Anne G Rosenfeld

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• DeVon, H. A., Burke, L. A., Vuckovic, K. M., Haugland, T., Eckhardt, A. L., Patmon, F., & Rosenfeld, A. G. (2016). Symptoms Suggestive of Acute Coronary Syndrome: When Is Sex Important?. The Journal of cardiovascular nursing.
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  Studies have identified sex differences in symptoms of acute coronary syndrome (ACS); however, retrospective designs, abstraction of symptoms from medical records, and variations in assessment forms make it difficult to determine the clinical significance of sex differences.
• Knight, E. P., Shea, K., Rosenfeld, A. G., Schmiege, S., Hsu, C. H., & DeVon, H. A. (2016). Symptom Trajectories After an Emergency Department Visit for Potential Acute Coronary Syndrome. Nursing research, 65(4), 268-78.
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  Many patients evaluated for acute coronary syndrome (ACS) in emergency departments (EDs) continue to experience troubling symptoms after discharge-regardless of their ultimate medical diagnosis. However, comprehensive understanding of common post-ED symptom trajectories is lacking.
• McSweeney, J. C., Rosenfeld, A. G., Abel, W. M., Braun, L. T., Burke, L. E., Daugherty, S. L., Fletcher, G. F., Gulati, M., Mehta, L. S., Pettey, C., Reckelhoff, J. F., & , A. H. (2016). Preventing and Experiencing Ischemic Heart Disease as a Woman: State of the Science: A Scientific Statement From the American Heart Association. Circulation, 133(13), 1302-31.
• Coats, H., Crist, J. D., Berger, A., Sternberg, E., & Rosenfeld, A. G. (2015). African American Elders' Serious Illness Experiences: Narratives of "God Did," "God Will," and "Life Is Better". Qualitative health research.
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  The foundation of culturally sensitive patient-centered palliative care is formed from one's social, spiritual, psychological, and physical experiences of serious illness. The purpose of this study was to describe categories and patterns of psychological, social, and spiritual healing from the perspectives of aging seriously ill African American (AA) elders. Using narrative analysis methodology, 13 open-ended interviews were collected. Three main patterns were "prior experiences," "I changed," and "across past, present experiences and future expectations." Themes were categorized within each pattern: been through it . . . made me strong, I thought about . . . others, went down little hills . . . got me down, I grew stronger, changed priorities, do things I never would have done, quit doing, God did and will take care of me, close-knit relationships, and life is better. "Faith" in God helped the aging seriously ill AA elders "overcome things," whether their current illness or other life difficulties.
• DeVon, H. A., Piano, M. R., Rosenfeld, A. G., & Hoppensteadt, D. A. (2014). The association of pain with protein inflammatory biomarkers: A review of the literature. Nursing Research, 63(1), 51-62.
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  PMID: 24335913;Abstract: BACKGROUND: Pain is a key diagnostic criterion in many medical conditions. In the absence of self-reported pain, measurement of a proxy for pain, such as an inflammatory biomarker, could aid in diagnosis and disease management. OBJECTIVES: The aim was to determine if there is an association between inflammatory biomarkers and self-reported pain in individuals with medical conditions associated with the symptom of pain and to clarify whether inflammatory biomarkers might aid in the diagnostic process. METHODS: An integrative literature review was conducted. PubMed, CINAHL, and Cochrane databases were searched for articles published between January 2000 and September 2012. Inclusion criteria were original research testing a relationship between inflammatory biomarkers and pain, pain measurement, laboratory measure of inflammatory biomarkers, and a prospective single-group experimental design or comparative nonrandomized or randomized design. Excluded were studies describing an association between inflammatory biomarkers and treatment, risk, and generation; pathophysiology; or genetic polymorphisms/transcripts. Ten studies meeting inclusion criteria were reviewed. RESULTS: In most of the studies, baseline elevations in both proinflammatory and anti-inflammatory cytokines were reported in painful conditions compared with healthy controls. In half of the studies, higher levels of proinflammatory markers (C-reactive protein, tumor necrosis factor-alpha, interleukin-2 [IL-2], IL-6, IL-8, IL-10, and CD40 ligand) were associated with greater pain. Proinflammatory cytokines decreased after treatment for pain in only two studies. DISCUSSION: The association between inflammatory markers varied in the direction and magnitude of expression, which may be explained by differences in designs and assays, disease condition and duration, variations in symptom severity, and timing of measurement. Elevation in anti-inflammatory cytokines in the presence of pain represents a homeostatic immune response. Further study is required to determine the value of cytokines as biomarkers of pain. Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.
