Suicidality

Suicide has been at an all-time high in recent years. It is reported that there is 1 billion successful suicides a year (Turecki & Brent, 2016). Per year there are 14.5 deaths for every 100,000 persons, that is equivalent to one death every 40 seconds due to suicide. Emile Durkheim demonstrated in his research that suicide has always been a constant throughout all these years. While society and its members are constantly changing so are their reasons as to why suicide is the only option to partake in. Suicide rates vary by country but regardless of the location, they keep rising (Nowotny, Peterson &Boardman, 2015). While suicide has been shown to be reducing amongst the elderly, it has been rapidly increasing amongst youth (Hawton & Heeringen van, 2009). Through past studies suicide has been shown to be spread socially but reasons as to why or how are too vast and still quite unknown. Factors such as gender, religion, technology, imitation and social economic status (SES) have been linked to dramatically affect suicidality rates. Suicidality is not to be confused with suicide. The term suicidality and suicide are two terms that are often interchanged but possess different definitions. Suicidality is the ideation and attempt to kill oneself without actually succeeding while suicide is the act of attempting to take one’s life and succeeding.

The objective of this study is to further understand why suicidality rates have been increasing. It is important to recognize underlying factors which affect and are associated with high suicide rates. This is important to the construction of further research and for the opportunity to be able to properly treat and care for those who are being affected by these extraneous factors before suicidal ideation turns into suicide. Many people die every day in cause of suicide, it is time to take a stand and investigate why these individuals think this is the only way to cope with stress, pain or monetary problems.

Suicidality is of utter importance to medical sociology because medical sociology is a multidisciplinary field in which psychology, sociology and the medical field interact all together to make up the overall well-being of a person. Suicidality ties in together the psychological factors and social factors that contribute to the medical health of a person. In order for us to fully understand why suicide is the choice to some, various factors have to be examined thoroughly to establish the reason as to why suicide is so common amongst our youth today. It is not merely enough to study the psychological stress a person is going through to further understand their reasons for wanting to end their life. Social factors such as imitation and social learning andnd biological factors such as pathophysiology, contribute tremendously to self-harm and suicidal behavior tendencies. Too quite often these suicidal behaviors tend to lead to a succesful suicide.

Definition of the literature

There are many definitions and different forms of suicidal behaviors. Suicide is when a person has suicidal ideations and acts upon them by attempting to kill themselves and succeeding. The difference between ideation and suicide is the fact that one has a life ending result. There are also many who engage in non-suicidal self-injuring, which is when a person self-harms themselves but lacks the motivation to end their life. Many of these behaviors are common amongst younger teenagers who want to relieve stress by feeling pain, as self-punishment or as an escape towards a difficult situation they are facing (Turecki & Brent, 2016). However, these behaviors do not usually lead to suicide attempts. Yet, some individuals start off by self-harming without suicidal ideations and end up either accidentally succeeding in their attempt or in further engagement of suicidal behaviors.

Connotation of “Suicide”

While it is fairly common for people to confuse the term suicide with suicidal ideation and self-harm, there is a fine line of distinction between them all. Suicide is when a person who has thoughts of ending their life acts upon those negative thoughts. In order for it to be considered a suicide a person needs to not only attempt but to be successful at ending their life. Being successful in a suicide attempt is what distinguishes between suicide and suicidal ideation. Ideation are the thoughts and ideas a person has before attempting to self -harm. Many times, self-harming will lead to suicidal events which is when a person attempts but does not succeed and actual suicide (Turecki & Brent, 2016).

Thinking of it and planning it

There are 2 types of suicidal ideation: active and passive. Active suicidal ideation is when a person has thoughts about ending their life and begins planning different methods to attain this desired effect. While passive suicidal ideation is when a person has thoughts about ending their life but does not necessarily have an intention of attempting to achieve it. There is a much greater risk for those with active suicidal ideation within a span of 12 months than those with passive suicidal ideation (Turecki & Brent, 2016). Passive suicidal ideation is most commonly found amongst early adolescences, who are experimenting with pain and self-harm.

