant, immediately post-transplant, less than one year, and one or more year post-transplant. Educational/cognitive, counselling/behavioural and psychosocial/affective strategies were assessed. Clinicians' responses (intervention present vs. absent; or incongruence in reporting intervention) were aggregated at the centre level.

RESULTS

The adherence assessment method most commonly used along the transplant continuum was questioning patients (range 75-88.9%). Pre-transplant, all three categories of intervention strategy were applied. Providing reading materials (82.9%) or instructions (68.6%), involving family or support persons in education (91.4%), and establishing partnership (91.4%) were used most frequently. Post-transplant, strategies closely resembled those employed pre-transplant. Training patients (during recovery) and cueing were more often applied during hospitalisation (74.3%). After the first year post-transplant, except for motivational interviewing (25.7-28.6%), the number of strategies decreased.

CONCLUSIONS

Across the transplant continuum, diverse adherence interventions are implemented; however, post-transplant, the frequency of adherence interventions decreases. Therefore, increased investment is necessary in long-term adherence interventions.

Merging an Activity Tracker with SystemCHANGE™ to Improve Physical Activity in Older Kidney Transplant Recipients

Motivational strategies to increase adherence to a long-term physical activity regimen have been unsuccessful for kidney transplant recipients. We propose a theory-based SystemCHANGE™ + Activity Tracker framework. The SystemCHANGE™ + Activity Tracker approach combines small, individual-driven experiments for increasing physical activity with visual feedback from the wireless activity tracker, which enables clients to study their progress in increasing physical activity. The SystemCHANGE™ + Activity Tracker approach is designed to empower kidney transplant recipients to improve and maintain their physical activity behavior.

Knowledge and Awareness Among Patients with Chronic Kidney Disease Stage 3

Knowledge is a prerequisite for changing behavior, and is useful for improving outcomes and reducing mortality rates in patients diagnosed with chronic kidney disease (CKD). The purpose of this article is to describe baseline CKD knowledge and awareness obtained as part of a larger study testing the feasibility of a self-management intervention. Thirty patients were recruited who had CKD Stage 3 with coexisting diabetes and hypertension. Fifty-four percent of the sample were unaware of their CKD diagnosis. Participants had a moderate amount of CKD knowledge. This study suggests the need to increase knowledge in patients with CKD Stage 3 to aid in slowing disease progression.

The Effects of Information and Support on Individuals Awaiting Cadaveric Kidney Transplantation

Context

No empirical studies exist to direct nursing interventions for individuals during the long period of waiting for a transplant.

Objective

To measure the effect of information and support on hope and uncertainty for individuals awaiting cadaveric kidney transplantation.

Design

Randomized, controlled study.

Setting

A university-affiliated hospital in the Midwest from 1997 to 1999.

Patients

Fifty participants awaiting cadaveric kidney transplantation.

Interventions

The control group received no intervention phone calls or mailings, which was the current standard of care. The treatment group received phone calls and mailings once every month for 6 months.

Main Outcome Measures

Hope, measured by the Herth Hope Index, and uncertainty, measured by the Mishel's Uncertainty in Illness Scale for Adults, were evaluated at the beginning of the study and 6 months later.

Results

No statistically significant effect of the nursing intervention was found on hope and uncertainty in this sample (F = 0.5322, P = .81). Hope was found to be negatively related to uncertainty both before ( r = $0.53, P = .0001) and after ( r = $0.59, P = .0001) intervention. No significant change was found between hope before and after intervention, and uncertainty before and after intervention in the treatment group (F = 1.10, P = .40) or the control group.

Conclusion

The individuals indicated that definite needs were met by the information and support intervention even though the results did not statistically support the effect of the nursing intervention.

Conclusions

Several conclusions can be drawn from the findings of this study. First, even though the nursing intervention of providing information and support did not have a statistically significant effect on levels of hope and uncertainty in individuals awaiting kidney transplantation, anecdotal reports from the respondents indicated that the phone calls and mailed information were helpful and appreciated. Valuable information, potentially impacting the outcomes of kidney transplantation, was gathered by the researchers and shared with the transplant team. Secondly, levels of hope were relatively high, whereas levels of uncertainty were moderate in this sample of individuals waiting for cadaveric kidney transplantation. Furthermore, in this sample, the average time since diagnosis of ESRD was more than 4 years and the average waiting time was more than 1 year. There may have been a change over time from viewing the waiting experience as a negative experience to a positive opportunity. Thirdly, the finding of a negative relationship between hope and uncertainty provided support to the growing body of knowledge of this association. Finally, time on the waiting list, gender, and marital status were not associated with levels of hope or uncertainty. Generally, the findings of this study are consistent with existing literature and add to the growing body of knowledge related to the midrange theories of hope and uncertainty.