• Dale, D., Rosenfeld, A. G., & Gilbert, K. (2013). Lives forever changed: Family bereavement experiences after sudden cardiac death. Applied Nursing Research, 26(4), 168-173.
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  PMID: 23968781;Abstract: Aim: To describe the bereavement experiences of families who survived the sudden cardiac death of a family member and identify meanings of loss. Background: Approximately 325,000 people experience sudden cardiac death (SCD) annually. It is important to examine family experiences after SCD because of the life altering impact of death on surviving family members. Methods: A descriptive design, using the qualitative method of narrative analysis, was used to analyze family stories of bereavement. Results: Five themes were identified across seven families: sudden cardiac death boom; saying goodbye; grief unleashes volatile emotional reactions; life goes on but never back to normal; and meanings in loss. Conclusions: This study adds to an understanding of family bereavement and findings suggest that providing information about the cause of death and allowing family members to tell their stories are potentially important interventions for clinicians who interact with bereaved families. © 2013 Elsevier Inc.
• DeVon, H. A., Patmon, F. L., Rosenfeld, A. G., Fennessy, M. M., & Francis, D. (2013). Implementing Clinical Research in the High Acuity Setting of the Emergency Department. Journal of Emergency Nursing, 39(1), 6-12.
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  PMID: 23099018;PMCID: PMC3655425;Abstract: Introduction: Clinical research in the emergency department provides supporting evidence needed for the development of practice guidelines, such as door-to-needle and door-to-balloon times for treatment of acute coronary syndromes, and is vital to improvements in patient outcomes. The purpose of this article is to describe barriers and lessons learned in launching a multisite clinical research study of symptoms of acute coronary syndromes in the emergency department. Methods: Participants included ED and research staff in 4 busy emergency departments in 3 states. At each step of the study launch, the principal investigator at the clinical site identified barriers that either were anticipated or experienced and discussed them with the site staff and study principal investigator to validate the issue as a barrier. Orientation sessions and ongoing communication between clinicians, research staff, and the research study team provided opportunity for adjustment of study protocols. Results: Barriers were lack of staff engagement in research, difficulty identifying eligible patients, perception of interference in clinical care, variability in research staff education and training, patient refusals, nurses' perceptions of lack of time, undifferentiated patients, and time-sensitive quality improvement indicators necessitating acceleration in care. Discussion: Important strategies to overcome barriers were developed, including identification and support of unit champions in emergency nursing and medicine; minor protocol modifications to improve enrollment goals; development of specific written expectations, roles, research protocols, and algorithms; and sharing successes among sites. © 2013 Emergency Nurses Association.
• DeVon, H. A., Rosenfeld, A., & Daya, M. (2013). Cardiac symptoms in women and men. JAMA Internal Medicine, 173(20), 1927-1928.
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  PMID: 24217380;
• Rosenfeld, A., Christensen, V., & Daya, M. (2013). Long enough to act?: Symptom and behavior patterns prior to out-of-hospital sudden cardiac death. Journal of Cardiovascular Nursing, 28(2), 166-175.
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  PMID: 22343214;Abstract: BACKGROUND:: Sudden cardiac death is a major cause of death in the United States. Most cases occur outside the hospital, yet little is known about the symptoms and actions of individuals who die before reaching the hospital. OBJECTIVE:: The purpose of this study was to describe the symptoms, symptom management, and care-seeking patterns in sudden cardiac death victims. METHODS:: This cross-sectional study used qualitative and quantitative data collection methods to obtain descriptions of symptoms and treatment-seeking delay from family members and bystanders (respondents) in 140 cases of sudden cardiac death due to presumed myocardial infarction. Decedents were identified from death certificate data from the state of Oregon in the United States. Respondents completed a survey of demographics and myocardial infarction symptoms and an in-depth interview. Narrative analysis was used to analyze qualitative data. RESULTS:: Three behavior patterns or trajectory types were developed focusing on key characteristics of the symptom patterns, the meanings attributed to those symptoms, the actions taken by the decedents and their family members or bystanders, and the time course of events. Each case was categorized as 1 trajectory type. The trajectory types are Normal Day (n = 49), Something Not Right (n = 62), and Thought It Was Something Else (n = 29). The key distinction across the trajectory types is the perception and interpretation of symptoms and the resulting actions between symptom perception and death. CONCLUSIONS:: This study is 1 of the first to describe what victims of sudden cardiac death are doing and thinking during the period between symptom onset and collapse. The trajectory types identified in this study suggest that misinterpretation of symptoms (the Something Not Right and Thought It Was Something Else groups) is common among victims and bystanders. Copyright © 2013 Lippincott Williams & Wilkins.