The attempting

Suicidal events are worsening suicidal behaviors in which a person actively tries to self-harm themselves to their lives but does not succeed. Self-injury is a behavior elicited by those who have suicidal ideations. Self-harm is a mixture of actual suicide attempts and of non-suicidal self-injuries (Turecki & Brent, 2016).

Age discrepancies for suicidal behavior

Age is an important distinction among those who commit suicide. While middle aged and elderly individuals have been known to be the highest number of cases dealing with suicide, teenagers have now climbed up the ladder. Youth and young adult suicides have increased dramatically over the past years and are now the second leading cause of death between the ages of 15-29 (Turecki & Brent, 2016). Suicidal ideation and attempted suicide could be more prevalent on young adults because they are more likely to be influenced by extraneous factors, such as social media and social pressure (Ramchand et al, 2015). During the young adult years, it is quite common that during this period, many are experiencing life changing events such as getting a job, going into university, some of them might even move out of town or out of their parent’s home. All of these events can cause tremendous amount of stress amongst youth which can negatively affect their psychological and psychosocial predisposition to depression. This depression can then ultimately lead to suicidal ideations because of increased levels of stress these big life changing events are producing (Dugas, et al, 2015). During adolescence and young adulthood high levels of stress may cause individuals to begin engaging in non-suicidal self- injuring. This is a type of self-harm in which teens engage as a way to escape or punish themselves. These types of behaviors can unfortunately increase the chances of suicidal ideation and ultimately suicide attempts (Heilbron & Prinstein, 2010).

Gender differences for suicide rates

Suicidal ideation is higher among females, but suicide is higher among men. Out of 100,000 people, there are 15 men who will commit suicide in comparison to 8 women who will successfully take their lives (Turecki & Brent, 2016). This may have something to do with the fact that women tend to overthink about problems and might contemplate to kill themselves but fall short of bravery because they often think first on their family, in specific kids, whom they need to tend for. Males tend to be more active in their ideations and succeed because they try methods of suicide which have higher success rates than women. In comparison to males, females are also more likely to visit a doctor to consult about their suicidal ideations whereas males keep emotions bottled up which result in successful suicides. in a study by Nowotny, Peterson & Boardman (2015), males show to have a higher suicidal ideation than females in only 2 out of 30 states studied. The suicidal ideation rates in males is 15.4% whereas females are 26.6%, that is a striking difference between the two. In addition to male and females, those who are a part of the LGBT community seem to experience the highest levels of suicidal ideation. This is quite common because they are usually judged by others, which results in high levels of stress in their lives. Suicide rates on a male to female ration are also higher amongst those who have a lower social economic status.

Social economic status

People who have low economic status tend to report having higher rates of suicidal ideation, which is not at all surprising. Stress is commonly found more amongst people of the lower class than people in the high social class. People at the top of the social class have experienced greater positive life changes and seem to have acquired a greater sense of self-control over life situations than people who are in the lower classes. In return this lack of control, can ultimately lead those in the lower classes with greater amounts of stress and depression that ultimately causes them to have suicidal ideations. It has been reported that economic downturns which result in unemployment usually give a rise to not only suicidal ideation but to suicide itself. When personal income lowers, stress increases which causes people to have these negative thoughts about killing themselves in attempt to relieve their stress and their economic status. Suicide rates among the unemployed show that successful suicides are often higher amongst men, than women (Turecki & Brent, 2016). While suicidal ideation is higher amongst women when unemployed, suicide attempts are more prevalent on males.

