The relationship between leadership practices and a medication safety regime

Errors in healthcare are commonplace and have significant impact on mortality, morbidity, and costs. Other high-risk industries are credited with strong safety records. These successes are due in part to a strong, committed organizational culture and their leadership. A consistent pattern of effective leadership behaviors; creating change, establishing a vision and strategic actions, and enabling and inspiring the organization's members to act, is present in these high-risk industries. This research examined the relationship between leadership practices and a medication safety regime. The hypothesis is strong leadership practices have a positive relationship with the degree of sophistication of a medication safety program (safety performance). Leadership was used as a surrogate for organizational culture and was measured in this research through the Kouzes and Posner's Leadership Practices Inventory. The Institute of Medicine's 14 Selected Strategies to Improve Medication Safety was used to measure the development of a medication safety regime. Leadership practices towards safety were assessed by surveying 2,478 critical care Registered Nurses in the greater Houston area. A response rate of 19% was achieved. Thirteen hospitals participated in the medication safety regime assessment. Data from 386 RN respondents from 53 institutions provided an overall description of unit (ICU) and organization (hospital) leader's practices towards safety. There is some recognition of the medical error problem and that leaders exhibit moderate levels of leadership practices to promote safety. There were no differences noted in unit and hospital leaders' behaviors, with the exception that unit leaders promote change and enable staff to act more often than hospital leaders. There were no statistically significant relationships between overall leadership, or individual leadership practices and the organization's safety performance. There was a significant relationship between leadership and safety performance when other factors in organizational culture were considered. Teaching and Magnet hospitals also exhibited stronger behaviors towards safety. Organizational culture, as measured by academic affiliation and Magnet recognition, is strongly related to safety performance as measured by the degree of development of a medication safety regime. ^

Temporal variations of dyspnea, fatigue, and lung function in chronic lung disease

Background. Research investigating symptom management in patients with chronic obstructive pulmonary disease (COPD) largely has been undertaken assuming the homeostatic construct, without regard to potential roles of circadian rhythms. Temporal relations among dyspnea, fatigue, peak expiratory flow rate (PEFR) and objective measures of activity/rest have not been reported in COPD. ^ Objectives. The specific aims of this study were to (1) explore the 24-hour patterns of dyspnea, fatigue, and PEFR in subjects with COPD; (2) examine the relations among dyspnea, fatigue, and PEFR in COPD; and (3) examine the relations among objective measures of activity/rest and dyspnea, fatigue, and PEFR in COPD. ^ Methods. The repeated-measures design involved 10 subjects with COPD who self-assessed dyspnea and fatigue by 100 mm visual analog scales, and PEFR by peak flow meter in their home 5 times a day for 8 days. Activity/rest was measured by wrist actigraphy. Single and population mean cosinor analyses and correlations were computed for dyspnea, fatigue, and PEFR; correlations were done among these variables and activity/rest. ^ Results. Circadian rhythms were documented by single cosinor analysis in 40% of the subjects for dyspnea, 60% for fatigue, and 60% for PEFR. The population cosinor analysis of PEFR yielded a significant rhythm (p < .05). The 8-day 24-hour means of dyspnea and fatigue was moderately correlated (r = .48, p < .01). Dyspnea and PEFR, and fatigue and PEFR, were weakly correlated in a negative way (r = −.11, p < .05 and r = −.15, p < .01 respectively). Weak to moderate correlations (r = .12–.34, p < .05) were demonstrated between PEFR and mean activity level measured up to 4 hours before PEFR measurement. ^ Conclusions. The findings suggest that (1) the dyspnea and fatigue experienced by COPD patients are moderately related, (2) there is a weak to modest positive relation between PEFR and activity levels, and (3) temporal variation in lung function may not affect the dyspnea and fatigue experienced by patients with COPD. Further research, examining the relations among dyspnea, fatigue, PEFR, and activity/rest is needed. Replication of this study is suggested with a larger sample size. ^