• Lasater, K., Ray, L., Driever, M. J., Rosenfeld, A., & Bradley, K. J. (2008). Creating international conference submission and review guidelines to facilitate transnational dialogue. Journal of Continuing Education in Nursing, 39(10), 473-479.
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  PMID: 18990894;Abstract: Globally, nurses have much knowledge to share and the increased calls for conference presentation abstracts reflect this. However, a recent literature review revealed no guidelines for presentation submission and review processes for international nursing conferences. During the past decade, one conference, the U.S.-Russian Conference Cruise, has used evaluation data from each conference to shape its submission and review processes in a way that promotes transnational dialogue during the conference. The purpose of this article is to describe the challenges and evolution of designing submission and review processes that support the goal of a scholarly program of intercultural exchange.
• Perry, C. K., Rosenfeld, A. G., & Kendall, J. (2008). Rural women walking for health. Western Journal of Nursing Research, 30(3), 295-316.
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  PMID: 17634383;Abstract: The purpose of this qualitative study is to describe rural women's barriers and motivators for participation in a walking program. Twenty rural women, ages 22 to 65, participated in a 12-week walking program. Data from field notes and focus groups were analyzed using qualitative content analysis. Data were inductively coded, codes were categorized into themes, and themes were classified as barriers or motivators to adopting a walking program. Three main barriers are identified: balancing family and self, chronic illness gets in the way of routine, and illness or injury breaks routine. Seven motivators are identified: being part of a group, group camaraderie, learning, pacesetter, seeing progress, energizing, and I am a walker. Women report that family responsibilities are a powerful and pervasive barrier. Motivators center on the importance of group interaction. This qualitative study increases our understanding of rural women's barriers and motivators to embarking on and sustaining a regular walking routine. © 2008 Sage Publications.
• Stephen, S. A., Darney, B. G., & Rosenfeld, A. G. (2008). Symptoms of acute coronary syndrome in women with diabetes: An integrative review of the literature. Heart and Lung: Journal of Acute and Critical Care, 37(3), 179-189.
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  PMID: 18482629;Abstract: Objective: To review studies comparing multiple acute coronary syndrome (ACS) symptoms in white and Latina women with and without diabetes. Methods: This empirical integrative review summarizes 8 studies and identifies the limitations of research to date. Results: There are conflicting results about acute coronary syndrome (ACS) symptoms in women with diabetes. Differences were found in associated ACS symptoms and symptom characteristics; however, some studies found no differences in frequency of chest pain by diabetic status. Diabetes is an independent predictor of "atypical" presentation of acute myocardial infarction in women, and research to date suggests that shortness of breath may be an important ACS symptom in women with diabetes. Conclusions: There is a paucity of literature on ACS symptoms in women, particularly Latina women, with diabetes, and results are inconclusive. Future research should examine the full range of ACS symptoms in multiethnic samples of women with diabetes. © 2008 Mosby, Inc. All rights reserved.
• Perry, C. K., Rosenfeld, A. G., Bennett, J. A., & Potempa, K. (2007). Heart-to-Heart: Promoting walking in rural women through motivational interviewing and group support. Journal of Cardiovascular Nursing, 22(4), 304-312.
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  PMID: 17589283;Abstract: BACKGROUND: Walking can significantly increase cardiorespiratory fitness and thereby reduce the incidence of heart disease in women. However, there is a paucity of research aimed at increasing walking in rural women, a high-risk group for heart disease and one for which exercise strategies may pose particular challenges. PURPOSE: This study tested Heart-to-Heart (HTH), a 12-week walking program, designed to increase fitness through walking in rural women. Heart-to-Heart integrated individual-oriented strategies, including motivational interviewing, and group-based strategies, including team building. METHODS: Forty-six rural women were randomized to either HTH or a comparison group. The primary outcome of cardiorespiratory fitness and secondary outcomes of self-efficacy and social support were measured preintervention and postintervention. Group differences were analyzed with repeated-measures analysis of variance. RESULTS: Women in HTH group had a greater improvement in cardiorespiratory fitness (P =.057) and in social support (P =.004) compared with women in the comparison group. Neither group of women experienced a change in exercise self-efficacy (P =.814). CONCLUSIONS: HTH was effective in improving cardiorespiratory fitness in a sample of rural women. Further research is needed to refine HTH and determine the optimal approach in rural women to increase their walking. © 2007 Lippincott Williams & Wilkins, Inc..
