Background: Delirium, an acute decline in cognition and attention, is a common and severe problem for hospitalized older adults, with incidence rates ranging from 11% to 56%, and 1.5 to 4.0-fold increased risk of death. Despite its multifaceted nature, delirium is preventable in 30% to 40% cases. A California academic community hospital experienced a higher incidence of delirium (30% to 40%) in adult non-critical care units as compared to delirium rates (11% to 29%) in similar hospital settings. The higher rates of delirium were believed to be due to fragmented, inconsistent, and non-individualized delirium care. Purpose/Objectives: The purpose of this evidence-based, quality improvement project was to determine whether a nurse-led Delirium Prevention Bundle (DPB) when compared to usual care, reduces delirium incidence in hospitalized geriatric patients. Method: The project was a two-group, pre-post design using the nurse-led DPB educational intervention for nurses. The project was implemented in two stages: 1) an educational session for nurses on completing the DPB including the Delirium Risk Factor Identification (DRFI) tool, targeted delirium prevention strategies (based on the Hospital Elder Life Program), and nursing documentation; and 2) the DPB implementation on a 26-bed geriatric unit at a 250-bed academic community medical center. Baseline data on delirium incidence rates were collected on eligible patients on the geriatric unit for one month before the intervention and prospectively on patients who were eligible following the educational intervention. Demographic data on eligible patients and unit nursing staff as well as nurse knowledge of delirium and adherence to the DPB were collected. Statistical analyses included descriptive statistics, t-tests, and chi-square test. Results: implementation of nursing education of the DPB, the addition of the DRFI tool, and documentation template in the hospital Electronic Health Record, was effective in reducing delirium incidence rate from 16% to 14% (p =<.001) and improving documentation compliance from <1% to 17%. Nurse delirium knowledge was also improved significantly (pre-test mean 80.0, post-test mean 94.3, p=.029). Conclusion: Nursing education utilizing the DPB is an effective approach in increasing nurse awareness of preventive care for delirium and decreasing incident delirium in this population.

The boom of in-home monitoring technology offers unprecedented information about an individual’s interaction with the environment. A variety of low cost sensors can continuously and unobtrusively collect information about activities in the living space. Capturing early changes in the daily routines of vulnerable older adults residing in these “smart homes” may allow clinicians to predict and prevent negative health consequences through timely intervention. However, the current state of science is hampered by the lack of theoretically driven approaches to analyze sensor data in relation to clinically meaningful health outcomes. The aims of the study are 1) to characterize an older adult’s daily routine, as captured with smart home sensors, 2) to assess if deviations from it are indicative of changes in their health trajectory, such as falls, ER visits or unplanned hospitalizations, and 3) identify between person factors that affect the characteristics of the daily routine. It used previously collected data from 10 residents of TigerPlace, a unique retirement facility that evaluates health technology affiliated with University of Missouri, Columbia. Older adults live in apartments equipped with network of motion, depth and bed sensors that unobtrusively collect information about daily activity of its resident. Thirty months of continuous sensor data were analyzed in the context of bi-annual clinical assessments and nursing notes extracted from the electronic health record. A retrospective multiple case study approach is guided by the conceptual model developed for this study that is grounded in nursing and gerontological literature. Changes in the temporality and frequency of daily activity were found for common geriatric symptoms, such as urinary symptoms and confusion. Seasonal and weekly effect was evident across participants in the duration of time spent in various areas of the apartment. Participants varied in their baseline daily routines, but for the majority of symptoms there were prodromal changes in at home activity that was detected with sensors. As the cost of technology adoption decreases, nurses can use these innovative tools to coordinate care and intervene early to prevent or mitigate the functional decline associated with vulnerable older adults.