Outcomes and cost effectiveness of treating type 2 diabetes with a nurse case manager following treatment algorithms versus primary care physicians

Background. Diabetes places a significant burden on the health care system. Reduction in blood glucose levels (HbA1c) reduces the risk of complications; however, little is known about the impact of disease management programs on medical costs for patients with diabetes. In 2001, economic costs associated with diabetes totaled $100 billion, and indirect costs totaled $54 billion. ^ Objective. To compare outcomes of nurse case management by treatment algorithms with conventional primary care for glycemic control and cardiovascular risk factors in type 2 diabetic patients in a low-income Mexican American community-based setting, and to compare the cost effectiveness of the two programs. Patient compliance was also assessed. ^ Research design and methods. An observational group-comparison to evaluate a treatment intervention for type 2 diabetes management was implemented at three out-patient health facilities in San Antonio, Texas. All eligible type 2 diabetic patients attending the clinics during 1994–1996 became part of the study. Data were obtained from the study database, medical records, hospital accounting, and pharmacy cost lists, and entered into a computerized database. Three groups were compared: a Community Clinic Nurse Case Manager (CC-TA) following treatment algorithms, a University Clinic Nurse Case Manager (UC-TA) following treatment algorithms, and Primary Care Physicians (PCP) following conventional care practices at a Family Practice Clinic. The algorithms provided a disease management model specifically for hyperglycemia, dyslipidemia, hypertension, and microalbuminuria that progressively moved the patient toward ideal goals through adjustments in medication, self-monitoring of blood glucose, meal planning, and reinforcement of diet and exercise. Cost effectiveness of hemoglobin AI, final endpoints was compared. ^ Results. There were 358 patients analyzed: 106 patients in CC-TA, 170 patients in UC-TA, and 82 patients in PCP groups. Change in hemoglobin A1c (HbA1c) was the primary outcome measured. HbA1c results were presented at baseline, 6 and 12 months for CC-TA (10.4%, 7.1%, 7.3%), UC-TA (10.5%, 7.1%, 7.2%), and PCP (10.0%, 8.5%, 8.7%). Mean patient compliance was 81%. Levels of cost effectiveness were significantly different between clinics. ^ Conclusion. Nurse case management with treatment algorithms significantly improved glycemic control in patients with type 2 diabetes, and was more cost effective. ^

A focused ethnographic study of community social capital

Social capital, a relatively new public health concept, represents the intangible resources embedded in social relationships that facilitate collective action. Current interest in the concept stems from empirical studies linking social capital with health outcomes. However, in order for social capital to function as a meaningful research variable, conceptual development aimed at refining the domains, attributes, and boundaries of the concept are needed. An existing framework of social capital (Uphoff, 2000), developed from studies in India, was selected for congruence with the inductive analysis of pilot data from a community that was unsuccessful at mobilizing collective action. This framework provided the underpinnings for a formal ethnographic research study designed to examine the components of social capital in a community that had successfully mobilized collective action. The specific aim of the ethnographic study was to examine the fittingness of Uphoff's framework in the contrasting American community. A contrasting context was purposefully selected to distinguish essential attributes of social capital from those that were specific to one community. Ethnographic data collection methods included participant observation, formal interviews, and public documents. Data was originally analyzed according to codes developed from Uphoff's theoretical framework. The results from this analysis were only partially satisfactory, indicating that the theoretical framework required refinement. The refinement of the coding system resulted in the emergence of an explanatory theory of social capital that was tested with the data collected from formal fieldwork. Although Uphoff's framework was useful, the refinement of the framework revealed, (1) trust as the dominant attribute of social capital, (2) efficacy of mutually beneficial collective action as the outcome indicator, (3) cognitive and structural domains more appropriately defined as the cultural norms of the community and group, and (4) a definition of social capital as the combination of the cognitive norms of the community and the structural norms of the group that are either constructive or destructive to the development of trust and the efficacy of mutually beneficial collective action. This explanatory framework holds increased pragmatic utility for public health practice and research. ^

