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AnteayerNursing Research

Challenges and Strategies for Conducting Research With Grandparent–Grandchild Dyads

imageBackground Given a marked increase in the number of grandparents who play a caregiving role for their grandchildren, there is a parallel urgency for more research involving grandparent–grandchild dyads. Objective The aim of this study was to describe methodological challenges we encountered when conducting grandparent–grandchild dyadic research, some of which were challenges specific to working with dyads where the grandparents were caregivers to the child participants and others, which were challenges of a sort that might be encountered in any research involving data collection with multigenerational family units and, in particular, multigenerational family units including older adults. Methods During and after an observational study conducted by the researchers involving grandparent–grandchild dyads, we explored challenges we encountered and strategies for improving our research outcomes. Results We found several challenges specific to grandparent–grandchild dyads, including complications with reaching legal guardians to obtain permission for child participants; collecting accelerometer data from grandchildren was difficult, particularly if the grandparents did not live with their grandchildren; and participants who had various preferences for data collection methods. We also found challenges that might be found with any family context dyadic research, particularly involving older adults and across multiple generations, including relatively low follow-up response rates from those grandparents who initially expressed interest and a need for an extended data collection period. We employed targeted strategies to overcome those obstacles, and in this article, we describe the outcomes of those strategies. Discussion Recommendations from our results include the following: (a) find a way to involve the parents and/or legal guardian as early as possible, (b) have multiple team members involved in recruitment/data collection, (c) be flexible about data collection methods, (d) use flexible scheduling, and (e) use multiple simultaneous recruitment activities/multiple advertisement channels. Additional strategies include enhancing children’s sense of control during the consent process, simplifying study procedures, considering usability when creating online data surveys, and identifying power dynamics within the families. Conclusion The insights we gained will be useful for informing future family context dyadic research, in particular, research involving grandparent–grandchild dyads.

Protocol for Pilot Study on Self-Management of Depressive Symptoms in Pregnancy

imageBackground Pregnant women with depressive symptoms face significant treatment challenges and are in great need of safe, effective, accessible, inexpensive, and nonpharmacological self-management therapies to enhance well-being, reduce the burden of symptoms both during their pregnancy and postpartum, and prevent chronic sequelae. Objectives In this article, we describe the protocol for our pilot study testing a self-management intervention entitled, “Mindful Moms,” designed to foster women’s ability to address current depressive symptoms and enhance resilience to prevent recurrence. Methods We will conduct a longitudinal pilot trial of the 12-week intervention with pregnant women with depressive symptoms (n = 40); the primary aim is to determine the feasibility and acceptability of the intervention. The secondary aim is to examine preliminary effects of the intervention on maternal psychobehavioral outcomes in pregnancy and 6 weeks postpartum. The third aim will quantify genome-wide and gene-specific DNA methylation patterns associated with depressive symptoms during pregnancy and investigate whether intervention participation influences these patterns. Results This study is currently ongoing. Discussion Findings from this study will inform future research addressing the need for nonpharmacological self-management interventions for pregnant women with depressive symptoms.

Moderator Effects in Intervention Studies

imageBackground Although nursing intervention studies typically focus on testing hypothesized differences between intervention and control groups, moderator variables can reveal for whom or under what circumstances an intervention may be most effective. Objectives The aim of the study was to explain and illustrate moderator effects using data from a nursing intervention study to improve cognitive abilities in those with a chronic health condition. Methods The sample consisted of 178 individuals with multiple sclerosis participating in an experimental study of a cognitive intervention. General linear models were used for analyses. Interaction terms were created to represent moderator effects on three outcomes: self-reported cognitive abilities, use of memory strategies, and verbal memory performance. Results The Charlson comorbidity index significantly moderated the intervention effect on self-perceived cognitive abilities. Years of education significantly moderated the intervention effect on use of memory strategies. Scores on a general self-efficacy measure significantly moderated the intervention effect on the Controlled Verbal Learning Test–Second Edition. Discussion These analyses highlight the key role that moderator effects can play in nursing research. Although random assignment to groups can control potentially biasing effects of extraneous differences among individuals in intervention and control groups, those very differences may suggest fruitful avenues for hypothesis generating research about what works best for whom in intervention studies.

