Member Scholarly Work

Member Scholarly Work

Share Your Research with other Epsilon Theta Members

We are pleased to provide our members with a spot to share their recent publications, presentations, and scholarly work. We hope you can connect with other Epsilon Theta members who share your interests. If you have any scholarly work you would like to share, email it to Megan Pfitzinger at

From Megan Pfitzinger:

Pfitzinger Lippe, M. “How STTI Chapters and Colleges of Nursing can make a Global Impact.”
Plenary Address, Sigma Theta Tau International Honor Society for Nursing Region 06
Research Conference, Shreveport, LA, April 2015.

Sigma Theta Tau International Honor Society of Nursing (STTI) chapters possess unique opportunities to
have an impact on the global landscape of health and human services. With members who are expert
nurses, researchers, philanthropists, and servants, each STTI chapter can find ways to impact their local,
regional, national, and global communities. The Epsilon Theta chapter has taken up STTI President
Hester Klopper’s call to “Serve Locally, Transform Regionally, Lead Globally.” By partnering with
organizations on campus and around the community, Epsilon Theta has identified multiple opportunities
to serve. At the local level, the chapter has conducted a fundraiser for a local wellness clinic and has
partnered with the College of Pharmacy to provide health education at Austin area health fairs.
Furthermore, plans are underway to partner with a local colon cancer foundation to provide health
education at an upcoming foundation event. At the global level, Epsilon Theta is arranging a donation
drive for books to help develop libraries in Africa. All of these service opportunities have been identified
from chapter member interests and passions for service. The steps taken by Epsilon Theta to answer the
President’s call can also be taken by other STTI chapters to have an impact around the globe.

Pfitzinger Lippe, M. “Decomposing End-of-Life Education: Identifying Successes and Gaps in
Current Education Practice.” Poster presentation, Sigma Theta Tau International Honor
Society for Nursing Region 06 Research Conference, Shreveport, LA, April 2015.

Purpose:  The purpose of this presentation is to share an innovative method for identifying critical components of palliative and end-of-life care education, derived from the End-of-Life Nursing Education Consortium (ELNEC) core curriculum. The identified components can be adapted into a survey to be used to determine components’ presence or absence within baccalaureate nursing programs. In the presentation, the researcher will present the decomposition method as well as the resulting identified key curricular components of the ELNEC core curriculum.

Methods: The ELNEC has developed a core curriculum for palliative and end-of-life care which is used to train nurses and nurse educators in accordance with current evidence based practice and healthcare standards. In the decomposition technique, programs are broken down into their key, essential components. Through this technique, the critical curricular components for palliative and end-of-life care education will be identified. The identified components can be adapted into a survey by which current baccalaureate programs can be evaluated for their inclusion or omission of critical content.

Findings: Critical curricular components have been identified for each of the eight ELNEC core curriculum modules. A survey was developed that includes these critical components. The survey will be used to assess a current baccalaureate curriculum in a future study.

Conclusions: This innovative decomposition technique provides a useful way for educational standards to be evaluated in detail within current baccalaureate nursing education programs.

Acknowledgement: Thank you to Dr. Gary Borich for sharing his decomposition technique.

Linton, B., Marquez, E., Pfitzinger Lippe, M., Seow, A., Spruell, C. “Palliative Care in Young
Adults with Cancer: Addressing Needs for an Overlooked Population.” Poster presentation,
McCombs Healthcare Symposium, Austin, TX, April 2015


Linton, B., Marquez, E., Pfitzinger Lippe, M., Seow, A., Spruell, C. “Palliative Care in Young
Adults with Cancer: Addressing Needs for an Overlooked Population.” Poster presentation,
St. David’s Centers for Health Promotion Research Annual Conference, Austin, TX, April

Purpose:  The purpose of this poster presentation is to disseminate results from an interdisciplinary (medicine, nursing, social work, counseling psychology, and pharmacy) project in which six domains of unique needs for young adults with cancer were identified and interventions proposed. For each domain primary goals/objectives, areas of shared responsibilities, and unique contributions by profession were identified to streamline future palliative care for our target population. The poster also presents an innovative method for identifying roles and responsibilities of healthcare professionals working in an interdisciplinary team.

Methods: Community partners from three Austin palliative care centers caring for young adults were interviewed to identify what, from experience, they have found to be the primary needs for this population. Literature from all five healthcare professions on the team was search in depth to find evidence to support identified needs and to identify additional areas of concern for the population. Extant literature was used to identify primary goals/objectives for each domain. Each healthcare professional then used literature and experience to identify, in a table format, what their respective profession does to help patients meet the identified goal/objective for each domain. Once the table was completed for all professions, commonalities across all disciplines were extracted as shared responsibilities. Remaining data were identified as unique contributions by profession.

