Renee A. Milligan

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.

Measuring women's fatigue during the postpartum period.

The Fatigue Symptom Checklist (FSC) (Yoshitake, 1978), developed in Japan, was selected to measure postpartum fatigue among American women. Minor wording changes and a change in the reference time frame were made. Reliability and validity of this modification of the FSC were tested in this reanalysis of data from a longitudinal study of 285 mothers. Internal consistency reliability for the total 30-item FSC was acceptable. Evidence for criterion-related and construct validity was found. Original FSC subscales were not confirmed in these analyses. Using factor analysis, a shortened 10-item postpartum scale and two postpartum subscales, physical and mental fatigue, were identified. LISRAEL confirmatory factor analysis supported the subscales. Results support appropriateness of the total 30-item FSC, the shortened 10-item postpartum scale, and postpartum subscales for measuring postpartum fatigue in American women.

Determinants of Late Prenatal Care Initiation by African American Women in Washington, DC

Objectives: The objective of this study was to identify the determinants of late prenatal care (PNC) initiation among minority women in Washington, DC. Methods: DC-resident, African American women (n = 303) were recruited at 14 PNC facilities, representing the various types of PNC facilities located in DC: 4 hospital-based clinics, 5 community-based clinics, and 5 private practices. The women were interviewed at their first prenatal care visits to determine their perceptions of 63 barriers, motivators and facilitators influencing PNC initiation; substance use; and sociodemographic background. PNC initiation was classified as early (prior to the 20th week of gestation) or late (after the 20th week of gestation). The responses of women who initiated PNC early versus late were compared using bivariate and multivariate statistical procedures. Classification and Regression Trees analysis was used to identify groups at risk of late initiation. Results: Variables contributing to late PNC initiation included maternal age not between 20 and 29 years, unemployment, no history of previous abortions, consideration of abortion, lack of money to pay for PNC, and no motivation to learn how to protect ones health. Three risk groups for late PNC initiation included 1) women considering abortion and not employed outside their homes; 2) women not considering abortion who had no previous abortion experience; and 3) teenagers not considering abortion and with no previous abortions. Conclusions: The results of this study indicate that psychosocial barriers are more important than structural barriers. Of the psychosocial barriers, the major determinants of late PNC initiation were consideration of abortion and previous abortion experience.

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.

Nursing intervention to increase the duration of breastfeeding

T HE U.S. DEPARTMENT OF HEALTH and Human Services (1994) published the Healthy People 2000 guidelines as a statement of national concerns regarding health in the U.S. One Healthy People 2000 objective is to increase the percentage of women who continue to breastfeed for the first 6 months of their infants life. The American Academy of Pediatrics recommends that women breastfeed their infants for the first year of life (Gartner, 1997). An intervention that increases the duration of breastfeeding in low-income women offers health benefits to mothers and babies (Krebs & Murtaugh, 1997). The benefits of breastfeeding are well established. Women who breastfeed are less likely to develop osteoporosis and some forms of cancer (Cummings, Kelsey, & Nevitt, 1985; Michels et al., 1996; Schneider, 1987). Furthermore, breastfeeding is empowering for low-income minority women (Locklin & Naber, 1993). Infants who are breastfed for at least 4 months are less likely to die of sudden

Positioning intervention to minimize fatigue in breastfeeding women

Nursing interventions to enhance breastfeeding affect the health of mothers and babies. Fatigue may interfere with breastfeeding, so interventions minimizing fatigue are important. This repeated measures study of 20 postpartum women investigated the relative efficacy of one intervention, promoting use of the side-lying position. Using the Modified Fatigue Symptoms Checklist, fatigue was measured after breastfeeding in two positions. In mothers who had vaginal deliveries (n = 14), significantly less fatigue was reported following nursing in the side-lying versus the sitting position. Instruction regarding restfulness of the side-lying position should be considered as part of routine postpartum or home health nursing care.

THE BREASTFEEDING SUPPORT TEAM FOR LOW-INCOME, PREDOMINANTLY-MINORITY WOMEN: A PILOT INTERVENTION STUDY

This quasiexperimental pilot study explored whether a focused breastfeeding intervention had potential to improve outcomes in low-income breastfeeding women. Twenty breastfeeding women (10 in intervention and 10 in usual care) were matched on type of delivery, previous breastfeeding experience, and race. Women were low-income, young, 65% high school graduates, and 40% minority. For this intervention, the BST, a breastfeeding support team (community health nurse and peer counselor) provided hospital and home visits and telephone support. Outcomes were measured weekly for the first month, and monthly through month five. At all time periods, more women who received the intervention were breastfeeding. Further, they had less nipple discomfort in the first month; significantly less fatigue in month four and at three and five months reported less fatigue, depression, and anxiety.This quasiexperimental pilot study explored whether a focused breastfeeding intervention had potential to improve outcomes in lowincome breastfeeding women. Twenty breastfeeding women (10 in intervention and 10 in usual care) were matched on type of delivery, previous breastfeeding experience, and race. Women were low-income, young, 65% high school graduates, and 40% minority. For this intervention, the BST, a breastfeeding support team (community health nurse and peer counselor) provided hospital and home visits and telephone support. Outcomes were measured weekly for the first month, and monthly through month five. At all time periods, more women who received the intervention were breastfeeding. Further, they had less nipple discomfort in the first month; significantly less fatigue in month four and at three and five months reported less fatigue, depression, and anxiety.

Evaluating Diabetes Educational Interventions With a Skill Development Component in Adolescents With Type 1 Diabetes A Systematic Review Focusing on Quality of Life

Purpose Adolescents with type 1 diabetes mellitus (T1DM) may have reduced quality of life (QOL) when compared with their peers. This systematic review evaluated the effectiveness of diabetes self-management education (DSME) interventions with a skills development component on the QOL of adolescents with T1DM. Methods Six databases were systematically searched for studies on the QOL outcomes of DSME interventions for adolescents with T1DM. Fourteen studies published between 1994 and 2014 met the inclusion criteria. Results Of the 14 studies, only 4 had significant QOL outcomes for the intervention participants. Successful DSME interventions had indirect behavioral skills foci or a combination of indirect and direct behavioral skills foci and a duration ≥2 months. Conclusion This review provides evidence that educational interventions with an indirect behavioral skills development that facilitates diabetes management may improve QOL among adolescents with T1DM. Structured interventions targeting adolescents’ QOL are needed to determine which are most effective in improving QOL. Adolescents with T1DM should be routinely screened and monitored for low QOL and referred to QOL-improving interventions.