Characteristics and Practices Within Research Partnerships for Health and Social Equity

imageBackground As federal research funding focuses more on academic/community collaborations to address health inequities, it is important to understand characteristics of these partnerships and how they work to achieve health equity outcomes. Objectives This study built on previous National Institutes of Health-funded research to (a) describe partnership characteristics and processes of federally funded, community-based participatory research (CBPR) or community-engaged research projects; (b) explore characteristics of these projects by stage of funding; and (c) build on previous understanding of partnership promising practices. Methods Between fall 2016 and spring 2017, we completed a cross-sectional analysis and principal component analysis of online survey data from key informants of federally funded CBPR and community-engaged research projects. Respondents for 179 projects (53% response rate) described project characteristics (e.g., type of partner, stage of partnership, and population) and the use of promising practices (e.g., stewardship, advisory board roles, training topics) by stage of partnership. Results Projects involved community, healthcare, and government partners, with 49% of respondents reporting their project was in the early stage of funding. More projects focused on Black/African American populations, whereas principal investigators were mostly White. The more established a partnership (e.g., with multiple projects), the more likely it employed the promising practices of stewardship (i.e., community safeguards for approval), community advisory boards, and training on values and power. Conclusions Community engagement is a developmental process with differences between early-stage and established CBPR partnerships. Engaging in active reflection and adopting promising partnering practices are important for CBPR partnerships working to improve health equity. The data provided in this study provide key indicators for reflection.

Recruitment Strategies for Nurse Enrollment in an Online Study

imageBackground Although there is a great deal of literature regarding effective recruitment and challenges of recruiting specific patient populations, there is less known about best practices for recruitment of nurses as study subjects. Objectives The purpose of this article is to report our experience with recruitment and retention for a randomized trial of an online educational program to prepare oncology nurses to discuss oncology clinical trials with patients. Methods The study population included currently employed oncology nurses with direct patient interaction. There were three phases of this study: (1) qualitative interviews, (2) a pilot test, and (3) the randomized trial. Phase 3 was rolled out in five waves of recruitment. The distinct phases of the study—and the gradual roll out of recruitment during Phase 3—allowed us to test and refine our recruitment and retention methods for the randomized trial. Upon analysis of our response rate and attrition after the first wave of recruitment in Phase 3, we made several changes to improve recruitment and retention, including adding incentives, shortening the survey, and increasing the number of reminders to complete the program. Results The response rate was higher when we used both e-mail and U.S. postal mail solicitations. After the first wave of recruitment in the final phase, changes in our strategies did not increase our overall response rate significantly; however, the rate of attrition following baseline declined. Discussion Recruitment planning is an important component of successful clinical research. The use of the Internet for both recruitment of subjects and testing of interventions remains a cost-effective and potentially high yield methodology. Our research demonstrated several successful approaches to yield increased participation and retention of subjects, including seeking formal relationships with professional organizations as sponsors or supporters, providing meaningful incentives to participants, keeping surveys or questionnaires as short as possible, and planning multiple follow-up contacts from the outset.

Sleep–Wake States and Feeding Progression in Preterm Infants

imageBackground Previous studies demonstrated a short-term relationship between infant sleep–wake states and oral feeding performance, with state being an indication of infants’ neurobehavioral readiness for feeding. However, the relationship between sleep–wake states and feeding skills has not been evaluated longitudinally during hospitalization. Objectives The purpose of this study was to examine preterm infants’ sleep–wake state developmental trajectories and their associations with feeding progression during hospitalization. Methods This descriptive and exploratory study was a secondary analysis using data from a longitudinal two-group, randomized controlled trial evaluating the effects of early and late cycled light on health and developmental outcomes among extremely preterm infants who were born ≤28 weeks of gestational age. Sleep–wake states were assessed for two 2-hour interfeeding periods per day (day and night hours), 30 weeks postmenstrual age, and every 3 weeks until discharge. Occurrences of active sleep, quiet sleep, and waking were recorded every 10 seconds. Feeding progression was assessed based on an infant’s postmenstrual age at five milestones: first enteral feeding, full enteral feeding, first oral feeding, half oral feeding, and full oral feeding. Trajectory analyses were used to describe developmental changes in sleep–wake states, feeding progression patterns, and associations between feeding progression and sleep–wake trajectories. Results Active sleep decreased while waking, and quiet sleep increased during hospitalization. Two distinct feeding groups were identified: typical and delayed feeding progression. In infants with delayed feeding progression, rates of active and quiet sleep development during the day were delayed compared to those with typical feeding progression. We also found that infants with delayed feeding progression were more likely to be awake more often during the night compared to infants with typical feeding progression. Discussions Findings suggest that delays in sleep–wake state development may be associated with delays in feeding progression during hospitalization. Infants with delayed feeding skill development may require more environmental protection to further support their sleep development.