Findings: Interviews and literature searching resulted in the identification of six domains: 1) health literacy, empowerment, and decision making in team approach; 2) symptom management; 3) fertility/sexuality; 4) peer and social isolation; 5) mortality, death and dying; and 6) end of life and advanced directive decision making. Goals for each domain all had at least one shared professional responsibility. Nursing and medicine both had unique contributions for all domains, whereas psychology and social work had unique contributions for all domains except symptom management. Pharmacy had unique contributions for all domains except the fifth and six domains.

Conclusions: This interdisciplinary method provided an innovative approach to identifying role and responsibilities for healthcare providers caring for young adults with cancer. The six identified domains need to be addressed, using proposed shared and unique interventions, by healthcare professionals working with young adults with cancer.

Acknowledgement: Thank you to course instructors Barbara Jones Ph.D., MSW, John Luk, M.D.,  and Mrinalini Kulkarni-Date, M.D.; Community partners Dr. Leigh Fredholm Seton Palliative Care Program, Christopher Hamilton (Young Adult Oncology Clinic), and Dr. Craig Hurwitz (Dell Pediatric Palliative Care Program); and additional partners Debra Sparks, LCSW and Holli Sadler, M.D.

Pfitzinger Lippe, M. (PI) & Carter, P. “Palliative Care Teaching Strategies in Pre-Licensure
Nursing Education: An Integrative Review.” Poster presentation, St. David’s Centers for
Health Promotion Research Annual Conference, Austin, TX, April 2014

Purpose: Current trends in the United States show that palliative care services are being used by Medicare patients at the highest rates in the past ten years (Teno et al., 2013). While there is a need for services, many nurses feel incompetent (Schlairet, 2009) and students experience anxiety (Smith-Stoner, 2011) in providing quality palliative care. Although education can be effective in decreasing student anxiety (Barrere, Durkin, and LaCoursiere, 2008) and increasing perceived competence (Allchin, 2006), little is known about which teaching strategies are most effective in increasing knowledge and competence in providing palliative care. Very little is known about how palliative care education impacts patient outcomes. An integrative review of the literature was conducted that critically evaluated characteristics and effectiveness of teaching strategies designed to improve student learning outcomes, and the subsequent impact on patient outcomes, associated with palliative care education.

Methods: An integrative review of the literature was conducted utilizing ten databases (both nursing and education). Articles from 1998 to present were considered, as this time marked the formation of the End of Life Nursing Education Consortium (ELNEC) that developed 15 palliative care competencies for practicing nurses. Multiple search terms where utilized to ensure all applicable articles were accessed. Articles were also obtained through manual searching of reference lists and related citations of relevant articles. A total of 14 articles were included in this review.

Findings: Palliative care education was most frequently taught within required courses not dedicated to palliative care or in palliative care elective courses. Lecture/didactic sessions were implemented most frequently (n=8), followed by film observation (n=5), and hospice clinical experiences (n=4). All other teaching strategies were implemented in only one or two studies. Teaching topics covered in the studies varied widely and most frequently focused on: nursing responsibilities, psychological topics, societal/cultural perspectives, the dying process, and ethical/legal issues. Learning outcomes demonstrated across a majority of studies included: decreased student anxiety (n=7), and increased knowledge (n=4), self-efficacy (n=2), and awareness about or appreciation of palliative care (n=4). A major limitation in the studies reviewed was over-inflated effect sizes, preventing critique of the effects of individual strategies. Additionally, no studies reviewed analyzed the effect of teaching strategies on patient outcomes.

Conclusions: The various teaching strategies utilized across studies demonstrated primarily positive student outcomes. However, the most significant findings from this review relate to the gaps or weaknesses in the literature that need to be addressed in future research. These gaps include: 1) inability to determine relative effectiveness of teaching strategies due to insufficient power and poor study design; 2) inability to distinguish the impact of multiple strategies when analyzed collectively within a specific course; 3) inadequate teaching strategy description for replication; and 4) lack of palliative care content taught within dedicated courses.

Acknowledgement: Thank you to Dr. Sharon Brown for all of her guidance and assistance in undertaking this integrative review.

From Janet Morrison:


Janet Morrison RN, MSN, MSCN

Alexa Stuifbergen, RN, PhD, FAAN

The University of Texas at Austin School of Nursing


Computer assisted cognitive rehabilitation programs (CACR) utilizing different software programs have proliferated yet little is known about user perceptions or preferences. The purpose of this study was to explore three software programs used to promote cognitive function in persons with MS.