Family stress, coping, communication, and adaptation in unintended adolescent pregnancy

Objective. This study examines post-crisis family stress, coping, communication, and adaptation using the Double ABC-X Model of Family Adaptation in families with a pregnant or postpartum adolescent living at home. ^ Methods. Ninety-eight pregnant and parenting adolescents between ages 14 and 18 years (Group 1 at 20 or more weeks gestation; Group 2 at delivery and 8 weeks postpartum) and their parent(s) completed instruments congruent with the model to measure family stress, coping, communication, and adaptation. Descriptive family data was obtained. Mother-daughter data was analyzed for differences between subjects and within subjects using paired t-tests. Correlational analysis was used to examine relationships among variables. ^ Results. More than 90% of families were Hispanic. There were no significant differences between mother and daughter mean scores for family stress or communication. Adolescent coping was not significantly correlated to family coping at any interval. Adolescent family adaptation scores were significantly lower than mothers' scores at delivery and 8 weeks postpartum. Mean individual ratings of family variables did not differ significantly between delivery and 8 weeks postpartum. Simultaneous multiple regression analysis showed that stress, coping, and communication significantly influenced adaptation for mothers and daughters at all three intervals. The relative contributions of the three independent variables exhibited different patterns for mothers and daughters. Parent-adolescent communication accounted for most of the variability in adaptation for daughters at all three intervals. Daughters' family stress ratings were significant for adaptability (p = .01) during the pregnancy and for cohesion (p = .03) at delivery. Adolescent coping (p = .03) was significant for cohesion at 8 weeks postpartum. Family stress was a significant influence at all three intervals for mothers' ratings of family adaptation. Parent-adolescent communication was significant for mother's perception of both family cohesion (p < .001) and adaptability (p < .001) at delivery and 8 weeks, but not during pregnancy. ^ Conclusions. Mothers' and daughters' ratings of family processes were similar regarding family stress and communication, but were significantly different for family adaptation. Adolescent coping may not reflect family coping. Family communication is a powerful component in family functioning and may be an important focus for interventions with adolescents and parents. ^

Physiologic and psychosocial stage-based differences for dietary fat consumption in women with type 2 diabetes

Purpose. This cross-sectional, observational study explored differences among groups staged for intent to decrease dietary fat intake in women with type 2 diabetes in relation to demographic, weight concern, physiological, and psychosocial variables. ^ Methods. A sample of 100 community-dwelling, English-speaking women, who were over age 30 and had type 2 diabetes for at least a year, was accessed through a culturally diverse endocrinology clinic. Subjects completed 7 self-report instruments: demographic sheet, with 11-point weight satisfaction scale; staging algorithm; fat intake (MEDFICTS); depression (CES-D); diabetes-specific dietary knowledge (ADKnowl), social support and self-efficacy scales (SE-Type 2). Physiological variables were abstracted from the medical record (HbA 1c, blood pressure, serum cholesterol and triglycerides). ^ Results. The women's average age was 57.69 years ( SD = 3.07); 50% were married. Subjects were well-educated ( M = 14 years; SD = 3.33), with average diabetes duration of 10.57 years (SD = 9.11), high body mass index (M = 35.72; SD = 8.36), low diabetes-specific dietary knowledge, low weight satisfaction, but in good diabetes control. Racial/ethnic composition was 44% non-Hispanic-White-American, 18% Hispanic-White-American, 15% non-Hispanic-African-American, 16% Hispanic-African-American and 5% other. Fat intake was low and differed by racial/ethnic demographics. The highest fat intake scores were for non-Hispanic-African-Americans (M = 53), followed by Hispanic-White-Americans (M = 51), non-Hispanic-White-Americans (M = 45), and Hispanic-African-Americans (M = 32), who had the lowest fat intake scores. ^ MANOVA analyses revealed no significant differences between stages of behavior change in relation to psychosocial or weight concern variables, age, education, HbA1c, or cholesterol levels. Single women were more likely to be in the three preaction stages (precontemplation, contemplation, and preparation); married women were equally distributed across stages (the preaction stages plus action and maintenance). African-American women (Hispanic and non-Hispanic) were more likely in contemplation and preparation. Triglycerides were higher in women in the action stage than contemplation or preparation. Systolic blood pressure was higher in action than preparation; diastolic blood pressure was higher in action than preaction. ^ Conclusions. Healthcare professionals should consider race, ethnicity, and marital status in client interactions. Dietary intake can vary according to both race and ethnicity; collapsing racial/ethnic groups can alter means and distributions, generating faulty conclusions. Further research is warranted to explore relationships between dietary self-care and marital status, race, ethnicity, and physiological variables. ^