Systematic Review and Meta-analysis of Psychosocial Uncertainty Management Interventions

imageBackground Psychosocial uncertainty management interventions (UMIs) targeting patients and their family members might help to alleviate the negative influences of illness-related uncertainty, such as diminished quality of life and poor adjustment. Objectives The aims of this study were to evaluate the key characteristics of psychosocial UMIs and assess intervention effects on patients' and their family members' short-term and long-term illness-related uncertainty. Methods We conducted a systematic review and meta-analysis of psychosocial UMIs published through 2017. We performed a comprehensive electronic search and manual review. The outcome indicator was illness-related uncertainty experienced by patients or their family members. Results We included 29 studies in the systematic review and 14 studies in the meta-analysis. The main intervention components were information and resource provision, coping skills training, social and emotional support, communication skills, symptom management and self-care, coordination of care, and exercise. Compared to usual care, patients who received UMIs reported less uncertainty immediately after intervention delivery (g = −0.44, 95% confidence interval [CI] [−0.71, −0.16]) and at later follow-up points (g = −0.47, 95% CI [−0.91, −0.03]). Family members who received UMIs also reported less uncertainty immediately after intervention delivery (g = −0.20, 95% CI [−0.33, −0.06]) and at later follow-up points (g = −0.20, 95% CI [−0.36, −0.04]). Discussion Psychosocial UMIs had small to medium beneficial effects for both patients and their family members. Questions remain regarding what intervention components, modes of delivery, or dosages influence effect size. More rigorously designed randomized controlled trials are needed to validate intervention effects on patients' and family members' uncertainty management.

Inpatient Maternal Mortality in the United States, 2002–2014

imageBackground Although prior studies of inpatient maternal mortality in the United States provide data on the overall rate and trend in inpatient maternal mortality, there are no published reports of maternal mortality data stratified by timing of its occurrence across the pregnancy continuum (antepartum, intrapartum, and postpartum). Objective The study objective was to determine whether the maternal mortality rate, trends over time, self-reported race/ethnicity, and associated factors vary based on the timing of the occurrence of death during pregnancy. Methods We conducted a cross-sectional analysis of the Nationwide Inpatient Sample database to identify pregnancy-related inpatient stays stratified by timing. Among women in the sample, we determined in-hospital mortality and used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify comorbidities and behavioral characteristics associated with mortality, including alcohol, drug, and tobacco use. Joinpoint regression was used to calculate rates and trends of in-hospital maternal mortality. Results During the study period, there were 7,411 inpatient maternal mortalities among an estimated 58,742,179 hospitalizations of women 15–49 years of age. In-hospital maternal mortality rate stratified by race showed that African Americans died at significantly higher rates during antepartum, intrapartum, and postpartum periods compared to hospitalizations for Whites or Hispanics during the same time period. Although the postpartum hospitalization represents only 2% of pregnancy-related hospitalizations among women aged 15–49 years, hospitalization during this time period accounted for 27.2% of all maternal deaths during pregnancy-related hospitalization. Discussion Most in-hospital maternal mortalities occur after hospital discharge from child birth (postpartum period). Yet, the postpartum period continues to be the time period with the least maternal healthcare surveillance in the pregnancy continuum. African American women experience three times more in-hospital mortality when compared to their White counterparts.

Effects of Physical Activity on Neurophysiological and Gene Expression Profiles in Chronic Back Pain: Study Protocol

