Browsing by Author "Brandon, Debra"

Parental confidence is an important factor in gaining expertise in the parental role. The process of becoming a confident parent requires a personal belief in one’s own capacity but also the ability to engage in mastery experiences (e.g. repeated exposure to specific behaviors). Yet, this repeated exposure and ability to gain confidence in parenting may be limited when an infant requires complex care and hospitalization. The separation and limited interaction between an infant and parent alter the parenting trajectory and can halt confidence and ability to acquire parenting skills that are needed to meet the complex caregiving needs of an infant with medical complexity.

This dissertation aimed to develop knowledge related to parental confidence among parents of infants with medical complexity by clearly delineating the concept, understanding parent engagement within intensive care, exploring relevant contextual factors, and examining the development of confidence and factors contributing to change in parental confidence. The primary study conducted for this dissertation was an exploratory longitudinal multi-method study to examine the development of parental confidence, relationship between contextual factors and confidence, and the extent to which confidence, contextual factors, and parent/infant demographic characteristics predicted parent and infant outcomes. Findings demonstrated a significant increase in parental confidence over time and significant association between better family functioning and higher confidence. The higher confidence was also predictive of higher maternal psychological well-being three months after discharge. Furthermore, findings from a second mixed-methods study revealed that parents described confidence as either an emotional state of being or their ability to engage in specific behaviors. Using multiple methods to examine the development of confidence, essential knowledge was generated about how parents of infants with medical complexity gain confidence in their parental role. Recommendations for clinical practice and future research are provided to advance our understanding of parental confidence in order to positively impact parent and infant health.

Malawi has the highest preterm birth rate in the world and preterm birth contribute to more than one-third of the neonatal deaths annually. Malawi is also faced with limited resources, both human and material. The lack of incubators led to the adoption of Kangaroo Mother Care (KMC) as routine care for preterm infants. Families also provide support, physical and emotional during this entire period. Evidence from developed countries has shown that preterm birth contributes to maternal emotional distress (depressive, anxiety, and posttraumatic stress symptoms and maternal worry about child’s health) and fewer maternal and infant interactive behaviors. The majority of published research globally has also focused on early-preterm infants and little research has been done on late-preterm infants. Studies in Malawi have also largely focused on postpartum depression and no published literature could be located on mother-infant-interactions. The purpose of this study was to explore emotional distress and mother-infant interactions of mothers with early-preterm, late-preterm, and full-term infants in Malawi.

This mixed method study and three-part investigation was conducted at Queen Elizabeth Central Hospital. The first part of the investigation was translation and validation of the Perinatal PTSD Questionnaire and the Child Health Worry Scale as measures for posttraumatic stress symptoms and maternal worry about child’s health, respectively. I conducted a focus group discussion with Malawian nurse-midwives (N=8) to assess content of translations in relation to original. I also tested the instruments on mothers in the perinatal period (N=30; 10 mothers of early-preterm infants, 10 mothers of late-preterm infants, and 10 mothers of full-term infants). Validated instruments from first phase were used in the second phase of the study. The second phase of the investigation compared emotional distress and mother infant interactions among 85 mother-infant dyads (28 mothers with their early-preterm, 29 mothers with their late-preterm, and 28 mothers with their full-term infants). Baseline assessments were done following birth for the three groups and follow-up assessments were conducted for mothers of the preterm groups. I also recorded and coded videos of mothers and infants to assess mother-infant interactions. The third phase of the investigation was qualitative (N= 19; 7 mothers with early-preterm infants, 7 mothers with late-preterm infants, and 5 mothers of full-term infants) and explored maternal perceptions of sources of concerns and social support following birth of their infants. In-depth interviews were conducted at the end of the study.

Findings showed that mothers of early-preterm infants experienced higher levels of emotional distress than mothers of full-term infants, with mothers of late-preterm infants being intermediate between the two. Cesarean birth was also associated with more anxiety and depressive symptoms. Kangaroo Mother Care had minimal effects on the change of emotional distress in mothers of the preterm groups. However, KMC interruptions were associated with an increase in emotional distress. Minimal differences were seen in mother-infant interactions among the mothers and infants of the three groups. KMC had no impact on the interactive behaviors. Mothers’ concerns during infant hospitalization were personal and family factors; prenatal and perinatal experiences; infant illness, treatments, and appearance; concerns about the infant’s outcome; loss of parental role; health care workers and the healthcare system; infant care including breastfeeding concerns; and provision of KMC. Types of support received during the hospitalization included instrumental/tangible support, emotional support including spiritual support, and financial support. Mothers also preferred to have their own family as their caregivers during hospitalization.