• Ryan, C. J., Devon, H. A., Horne, R., King, K. B., Milner, K., Moser, D. K., Quinn, J. R., Rosenfeld, A., Hwang, S. Y., & Zerwic, J. J. (2007). Symptom clusters in acute myocardial infarction: A secondary data analysis. Nursing Research, 56(2), 72-81.
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  PMID: 17356437;Abstract: BACKGROUND:: Early recognition of acute myocardial infarction (AMI) symptoms and reduced time to treatment may reduce morbidity and mortality. People having AMI experience a constellation of symptoms, but the common constellations or clusters of symptoms have yet to be identified. OBJECTIVES:: To identify clusters of symptoms that represent AMI. METHODS:: This was a secondary data analysis of nine descriptive, cross-sectional studies that included data from 1,073 people having AMI in the United States and England. Data were analyzed using latent class cluster analysis, an atheoretical method that uses only information contained in the data. RESULTS:: Five distinct clusters of symptoms were identified. Age, race, and sex were statistically significant in predicting cluster membership. None of the symptom clusters described in this analysis included all of the symptoms that are considered typical. In one cluster, subjects had only a moderate to low probability of experiencing any of the symptoms analyzed. DISCUSSION:: Symptoms of AMI occur in clusters, and these clusters vary among persons. None of the clusters identified in this study included all of the symptoms that are included typically as symptoms of AMI (chest discomfort, diaphoresis, shortness of breath, nausea, and lightheadedness). These AMI symptom clusters must be communicated clearly to the public in a way that will assist them in assessing their symptoms more efficiently and will guide their treatment-seeking behavior. Symptom clusters for AMI must also be communicated to the professional community in a way that will facilitate assessment and rapid intervention for AMI. Copyright © Lippincott Williams & Wilkins.
• Mayer, D., & Rosenfeld, A. (2006). Symptom interpretation in women with diabetes and myocardial infarction: A qualitative study. Diabetes Educator, 32(6), 918-924.
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  PMID: 17102159;Abstract: Purpose: The purpose of this study was to describe the role of diabetes in acute myocardial infarction (MI) symptom interpretation. Methods: This is a secondary data analysis of a study of treatment-seeking delay in women with acute MI (N = 52). This study included a subsample of those with diabetes (n = 16). Women were interviewed while hospitalized with MI about their actions, thoughts, and feelings from symptom onset to entry into the health care system. Qualitative description was the method of analysis. Results: Three major themes were identified in the qualitative data: diabetes and decision making, presenting symptoms, and symptom attribution. Not all women included information about diabetes in their story, but those who checked blood sugars generally found it to be elevated. Diabetes was a factor in decision making for more than half of the sample. Presenting symptoms were variable but raised hypotheses about shortness of breath as a common presenting symptom for women with diabetes and MI. The third theme, symptom attribution, revealed confusion as to the cause of symptoms. Conclusions: These results provide insight into symptom interpretation in women with diabetes and MI. Women with diabetes should consider atypical symptoms such as shortness of breath, gastrointestinal symptoms, and fluctuating blood sugars as reasons to seek care. Education for women with diabetes should include action plans for how to recognize and respond to symptoms. More research on the influence of diabetes on MI symptom attribution and decision making is needed.
• Rosenfeld, A. G. (2006). State of the heart: Building science to improve women's cardiovascular health. American Journal of Critical Care, 15(6), 556-566.
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  PMID: 17053263;Abstract: Cardiovascular disease is the No. 1 killer of women in the United States, and marked disparities in cardiovascular health exist between women and men and among groups of women. Coronary heart disease is underdiagnosed, undertreated, and underresearched in women. Women with suspected heart disease are less likely than men to receive indicated diagnostic tests and procedures; sex-based biases in treatment of myocardial infarction persist; and women continue to be underrepresented in cardiovascular research. An accumulating body of literature points to 3 major explanations: sex-based physiology, provider bias, and psychosocial influences. Women's acute and prodromal signs and symptoms of myocardial infarction have been described, yet women have difficulty recognizing and acting on these indications. Primary and secondary prevention of heart disease in women is imperative; although the science is lacking in several areas, existing evidence on diet, hormone therapy, aspirin, physical activity and obesity, and diabetes can serve as the basis for interventions. Potentially, large impacts could be made on women's morbidity and mortality if current scientific knowledge were implemented. The state of the science of women and heart disease is reviewed, with a focus on those areas with the greatest potential to address the needs of women's cardiovascular status. Key gaps in the science and remaining questions are presented as a research agenda for the coming decade. © 2006 by AACN.