The meaning of informal BMT caregiving

Objectives. The aims of this qualitative descriptive exploratory study were to (1) describe informal caregiver commitment in informal caregiving; (2) describe caregiver expectations in informal caregiving; (3) describe caregiver role negotiation in informal caregiving, (4) identify other important caregiver energy sources; and (5) refine the conceptual model of Informal Caregiving Dynamics based on the study results. ^ Methods. Participants were 40 informal caregivers of blood and marrow transplant patients being treated at a comprehensive cancer center who told their caregiving stories in an audiotaped dialogue. Patients consented to have their caregivers contacted about the study and to have information collected from their medical records. To address the specific aims, the dialogues were analyzed for major elements and themes with an adaptation of the descriptive exploratory method. ^ Findings. Commitment was redefined as enduring caregiver responsibility that inspires life changes to make the patient a priority. Commitment calls caregivers to supportive presence and self-affirming loving connection with the patient. Expectation management was defined as envisioning the future and yearning to return to normal. Expectation management includes taking one day at a time, gauging behavior from past experiences with the patient, and reconciling anticipated to actual treatment twists and turns. Role negotiation was defined as appropriate pushing by the caregiver toward patient recovery and independence after getting a handle on complex care that demands shared responsibilities. Role negotiation happens as caregivers determine action with attention to patient voice and vigilantly bridge communication between patients and the health care system. Three additional energy sources of caring for self, gaining insight, and connecting with others, were identified and added to the model as underpinnings for commitment, expectation, and role negotiation respectively. ^ Discussion and implications. Methods of supporting informal caregivers that deserve investigation include consistent acknowledgment of caregiver contribution to patient care; provision of clear, present-focused information; opportunities to reconcile expectations with outcomes by developing a coherent caregiving story; and encouragement to maintain good health habits while caregiving. Patient contribution to the dynamics of caregiving warrants future research attention as does change in energy sources over time as a caregiver. ^

Factors affecting the symptom burden in chronic heart failure

Background. Heart failure (HF) is a health problem of epidemic proportions and a clinical syndrome that leads to progressively severe symptoms, which contribute significantly to the burden of the disease. Several factors may affect the symptom burden of patients with HF, including physiological, psychological, and spiritual factors. This study was designed to examine the inter-relationship of physiological, psychological, and spiritual factors affecting symptoms for patients with HF. ^ Objectives. The aims of this study were to examine symptom burden of heart failure patients related to: (1) the physiological factor of brain natriuretic peptide (BNP); (2) the psychological factor of depression; (3) the spiritual factors of self transcendence and purpose in life; and (4) combined effects of physiological, psychological and spiritual factors. One additional aim was to describe symptom intensity related to symptom burden. ^ Methods. A cross-sectional non-experimental correlational design was used to examine factors affecting symptom burden in 105 patients with HF from a southwestern medical center outpatient heart failure clinic. Both men and women were included; average age was 56.6 (SD = 16.86). All measures except BNP were obtained by patient self-report. ^ Results. The mean number of symptoms present was 8.17 (SD = 3.34) with the three most common symptoms being shortness of breath on exertion, fatigue, and weakness. The mean symptom intensity was 365.66 (SD = 199.50) on a summative scale of visual analogue reports for 13 symptoms. The mean BNP level was 292.64 pg/ml (SD = 57 1.11). The prevalence rate for depression was 43.6% with a mean score of 3.48 (SD = 2.75) on the Center for Epidemiological Studies - Depression scale (CES-D 10) scale. In a multivariate analysis, depression was the only significant predictor of symptom burden (r = .474; P < .001), accounting for 18% of the variance. Spirituality had an interaction effect with depression (P ≤ .001), serving as a moderator between depression and symptom burden. ^ Conclusion. HF is a chronic and progressive syndrome characterized by severe symptoms, hospitalizations and disability. Depression is significantly related to symptom burden and this relationship is moderated by spirituality. ^