Future studies need to focus on longitudinal methods to explore whether emotional distress experiences change over time and also to explore maternal and infant interactive behaviors as the babies mature. The Malawi healthcare system needs to provide support for mothers throughout the prenatal and perinatal period in order to lower maternal distress symptoms and promote positive mother-infant interactions.

Postoperative pulmonary complications (PPCs) remain a serious concern in health care. PPCs are associated with high rates of mortality and morbidity, intensive care admission, hospital length of stay, and resource utilization. PPCs are generally defined as any abnormality or condition involving the respiratory system that includes clinically significant dysfunction after surgery. PPCs are attributable to both modifiable and non-modifiable risk factors associated with characteristics of patients (e.g., age, sex, comorbidities), surgery (e.g., anatomical location, procedure length), and anesthesia (e.g., general anesthesia, mechanical ventilation). Although many PPC risks are not modifiable, intraoperative ventilation parameters (e.g., the fraction of inspired oxygen [FiO2], tidal volume [VT], sufficient positive end expiratory pressure [PEEP]) can be adjusted to reduce risk. Lung protective ventilation (LPV) has been adapted for intraoperative use to protect pulmonary parenchyma against ventilator-induced lung injury (VILI). LPV typically entails physiologic volume (i.e., lower VT) and pressure (i.e., PEEP), as well as optimal inspiratory time and alveolar recruitment maneuver. Despite growing evidence that intraoperative LPV can reduce the incidence of PPCs, questions remain regarding “how”, “when”, and for “whom” LPV can be used to reduce PPCs. Individualized care is one solution that could potentially minimize VILI leading to PPCs. Individualized care can be initiated by phenotyping patients based on observable nonmodifiable characteristics and modifiable characteristics as well as interactions among these characteristics. The goal of this dissertation was to advance knowledge around individualization of intraoperative ventilator parameters to reduce the incidence of PPCs. The first study (Chapter 3) answered “who” and “when” LPV in reducing the incidence of PPCs by leveraging the electronic health records (EHRs) and machine learning algorithms. We classified the adult surgical patients into phenotypes based on non-modifiable preoperative risks (e.g., age, sex, surgery type). First, a nonparametric machine learning algorithm, least absolute shrinkage and selection operator regression was used to select relevant variables. Then, a decision tree algorithm, classification and regression tree was then employed to identify phenotypic subgroups against the PPCs, and seven phenotypes were yielded for each outcome. This study suggested that phenotypes can be generated using the preoperative non-modifiable risks to predict PPCs. By extending the knowledge generated in chapter 3, the second study (Chapter 4) answered “how” to deliver individualized mechanical ventilation to optimize outcomes. We identified the optimal intraoperative mechanical ventilator parameters that were associated with the lowest incidence of PPCs for each phenotypic subgroup. The area under the receiver operating characteristic curve receiver operating characteristic curve was plotted using the estimates in the logistic regressions. The identified optimal values for VT and PEEP were associated with the lowest PPC incidence and the most desirable respiratory status postoperatively. What was considered optimal for VT and PEEP ranged between 5.11 and 9.31 ml/kg PBW and 5 and 11 cmH2O respectively. The results of this study suggested that intraoperative mechanical ventilator parameters should be adjusted based on a patient phenotype to optimize the postoperative outcomes. By utilizing machine learning algorithms and data-driven approach, this dissertation defined phenotypes based on non-modifiable preoperative PPC risk factors and identified the optimal ventilator parameters for each phenotypic subgroup. Simultaneously, we identified several future directions to advance our understanding on health care individualization to reduce incidence of PPCs and optimize PRS. This dissertation informs a future prospective study to vilify the optimal ventilator parameters, which may lead to the development of artificial intelligence to deliver individualized intraoperative mechanical ventilator parameters.