• Rosenfeld, A. G. (2006). State of the heart: building science to improve women's cardiovascular health.. Communicating nursing research., 39, 33-50.
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  PMID: 16729516;
• Perry, C. K., & Rosenfeld, A. G. (2005). Learning through connections with others: Women's cardiac symptoms. Patient Education and Counseling, 57(1), 143-146.
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  PMID: 15797164;Abstract: Conducting group sessions in which women can share experiences, develop connections, and learn from each other may potentially be a powerful health educational tool. In a focus group conducted for evaluative feedback, the authors found that women began spontaneously sharing their experiences and feelings, receiving validation, and learning from each other almost from the start of the group session. The participants who were dissimilar in age, ethnicity/race, and socioeconomic status developed a strong connection based on the common experience of having had a heart attack. Although the participants had received patient education after their heart attack, they learned new information about cardiac symptoms and how to respond to them in the group session. This case example is a compelling reminder that women learn through connections. Therefore, a group approach to health education that acknowledges the salience of personal experiences, the experiences of others, the development of connections, and the exchange of information may provide a meaningful learning environment. Further research needs to be conducted to determine if conducting group appointments for women that fosters the development of connections and the exchange of information enriches the learning environment and enhances patient education. © 2004 Elsevier Ireland Ltd. All rights reserved.
• Rosenfeld, A. G., Lindauer, A., & Darney, B. G. (2005). Understanding treatment-seeking delay in women with acute myocardial infarction: Descriptions of decision-making patterns. American Journal of Critical Care, 14(4), 285-293.
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  PMID: 15980419;Abstract: BACKGROUND: Women delay seeking treatment for symptoms of acute myocardial infarction longer than men delay. Women s delay time has not been thoroughly characterized. OBJECTIVES: To qualitatively describe the period between the onset of symptoms of myocardial infarction and enactment of the decision to seek care (decision time) and to identify common patterns of cognitive, affective, and behavioral responses to the symptoms (decision trajectories). METHODS: In this qualitative study, 52 women were asked in semistructured interviews to describe the symptoms and related thoughts, decisions, and actions from the onset of symptoms of myocardial infarction to arrival at the hospital. Narrative analysis was used to examine the stories and to identify patterns of decision-making behavior. RESULTS: Six common patterns of behavior during the decision time were identified: knowing and going, knowing and letting someone take over, knowing and going on the patient's own terms, knowing and waiting, managing an alternative hypothesis, and minimizing. The patterns were further grouped as knowing or managing. Women in the 2 groups (knowing and managing) differed primarily in their awareness and interpretations of the symptoms and in their patterns of behavior in seeking treatment. CONCLUSIONS: Women's delay in seeking treatment for symptoms of myocardial infarction can be categorized into distinct patterns. Clinicians can use knowledge of these patterns to detect responses and situations that can decrease decision time in future cardiac events and to educate women about how to respond to cardiac symptoms.
• Shapiro, S. E., Rosenfeld, A. G., Daya, M., Larson, J. L., & McCauley, L. A. (2005). Determining severe respiratory distress in older out-of-hospital patients. Prehospital Emergency Care, 9(3), 310-317.
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  PMID: 16147481;Abstract: Objectives. This preliminary investigation represents the first step in developing a clinical decision rule (CDR) to assist out-of-hospital providers in caring for older patients in respiratory distress. The specific aims of the study were: 1) to identify up to ten candidate clinical indicators of severe respiratory distress in older out-of-hospital patients and 2) to determine the feasibility of obtaining data on these indicators from out-of-hospital treatment records, and of obtaining a measure of severe respiratory distress from the emergency department (ED) medical record. Methods. This mixed-methods study included a qualitative component to list possible clinical indicators of severe respiratory distress, and a Delphi survey (N = six experts) to reduce the comprehensive list that resulted (aim 1). The feasibility of gathering clinical indicators and a measure of severe distress was evaluated using a retrospective chart review (N = 640) of out-of-hospital and ED medical records (aim 2). Results. Nine clinical indicators were identified: level of consciousness/ mentation, inability to speak in full sentences, position of the patient on arrival, decreased oxygen saturation, accessory muscle use, dyspnea, increased respiratory effort, altered respiratory rate, and retractions. There were sufficient data available on all indicators except dyspnea and retractions; a measure of severe distress was readily obtained from the ED medical record. Conclusion. Medical record data were available on seven out-of-hospital clinical indicators and an ED measure of severe distress. Further work needs to be done to refine the operational definitions of the indicators and to standardize the way they are documented in the out-of-hospital medical record.