Religion and levels of suicidality

Religion like in many sociological theories plays a large role in suicidality. As we studied the literature it is clear that the higher their levels of commitment to a religion—which forbids suicide—the lower the suicide attempts (Gearing & Lizardi, 2009). A study conducted by Gearing & Lizardi in 2009 showed the differences on suicidal ideation and actual suicide amongst different religions. These two researched on Christianity, Hinduism, Islamic religions, and Judaism. Of all these religions Judaism showed to have the lowest rates of suicide in the world because of the negative effects a person goes through if they decide to end their life. Islamic religions showed similar signs as Judaism. Islamic religion places a strong emphasis on forbidding suicide. Engaging in suicide will result in the personal burning in hell. Suicide rates are low in predominant Islamic countries in comparison, yet they do have high suicidal ideation because of high psychological stress. However, in both Judaism and Islamic religions, suicide rates have increased. Hinduism shows higher rates of suicide amongst males with psychiatric problems than in women. Hinduism strongly believes in the philosophy of reincarnation, which means that for Hindus, life does not end at death. Hinduism is less strongly endorsed by moral objections towards suicide. Of the religions examined in this study, Christians have higher suicidality and suicide rates especially among men. In Christianity suicide is viewed as a sin, and upon the funeral service forgiveness in behalf of the victim is asked. However, Catholic and Baptist show lower rates than other denominations of Christianity because they have higher rates of integration and peer support. As we study these religions and their attitudes towards repercussions after suicide affect the rates of suicidality and effective suicides. The degree of religiosity that a person has can serve as a protective factor against suicidal behavior. Data also showed that people who go attend church more often exhibit lower suicide ideation and are 4 times less likely to commit suicide than those who do not attend church.

Following the study on Christianity, Hinduism, Islamic religions and Judaism, Gearing & Lizardi (2010) meta-analyzed Buddhism, Native American religions, African religions and Atheism & Agnosticism. In Buddhism, killing oneself is considered harming and killing a living thing, which is frowned upon by the main Buddhist principle. Suicidality rates and behavior vary on the levels of commitment to this principle. In Native American religions suicide is the 6

^th

leading cause of death. Similarly, to the rest, commitment to spirituality show a positive factor against suicidality. Native Americans across all tribes believe that life is a cycle. Therefore, suicide might be considered a positive action since death, can be also viewed as a beginning, as many of them believe in reincarnation. Suicidal ideation amongst African religions are subjectively low compared to Islamic religions, particularly in Nigeria. Nigerians show high negative attitudes towards suicide however, not much research has been done in these types of religions. Little research has been done on Atheism, Agnosticism and Suicide therefore, it is unclear if their beliefs affect them negatively. Agnosticism and Atheism are the smallest minority non-religious group, with less than 0.5% of the world’s population. 95% of them firmly believe in Physician-Assisted Suicide in comparison to religiously driven health practitioners. Although many of the religions talked about above have been limited to research studies, there is a positive association between levels of religiosity, suicidality and suicide behaviors. The higher the levels of religiosity one exerts, the lower the prevalence of suicidal ideation one has.

Religion isn’t the only factor that plays in suicidality. Recent studies have shown that negative use of technology has increased suicidality and unfortunately suicide rates. 95% of all youth have access to the internet, and of those 75% have instant access on their cellphones (Nikolau, 2017). Cyberbullying has increased from 18.8% in 2007 to 34% in 2016. Cyberbullying not only affects suicidality rates, it also has negatively affected actual suicide fatalities. Of 25 suicide attempts one is successful. Not only does cyberbullying affect those who are bullied but those who bully others are also negatively affected (Hinduja & Patchin, 2010). Many believe that only people who are bullied suffer emotionally but there are many underlying factors that bullies have that add up into them lashing out and projecting their hate and anger unto other people. Being cyberbullied is associated with high levels of depression, decreased self-worth, hopelessness and loneliness. All of these which are contributors to suicidal ideation and ultimately a fatality. A study was conducted by Hinduja & Patchin to further research the associations between bullying cyberbullying and suicide. A total of 1.963 students from grades ranging in 6 through 8, participated in the study. Traditional bullying victimization, traditional bullying offending, cyberbullying victimization and cyberbullying offending was measured. Results showed that 20% of participants were seriously thinking of committing suicide. Of the entire 1,963 students, 23.1% said they were most frequently victimized by someone posting an upsetting picture about them online. While, 18.3% said they had been cyberbullied by receiving negative texts from someone they know. While social media is supposed to aid in keeping a close relationship to those around you, it seems that it keeps pushing people to hurt each other and alienate one another. Can it be that the more social media one engages in the more you are susceptible to suicidal behaviors?