The population of the United States is aging. Depression in older adults has serious consequences. Social support has long been recognized as a beneficial and protective factor in the prevention of depression in older adults. Social media have allowed older adults to connect with their social networks and social support systems. The use of social media was highlighted during the coronavirus disease (COVID-19) pandemic as social distancing and self-quarantine discouraged face-to-face interactions. While social media behaviors and their influence on mental health is a growing area of research, the digital behaviors of an aging population specific to the relationship between their social media behavior, social network structures, social support, and depression under the context of the Coronavirus pandemic of 2019 (COVID-19) is understudied. This dissertation’s overall purpose is to explore the relationship between social media use, social support, and depression in older adults. The First Manuscript is a review of the literature aimed at identifying and synthesizing quantitative studies addressing the relationship between social media use and depression in older adults. The findings of this review showed a dearth of literature and a complicated relationship between social media use and depression in older adults. Furthermore, there is a paucity of studies that use validated measures to measure social media use in the older adult population. Age-related health and social variables could potentially influence the relationship between social media use and depression. Further, studies of current social media use measurements in older adults omit descriptions of social network characteristics to include social network structure and function. The Second Manuscript is a cross-sectional study of 371 older adults. Using multiple mediation models, this study examines the mediating effect of social support in the relationship of social network structures (online and offline) and depression in older adults. This study found that social support does not significantly mediate the relationship between online social network structure and depression. However, social support mediated the relationship between offline social network structure and depression to some extent. The tangible and emotional/informational social support domains did not mediate the known relationship between network structure and depression in older adults. Both structural sizes of online and offline social network size did not show any significant relationship to depression. The size of the offline social network, not the online social network size, predicted higher levels of social support. Higher total social support scores predicted lower depression scores in both online and offline network size models. Online and offline social network size models showed that increased social support predicts lower depression scores on all social support scales except the emotional/informational subscale. Certain domains of social support did not mediate the known relationship between offline social network structure and depression in older adults in the context of the COVID-19 pandemic. The Third Manuscript examined the mediating effect of social support in the relationship between social media use and depression in older adults, using the Social Media Use Integration Scale. This study showed that social support did not significantly mediate the relationship between social media use and depression in older adults in models that controlled for demographic and health covariates. Greater social media use significantly predicted higher depression scores in older adults when including only basic demographic covariates (β=.070, se=.333, p=.037). However, when health covariates are included, this significant association between social media use and depression is removed (β=.046, se=.032, p=.146). Social media use did not show a significant relationship with total social support scores and within each of its subscales in all our models. Increased social support predicts lower depression on all social support scales, except the emotional/informational subscale. The inclusion of health variables in social media use and depression studies could influence the identified relationship between social media use and depression outcomes for older adults. The COVID-19 pandemic, along with an infodemic, may have influenced the results of this study, as older adults’ social life changed—from their social media use, social support, and uncertainties brought about by the pandemic. This dissertation’s findings contribute to gaps in our understanding of an older adult’s social media and characteristics and media behavior and its relationship to depression and social support. Health and social variables must be considered when exploring the relationship between social media use and depression in older adults. The relationship between social network size (offline and online) to social support and depression might have been complicated during the COVID-19 pandemic as certain domains of social support did not offer significant benefits against depression.

Workplace violence (WPV) has been cited as one of the most worrisome occupational hazards for nurses (Gacki-Smith, Juarez, Boyett, Homeyer, Robinson & Maclean, 2009). Registered nurses (RNs) experience the majority of the incidences of WPV with a 5% increase in incidence since 2006 (Wassell, 2009 and the highest levels of WPV occur in psychiatric and emergency department settings (Chapman, Styles, Perry & Combs, 2010). This study employed a cross-sectional design using surveys administered online to Emergency Department RNs (ED RNs) via Facebook and staff emails in multiple Southern California hospitals and universities. This study examined the relationships between appraisal, coping styles, perceptions of organizational safety

and patient safety and intent to leave in ED RNs who have experienced WPV. The following tools were used: a modified version of Lazarus and Folkman's Ways of Coping questionnaire, the Jaloweic Coping Scale, the Survey of Perceived Organizational Support and the Safety Attitudes Questionnaire. Intent to Leave was measured using a two part question. A total of 190 surveys were initiated resulting in 159 complete. ANOVA statistics demonstrated a significant relationship between the appraisal question "You had to hold yourself back from doing what you wanted to do" and confrontive and fatalistic coping styles F (4, 161)= 2.50, p=.045 and F (4, 161) = 2.73, p=.031 respectively. The effects of fatalistic, evasive, emotive and optimistic coping were significant with organizational support, F (2, 162) = 3.40, p=.036, F (2,162)=3.837, p=.024, F (2, 162)=4.098, p=.018 and F (2, 162)=4.832, p=.009, respectively. Pearson correlation coefficients showed a positive correlation between PWPV and VWPV r(113)=.201, p <.05. Negative correlations existed between social support and PWPV and VWPV r(139)=-.210, p <.05 and r(129)= -.197, p <.05 respectively. The analysis of the relationship between organizational support and perceived patient safety demonstrated a significant correlation (rs[158] = 0.59, p <.0001). The Spearman's rho revealed a significant relationship between VWPV and perceived patient safety (rs[126] = -0.29, p < .001). Only 13.7% of ED RNs reported an intention to leave their current job in the next year, 19.8% said maybe and 53.8% said no. However, of the "yes" and "maybe" responses 49.2% reported that their intentions to leave were related to WPV. This study demonstrates relationships between higher levels of WPV (both verbal and physical), certain coping styles, organizational support and perceived patient safety. As levels of WPV increase, utilization of negative coping styles increases and perceptions of organizational support and patient safety decrease.