• Rosenfeld, A. G. (2004). Treatment-seeking delay among women with acute myocardial infarction: Decision trajectories and their predictors. Nursing Research, 53(4), 225-236.
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  PMID: 15266161;Abstract: Background: Women's delay in seeking treatment for acute myocardial infarction symptoms results in higher rates of mortality and morbidity for women. Objectives: To describe decision trajectories used by women when experiencing symptoms of acute myocardial infarction, and to identify predictors of the decision trajectory used by women with acute myocardial infarction. Methods: A cross-sectional, descriptive design was used. The nonprobability sample included 52 women hospitalized for acute myocardial infarction. To elicit descriptions of decision making, focused, semistructured interviews were used in this mixed-methods study. Predictors of decision trajectories were measured with standardized instruments among the same women. Narrative analysis was used to examine the stories from the qualitative data and to identify decision trajectory types. Discriminant analysis was used to predict trajectory type membership. Results: The median delay time was 4.25 hours. Most of the women used one of two trajectory types: knowing (defined as those women who knew almost immediately that they would seek help, n = 25) and managing (those women who managed an alternative hypothesis or minimized their symptoms, n = 23). Discriminant analysis correctly classified 71% (χ 2[4] = 11.2; n = 48; p = .02) of the cases into trajectory types on the basis of four predictor variables: social support, personal control, heart disease threat, and neuroticism. Discussion: Women's behaviors during the period between onset of acute myocardial infarction symptoms and treatment seeking can be categorized into a small number of patterns termed decision trajectories. A profile of sociostructural and intrapersonal factors with potential for predicting behavior in relation to future coronary events was developed.
• Tilden, V. P., Drach, L. L., Tolle, S. W., Rosenfeld, A. G., & Hickman, S. E. (2002). Sampling challenges in end-of-life research: Case-finding for family informants. Nursing Research, 51(1), 66-69.
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  PMID: 11822572;Abstract: Background: Research on end-of-life care is hampered by challenges in accessing appropriate subjects for data collection. Although families of decedents are rich sources of research data, they are underutilized, most likely due to the access difficulties they present to investigators. Objectives: To describe case-finding strategies that can achieve a large and representative sample of family informants for research studies about end-of-life care. Methods: Case-finding strategies were developed and honed over the course of three epidemiological studies on end-of-life care. Family location information was culled from death certificates and a combination of public and commercial sources. Results: The researchers generated large random samples of study-eligible decedents and, using the case-finding strategies described, recruited family members of decedents as informants. By the third study, two-thirds of family members were located and interviewed within the narrow time frame of 2-5 months following the death of their loved one. Discussion: Epidemiological studies on end-of-life, using large random samples of decedents and their family members, are feasible when armed with an array of effective case finding strategies.
• Davidson, S. B., Beardsley, K., Busch, A. H., Garner, A., Heresa, S., Hodges, N. D., Snyder, K. N., & Rosenfeld, A. (2001). Statutory and regulatory recognition for clinical nurse specialists in Oregon.. Clinical nurse specialist CNS, 15(6), 276-283.
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  PMID: 11855485;Abstract: Clinical nurse specialists (CNSs) in Oregon initiated the process of achieving statutory and regulatory recognition several years ago. Throughout this process, specific phases of activity and events helped CNSs to identify what was required to achieve this goal. The resulting lessons learned are shared in this report. Statutory recognition of CNSs in Oregon occurred in 1999, and the administrative rules for CNS practice were published in 2001. These administrative rules delineate the CNS scope of practice and other aspects of CNS practice consistent with national standards.
• Rosenfeld, A. G. (2001). Women's risk of decision delay in acute myocardial infarction: implications for research and practice.. AACN clinical issues, 12(1), 29-39.
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  PMID: 11288326;Abstract: Cardiovascular disease is the leading cause of death for women in the United States. Despite recent advances in treatment options for acute myocardial infarction (AMI), there has not been similar progress in decreasing the time between symptom onset and the decision to seek medical help (labeled "decision delay") and therefore availability of such treatments. Women delay longer than men before seeking help for symptoms of AMI, yet few studies have analyzed decision delay by gender. Factors studied to date do not adequately explain the differences in decision delay among women or between women and men with AMI. Additional research is needed to guide interventions to limit decision delay in women at risk for AMI. Until then, clinicians should use existing general guidelines to assist women at risk of AMI to avoid decision delay.