Imitation and social media coverage

Negative behaviors elicited by technological use are not only derived from cyberbullying but by exposure of suicide on social media. It is quite common for people to have social media, especially the young. The media is constantly reporting suicide fatalities which have been positively associated with spikes in suicide rate. When media coverage extends to publicly announce about these tragedies, suicide rates have shown an increase especially within the first 30 days of the incident. High rates are also many times associated with the explicit and detailed coverage the media gives about these events. When a suicide is romanticized and when a celebrity is involved, young adults can be very vulnerable and prone to engage in suicidal behaviors (Turecki & Brent, 2016). In a study by Mueller (2017), examined a cluster of suicides in a community called Popular Grove. The media coverage in this area exposed the high suicidal ideation of students which was already present in the community; thus, resulting in the community’s solid view of suicide as an escape. It all started in the early 2000s when a cluster of people committed suicide. 2 females and a male committed suicide within a twelve-month period. The second cluster of suicides was 2 male graduates, followed by a female 6 months after. A third cluster in 2009 emerged four friends committed suicide within 9 weeks of each other. Ever since, at least one student or graduate from Popular Grove has successfully committed suicide. Studying the media, it was found that the framing of suicide motives and the presentation of the information had massive associations between the preceding suicides. Media coverage following all suicides, resulted in exposure to the motives for suicide. One of the reasons was teasing and pression. The local media made young viewers associate teasing and pressure with suicide. Constant bombardment of headlines, and front- page details of the fatalities also aided in the increase of suicides. For weeks following the suicides, headlines and front-pages of newspapers were used to continue marketing these suicides. These 2 factors showed to create a negative effect on the youth by encouraging them to commit suicide rather than help reduce the suicide rates in the community. Suicide contemplation can be spread through social relationships via suggestion (Abrutyn & Mueller, 2014). In this case, the more the media exposed the youth to the suicide victims, the more the viewers became socialized with them thus resulting in the suggestion of suicide to solve their problems. Suicides via suggestion are more common amongst females (Abrutyn & Mueller, 2014). High suicide rates can be reduced through various factors. As previously seen, negative exposure from the media can unfortunately cause negative effects on suicidality and suicide fatalities. Raising awareness of suicidal ideation amongst our youth should be done. However, the way in which we do it is important. Constantly bombarding through social media about suicides has caused negative effects. Suicidal imitation is brought upon the rapid medial exposure of celebrity suicides. As celebrity suicides are publicly announced in excruciating detail, young adults who are facing similar trials are given the idea to take this route as well. Not only is the idea inserted in their heads by social media bombarding them with the reoccurrence of the events, but it also provides with details in the method used to commit suicide that it is so easy to follow in their footsteps. Therefore, instead of speaking out about fatalities, the media should promote self-care and ways to identify those at high risk of committing suicide (Turecki & Brent, 2016).

Biophysiology of Suicidal ideation

As opposed to imitation, suicidal ideation and suicidal behavior can be genetically transmitted. Studies focused on family configurations have shown that there is a higher risk of suicidal behavior in people who have a relative who committed suicide than those who do not. While this can be mistaken for imitation, adoptions studies show that there is an association between high suicide attempts between biological off-springs of those who committed suicide and not in adoptive relatives. Studies have shown that suicidality is estimated to be 17.4% hereditary transmittable from parent to offspring and suicidal ideation can be up to 36% transmitted. Genetically induced suicidal behavior is most common amongst females (Hawton & Heeringen van, 2009).