The impact of a brief foot care intervention for persons with diabetes

Purpose of the study. The purpose of this randomized controlled clinical trial was to determine if a brief intervention would improve foot self-care behaviors in adult patients with Type 2 diabetes who presented to the emergency department for non-emergent care in a predominantly Hispanic southwestern border community. ^ Methods. A pre-post-test, three-group design was used to compare the foot self-care behaviors of patients who received usual care to those who received lower extremity amputation (LEA) risk assessment and to those who received LEA risk assessment plus a brief foot self-care intervention. After being randomized into 3 groups (N = 167), baseline assessments of demographics, diabetes history, acculturation, and the Summary of Diabetes Self Care Activities (SDSCA) questionnaire and Modified Insulin Management Diabetes Self Efficacy Scale (MIMDSES) were completed in English or Spanish. At one-month, 144 (84%) participants were available for follow-up by the research assistant masked to group assignment. ^ Results. At baseline, significant differences in foot self-care behaviors and self monitoring blood glucose were noted based on ethnicity and gender. Men had significantly lower confidence in their ability to manage their diabetes overall. There was a significant difference between baseline and follow up self reported foot self-care behaviors within the intervention group (t (47) = −4.32, p < .01) and the control group (t (46) = −2.06, p < .05). There were no significant differences between groups for self-reported foot self-care behaviors. There was a significant difference in observed foot self-care behaviors between groups (F(2,135) = 2.99, p < .05). Self-efficacy scores were positively correlated with self-reported self-care behaviors. ^ Conclusions. This predominantly Hispanic population with type 2 diabetes reported performing diabetes self-care behaviors less than five days a week. There were within group changes, but no significant between group changes in reported self-care behaviors. However, at the one month follow up, there were significant differences between groups in observed foot self-care behaviors with the intervention group demonstrating the most accurate behaviors. Differences based on gender and ethnicity emphasize the need to individualize diabetes education. Priorities for culturally competent diabetes education, approaches to increasing self-efficacy and future research directions are suggested. ^

Development and validation of the Neuro Symptom Inventory in the primary brain tumor patient population