Evaluation data from a community-based intervention study combining group sessions and CACR homework using the web-based Neuropsychonline (NPO) program revealed participant criticisms (unpleasant audio/visual features, unsophisticated animation and limited performance feedback). An 8-week follow-up study was conducted to evaluate two other web-based CACR programs: Challenging Our Minds (COM) and Lumosity. Fourteen individuals with MS were recruited from the completed NPO study; most were college-educated White females, average age of 49 years, diagnosed with MS for over 10 years. Participants were randomly assigned to COM (N=5) or Lumosity (N=9), completed five neuropsychological tests and the Everyday Problems Test-R (EPT-R) prior to and following 8 weeks of computer training, and logged the number of sessions and time spent practicing on-line each week.


The number of participants attaining the recommended number of minutes (1080) and sessions completed (24) was higher for Lumosity (78% minutes; 56% sessions) than COM (40% minutes; 20% sessions). Improvement on the neuropsych tests varied; yet 78% of those using Lumosity improved on the EPT-R compared to 20% of those using COM. Post-study evaluations of software usability had higher ratings for Lumosity than COM and recall of previous NPO practice.


Findings from this study indicate the participants completed more minutes of practice and more sessions with Lumosity than COM, showed greater improvement on a test of everyday neurocognitive functioning (EPT-R) with Lumosity than COM, and rated Lumosity higher on usability than COM or recall of NPO. Future studies should investigate the effects of CACR practice using high-usability web-based CACR programs in other populations with more diverse demographic and clinical characteristics.

Acknowledgement: Project support by Grant 1R21NR011076, NINR, NIH

Abstracts  July 2013 to present

Morrison, J. D., & Stuifbergen, A. (2014). Factors predicting fatigue impact in people with longstanding multiple sclerosis [Special issue: Abstracts from the 28th Annual Meeting of the Consortium of Multiple Sclerosis Centers]. International Journal of MS Care, 16(Suppl. 3), 103.

Stuifbergen, A., Becker, H., Schnyer, R., Kullberg, V., Morrison, J., Wommack, J., & Henneghan, A. (2014). Feasibility of combining group acupuncture with a wellness intervention for women with multiple sclerosis [Special issue: Abstracts from the 28th Annual Meeting of the Consortium of Multiple Sclerosis Centers]. International Journal of MS Care, 16(Suppl. 3), 98-99.

Morrison, J., & Stuifbergen, A. (2014, April). Computer programs to promote cognitive function in persons with multiple sclerosis. Poster presented at St. David’s Center for Health Promotion and Disease Prevention Research in Underserved Populations annual conference, The University of Texas at Austin. Abstract online:

Publications July 2013 to present

Morrison, J. D., & Stuifbergen, A. K. (2014). Outcome expectations for physical activity in persons with longstanding multiple sclerosis. Journal of Neuroscience Nursing, 46, 171-179. doi:10.1097/JNN.0000000000000050

From C. Andrew Martin:

Promoting Advance Directives and Ethical Wills With the HIV-Aging Cohort by First Assessing Clinician Knowledge and Comfort Level, Journal of the Association of Nurses in AIDS Care, In Press,
The cohort of HIV-infected adults is aging at a rapid rate. According to the Centers for Disease Control and Prevention, 31% of people living with HIV nationwide are over the age of 50 years, and data suggest that this rate will increase to 50% by 2015 (Department of Health & Human Services, Administration on Aging, n.d.). Thus, it is important for HIV care clinicians to question whether they are meeting the holistic needs of their clients. Who will serve as their clients' personal/professional caregivers and advocates? Will this be a population at risk for diminished social support secondary to stigma associated with HIV? Older HIV-infected adults, oftentimes socioeconomically marginalized, might have distinct perspectives on advanced care planning.

Aging ALONGSIDE HIV/AIDS: From a Caregiver's Viewpoint, 2014 HIV/AIDS and Aging Symposium; May 2, 2014; Austin, TX

During this one hour presentation, participants will be encouraged to create/facilitate self/client HIV/AIDS life stories through a discussion on the importance of documenting HIV/AIDS life stories.

Following a discussion on the importance of completing Advance Directives, participants will be guided to complete self/client Advance Directives.

After a discussion on ethical wills, participants will be led to draft/facilitate self/client ethical wills in the practice setting. Stream of conscious writing will be introduced as a method of self expression.