There are other biological factors that play a part in suicidal ideation. In postmortem studies, there has also been scientific proof that there are different neurotransmission functions that differ from those who die from suicide than those who die of natural causes. There seems to be a difference in the hypothalamic-pituitary-adrenal axis, which seems to be associated with people who suffer from depression. This might be a way to detect those who are susceptible to suicidal behaviors and enable us to help these individuals overcome these negative thoughts (Hawton & Heeringen van, 2009).

Theory

While many factors can impact suicidal behaviors, there are three which are heavily associated with suicidal ideation. As we studied the different studies on suicide rates, we can see that suicidality is at an all-time high. Suicidality differs by gender, age, socioeconomic status, and biophysiology. All of these factors ultimately affect our behaviors and beliefs. Levels of religiosity can be affected by gender, age, and socioeconomic status. In turn religiosity impacts the likelihood of developing suicidal behavior. Religiosity is more prevalent amongst middle-aged adults and elderly, which can be a reason as to why suicide rates have dramatically decreased for their age groups. While suicide rates have increased for young adults and adolescence, their levels of religiosity have decreased. It is not as common to see young people passionate for their religion, many of them partake on religious customs because they are forcibly made to by their parents. However, their levels of conviction are low, which ultimately affects suicidal ideation. The higher the levels of conviction in a certain high entity you have, the lower the chances are that a person would engage in suicidal behaviors because of the reprimands one would suffer.

While suicidal behavior can be affected by the use of social media. The negative use of technology has increased levels in suicidal ideation and in suicide rates. Social media and technology play a vital part in suicidal ideation because, in this century, everything is linked to the internet. Almost everyone knows how to use a computer, or at least a phone. Electronics have become so easy to use that people start using them at a younger age than before. It is fairly easy for someone to go online and search methods on to take their own life. Everything is written in detail, and anyone can get a hold of it. Most of the time, one does not even have to search for it, it is given to us by the media. Nowadays, it seems that celebrity suicide is more and more common. The media wants to work all angles to ensure that they are getting exclusive details out to the public. What they do not understand is that there are negative consequences when people are exposed to these types of details. With doing this, they are increasing the chances of a person who is actively following the coverage to have the desire to engage in the same behavior by imitation. In every form of media outlet all we see is the different reasons and ways people commit suicide, it only pushes young adults who are passing through these same life situations to think that suicide is the only way out.

Technology has not only affected us by the media coverage, it affects everyone because it is so easy to hurt others behind a computer screen. When online, people can post the most hurtful comments on a picture they posted and can ultimately lead a person to a depressive state which will then result in them having suicidal ideations. If these types of hurtful comments keep surfacing in this person’s life, feelings of unworthiness will surface and lead to a suicide attempt. There have been many suicides that have been because of cyberbullying. While technology keeps advancing, suicide rates are increasing.

If only teenagers would exert higher levels of religiosity, neither social media nor technology would not measure up to the barrier that it has against suicidality. While the separation of the church and state seemed to be the right answer back in 1971. Nowadays, it seems that if only we had instilled religiosity amongst our youth, they would not only love one another more as the Bible says, but those negative thoughts and suicidal ideologies would not partake in their lives. it is saddening to see young people who have a whole life ahead of them take their lives for something that could be solved by communication. It is important to understand that when you believe in something, something bigger than you, then you have a higher rate of pushing out these negative thoughts and feelings out of your mind and pushing through and making it in life.

it is important to continue researching different factors which contribute to the dramatic increase of suicide rates. It is also important to continuously keep pushing the efforts to educate others about why people participate in suicidal ideations and suicide. Many are oblivious to the fact that these negative thoughts can be a part of anyone’s life. Teaching the younger generations about using technology to encourage one another and about our religions can ultimately reduce the suicide rates among our youth. Religiosity must be instilled amongst the new generations, for it will ultimately be their choice if they want to believe and follow it or not. You are not only giving them a chance to believe, but a better chance at survival.