This dissertation aimed to investigate the use of electronic nursing documentation as a strategy to improve the quality of care provided to hospitalized patients. The literature to support the use of electronic nursing documentation on the quality of care delivered to patients is limited to date. Additionally, the literature describing the use of information for the delivery of care on paper-based nursing documentation is limited. This dissertation reviews the current literature, investigated the knowledge needed for nurses to know their patients and established categories of nurses' information needs as preliminary work to be able to descriptively compare the use of paper with electronic nursing documentation on inpatient care units within a hospital setting. The main study conducted for this investigation used a mixed-methods multiple case study design, to describe the processes of information use on two inpatient care units, while first using paper and subsequently electronic nursing documentation. Findings revealed the importance of the categories of nurses' information needs for both cases in addition to the use of verbal, paper-based and electronic information sources for the collection, communication and temporary storage of information needs. Additionally, the conversion to electronic nursing documentation introduced new challenges related to three quality metrics: efficiency, timeliness and safety. Recommendations are provided for further evaluation of electronic health records with additional consideration for appropriate hardware devices in the context of the care environment.

Obesity and overweight disproportionately impact Black American adolescent females—placing them at a lifetime of elevated physical health risks. Despite this burden, the literature that explores the contributors to obesity and overweight among Black American adolescent females remains limited and unclear. This dissertation aims to develop knowledge related to obesity and overweight in Black American adolescent females, by appraising the current understanding of factors that contribute to their obesity and overweight, and explicating the everyday social influences on dietary practices. The primary study conducted for this dissertation used a mixed method, multiple case study design to examine the mother, daughter, and other household contributors to Black American adolescent daughters’ everyday practices of food consumption, acquisition, preparation, and planning. Findings reveal the importance of understanding the complex and dynamic ways mothers and other household members contribute to a holistic view of everyday dietary practices among adolescent daughters. By deeply examining the nuanced ways the multiple cases varied, context-dependent knowledge essential to understanding the complicated health challenge of obesity was produced. Subsequently, recommendations are provided for health providers and scholars to more holistically approach and examine obesity—particularly among populations who are disproportionately affected.

For most parents there is no imaginable event more devastating than the death of their child. Nevertheless, while bereaved parents grieve they are also expected to carry on with their life. The day-to-day activities that were once routine for these parents may now be challenging due to the emotional turmoil they are experiencing. To date parental bereavement has been described as complex, intense, individualized, and life-long and their grief responses are interwoven with their daily activities, but the nature of their daily life challenges are not known.

This dissertation highlights the significance of how parents respond to their bereavement challenges because bereaved parents have higher morbidity and mortality rates than non-bereaved parents or adults who have lost their spouse or parents. Many bereaved parents in their daily routines include activities that allow them to maintain a relationship with their deceased child. These behaviors have been described as “continuing bonds”, but with this dissertation the continuing bonds concept is analyzed to provide a clear conceptual definition, which can be used for future research.

Using the Adaptive Leadership Framework as the theoretical lens and a mixed method, multiple case study design, the primary study in this dissertation aims to provides knowledge about the challenges parents face in the first six months following the death of their child, the work they use to meet these challenges, and the co-occurrence of the challenges, and work with their health status. Bereaved parents challenges are unique to their individual circumstances, complex, interrelated and adaptive, as they have no easy fix. Their challenges were pertaining to their everyday life without their child and classified as challenges related to: a) grief, b) continuing bonds, c) life demands, d) health concerns, f) interactions, and g) gaps in the health care system. Parents intuitively responded to the challenges and attempted to care for themselves. However, the role of the healthcare system to assist bereaved parents during this stressful time so that their health is not negatively impacted was also recognized. This study provides a foundation about parental bereavement challenges and related work that can lead to the development and testing of interventions that are tailored to address the challenges with a goal of improving bereaved parents health outcomes.