Background: The literature has shown that at least one medication discrepancy occurs in 75% ofhospital-to-skilled nursing facility (SNF) admissions. Medication discrepancies are responsible for over 1.5 million adverse drug events costing the United States health care system over $3.5 billion. The use of an electronic health record (EHR) to minimize medication discrepancies lends one of many avenues for further studies to evaluate means of reducing these discrepancies thereby improving patient care and outcomes. Objectives: This pre and post study design project evaluated the efficacy of an EHR on decreasing medication discrepancies during transition of care (TOC) of patients from the hospital to the SNF. Methods: Evaluation of the impact of a iii practice change (implementing the new EHR) focused on comparing medication discrepancies on patients admitted to one SNF from two related Los Angeles area hospitals. The pre-EHR group was compared to the post-EHR group for number and type of medication discrepancies. Documents reviewed included the hospital discharge (DC) summary, the hospital interfacility transfer summary, and finally the SNF admission orders for accuracy of medication lists. Results: Four types of medication discrepancies were significantly lower in the post-EHR sample compared to the pre-EHR sample. Specifically, discrepancies were lower post-EHR for omissions (p = .03), additions (p = .004), incorrect doses (p = .04), and missing frequencies (p = .01). Although the chi square analysis was not statistically significant at the p=.05 level, from a clinically significant standpoint two times as many post-EHR patients (34.1% versus 16.3%) had no medication discrepancies compared to pre-EHR patients. These results provide an indication that further projects exploring the implementation of an EHR to reduce medication discrepancies may be a valuable tool to aid in and improve patient care and outcomes specifically in relation to maintaining accurate medication lists. Conclusion: An EHR implemented into routine SNF care can reduce medication discrepancies on patients being admitted to the SNF from the hospital when used by SNF nurses to input newly admitted patient medication lists. Keywords: skilled nursing facility, medication errors, transition of care, medication reconciliation.

Stigmatization toward people with mental illness is a global problem that has been shown to have negative impact on the quality of life of those affected. In African countries, beliefs in supernatural causes of mental illness is a major driver of societal perceptions towards mental illness. Some healthcare professionals have also been found to share similar perceptions towards patients with mental illness and that the mechanisms of stigma can be redirected towards healthcare professionals, including nurses, who care for people with mental illness. This phenomenon is known as ‘associative stigma.’ Many African immigrant nurses are employed as mental health professionals and are dissatisfied and burned out at work, which may be exacerbated by associative stigma. Little is known about these types of stigma among African immigrant nurses based in the United States. Thus, the purpose of this study was to explore stigma towards individuals with mental illness among U.S.-based African immigrant nurses, the experiences of associative stigma among U.S.-based African immigrant nurses and the association with occupational burnout; and determine whether experiences of associative stigma was related to increased stigmatizing behaviors towards individuals with mental illness. The study was a cross-sectional survey assessing stigma among 73 U.S.-based African immigrant registered nurses and nurse practitioners recruited using voluntary response and snowball sampling methods. The survey utilized the Opening Minds Stigma Scale for Healthcare Providers (OMS-HC) to measure stigma, Clinicians’ Associative Stigma Scale (CASS) for associative stigma, Copenhagen Burnout Inventory (CBI) Scale for occupational burnout, and the modified Bicultural Involvement Questionnaire (M-BIQ) Scale measured the degree of acculturation. Statistical analyses using t-tests, ANOVA, and linear regression were conducted. Over three-fourths of the participants were female (76.7%, n = 56). Over half of the participants had more than ten years of experience as a nurse (54.8%, n = 40). The average age of the participants in the study was 47.19 years (SD = 10.09). The average age at migration of the participants was 26.46 years (SD = 8.73). The average time since migration was 20.42 years (SD = 9.51). The average stigma towards mental illness score was 30.22 points (SD = 7.12), which was a moderate level of stigma (range 15–75). The results of the study suggested that stigma of people with mental illness and occupational burnout have a significant positive association (b = 0.16, p = 0.03). Likewise, associative stigma of African immigrant nurses has a significant positive association with occupational burnout (b = 0.61, p = 0.01). These results implied that stigma toward persons with mental illness and the associative stigma experience of African immigrant nurses who care for them were associated with occupational burnout, and interventions should target these areas in healthcare workplaces to reduce burnout, thereby increasing the quality of care these nurses provide.