Teaching Patients about Kidney Transplantation: Documentation

Increasing demands are being placed on transplant nurse coordinators for more precise documentation of their teaching of kidney transplant patients, but the amount of time nurses have for this added documentation remains unchanged or has diminished. After a thorough review of the literature, our transplant team found no patient teaching documentation format that assisted us in overcoming the problem of increased demands. Consequently, following the Joint Commission on Accreditation of Healthcare Organization standards, we developed a Renal Transplant Patient Teaching Record that has assisted our team in documenting the pre- and post-transplant patient teaching that we complete.

Evaluation Guidelines for Adult and Pediatric Kidney Transplant Programs: The Missouri Experience

Context

Rigorous candidate evaluation is paramount for estimating risk and long-term success with transplantation. In addition, because of increasing waiting times, patients are seeking listing at multiple centers or transferring waiting time from one center to another. Variations in center evaluation criteria are becoming increasingly important to patients.

Objective

To describe the similarities and differences among the evaluation guidelines for adult and pediatric kidney transplant programs in Missouri.

Design

A descriptive design was used.

Setting and Participants

Kidney transplant nurse coordinators from 7 adult and 4 pediatric kidney transplant programs from 10 centers in Missouri were invited to submit the kidney transplant candidate evaluation guidelines from their programs.

Results

Guidelines were submitted by nurse coordinators from all programs. Consults with the kidney transplant team members, including surgeon, nephrologist, social worker, and nurse coordinator, were included in all of the programs. For the adult programs, 67% (20/30) of the tests and laboratory values were agreed on by at least 70% of the program transplant team members. Similarly, for the pediatric programs, 62% (16/26) of the age-appropriate tests and laboratory values were agreed on by at least 75% of the program transplant team members.

Conclusions

Within the Missouri programs, testing is consistent whether the center is large or small, adult or pediatric. Transplant teams should periodically review their kidney transplant recipient evaluation criteria for similarities to and differences from the current state-of-the-science and surrounding programs.

Transplant Nurses' Work Environment: A Cross-Sectional Multi-Center Study

BACKGROUND Numerically, nurses represent the largest healthcare profession, thus setting norms for the quality and safety of direct patient care. Evidence of a global shortage of nurses in all clinical practice settings across different healthcare systems and countries has been documented. The aims of the present study were: (1) to assess work environments in a sample of German transplant nurses, and (2) to compare their statements with a US-based sample. MATERIAL AND METHODS In a cross-sectional study, 181 transplant nurses from 16 German transplant centers provided information on their work environments. The translated version of the Job Design (JD) and Job Satisfaction (JS) survey showed satisfactory internal consistency for the JD (0.78) and JS (0.93) subscales. German nurses' work environments were compared with 331 transplant nurses from the US. RESULTS The majority of transplant nurses were female (81.8%), 55.4% were age 21-40 years, and 78.1% were employed full-time. German (versus US) transplant nurses reported their job design to be best for 'skill varieties' (p≤0.0002), and worst for 'autonomy' (p≤0.01). Job satisfaction was best with 'opportunities for autonomy and growth' (p≤0.0001), and 'pay and benefits' (p≤0.0001) was lowest. A higher professional degree (OR 1.57; p≤0.03; 95% CI 1.19-2.86), and longer time in transplant (OR 1.24; p≤0.001; 95% CI 1.11-1.38) showed a positive impact on German transplant nurses' perceptions of 'job satisfaction'. Nurses with time-dependent working contracts perceived more stress negatively affecting job satisfaction (OR 1.13; p≤0.009; 95% CI 1.02-12.82). CONCLUSIONS German specialty nurses working in the field of solid organ transplantation rate their work environments with respect to job design and job satisfaction as satisfactory. Institutions' investment into satisfactory nurse work environments and specializing nurses might increase the quality of care, thus improving patient outcomes.

Intrasubject Medication Adherence Patterns

The purpose of this prospective descriptive study was to explore the patterns of intrasubject (between medication) adherence of two similarly timed, twice-daily medications using the Medication Event Management System® electronic monitoring cap. Medication adherence was measured for 6 months using electronic monitoring in 25 adult renal-transplant recipients. Data were available from 7,119 electronic medication events. Results indicated that two twice-daily medications scheduled to be taken simultaneously were taken within 5 min of each other 77% of the time and within 10 min, 92% of the time. When only the first scheduled dose of the day was examined, the results are 79% and 95%, respectively. These findings are important to researchers and clinicians who must evaluate medication adherence in transplant recipients while balancing cost and subject burden. This study provides empirical support for monitoring a single immunosuppressive medication electronically to estimate medication adherence with double or triple immunosuppressive drug therapy.