imageBackground Despite the emphasis on exercise to reduce pain and improve function among people with chronic low back pain (cLBP), little is known about the underlying mechanism of the impact of exercise on the neurophysiological and gene transcription alterations that characterize cLBP. Objectives To present a study protocol to examine the feasibility, acceptability, and initial efficacy of Problem-Solving Pain to Enhance Living Well (PROPEL) with the support of nurse consultations and wearable activity-tracking technology on self-management (SM) knowledge, skills, physical activity, and pain and to examine the differential neurophysiological and gene expression profiles in cLBP participants from pre- to post-PROPEL. Methods A pretest and posttest study is employed on 40 adults ages 18–60 years with cLBP who do not have serious complications and/or comorbidities that affect sensorimotor function. Participants will receive video modules focused on SM and biweekly phone consultations to facilitate symptom monitoring and problem-solving while increasing physical activity frequency and duration. Participants will be assessed for outcomes including SM skills, physical activity, and pain every 2 weeks for 12 weeks. We will examine the participants’ differential neurophysiological and gene expression profiles at 12 weeks postintervention and correlate these outcomes with the total duration of physical activity. Results The study began in September 2018. Of the 99 subjects that were screened, 23 were enrolled and 8 completed data collection. Discussion Comparing the neurophysiological and gene expression profiles of people with cLBP exposed to PROPEL could inform the development of interventions that offer personalized physical activity dosage along with general SM support. Web-based programs such as PROPEL have the potential to enhance accessibility of evidence-based interventions that improve functionality and quality of life among people living with cLBP.

Health and Disability Among Young Black Men

imageBackground Black men experience the highest rate of disability compared to White, Asian, and Hispanic men. Yet, we know little about how Black men with disabilities experience the embodiment of their gender, race, social class, and disability positionalities and how they draw from their cultural backgrounds as they engage in health-seeking behaviors. Objectives The purpose of this study was to explore how young Black men experienced the onset of chronic disabling conditions while negotiating health-promoting activities in the context of gender, race, social class, disability positionalities, and culture. Methods This descriptive study used hermeneutic phenomenology to achieve study objectives. This study’s research questions were answered using audiotaped, one-on-one qualitative interviews, along with detailed field notes. Each participant was interviewed twice at a mutually decided upon location to ensure their privacy and comfort. Results In relation to their embodied interactions of self in the context of disability, these men described their health-related decisions using four themes: maintaining manhood, economic constraints, the “risk” of healthcare, and health promotion. Conclusions By examining the experiences of young adult Black men living with disabilities, knowledge of their perspectives and experiences at earlier stages in their life course contributes to the understanding of their personal challenges, health needs, and their perspectives of health-promoting strategies.

Efficacy of Osteoporosis Prevention Smartphone App

imageBackground The Striving to be Strong study tested the efficacy of a multifaceted, theory-based, complex osteoporosis prevention smartphone application (app). We hypothesized use of the app would improve bone mineral density and trabecular bone scores. Methods The study was a three-group, prospective, repeated-measure, longitudinal randomized trial. Baseline sample consisted of 290 healthy women between 40 and 60 years of age. Participants were randomly assigned to one of three groups: “Striving,” a dynamically tailored, person-centered app; “Boning Up,” a standardized osteoporosis-education e-book; and “Wait List,” a participant’s choice of intervention in the final 3 months of the 12-month study. Participants had or were provided a smart phone. Bone mineral density and trabecular bone scores were measured using dual-energy X-ray absorptiometry at baseline and 12 months. To assess engagement in health behavior change processes, ecological momentary assessments were administered via text messaging during the 12 months participants actively used the app. Results The final sample reflects an 89.6% retention rate. There were decreases in bone mineral density over time but not among the three groups. The percentage of bone density lost over 12 months was lower than expected. Trabecular bone scores were not different over time or by group but improved across all three groups. Discussion Small but positive results were observed across all groups, suggesting one or more aspects of participation might have affected outcomes, including dissemination of the intervention across groups, retention without participation, ecological momentary assessments functioning as both an intervention and measure, and selective engagement in research-based recommendations.

Agent-Based Modeling: A Method for Investigating Challenging Research Problems

imageBackground For all our successes, many urgent health problems persist, and although some of these problems may be explored with established research methods, others remain uniquely challenging to investigate—maybe even impossible to study in the real world because of practical and pragmatic obstacles inherent to the nature of the research question. Objectives The purpose of this review article is to introduce agent-based modeling (ABM) and simulation and demonstrate its value and potential as a novel research method applied in nursing science. Methods An introduction to ABM and simulation is described. Examples of current research literature on the subject are provided. A case study example of community nursing and opioid dependence is presented. Results The use of ABM and simulation in human health research has increased dramatically over the past decade, and meaningful research is now commonly found published widely in respected, peer-reviewed journals. Absent from this list is innovative ABM and simulation research published by nurse researchers in nursing-specific journals. Discussion ABM and simulation is a powerful method with tremendous potential in nursing research. It is vital that nursing embrace and adopt innovative and advanced research methods if we are to remain a progressive voice in health research, practice, and policy.