• Rosenfeld, A. G., & Gilkeson, J. (2000). Meaning of illness for women with coronary heart disease. Heart and Lung: Journal of Acute and Critical Care, 29(2), 105-112.
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  PMID: 10739486;Abstract: OBJECTIVE: The goal of this study was to describe the meaning of an acute cardiac event and cardiac illness for women with coronary heart disease. DESIGN: A longitudinal, descriptive design was used. SETTING: The study was undertaken at a tertiary care hospital in the Pacific Northwest. PATIENTS: The study considered a purposive sample of 6 women ranging in age from 47 to 67 years, who were hospitalized for coronary heart disease (3 for coronary bypass surgery and 3 for coronary angioplasty). METHODS: We completed a series of 2 focused semistructured interviews, 1 while women were hospitalized for coronary heart disease and the second 3 months later. The qualitative method-of grounded theory guided the collection and analysis of data. RESULTS: The meaning of illness, for women with coronary heart disease evolved over time in a process we termed seeking understanding. After the onset of symptoms, women described 3 responses: denial, acknowledging, and being scared. These did not occur in sequence, but as iterative processes. They described 4 additional themes after obtaining medical attention: naming, seriousness of illness, comparing self with others, and causality. CONCLUSIONS: A substantive theory of seeking understanding was described in this study and contributes to our understanding of meaning and behavior of women with coronary heart disease. Future research with use of similar methods may lead to an understanding of women's decision-making process regarding their illness.
• Tolle, S. W., Tilden, V. P., Hickman, S. E., & Rosenfeld, A. G. (2000). Family reports of pain in dying hospitalized patients: A structured telephone survey. Western Journal of Medicine, 172(6), 374-377.
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  PMID: 10854381;PMCID: PMC1070920;Abstract: Objectives: To see how often families in Oregon reported moderate to severe pain in dying patients in late 1998 compared with late 1997. Design: A systematic random sample of death certificates was used to identify family members of decedents who died in a hospital setting between October 1 and December 31, 1998. A structured telephone interview was used to obtain data. Participants: Family members of 103 decedents (who died in hospitals 2 to 4 months before data collection) were identified with the use of death certificates. Results: In late 1998, 56 family members (54%) reported that their loved one experienced moderate to severe pain in the last week of life. Conclusions: Family reports of moderate to severe pain in dying hospitalized Oregonians remain high. The influence of environmental factors on pain management may have implications for practice and policy nationwide.
• Tolle, S. W., Tilden, V. P., Rosenfeld, A. G., & Hickman, S. E. (2000). Family reports of barriers to optimal care of the dying. Nursing Research, 49(6), 310-317.
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  PMID: 11093695;Abstract: Background: In response to intense national pressure to improve care of the dying, efforts have been made to determine problems or barriers to optimal care. However, prior research is limited by such factors as setting, focus, and sampling. Objectives: The purpose of this study was to identify barriers to optimal care of a population-based representative sample of decedents across a full range of settings in which death occurred. Methods: Families were contacted 2 to 5 months after decedents' deaths by using data on their death certificates. Over a 14-month period, telephone interviews were conducted with 475 family informants who had been involved in caring for the patient in the last month of life. Interviews were standardized by use of a 58-item structured questionnaire. Results: Data show a high frequency of advance planning (68%) and a high level of respect by clinicians for patient-family preferences about end-of-life location and treatment decisions. Family satisfaction with care was generally high, even though pain was a problem in one third of the sample of decedents. Conclusions: Barriers to optimal care of the dying remain, despite a generally positive overall profile; barriers include level of pain and management of pain, as well as some dissatisfaction with physician availability.
• Tolle, S. W., Rosenfeld, A. G., Tilden, V. P., & Park, Y. (1999). Oregon's low in-hospital death rates: What determines where people die and satisfaction with decisions on place of death?. Annals of Internal Medicine, 130(8), 681-685.
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  PMID: 10215565;Abstract: Where Americans die is much more influenced by what part of the country they live in than by what their preferences are for location of death. Although most Americans report a preference for death at home, a majority still die in acute care hospitals. We describe the experiences of patients who died in Oregon (the state that currently has the lowest in-hospital death rate in the United States - 31%) and the views of their families. We examine the factors influencing respect for dying patients' preferred location of death. Data from Oregon studies confirm that decisions to avoid hospital admission are far more common than discharge of the actively dying. Do-not- resuscitate orders were reported for 91% of nursing home residents in one study and living wills were reported for 67% of a random sample of adult Oregon decedents in a second study. In the second study, decisions not to start treatment were far more common than decisions to stop treatment (79% compared with 21%). Only 2.4% of families reported that 'too little' treatment was given. Throughout the United States, use and availability of beds in acute care hospitals have been confirmed to be the principal determining factors in location of death. Within that constraint, however, the availability of other resources and services both facilitates the process of arranging for patients to die outside the hospital and improves satisfaction with the quality of terminal care.