From Dr. Linda Benskin:

Unique Solution for Infected Lower Extremity Wounds with Extensive Tendon or Bone Involvement

Problem: An elderly diabetic woman came after three months of suffering from foot abscesses with destroyed joints and exudate deep in her sole. A 67-year-old woman with poor venous return from a knee deformity developed painful 9.0cmx4.5cm and 7.5cmx4.5cm foul-smelling abscesses with extensive tunneling beginning along her Achilles tendon, which was deteriorating with dried brown areas. A middle-aged man with Hansen’s disease had dorsal foot ulcers, including a heavily exudating 10.5cmx4cmx2cm wound with fully exposed tendons. Prior to coming to our remote clinic, these patients had no wound treatment other than keeping off flies with tied cloths.

Rationale: Components in polymeric membrane dressings (PMDs) draw and concentrate the body’s natural healing substances into the wound bed to promote rapid healing while loosening bonds between slough and the wound bed, atraumatically pulling the slough and excess exudate into the PMDs. The hydrophyllic foam and glycerin in PMDs helps moisturize structures such as tendon and bone.

Methodology: Treatment included oral antimicrobials, acetaminophen, prayer, nutritional counseling, and direct wound care. Initially, all wounds were sharply debrided and cleansed with saline or EUSOL. PMD filler was inserted into cavities and tunnels so all wounded surfaces contacted the dressing material. Exposed filler was covered with standard PMDs. Dressings were changed daily or every-other-day, with frequency decreasing as wound healing progressed. All three patients remained ambulatory throughout treatment.

Results: Exposed tendons and bones stayed moist and viable, allowing retention of full foot mobility. The diabetic woman’s wounds closed in 8 weeks. The Hansen’s’ sufferer experienced wound closure in 38 days. Even the woman with poor venous return received quick wound healing: slough was completely cleared in 3 weeks and all of her wounds were closed within four months.

Conclusion: PMDs kept these extensive lower extremity wounds with exposed structures clean and moist, supporting consistent, rapid healing.

Restoring Quality of Life for Patients with Infected Acute Wounds

Problem: Patients with acute wounds may not seek medical assistance until their wounds are severely infected. Keeping the wounds clean, decreasing pain, and promoting quick healing so that the patient can resume normal activities are the primary goals for these patients. At our clinic in northern Ghana, we found that polymeric membrane dressings (PMDs) were able to meet these patient needs while decreasing clinician time required for appropriate wound management. This case series describes three otherwise healthy patients with significant acute wounds who had no treatment until severe infections motivated them to request care.

Rationale: We wanted to meet patient goals to restore quality of life while using minimal clinic resources. Wounds managed with standard PMDs and PMD cavity filler in our clinic usually heal more quickly than those managed with other dressings. PMDs have a built-in non-toxic cleanser which loosens slough. This simplifies dressing changes because after initial cleaning/debriding, usually no further active cleansing is needed. The dressing change process is very quick and easy: just remove the used non-adherent dressing and apply a new one. Standard PMDs and PMD cavity filler also contain glycerin and a super-absorbent starch which pull fluid into the wound bed. Therefore, PMDs donate moisture to dry wounds while absorbing excess exudate. The components in PMDs, working together, can provide dramatic pain relief by inhibiting nociceptors.

Methodology: After initial cleansing/debriding, an appropriate configuration of PMDs was applied to the exposed surfaces of the wound; dressings were changed when saturated.

Results: All three patients healed quickly without return of infection. Usually no cleansing was necessary at dressing changes.

Conclusion: Management of these wounds with PMDs met patient goals: quick healing, freedom from infection, decreased pain and minimal inconvenience. In addition, with PMDs patients required far less time from our clinic staff through complete wound closure.

Pain Relief Provides Key to Healing for Patient with Circumferential Pyoderma Gangrenosum

Problem: A 37-year-old female ulcerative colitis sufferer developed an excruciatingly painful slough-filled lower leg pyoderma gangrenosum. Topically, only bismuth tribromophenate/petrolatum gauze dressings were tolerated. The patient required 6-8 propoxyphene/acetaminophen/day to keep her continuous pain at 5/10-8/10. Despite high doses of steroids, the wound increased to ~10cm x 7.5 cm.

Replacing dapsone with cyclosporine for three weeks failed to decrease the wound size and/or pain, so the patient decided (with physician consent) to try extra-thick polymeric membrane silver dressings (SPMDs) with email/telephone guidance.