Decreasing Barriers to Research Utilization Among Labor and Delivery Nurses

imageBackground Intermittent fetal monitoring (IFM) is a recommended strategy for intrapartum fetal heart rate assessment in low-risk pregnancies; however, this “high touch, low tech” approach is underutilized. Objective The aim of the study was to examine the relationships between labor and delivery nurses’ intellectual capital and their perceptions of barriers to research utilization in the work setting. Methods A cross-sectional correlational design using data derived from a larger study of labor and delivery nurses (N = 248) was used. Covell’s theory of nursing intellectual capital was used as the conceptual and analytic framework to examine labor and delivery nurses’ intellectual capital and their perceived barriers to research utilization. Results Nurses who receive paid time off from their employer to attend conferences (p

Diabetes Distress, Depressive Symptoms, and Cardiovascular Health in Adults With Type 1 Diabetes

imageBackground The prevalence of adults with Type 1 diabetes (T1D) is increasing, and their risk of cardiovascular disease is high. Comorbid diabetes distress and depressive symptoms may affect their cardiovascular health. Objectives The purpose of this study was to describe the relationship between diabetes distress and depressive symptoms with cardiovascular health factors. Methods This was a cross-sectional survey of a sample of adults with T1D. Valid and reliable instruments were used to collect the data on sociodemographics, diabetes-related complications, psychological factors, and cardiovascular health factors. Independent-sample t tests, analysis of variance, chi-square analyses, and linear regression were used to compare the cardiovascular health factors among the three levels of diabetes distress scores and the two levels of depressive symptom scores. Results Our sample included 83 adults with a mean age of 45.2 years and a mean duration of T1D of 20 years. The majority scored low in the Diabetes Distress Scale, whereas 18% scored moderate and 18% scored high. Twenty-two percent had increased levels of depressive symptoms. There were significant correlations between diabetes distress and fear of hypoglycemia, depressive symptom scores, hemoglobin A1c, and total cholesterol. Depressive symptom scores were significantly correlated with hemoglobin A1c. Hemoglobin A1c and total cholesterol were significantly higher in those with higher levels of diabetes distress. There were no significant differences in cardiovascular health between those who scored below or above the cut point for depressive symptoms, but there was a finding toward higher mean body mass index, hemoglobin A1c, and a lower weekly step count in those who had elevated depressive symptoms. In the linear regression, only diabetes distress was significantly associated with hemoglobin A1c. Discussion This is a sample with elevated diabetes distress and depressive symptoms, both of which may affect their risk of cardiovascular disease.

Validation of the Presence of Nursing Scale Using Data Triangulation

Background Nursing presence has been developed as a distinct concept with identifiable behaviors but remains only partially defined as a quantifiable construct. Objectives This study asked if the Presence of Nursing Scale (PONS) is a reliable and valid instrument to measure nursing presence from the patient’s perspective. Methods A convenience sample of 75 adult acute care inpatients were verbally administered the 25-item PONS considering the registered nurse taking care of them on the day of data collection. Open-ended questions elicited the patients’ explanations of their ratings. They also rated their overall satisfaction with the nursing care provided by the subject nurse using a 5-point scale. Results The mean PONS score was 104.5 (SD = 17.26) on the 25–125 scale. Instrument reliability reported as a Cronbach’s alpha coefficient of .95 was .94 in this study. Instrument validity was tested correlating PONS scores to the satisfaction rating. The Spearman’s rho correlation was large and statistically significant, r (73) = .708. The higher the PONS score, the more satisfied the patient was with care from that nurse. Nineteen narratives selected from the lower quartile PONS scores (PONS 116) were thematically analyzed. Lower PONS scores corresponded with themes of patients being objectified as the work of the nurse without a respectful and caring nurse–patient relationship. Higher PONS scores coincided with patients’ perceptions of enhanced nurse–patient rapport, feelings of better coping, and decreased anxiety. Discussion These results demonstrate reliability and validity of the PONS and add to the body of evidence about nurse behaviors exhibited in the nurse–patient relationship, which influence patients’ feelings of being cared for and satisfied with nursing care. These findings may be useful in the development of educational materials aimed at the advancement of nursing presence competency.