Symptoms has been shown to predict quality of life, treatment course and survival in solid tumor patients. Currently, no instrument exists that measures both cancer-related symptoms and the neurologic symptoms that are unique to persons with primary brain tumors (PBT). The aim of this study was to develop and validate an instrument to measure symptoms in patients who have PBT. A conceptual analysis of symptoms and symptom theories led to defining the symptoms experience as the perception of the frequency, intensity, distress, and meaning that occurs as symptoms are produced, perceived, and expressed. The M.D. Anderson Symptom Inventory (MDASI) measures both symptoms and how they interfere with daily functioning in patients with cancer, which is similar to the situational meaning defined in the analysis. A list of symptoms pertinent to the PBT population was added to the core MDASI and reviewed by a group of experts for validity. As a result, 18 items were added to the core MDASI (the MDASI-BT) for the next phase of instrument development, establishing validity and reliability through a descriptive, cross-sectional approach with PBT patients. Data were collected with a patient completed demographic data sheet, an investigator completed clinician checklist, and the MDASI-BT. Analysis evaluated the reliability and validity of the MDASI-BT in PBT patients. Data were obtained from 201 patients. The number of items was reduced to 22 by evaluation of symptom severity as well as cluster analysis. Regression analysis showed more than half (56%) of the variability in symptom severity was explained by the brain tumor module items. Factor analysis confirmed that the 22 item MDASI-BT measured six underlying constructs: (a) affective; (b) cognitive; (c) focal neurologic deficits; (d) constitutional symptoms; (e) treatment-related symptoms; and (f) gastrointestinal symptoms. The MDASI-BT was sensitive to disease severity and if the patient was hospitalized. The MDASI-BT is the first instrument to measure symptoms in PBT patients that has demonstrated reliability and validity. It is the first step in a program of research to evaluate the occurrence of symptoms and plan and evaluate interventions for PBT patients. ^

Clinical decisions related to CBC screening of asymptomatic full-term infants at risk for group B streptococcus disease

Objective. Although complete blood count (CBC) changes occur with the development of clinical sepsis in newborns, the CBC has not been reported to be a sensitive predictor of sepsis in asymptomatic full-term newborn infants, nor has it been reported to be related to risk factors for sepsis or clinical decisions. The objective of this study was to evaluate the relationship between the WBC/I:T (immature:total neutrophil) ratio and maternal group B streptococcal (GBS) risk factors (rupture of membranes ≥18 hours, maternal temperature ≥100.4°F, maternal age ≤20 years, previous infant with invasive GBS disease, maternal GBS bacteriuria, and black ethnicity); and to evaluate the relationship between the WBC/I:T ratios and providers' clinical decisions (observe versus repeat the CBC or complete sepsis evaluation) in the asymptomatic full-term newborn at risk for early-onset GBS sepsis. ^ Methods. Medical records of infants admitted to the well baby nursery at a tertiary care teaching hospital in Houston, TX between 1/1/99 and 12/31/00 whose gestational ages were ≥35 weeks; who had mothers with GBS positive or unknown culture status and inadequate intrapartum antibiotic prophylaxis; and who had screening CBCs performed in the first 30 hours of life because of GBS risk were reviewed (n = 412). Demographic information, maternal GBS risk factors, CBC results, clinical decisions, and rationales for clinical decisions were collected. ^ Results. With the exception of black ethnicity (p = .0000, odds ratio = 0.213), no statistically significant differences in risk factors between infants with normal and abnormal WBC counts or normal and abnormal I:T ratios were found. Infants with abnormal WBCs had a significantly higher likelihood of having a CBC repeated (p = 0.002 for WBC). Providers documented the CBC result in the rationale for clinical decisions in 62% of the cases. ^ Conclusion. The CBC results were not related to maternal risk factors for GBS except for ethnicity. Black infants had significantly lower WBC levels than infants of other ethnicities, although this difference was clinically insignificant. Infants with abnormal WBCs had a significantly higher likelihood of undergoing repeat CBCs but not sepsis evaluations. Provider rationale was difficult to evaluate due to insufficient documentation. The screening CBC result did not impact the clinicians' decisions to initiate sepsis evaluations in this population. ^

The Spanish translation, cultural adaptation and validation of the Powe Fatalism Inventory