Patient-centered goals were:

1) Decrease pain to permit wearing warm socks;

2) Close wound;

3) A more cosmetically acceptable scar than from a previous PG wound

Rationale: Pyoderma gangrenosum is a notoriously painful inflammatory wound. Manual debridement is contraindicated. SPMDs can help dramatically decrease pain and inflammation while gently continuously debriding wounds and promoting brisk wound healing. Bacteria are killed as they come in contact with silver PMDs. Extra-thick SPMDs provide cushioning and additional absorption.

Methodology: The patient changed the nonadherent SPMDs herself with frequent clinician email/telephone guidance, faithfully emailing digital photographs and faxing data collection sheets documenting every wound-related intervention. Initially, she sprayed tap water on the wound bed at dressing changes to decrease the dressing application’s impact (the dressing absorbed the free water before pulling fluid/slough out of the wound bed). SPMDs were changed twice daily for 8 weeks, then daily. Manual wound cleansing was never required.

Outcomes: The wound was markedly cleaner and measurably smaller by day four. The patient rapidly weaned herself off narcotic pain relievers. At less than one month, she wore warm socks. The wound fully closed in 3½ months. The patient was pleased with cosmetic outcome.

Conclusion: SPMDs, used persistently, resulted in decreased inflammation, excellent pain relief, brisk slough removal, and healing to closure. All patient goals were met or exceeded.

A Story Completion method for Obtaining Accurate Survey Data in Rural Areas of Developing Countries

Background: Unrelenting heat, poor sanitation, lack of knowledge, and poverty all contribute to a disabling wound prevalence often exceeding 20% in rural areas of tropical developing nations. Detailed descriptions of usual wound management practices by village care providers are needed to design effective, culturally appropriate wound management protocols. No such descriptions were found in the literature.

Purpose: A study design was needed to obtain accurate descriptions of usual topical wound management practices in tropical villages. Barriers to obtaining accurate survey data in this setting include:

1. cultural differences that prevent classical surveys from being understood

2. a universal reluctance to expose ones’ work to strangers for evaluation

3. a sense of hospitality which dictates that one provide pleasing answers, in preference to accurate answers

4. the challenge of presenting queries with adequate relevance to elicit quantifiable responses

Method: Thirty actual wound cases (photos/histories) were presented to five Ghanaians experienced in wound care and familiar with village life. Based upon their responses, seven cases were chosen as representative interview prompts for the 75 study participants in 25 villages throughout Ghana. Semi-structured interviews were guided by these case studies because story-telling is integral to village cultures and is relatively unintimidating. Open-ended questions avoided inferring that any particular aspect of wound management, such as cleansing, is expected.

Results: Most of the study participants offered detailed descriptive responses, verifying that the seven chosen wound exemplars were familiar and the case study method put them at ease. The eclectic detailed nature of the responses indicates that the participants did not simply provide answers they believed would be pleasing.

Conclusion: Using representative wound cases to elicit objective data overcame the significant barriers that have prevented researchers from discovering actual wound management practices in rural developing areas. This study design template can be utilized in other settings.


PROBLEM: Skin tears are an often overlooked wound type. Facilities need an effective evidence-based protocol for the prevention and treatment of skin tears that’s rigorous enough for physicians, but practical enough for teaching basic caregivers.

RATIONALE: An ideal protocol is evidence-based, addresses regulatory and in-servicing needs and can be used by all staff regardless of their training level. Patient, family and staff needs, including those for education, must be met. The protocol included polymeric membrane dressings because their attributes best met published skin tear dressing criteria.

METHODOLOGY: A new evidence-based skin tear protocol was beta-tested in nine facilities. After a thorough review of the literature, it was refined and detailed information on the causes and prevention of skin tears was added. The protocol was presented in over 450 long-term-care and other facilities. Independent clinicians divided skin tears into two groups. One group would be treated according to the new protocol; the second group would be treated according to prior practice. Both groups (4 – 12 new skin tears each) would be evaluated using one evaluation tool. Clinicians weren’t compensated for participating.

RESULTS: When caregivers saw the results of the new protocol, they often insisted on switching exclusively to the new protocol prematurely. Evaluation is on-going, but 60 days into the trial 88% of facilities who had completed the evaluation had ordered polymeric membrane dressings and converted to the new protocol. Nurses reported dressing changes using the new protocol took, on average, less than 2 minutes to complete. Cases healed in about 10 days with an average of just over 2 dressings. Early data shows previous methods took much longer and used significantly more dressings. Final conclusions await further data.

CONCLUSION: Preliminary results show the new skin tear protocol results in superior healing, decreased pain, and dramatically diminished dressing change time.

Wound Pain. What You Don’t Know Can Hurt . . . Your Patient

Speaker Introduction (40 words)

Dr. Linda Benskin is an international nurse researcher and educator who chose to specialize in wound care 15 years ago. She divides her time between teaching the latest modern evidence-based wound practices and researching sustainable wound management in developing countries.