Objective: To determine if spiritual factors defined as positive spiritual coping, negative spiritual coping and spiritual resilience, are related to more positive health related outcomes (HROs), such as physical health, health related quality of life, well-being and CD4 counts and investigate if spiritual factors change the relationship between current substance use and parental substance abuse.Background: In 2022 African American Women were the second highest group to be diagnosed with HIV/AIDS disease, largely driven by personal and parental history of substance use disorder in African American Women which contributes to an increase in condomless sex with men with HIV. This leads women who have acquired HIV to rely on spiritual factors to deal with the reality of managing HIV/AIDS and the use of substances. Method: This study used a quantitative, cross-sectional internet survey design to understand the impact of spiritual factors related to specific health-related outcomes (HROs) in African American women with HIV. Regression analyses were conducted to examine the relationship between positive and negative spiritual coping, spiritual resilience and HROs. A moderation analysis was used to examine the ability of spiritual variables to moderate the relationship between current substance use and parental substance use. Based on prior knowledge the assumption is there is an association between parental substance abuse and current substance abuse which could then be moderated by spiritual factors. This relationship was examined and analyzed. Results: Thirty-eight Older African American Women (OAAW) from across the U.S. completed the internet survey. Significant results found that negative spiritual coping had a stronger impact in the research study than positive spiritual coping. In the unadjusted model, HRQOL and well-being both had inverse significant relationships with negative spiritual coping. When controlling for age and substance use, only HRQOL was statistically significant and inversely related. Positive spiritual coping was inversely related to HRQOL before controlling for age and substance use). After controlling for substance use and age, HRQOL was no longer significant. In the moderation analysis, positive spiritual coping moderated the relationship between current substance use and parental substance abuse. As positive spiritual coping increased, the relationship between current substance use and parental substance abuse strengthened. Conclusion: In this study, negative spiritual coping had a stronger effect on HRQOL outcomes and well-being than positive spiritual coping or spiritual resilience, suggesting that the use of negative spiritual coping impaired HRQOL in the participants. In addition, the finding that positive spiritual coping strengthened the relationship between personal and parental substance use was unexpected, as it is widely cited in literature that positive spiritual coping as a protective factor helps prevent drug use within families of people who engage in drug use. A possible explanation is that families who use drugs and have a strong family connection influence the individual’s risk of future substance use even when positive spiritual coping is practiced. Another explanation for the results is OAAW with difficult family influences rely heavily on positive spiritual coping. The associations of positive spiritual coping with the relationship between parental and individual substance use have not yet been fully elucidated but may be clarified through a future prospective study to look at positive spiritual coping over time

Managing a serious mental illness (SMI) is a precursor for multiple comorbidities, geriatric syndromes and premature mortality. The purpose of this dissertation was to examine the health status of 150 older African Americans diagnosed with SMI. The first manuscript examined chronic illnesses and geriatric syndromes among two age cohorts (< 55 years of age and 56 and older years of age). Utilizing descriptive, correlational, and bivariate analyses, the most prevalent medical conditions in this sample were hypertension (64%), chronic pain (60%), and arthritis (44%). The most frequently reported geriatric syndromes were sleeping problems (65%), vision issues (58%), and dizziness (47%). Psychiatric illnesses and geriatric syndromes were more found to be higher in the younger age cohort as compared to the older cohort.

The second manuscript focused on understanding the intersection of quality of life (QOL), self-perceived health and chronic health conditions. Almost two-thirds of the sample population rated their health as “fair” or “poor”. Lower scores of QOL was associated with multiple chronic health illnesses and geriatric syndromes, including major depression (p=.021), pain (p=.002), lung disease (p=.042).