Background/significance. The scarcity of reliable and valid Spanish language instruments for health related research has hindered research with the Hispanic population. Research suggests that fatalistic attitudes are related to poor cancer screening behaviors and may be one reason for low participation of Mexican-Americans in cancer screening. This problem is of major concern because Mexican-Americans constitute the largest Hispanic subgroup in the U.S.^ Purpose. The purposes of this study were: (1) To translate the Powe Fatalism Inventory, (PFI) into Spanish, and culturally adapt the instrument to the Mexican-American culture as found along the U.S.-Mexico border and (2) To test the equivalence between the Spanish translated, culturally adapted version of the PFI and the English version of the PFI to include clarity, content validity, reading level and reliability.^ Design. Descriptive, cross-sectional.^ Methods. The Spanish language translation used a translation model which incorporates a cultural adaptation process. The SPFI was administered to 175 bilingual participants residing in a midsize, U.S-Mexico border city. Data analysis included estimation of Cronbach's alpha, factor analysis, paired samples t-test comparison and multiple regression analysis using SPSS software, as well as measurement of content validity and reading level of the SPFI. ^ Findings. A reliability estimate using Cronbach's alpha coefficient was 0.81 for the SPFI compared to 0.80 for the PFI in this study. Factor Analysis extracted four factors which explained 59% of the variance. Paired t-test comparison revealed no statistically significant differences between the SPFI and PFI total or individual item scores. Content Validity Index was determined to be 1.0. Reading Level was assessed to be less than a 6th grade reading level. The correlation coefficient between the SPFI and PFI was 0.95.^ Conclusions. This study provided strong psychometric evidence that the Spanish translated, culturally adapted SPFI is an equivalent tool to the English version of the PFI in measuring cancer fatalism. This indicates that the two forms of the instrument can be used interchangeably in a single study to accommodate reading and speaking abilities of respondents. ^

The effectiveness of a promotora-led intervention for Mexican Americans with type 2 diabetes

Purpose. The purpose of this randomized control repeated measures trial was to determine the effectiveness of a self-management intervention led by community lay workers called promotoras on the health outcomes of Mexican Americans with type 2 diabetes living in a major city on the Texas - Mexico border. The specific aims of this study, in relation to the intervention group participants, were to: (1) decrease the glycosylated hemoglobin (A1c) blood levels at the six-month assessment, (2) increase diabetes knowledge at the three and six-month assessments, and (3) strengthen the participants' beliefs in their ability to manage diabetes at the three and six-month assessments.^ Methods. One hundred and fifty Mexican American participants were recruited at a Catholic faith-based clinic and randomized into an intervention group and a usual-care control group. Personal characteristics, acculturation and baseline A1c, diabetes knowledge and diabetes health beliefs were measured. The six-month, two-phase intervention was culturally specific and it was delivered entirely by promotoras. Phase One of the intervention consisted of sixteen hours of participative group education and bi-weekly telephone contact follow-up. Phase Two consisted of bi-weekly follow-up using inspirational faith-based health behavior change postcards. The A1c levels, diabetes knowledge and diabetes health beliefs were measured at baseline, and three and six months post-baseline. The mean changes between the groups were analyzed using analysis of covariance. ^ Results. The 80% female sample, with a mean age of 58 years, demonstrated very low: acculturation, income, education, health insurance coverage, and strong Catholicism. No significant changes were noted at the three-month assessment, but the mean change of the A1c levels (F (1, 148 = 10.28, p < .001) and the diabetes knowledge scores (F (1, 148 = 9.0, p < .002) of the intervention group improved significantly at six months, adjusting for health insurance coverage. The diabetes health belief scores decreased in both groups.^ Conclusions. This study demonstrated that an intervention led by promotoras could result in decreased A1c levels and increased diabetes knowledge in spite of the very low acculturation, educational level and insurance coverage of the intervention group participants. Clinical implications and recommendations for future research are suggested. ^