Problem: Many birthing individuals experience postpartum symptoms which are associated with adverse health conditions including long-term weight gain and depression. Postpartum symptoms often occur in clusters (i.e., three or more co-occurring symptoms that are related to each other) which makes it more difficult to manage. To date, research has been focused on individual symptoms which limits our understanding of how postpartum symptom clusters manifest and impact health. Therefore, the purpose of this dissertation was to develop knowledge on postpartum symptom clusters among birthing individuals. One systematic review (Chapter 2) and three quantitative studies (Chapters 3 to 5) were conducted to achieve this purpose.Methods: For the systematic review, five databases were searched to locate articles. Two reviewers performed title/abstract and full-text screening. Article qualities were examined using Standard Quality Assessment Criteria. Key information was extracted and synthesized using a narrative synthesis. For three quantitative studies, secondary data from the Community and Child Health Network study was used. First, latent profile analysis was performed in Chapter 3 to identify subgroups of postpartum women with different postpartum symptom profiles at 6 months postpartum using observed variables (i.e., general stress, posttraumatic stress, postpartum depression, and sleep disturbance-quality and -quantity). Next, in Chapters 3 to 5, associations between the identified symptom profiles and (a) clinical and social determinants of health (SDOH) characteristics and/or (b) maternal health outcomes (i.e., long-term depression, well-being, and allostatic load) were examined using bivariate and multivariate analysis. Findings: A total of 30 articles were included in the systematic review (Chapter 2). The majority were quantitative and cross-sectional. Factor analysis was the most frequently used. Stress, depression, somatic, and anxiety clusters were the most frequently identified. In Chapter 3, five distinct postpartum symptom profiles were identified which were labeled as Profile 1: Minimum, Profile 2: Highly disturbed sleep quantity, Profile 3: Mild-moderate, Profile 4: High, and Profile 5: High psychological symptoms. Postpartum women in high symptom severity profiles (Profiles 4 and 5) had significantly more early postpartum complications and a history of depression (Chapter 3). Experiences of different social-economic hardships (e.g., discrimination in healthcare settings or food insecurity) also had a significant impact on postpartum symptom profiles (Chapter 4). Furthermore, postpartum women in high symptom severity profiles had significantly higher depression at 18 and 24 months, lower well-being at 24 months, and higher overall allostatic load at 12 months (Chapters 3 and 5). Conclusion: This dissertation study found that birthing individuals do have complex and unique postpartum symptom cluster experiences and such experiences have a significant impact on their long-term health. Future research and practice should consider providing targeted interventions to optimally manage postpartum symptom clusters and prevent the development of adverse health outcomes. In doing so, it is critical to consider and address comprehensive SDOH from multiple layers of society.

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Very premature infants are at risk for thermal instability due to thermoregulatory immaturity. Thermal instability upon neonatal intensive care unit admission has been associated with mortality and morbidity in these infants. Bronchopulmonary dysplasia (BPD), a developmental respiratory morbidity, is the most common complication of very premature birth. BPD is associated with admission temperature instability; however, its relationship with longitudinal temperature instability is poorly understood. An exploratory mixed-methods approach was used to examine the association between very premature infant temperatures over time and acute and chronic respiratory morbidities. The impact of daily care and respiratory care on infant body temperatures over time was also examined.

Research in the systematic literature review (Chapter 2) found that lower incubator temperatures can result in cold and dehumidified inspired air, and cold and dry inspired air can alter infant thermal stability. The studies in Chapter 3 and 4 found that infant temperatures (i.e., body, foot, abdominal-foot (temperature differential)) did not change significantly across the first five and 14 days of life, respectively. Daily care, respiratory care, and artificial respiratory support (i.e., MV, CPAP, RA) were associated with hypothermia. In addition, infants without chronic lung disease (CLD) had lower body temperatures and longer episodes of hypothermia compared to infants with CLD. Also, acute respiratory morbidities (i.e., bradycardia with desaturations and increases in supplemental oxygen and increased respiratory support) were associated with higher odds of hypothermia.

The relationships between hypothermia and both daily care and respiratory care support the need for bundling infant care, and potentially limiting care duration. The associations between hypothermia and respiratory support and acute and chronic respiratory morbidities should be explored further using advanced longitudinal methodologies. Ecological momentary assessment (EMA) can help delineate antecedent-consequence relationships to guide future intervention studies that are designed to reduce infant thermal instability over time and its associated morbidities.