MAGIC Study: Aims, Design and Methods using SystemCHANGE™ to Improve Immunosuppressive Medication Adherence in Adult Kidney Transplant Recipients

Background

Among adult kidney transplant recipients, non-adherence to immunosuppressive medications is the leading predictor of poor outcomes, including rejection, kidney loss, and death. An alarming one-third of kidney transplant patients experience medication non-adherence even though the problem is preventable. Existing adherence interventions have proven marginally effective for those with acute and chronic illnesses and ineffective for adult kidney transplant recipients. Our purpose is to describe the design and methods of the MAGIC (Medication Adherence Given Individual SystemCHANGE™) trial

Methods/Design

We report the design of a randomized controlled trial with an attention-control group to test an innovative 6-month SystemCHANGE™ intervention designed to enhance immunosuppressive medication adherence in adult non-adherent kidney transplant recipients from two transplant centers. Grounded in the Socio-Ecological Model, SystemCHANGE™ seeks to systematically improve medication adherence behaviors by identifying and shaping routines, involving supportive others in routines, and using medication taking feedback through small patient-led experiments to change and maintain behavior. After a 3-month screening phase of 190 eligible adult kidney transplant recipients, those who are <85 % adherent as measured by electronic monitoring, will be randomized into a 6-month SystemCHANGE™ intervention or attention-control phase, followed by a 6-month maintenance phase without intervention or attention. Differences in adherence between the two groups will be assessed at baseline, 6 months (intervention phase) and 12 months (maintenance phase). Adherence mediators (social support, systems-thinking) and moderators (ethnicity, perceived health) are examined. Patient outcomes (creatinine/blood urea nitrogen, infection, acute/chronic rejection, graft loss, death) and cost effectiveness are to be examined.

Discussion

Based on the large effect size of 1.4 found in our pilot study, intervention shows great promise for increasing adherence. Grounded in the socio-ecological model, SystemCHANGE™ seeks to systematically improve medication adherence behaviors by identifying and shaping routines, involving supportive others in routines, and using medication taking feedback through small patient-lead experiments to change and maintain behavior. Medication adherence will be measured by electronic monitoring. Medication adherence persistence will be examined by evaluating differences between the two groups at the end of the 6-and 12- month phases. Mediators and moderators of medication adherence will be examined. Patient outcomes will be compared and a cost-effectiveness analysis will be conducted.

Trial registration

ClinicalTrials.gov Registry: NCT02416479 Registered April 3, 2015

Culturally Responsive Interventions to Enhance Immunosuppressive Medication Adherence in Older African American Kidney Transplant Recipients

Context

Immunosuppressive medication nonadherence is variable among older kidney transplant recipients and is a problem in African American recipients despite the severe consequences of this behavior. Many factors place older African American recipients at risk for medication nonadherence.

Objective

To provide an overview of interventions to enhance immunosuppressive medication adherence in older African American kidney transplant recipients using a culturally responsive model. Culturally sensitive, innovative, and transformation interventions are discussed. Situations when each intervention would be most and least appropriate are described.

Conclusion

Moving culturally appropriate interventions forward into practice and testing their effectiveness in improving adherence outcomes in vulnerable, older African American kidney transplant recipients is a worthy practice and research goal for transplant nursing.

An Overview of the Integrative Research Review

The integrative literature review has many benefits to the scholarly reviewer, including evaluating the strength of the scientific evidence, identifying gaps in current research, identifying the need for future research, bridging between related areas of work, identifying central issues in an area, generating a research question, identifying a theoretical or conceptual framework, and exploring which research methods have been used successfully. The 5-stage integrative review process includes (1) problem formulation, (2) data collection or literature search, (3) evaluation of data, (4) data analysis, and (5) interpretation and presentation of results. Maintaining scientific integrity while conducting an integrative research review involves careful consideration to threats to validity. Strategies to overcome these threats are reviewed. The integrative review methodology must involve detailed and thoughtful work, the outcome of which can be a significant contribution to a particular body of knowledge and, consequently, to practice and research.

Self-management interventions in stages 1 to 4 chronic kidney disease: an integrative review

The prevalence, effect on health outcomes, and economic impact of chronic kidney disease (CKD) have created interest in self-management interventions to help slow disease progression to kidney failure. Seven studies were reviewed to identify knowledge gaps and future directions for research. All studies were published between 2010 and 2013; no investigations were conducted in the United States. Knowledge gaps included the focus on medical self-management tasks with no attention to role or emotional tasks, lack of family involvement during intervention delivery, and an inability to form conclusions about the efficacy of interventions because methodological rigor was insufficient. Educational content varied across studies. Strategies to improve self-management skills and enhance self-efficacy varied and were limited in scope. Further development and testing of theory-based interventions are warranted. There is a critical need for future research using well-designed trials with appropriately powered sample sizes, well-tested instruments, and clear and consistent reporting of results.