Linda C. Pugh

The middle-range theory of unpleasant symptoms: an update.

A detailed description of the newly revised and updated theory of unpleasant symptoms is provided. Revisions have resulted in a more accurate representation of the complexity and interactive nature of the symptom experience. Examples are provided to demonstrate the implications of the revised theory for measurement and research, and its application in practice. A detailed exemplar describes how it guided the design of a multifaceted intervention to encourage successful breastfeeding.

Collaborative development of middle-range nursing theories: Toward a theory of unpleasant symptoms

One promising approach to strengthening theory-research and theory-practice linkages is to place greater emphasis on developing and using theories of the middle range to underpin nursing research and practice. In this article, a postpositivistic definition of middle-range theory is advanced, an argument is made for shifting nursings theory development activities from discipline-defining grand theories to middle-range theories, and a collaborative and incremental approach to middle-range theory development is described and illustrated, A sustained substantive example is provided by the beginning development of a theory of unpleasant symptoms.

The influence of abuse on pregnancy intention

The preliminary investigation of the relationship of abuse to unintended pregnancy was conducted using focus group data. The two separate focus groups were held in Middle Atlantic urban and Southern urban. Results indicated the connections between relationship abuse and unintended pregnancy through partners control of contraception and the mans desire to have a child. Besides the lack of using contraception seemed to be related to the male partners definition for manhood. Mens refusal in using condoms contributes female partners risk of acquiring sexually transmitted diseases including HIV/AIDS. Moreover women in the focus groups suggest that health care professionals need to be assessed for abuse.

Evidence-based practice: a practical approach to implementation.

Organizations often do not have processes in place to support nurses through a systematic approach for developing and evaluating nursing interventions, protocols, critical pathways, and policies that are derived from scientific evidence. The development of a framework to guide inquiry will have a positive impact on patients. This process may foster a higher level of professional engagement by nurses that may, in the long-term, help improve nurse retention and recruitment. The authors discuss a nursing evidence-based practice model and guidelines that were developed by a team of hospital and academic nurse leaders and is practical and easy to use. This model has been successfully implemented across the department of nursing as a strategic initiative. Results of the implementation have shown that staff nurses can effectively use this model with the help of knowledgeable mentors.

A randomized controlled community-based trial to improve breastfeeding rates among urban low-income mothers.

OBJECTIVE The purpose of this study was to assess whether providing a breastfeeding support team results in higher breastfeeding rates at 6, 12, and 24 weeks postpartum among urban low-income mothers. METHODS DESIGN A randomized controlled trial with mother-infant dyads recruited from 2 urban hospitals. PARTICIPANTS Breastfeeding mothers of full-term infants who were eligible for Special Supplemental Nutrition Program for Women, Infants, and Children (n=328) were randomized to intervention (n=168) or usual-care group (n=160). INTERVENTION The 24-week intervention included hospital visits by a breastfeeding support team, home visits, telephone support, and 24-hour pager access. The usual-care group received standard care. OUTCOME MEASURE Breastfeeding status was assessed by self-report at 6, 12, and 24 weeks postpartum. RESULTS There were no differences in the sociodemographic characteristics between the groups: 87% were African American, 80% single, and 51% primiparous. Compared with the usual-care group, more women reported breastfeeding in the intervention at 6 weeks postpartum, 66.7% vs 56.9% (odds ratio, 1.71; 95% confidence interval, 1.07-2.76). The difference in rates at 12 weeks postpartum, 49.4% vs 40.6%, and 24 weeks postpartum, 29.2% vs 28.1%, were not statistically significant. CONCLUSIONS The intervention group was more likely to be breastfeeding at 6 weeks postpartum compared with the usual-care group, a time that coincided with the most intensive part of the intervention.

Childbirth and the measurement of fatigue.

Fatigue during labor concerns women and nurses alike, yet few studies have directly measured fatigue during childbirth. Many issues and difficulties with the conceptualization and measurement of fatigue have been raised because of the multidimensionality of the concept. Fatigue was conceptualized as including subjective, cognitive, and physical dimensions, and was therefore operationalized using multiple methods. In the two studies described, fatigue was measured using the Modified Fatigue Symptom Checklist (MFSC), the Pearson-Byars Feeling Checklist (PBFC), Visual Analogue Scales (VAS), the Digit Span Subtest of the Wechsler Intelligence Test (revised R), and a hand held bulb dynamometer. These studies support the reliability and validity of the measures used to quantify fatigue during labor. These findings support the operationalization of fatigue as a multidimensional concept.