Brief Description (60 words)

Pain may be “God’s greatest gift to mankind,” but it also can delay healing. This session is designed to offer beneficial information for both novices and experienced wound nurses. Learn how to assess the various types of pain your patients experience and discover innovative ways to help them control their pain in order to maximize healing and overall good health.

From Dr. Gendy Joiner-Rogers

Jurisprudence for Advanced Practice Nurses in Texas


Nursing jurisprudence is that area of law that is comprised of the legal laws, rules and regulations affecting the practice of nursing. Knowledge of and compliance with these rules and regulations assists in ensuring patient safety. When these rules and regulations are violated, complaint investigations may be conducted by the Texas Board of Nursing and/or civil or criminal charges may be brought regarding the conduct or decision making of the Advance Practice Nurse and their continued licensure to practice. Advance Practice Nurses should know how to avoid such situations and be able to identify elements of negligence. Advance Practice Nurses should also understand the Texas Board of Nursing investigation process and their legal rights to protect themselves should their practice come under review.


1. Become familiar with the Texas Board of Nursing rules and regulations including requirement for Jurisprudence continuing education for Advance Practice Registered Nurses

2. Know the five elements of negligence

3. Understand the Texas Board of Nursing investigation process and your legal rights if you/your license is under review

Involvement of Older-aged Adults in Chronic Illness Care Decisions: A Meta-synthesis

Purpose: This study aimed to describe perceptions of current older-aged community or facility-dwelling patients involvement in chronic illness care decision-making to meet the demand of future older-aged generations for person-centered chronic illness care.

Background/Significance: People are living longer due to advances in health care and healthier lifestyles; but longer life allows greater time to acquire and suffer from chronic disease. As people have aged and developed chronic illnesses, they have tended to become less involved in their health care decisions due to cognitive impairment, loss of interest, and/or loss of autonomy in institutional settings. It is likely that individualized, patient-centered chronic illness care provided by ARPNs will be in higher demand in the future due to the shortage of physicians specializing in gerontology and higher costs associated with physician provided care.

Description: A meta-synthesis of qualitative literature was conducted which included studies of chronically ill persons ≥ 50 years of age with minimal cognitive impairment and used a qualitative methodology describing older-aged persons’ perceptions of involvement in chronic illness care decisions. Five health databases were searched for terms including: decision-making, person-centered, older-age, nursing home, chronic illness, and involvement. Quality appraisal was based on data transformation. Domain and comparative analysis techniques were used. Trustworthiness was maintained through team discussion and audit trail.

From Dr. Patricia Carter

Sleep, Mood, and Social Media use in College Students. (Carter, P., Kercher, C. & Gettel, D.) SLEEP, Annual meeting of the Sleep Research Societies. Seattle, WA. June 2015 (Podium) [Also presented locally at St. David’s CHPR health disparities conference in Austin TX April 2015 (poster)]

Introduction: College students are notoriously poor sleepers. The overwhelming opportunities to be connected with their peers, demands of class schedules, and study hours often leave little time for sleep. Add to this the social expectations of being ‘plugged in’ to their networks and even rest time can be less than optimal. In order to better reach this at risk population we need to understand the relationships between college student sleep quality, depressive symptoms, and their use of social media.

Methods: We used a descriptive cross-sectional design to explore the relationships between college student sleep quality, depressive symptoms, and their use of social media. Sleep disturbance and impairment (PROMIS scales), sleep habits, depressive symptoms (CESD) and social media use were assessed using an online survey administered to full-time undergraduate and graduate students at The University of Texas at Austin.

Results:  141 students have completed the survey to date. Students are primarily female (84.5%), Caucasian (62.7%), and in their first two years of college (77.5%). Students reported moderate sleep disturbance and impairment and moderately high depressive symptoms. Sleep habits indicated irregular sleep schedules and an average of 5 hours sleep per 24/hour period. A majority of participants (93%) accessed social media at least daily using smart phones or computers. Sleep scores were significantly correlated with depressive symptoms (r=0.256, p=0.002). Social media use was significantly correlated with later sleep onset times (r=232, p=0.006).

Conclusion: College students are at increased risk for sleep deprivation and depressive symptoms. Social media use was correlated with later sleep times and may contribute to irregular sleep onset times. Further work needs to be conducted to inform students of the impact sleep quality can have on their mood and how poor sleep habits may contribute to lower sleep quality.