Presentations

• Knight, E. P., Shea, K. D., Rosenfeld, A. G., Hsu, C., Schmiege, S., & DeVon, H. A. (2016, April). SYMPTOM TRAJECTORIES AFTER EMERGENT EVALUATION FOR ACUTE CORONARY SYNDROME. Western Institute of Nursing. Anaheim, CA: Western Institute of Nursing.
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  Background: Many patients evaluated for acute coronary syndrome (ACS) in emergency departments (EDs) experience ongoing or recurrent symptoms after discharge, regardless of their ultimate medical diagnosis. A comprehensive understanding of post-ED symptom trajectories is lacking.Aim: To identify common trajectories of symptom severity in the six months after an ED visit for potential ACS.Methods: This was a secondary data analysis from a study conducted in five U.S. EDs. Patients (n=1002) who had abnormal electrocardiogram or biomarker testing and were identified by the triage nurse as potentially having ACS were enrolled. Symptom severity was assessed in the hospital and 30 days and six months post-discharge using the 13-item ACS Symptom Checklist. Severity of the eight most commonly reported symptoms (chest pressure, chest discomfort, unusual fatigue, chest pain, shortness of breath, lightheadedness, upper back pain, and shoulder pain) was modeled across the three study time points using growth mixture modeling. Models with increasing numbers of classes were compared, and final model selection was based on a combination of interpretability, theoretical justification, and statistical fit indices. Results: The sample was 62.6% male with a mean age of 60.17 years, and 57.1% ruled-out for ACS. Between two and four distinct trajectory classes were identified for each symptom. Identified trajectories were labeled “tapering off,” “mild/persistent”, “moderate/persistent,” “moderate/worsening”, “moderate/improving,” “late onset”, and “severe/improving.” Implications: Research on the individual nature of symptom trajectories can contribute to patient-centered, rather than disease-centered, care. Further research is needed to verify the existence of multiple symptoms trajectories in diverse populations and to assess the antecedents and consequences of individual symptom trajectories.
• Rosenfeld, A. G., DeVon, H. A., Burke, L., Vuckovic, K., Haugland, T., Eckhardt,, A., & Patmon, F. (2016, Fall). Symptoms suggestive of acute coronary syndrome: Sex as an important determinant of health.. CANS State of the Science Conference. Washington DC: Council for the Advancement of Nursing Science.
• Rosenfeld, A. G., Taylor-Piliae, R. E., Carrington, J. M., Gephart, S. M., Insel, K. C., Loescher, L. J., & Reed, P. G. (2016, January). Defying the skeptics! Strategies and successes of an online PhD program.. AACN Doctoral Education Conference. Florida: AACN.
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  I was the sole presenter.

Poster Presentations

• Rosenfeld, A. G., Coats, H., Crist, J. D., Sternberg, E. M., & Berger, A. (2016, April). African American views: Content validity of multidimensional healing measure.. Western Insitute of Nursing Communicating Nursing Research Conference. Anaheim CA: Western Institute of Nursing.
• Rosenfeld, A. G., Crawford, R. S., Insel, K. C., & Reed, P. G. (2016, Spring). Health beliefs related to physical activity in patients living with implantable cardioverter defibrillators.. Preventive Cardiovascular Nurses Association 22nd Annual SymposiumPreventive Cardiovascular Nurses Association.
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  Winning Abstracts: Poster Abstracts. Journal of Cardiovascular Nursing, 31, 483-487. doi:10.1097/JCN.0000000000000363
• Rosenfeld, A. G., Hsu, C., & McEwen, M. M. (2016, April). Symptom experience of Mexican American women with diabetes & heart disease.. Western Institute of Nursing Communicating Nursing Research Conference. Anaheim CA: Western Institute of Nursing.
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  This was work from our Emmons grant.
• Rosenfeld, A. G., Pace, T. W., & McEwen, M. M. (2016, April). Symptom biomarkers in Mexican American women with diabetes & heart disease.. Western Institute of Nursing Communicating Nursing Research Conference. Anaheim CA: Western Institute of Nursing.
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  This was work from our Emmons grant.