Symptoms of Postpartum Depression Associated With Elevated Levels of Interleukin-1 Beta During the First Month Postpartum

Postpartum depression (PPD) is a devastating disorder that may carry lifetime consequences. Although several psychosocial risks for PPD have been identified, biological contributors are unclear. Elevated inflammatory cytokines contribute to depression in nonpregnant, nonpostpartum populations; yet, their role in PPD has been minimally studied. The objective of this study is to determine whether inflammatory cytokines early in the postpartum period contribute to the development of PPD. Women were recruited within 24 hr of delivery, and 26 provided urine for analysis of interleukin-1 beta (IL-1β) and interleukin-6 (IL-6) on postpartum days 7, 14, and 28. Participants completed a depression symptom survey (Centers for Epidemiologic Studies Depression Scale; CES-D) on Day 28. An increase in IL-1β was seen on Day 14 in women with symptoms of depression (CES-D ! 11) on Day 28 compared to levels in women without depressive symptoms (F = 4.50, p = .045). These preliminary findings suggest elevated IL-1β early in the postpartum period may increase the risk of PPD. Further studies involving a larger sample of women, including those clinically diagnosed with PPD, are required.

How Motivation Influences Breastfeeding Duration Among Low-Income Women

In-depth interviews were conducted with 44 low-income breastfeeding women to explore the incentives and disincentives to breastfeeding experienced within 6 months postpartum. Using an individual net benefit maximization (INBM) framework based on economic theory, we assessed womens motivations, incentives, and disincentives for breastfeeding. Based on the framework and their experience breastfeeding, women fell into 3 groups: intrinsically motivated, extrinsically motivated, and successfully experienced with both intrinsic and extrinsic motivation. Successfully experienced women were most likely to breastfeed to 6 months. Intrinsically motivated women valued breastfeeding but often required information and instruction to reach breastfeeding goals. Extrinsically motivated women were least likely to continue breastfeeding even with support and instruction. Providers can screen women to determine their experience and motivation then tailor interventions accordingly. Intrinsically motivated women may need support and instruction, extrinsically motivated women may benefit from motivational interviewing, and successfully experienced women may need only minimal breastfeeding counseling. J Hum Lact. 25(2):173-181

Breastfeeding Duration among Low Income Women

Breastfeeding has been identified as a possible deterrent to the development of osteoporosis and breast cancer in women. In addition, infants who are breastfed exclusively for at least 4 months reportedly have fewer incidence of SIDS, ear infection, diarrhea, and allergies. Further, low income women who breastfeed may be empowered by the experience. Increasing the frequency and duration of breastfeeding is recognized as a national priority, particularly for low income, minority women. Yet, recent national data indicate that in 1997, only 16.5% of low income mothers breastfed for at least 6 months. Short breastfeeding duration in low income women may be due to problems unique to them; thus, consistent and comprehensive breastfeeding support should be provided by midwives, nurses, lactation consultants, and peer counselors who are skilled in culturally sensitive management of lactation within the context of limited financial and social resources. This article focuses on the benefits of breastfeeding, and factors that may influence its duration. It also explores culturally relevant strategies as well as suggested interventions to increase breastfeeding duration among low-income women.

Interleukin-1ß elevation during the postpartum period

During the postpartum period, women frequently report increased fatigue, which, if severe, may interfere with maternal-child bonding, delay a new mother’s return to her activities of daily living, and contribute to depression. Several studies have sought to determine psychosocial contributions to fatigue during the postpartum period, but few evaluate any physiological changes that may contribute to fatigue during this time. The following study was designed to test whether the potent, proinflammatory cytokine interleukin-1beta (IL-1ß), known to be a physiological mediator of fatigue in several clinical and experimental conditions, is elevated in women during the postpartum period and whether it might be related to symptoms of fatigue. Levels of fatigue and the urinary excretion of IL-1ß were measured in 26 women over 4 weeks postpartum. Correlations between fatigue and activation of the inflammatory response were investigated. Results demonstrated a significant elevation in IL-1ß during the postpartum period compared to control participants (p < .05) and a significant, although delayed, correlation between IL-1ß elevation and fatigue (p < .05). These results suggest that activation of the inflammatory response, as reflected by elevation in urinary IL-1ß, occurs in association with postpartum fatigue. Studies to explore further this association and to identify specific mechanisms of action are needed.