Brief Clinic Based CBTI for Patient-Caregiver Dyads (Carter, P. & Mikan, S.). Oncology Nursing Society 40th Congress. Orlando, FL. April 2015. (podium)

Significance/Background/Purpose: Over 40% of cancer patients and 50% of family caregivers experience insomnia. Cognitive behavioral therapies for insomnia (CBT-I) are effective in treating insomnia. However, the time burden associated with cancer treatment precludes additional travel for insomnia treatment. In response, we developed a brief CBT-I (cognitive therapy, stimulus control, sleep hygiene, relaxation techniques, and individual goal setting and monitoring) and explored the feasibility of delivering this brief CBT-I in the oncology clinic infusion room to the patient-caregiver dyad.

Design A 4-week quasi-experimental study design was used. Sleep was measured with Actigraphs, PSQI, and ISI. The CESD, PSS, and FACT-G were also used to assess contextual factors. Actigraphs were worn continuously for 4 weeks. Other measurments were taken weekly.

Findings: Four patient-caregiver dyads participated (n=8 individuals). Dyads were cohabitating. Patients’ mean age was 71 (SD=1.2), Caregivers’ mean age was 66 (SD=3.4). 3 of the dyads were legally married; one was an adult daughter-mother dyad. Two of the cancer patients were female, two male. Patient baseline sleep scores were: Duration 6.8h (sd=1.4); Latency 27m (sd=2); Efficiency 79% (sd=7). Caregiver baseline sleep scores were: Duration 5.5h (sd=.15); Latency 27.5m (sd=1.5); Efficiency 87% (sd=.5). Average PSQI improvement for patients was 2 points and 5 points for caregivers. The intervention administration averaged 60 minutes [initial] with 2- 15 minute follow ups. Infusion room nurses reported no interruption of workflow. A positive synergistic effect was noted by delivering this brief CBT-I to the patient and caregiver in a joint session.

Conclusions: Cancer patient-caregiver dyads report similar levels of sleep disturbance. This can be addressed with a brief CBT-I delivered during patient therapy in the infusion room with little to no negative effects on clinic flow. Patient-caregiver dyads learning to improve their sleep together may reinforce positive behavior changes that may result in greater improvements than seen with interventions targeting the individual. 

Oncology nurses frequently hear of patient-caregiver sleep disturbances. A brief CBT-I delivered in the infusion room to the dyad during therapy helps to bring empirically supported interventions to the dyad while they are already at the clinic. Further work is needed to determine longitudinal effects and wide scale implementation factors.

Sleep, Stress & Home Symptom Management in Cancer Patient-Caregiver Dyads (Carter, P., Mikan, S. & Patt, D) SLEEP, Annual meeting of the Sleep Research Societies. Minneapolis, MN. June 2014 (poster)

Introduction: To date, 41.4%% of cancer patients and 50% of family caregivers experience insomnia that can result in chronic sleep deprivation (CSD). CSD results in mood disturbances that further perpetuate insomnia symptoms. Cancer patient experiences and family caregivers’ responses to providing care to a loved one with cancer have been described separately; however, few have explored the dyadic interaction. And none have described the impact caregiver’s CSD has on home symptom management. The purpose was to explore the relationships between patient and caregiver symptoms and caregivers’ CSD impact on symptom management. Questions included:

  1. What are the relationships between caregiver confidence with symptom management & caregiver sleep quality?
  2. What are the dyadic relationships between Patient and Caregiver sleep, depressive symptoms, & perceived stress?

Methods: A cross-sectional descriptive design was used. Participants were adult, English speaking cancer patient-caregiver dyads recruited at a large community cancer center in Texas. Following consent, participants completed sleep (PSQI & ISI), mood (PSS & CESD), quality of life [patients] (FACT-G), and confidence in symptom management [caregivers] (investigator developed) questions.

Results: 25 dyads completed all items. Caregiver and patient mean ages were 61.2 and 59. Participants were 74% Caucasian, 14% Black, & 14% Latino. Sleep was moderately disturbed in caregivers and patients (PSQI m= 8.7 & 8.1; ISI m= 8.1 & 5.5). Mood was similarly disturbed (CESD m= 13.6 &13.2; PSS m= 22.0 & 22.3). Dyadic models using indicators of ISI or PSQI to predict CESD were similar, suggesting that patient sleep quality, whether specific or global, is a significant predictor of depression. Relationship status and patient ISI were the most significant predictors of stress.

Conclusion: Sleep is important to home management of cancer symptoms. Dyadic interactions demonstrate that work is needed to explore longitudinal relationships and the impact sleep interventions may have on patient outcomes.