Pilot Study of the Mastery Lifestyle Intervention

imageBackground Recognizing the effects of acculturation on quality of life and emotional health, especially during pregnancy, we developed an intervention that would target these factors in order to improve maternal well-being during the prenatal period and potentially improve infant outcomes, particularly preterm birth for Mexican-American women (Latinas). Objective The purpose of these pilot studies was to test the acceptability, feasibility, and preliminary efficacy of the mastery lifestyle intervention (MLI) to decrease depressive and anxiety symptoms and improve coping as implemented in prenatal clinics with culturally homogenous groups of Latinas. Methods The MLI was tested in three small pilot studies (n = 15), one in El Paso, Texas (an urban area), and two in Bastrop, Texas (a rural area outside Austin), for acceptability and feasibility. A pretest/posttest, quasi-experimental design was used with pregnant self-identified Mexican-American Latinas at 14–20 weeks' gestation. Measures of anxiety, depressive symptoms, and positive and negative coping were used. Results Feasibility was a success in terms of implementation of the MLI in an active prenatal clinic setting and the use of electronic tablets for data collection and entry of data into REDcap. Satisfaction was high, with the location of the MLI being at their primary OB/GYN clinic. Participants reported that six intervention sessions appear to be ideal as was the class length of 1.5 to 2 hours. On Cohen's d, there were medium to large effect size decreases in depressive and anxiety symptoms and small to medium effect size decreases in the use of negative coping strategies and small effect sizes for increases in positive coping strategies. Discussion Pilot testing of the MLI indicated that it was well accepted from the participants and feasible as a culturally tailored behavioral therapy administered in a group setting by nurse practitioners. Our initial pilot results also suggest preliminary efficacy as indicated by moderate to large Cohen's d effect sizes for depression and anxiety.

Integrative Review of Recruitment of Research Participants Through Facebook

imageBackground Facebook (FB) has been widely used recently to recruit participants for adult health research. However, little is known about its effectiveness, cost, and the characteristics of participants recruited via FB when compared to other recruitment methods. Objectives The purpose of this integrative review was to examine the published evidence concerning the use of FB in participant recruitment for adult health research, as compared to other social media, online, and traditional recruitment methods. Methods In this integrative review, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, CINAHL, SCOPUS, and Web of Science were the electronic databases used to identify the published articles. In regard to language, the search was limited. Results The efficacy and cost-effectiveness of using FB for recruitment in healthcare research as compared to more traditional forms of recruitment remain unclear. Reporting of recruitment strategies is inconsistent, and costs are often not included. FB is being used for recruitment frequently with other methods and, although often effective, can be costly. Discussion FB is used to recruit participants for a variety of studies, with researchers using both free and paid ads to reach potential participants. Reporting of recruitment methods needs to be more rigorous, streamlined, and standardized in scientific papers.

Perspectives on Conducting Research in Indian Country

imageBackground Certain research principles, framed within an indigenous context, are helpful guideposts to practice ethical, relevant, and sensitive inquiries. It is essential to further adapt research approaches based on the unique geographical, sociopolitical, and cultural attributes of partnering tribal communities. These adaptations are largely shaped by trial and error. Objectives The purpose of this article is to offer the prospective novice nurse researcher lessons that we learned when entering Indian country to conduct research for the first time. As indigenous and nonindigenous researchers, we are not seeking to set down a methodology but rather offer a list of processes, environments, timelines, and barriers that we never learned in didactic, seminar, clinical, practicum, or any other academic setting. Methods We organized a set of memories and thoughts through a series of semistructured iterative sessions specific to our first encounters as researchers in Indian country. We compiled our written responses and field notes from our dialogue, interpreted these data, and organized them into themes. We have reported what we felt would be the most surprising, frequent, or important information to note. Results We identified three overarching themes in our collective experience: orientation and negotiation, situating ourselves and our work, and navigating our way. Subthemes included perceiving ourselves as outsiders, negotiating distance and time realities, relying on the goodness of gatekeepers, shaping research questions per community priorities, honing our cross-cultural and intercultural communication skills, discovering the many layers of tribal approval processes, and developing sensibilities and intuition. Discussion Our previous experiences as novices leading research projects in Indian country have produced unique sensibilities that may serve to guide nurse researchers who seek to partner with tribal communities.
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