The third manuscript investigated functional status and chronic health conditions in this population. The majority of the subjects (N=66, 44%) reported that their health is the same, while 31% stated that their health is worse than one year ago. Lower physical functioning was associated with panic disorder (p=.018), seizures (p=.039), pain (p=.03), and falls (p=.011).

The fourth manuscript focused on substance use among this population. Findings showed that less than half (42%) consumed alcohol, 46% are tobacco smokers, and half (50%) have either a current or former history of illicit drug use. Cigarette smoking was associated with asthma (p=.018), bladder control problems (p=.015), and schizophrenia (p=.004). Illicit drug use was associated with falls (p=.05) and vision problems (p=.046). Alcohol use was significantly associated with major depression (p=.026), kidney disease (p=.019), stomach disease (p=.05) and bladder control issues (p=.038).

These findings contribute to a growing body of literature regarding the health of minority populations diagnosed with SMI. Overall, the results can lead to the creation and implementation of nurse-driven interventions for populations of color.

Background: Caregivers are the foundation of care for patients with dementia (PWD), yet they receive little support or information when the PWD is hospitalized. Insufficient caregiver support results in poor caregiver self-efficacy (SE), which is the perception of one’s ability to successfully and confidently provide care for another individual. This project evaluated if a guidebook developed specifically for caregivers of PWD increased caregiver SE scores after an acute hospitalization. Methods: Using a single-group, single-center design, SE was evaluated in 35 caregivers before and after implementation of the Inpatient Dementia Guidebook in the geriatric unit of a large academic medical center in the Western United States. The Caregiver SE scale was administered pre-intervention and repeated within two weeks after discharge (post-intervention). Statistical analyses included descriptive statistics and Wilcoxon tests. Results: After administration of the Inpatient Dementia Guidebook, caregivers showed higher scores on the Caregiver SE scale, compared to the pre-tests (p < 0.001), which demonstrated an improvement in caregiver SE. Results also exhibited an increase in caregiver self-reported health (p = .002) and more frequent use of community-based organizations (p = .02) after the guidebook intervention. Conclusion: The provision of a guidebook was beneficial in supporting caregivers during an acute hospitalization. Thus, healthcare systems and hospitals should adopt similar measures to support caregivers for PWD. Key words: dementia, caregivers, self-efficacy, hospitalization, Alzheimer’s Disease

Background: The use of many medications is common among those over 65 and older living inthe United States. However, the increased number of medications used, especially prescription medications, results in harmful consequences: prescription of potentially inappropriate medications (PIMs) and medications without clinical indications. The World Health Organization reported that four out of ten patients are harmed in outpatient settings because of unsafe healthcare-related to wrong prescriptions. There are works of literature suggesting that healthcare providers (HCP) often do not follow clinical practice guidelines. Objectives: This quality improvement project implemented an NP-led educational intervention to decrease the frequency of potentially inappropriate medications in older patients in the outpatient setting. The intervention provided the healthcare providers a mechanism to address PIMs. Methods: This pre-post quality improvement project used a nurse practitioner-led educational intervention and applied an evidence-based screening tool to manage PIMs. This study was conducted between November 2020 and March 2021. Quantitative measurements were used to evaluate the intervention's effects in addressing PIMs in the outpatient setting in eight weeks. Descriptive statistics were used to characterize variable distributions. The t-tests estimated group comparisons between pre-educational intervention and post-educational intervention number of inappropriate medications, the proportion of patients with inappropriate medications, patients with duplicated medications, and medications that had matching diagnoses. Results: There were a total of 166 patients' medical records reviewed. The mean age for all the patients was 73.2, 49.4%, and the majority were female and predominantly Hispanic (50.6%). Throughout the entire period, reviewed medical records showed that the three most prevalent diagnoses were hypertension (63.9%), hyperlipidemia (49.4%), and type 2 diabetes mellitus (43.4%). There was no observed statistically significant difference in the number of inappropriate medications between pre-and post-intervention. However, there was a trend of improvement in the number of patients receiving duplicated medications from pre-intervention to post-intervention. Conclusion: Although there was no significant decrease in the frequency of inappropriate medications in the eight weeks, issues associated with PIMs in the multimorbid older patients require further quality improvement projects. A longer process evaluation period is necessary to provide HCPs the time to adapt and use evidence-based screening tools and increase patient-provider consistency in decreasing PIMs.

Keywords: inappropriate medications, older patients, outpatient setting, nurse practitioner-ledintervention.