Border intervention by Promotores for type 2 diabetes

Purpose of the study. This study had two components. The first component of the study was the development and implementation of an infrastructure that integrated Promotores who teach diabetes self-management into a community clinic. The second component was a six-month randomized clinical trial (RCT) designed to test the effectiveness of the Promotores in changing knowledge, beliefs, and HbA1c levels among Mexican American patients with type 2 diabetes. ^ Methods. Starfield's adaptation of the Donbedian structure, process, and outcome methodology was used to develop a clinic infrastructure that allowed the integration of Promotores as diabetes educators. The RCT of the culturally sensitive Promotores-led 10-week diabetes self-management program compared the outcomes of 63 patients in the intervention group with 68 patients in a wait-list, usual care control group. Participants were Mexican Americans, at least 18 years of age, with type 2 diabetes, who were patients at a Federally Qualified Health Center on the Texas-Mexico border. At baseline, three months, and six months, data were collected using the Diabetes Knowledge Questionnaire (DKQ, the Health Beliefs Questionnaire (HBQ, and HbA1c levels were drawn by the clinic laboratory. A mixed model methodology was used to analyze the data. ^ Results. The infrastructure to support a Promotores-led diabetes self-management course designed in concert with administration, the physicians, and the CDE, resulted in (1) employment of Promotores to teach diabetes self-management courses; (2) integration of provider and nurse oversight of course design and implementation; (3) management of Promotora training, and the development of teaching competencies and skills; (4) coordination of care through communication and documentation policies and procedures; (5) utilization of quality control mechanisms to maintain patient safety; and (6) promotion of a culturally competent approach to the educational process. The RCT resulted in a significant improvement in the intervention group's DKQ scores over time (F [1, 129] = 4.77, p = 0.0308), and in treatment by time (F [2, 168] = 5.85, p = 0.0035). Neither the HBQ scores nor the HbA1c changed over time. However, the baseline HbA1c was 7.49, almost at the therapeutic level. The DKQ, HBQ, and HbA1c results were significantly affected by age; the DKQ and HbA1c by years with diabetes. ^ Conclusions. The clinic model provides a systematic approach to safely address the educational needs of large numbers of patients with type 2 diabetes who live in communities that suffer from a lack of health care professionals. The Promotores-led diabetes self-management course improved the knowledge of patients with diabetes and may be a culturally sensitive strategy for meeting patient educational needs. The low baseline HbA1c levels in this border community suggested that patients in this Federally Qualified Health Center on the Texas-Mexico border were experiencing good medical management of their diabetes. ^

Exploring parents' memories of their child's death related sensory experiences as a dimension of grieving

Little is known about how dying children and their parents experience death. Dying children have reported death related sensory experiences (DRSEs), defined as seeing or hearing someone or something not visible or audible to others, associated with dying. Although parents report that they and the dying child benefit from these experiences, healthcare providers often unknowingly dismiss them. The aims of this phenomenological inquiry were to describe children's DRSEs and their meaning from the parents' perspectives. Four fathers and six mothers of African American, Caucasian, or Hispanic ethnicity, all Christian, ranging in age from 35 to 59 years, whose child died 23 to 52 months prior and was treated at a children's cancer center, were interviewed in the home or hospital setting of their choice. Children's ages at the time of their death ranged from 4 to 13 years. A modification of van Kaarn's phenomenological method of analysis was used to analyze data. Themes emerging from the data for the first aim were: perceiving someone or something from a spiritual realm others could not, expressing awareness tempered by parental reactions, and embracing transcendence. Themes emerging from the data for the second aim were: spiritual beings prepared child; child revealed reality, preparing parents; and child transcended wholly, easing parents' grief. Post-interview surveys revealed that parents found participating in this study a "very positive" or "positive" experience, particularly being able to tell the story of their child. Children's DRSEs have clinical implications for all who provide care near the end of life. Informing parents of DRSEs, cautioning that not all dying children express them, may help parents to anticipate this phenomenon, which may decrease anxiety when their child expresses them, increasing the opportunity for open dialogue between parent and child about dying and death, and decrease regrets associated with being unreceptive to their child's expressions of death awareness. Validating a child's DRSE can have profound effects on bereaved parents. Examining DRSEs from the child's perspective and the influence of informing parents of DRSEs on the dying experience of the child and the parental grieving process are recommended. ^