Sleep affects my grades? Perceptions of college undergraduates.  (Carter, P., Schnyer, R., Betcher, M. & Hanna, C.) SLEEP, Annual meeting of the Sleep Research Societies. Baltimore, MD. June 2013 (poster) [Also presented locally at St. David’s CHPR health disparities conference in Austin TX March 27, 2013]

Introduction: First year undergraduate students at research intensive universities spend years gaining admission. Unfortunately, many suffer as they become independent adults with no ‘bed times’. In order to be academically successful, students must learn to structure their lives for success. These behavioral choices must rise to their attention and be deemed important to trigger change. We are exploring student perceptions of the relationships between sleep and performance.

Methods: This longitudinal study measures undergraduate sleep quality and perceptions of academic performance over time. First year students from The University of Texas at Austin are being enrolled. We are using the Insomnia Severity Index (ISI), two subscales of the PROMIS (Sleep Disturbance Scale & the Sleep Related Impairment Scale) and a Sleep in School scale. Measurements are taken at baseline, 8 and 12 weeks.

Results: Data collection is ongoing. 49 students have enrolled. Students are primarily female (92%), Latino (30%) or Caucasian (55%), living on (65%) or near (30%) the campus with one roommate (78%). There is a good mix of students across majors: Nursing (59%) and Natural Sciences (16%), while 10% were undeclared.  At baseline, students reported moderate insomnia levels (m=9;sd=4) sleep disturbances (m=21;sd=6), and daytime impairment (m=22;sd=6). Students also reported moderate academic performance problems (m=18;sd=6). Sleep and academic performance indicators were significantly correlated in many areas. Analysis of changes in sleep and perceptions of academic performance over time is ongoing and will be reported at the meeting.

Conclusion: New freedoms can come with a price. Teaching students how important sleep is to their goal of academic success is an important lesson to learn early! How to sleep better may be one of the most important things we can teach them; but they have to be ready to learn. Readiness starts with perception of need.   

From Dr. Linda Yoder

Should a Military Version of the Burn Specific Health Scale be Developed?

Linda H. Yoder, PhD, RN1; D. Curk McFall, MSN, RN1; Leopoldo C. Cancio, M.D., FACS2

1 University of Texas at Austin, School of Nursing, Austin, TX

2 US Army Institute of Surgical Research, Fort Sam Houston, TX

Introduction: There are three versions of the Burn Specific Health Scale (BSHS) currently in use: Abbreviated, Revised, and Brief. These quality of life (QOL) instruments have demonstrated reliability and validity in civilian burn populations. However, because military burn patients are typically younger and have physically demanding military duties, these versions of the BSHS might not provide the right constellation of questions, while minimizing response burden to the patient.

Methods: Seventy-eight participants were enrolled in this descriptive longitudinal study at the time of discharge. Data were gathered using the BSHS-A at 5 time points: burn center discharge; 3, 6, 12, and 18 months post-discharge. Frequencies on all items were examined to determine the 1) areas in which the service members experienced the most difficulty post burn, and 2) which questions might signal that additional screening would be warranted.

Results: The participants were primarily male (n=76), Army (74%), enlisted service members (96%) with an average age of 25 years; they served in the military for an average of 62 months. Most were Caucasian (69%), had at least a high school education or GED (56%) with an annual income of $40,000 or less (78%); 46% were single and 45% were married. They presented with thermal burns and polytrauma resulting from combat injuries and accidents with a mean total body surface area burned = 24% (median = 17%). At least 25% of the participants reported they had quite a bit to extreme difficulty in 13 areas that are not asked about in the BSHS-R or BSHS-B. Additionally, 6 questions only asked on the BSHS-A would indicate that further screening may be needed to determine mental health problems such as depression or post-traumatic stress or increased levels of pain. Furthermore, military participants indicated relatively few problems regarding 29 questions on the BSHS-A. Thirteen questions that can be found on all versions on the BSHS were identified as creating quite a bit to extreme difficulty among at least 25% the service members regarding their QOL. If a BSHS-M version were created that consisted of the questions designated as the most important for military burn patients it would consist of 32 questions with a Cronbach’s alpha of .92.

Conclusions: Because of the unique demographic characteristics and circumstances in which military service members are burned, a parsimonious QOL measure may be needed for this population. Since most of the patients were treated as outpatients at a facility located in a southern state with extreme heat conditions, questions about skin issues were of particular importance to these burn patients.

Applicability of Research to Practice: A military version of the BSHS would focus on the areas of importance to military patients and clinicians while decreasing response burden.

Grant Information: This study was funded by the TriService Nursing Research Program.