SOCIAL MEDIA

MENTAL HEALTH

IMITATION

LEVEL OF USAGE

CELEBRITIES/ROLE MODELS

SUICIDE

BIOPHYSIOLOGY

SUICIDAL IDEATION

GENDER

LEVEL OF RELIGIOGIOSITY

TYPE OF RELIGION

RELIGION

References

• Abrutyn, S. & Mueller, A.S. (2014) Are suicidal behaviors contagious in adolescence? Using longitudinal data to examine suicide suggestion. American Sociological Review, 79(2). 211-227. DOI: 10.1177/00031224135194457
• Dugas, E.N., Low, N.C., O’Loughlin, E.K., & O’Loughlin, J.L. (2015) Recurrent suicidal ideation in young adults. Canadian Journal of Public Health, 106(5). e303-e307. doi: 10.17269/CJPH.106.4774
• Gearing, R.E., & Lizardi, D. (2009) Religion and Suicide. Journal of Religion and Health, 48(3). 332-341. DOI 1 0. 1 007/s 1 0943-008-9 181-2
• Hawton, K. & Heeringen van K. (2009) Suicide,
  
  Seminar, 373
  
  , 1372-1381.
• Hinduja, S. & Patchin, J.W. (2010) Bullying, cyberbullying, and suicide,
  
  Archives of Suicide Research, 14
  
  (3), 206-221, DOI: 10.1080/13811118.2010.494133
• Heilborn, N., & Prinstein, M.J. (2010) Adolescent peer victimization, peer status, suicidal ideation, and nonsuicidal self-injury: Examining concurrent and longitudinal associations. New Directions in Peer Victimization Research. Merill-Palmer Quarterly, 56(3). 388-419.
• Kubrin, C.E., & Wadsworth, T. (2009) Explaining suicide among blacks and whites: How socioeconomic factors and gun availability affect race-specific suicide rates. Social Science Quarterly, 90(5). 1203-1227.
• Lizardi, D., & Gearing, R.E. (2010) Religion and suicide: Buddhism, native american and african religions, atheism, and agnosticism. Journal of Religion and Health, 49(3). 377-384. DOI 10.1007/sl0943-009-9248-8
• Maimon, D., & Kuhl, D.C. (2008) Social Control and Youth Suicidality: Situating Durkheim’s Ideas in a Multilevel Framework. American Sociological Review, 73(6). 921-943.
• Mueller, A. S., & Abrutyn, S. (2015) Suicidal disclosures among friends: using social network data to understand suicide contagion. Journal of Health and Social Behavior, 56(1). 131-148. DOI: 10.1177/0022146514568793
• Nikolaou, D. (2017) Does Cyberbullying impact your suicidal behaviors?
  
  Journal of Health Economics, 56
  
  , 30-46. http://dx.doi.org/10.1016/j.jhealeco.2017.09.009
• Nowotny, K.M., Peterson, R.L., & Boardman, J.S. (2015) Gendered contexts: variation in suicidal ideation by female and male youth across U.S. states. Journal of Health and Social Behavior, 56(1). 114-130.: DOI:10.1177/0022146514568350
• Ramchand, R., Ayer, L., Fisher, G., Osilla, K.C., Barnes-Proby, D., & Wertheimer, S. (2015) Suicide Prevention After a Suicide. RAND Corpotation. 17-29.
• Turecki, G. & Brent, D.A. (2016) Suicide and suicidal behavior,
  
  Seminar, 387
  
  ,1227-1239. http://dx.doi.org/10.1016/ S0140-6736(15)00234-2

Abstract

Study Objective:

Goal of this study is to present a cases series endorsing same-day discharge after minimally invasive robotic surgery for endometrial cancer and to determine factors that affect the length of hospital stay.

Design:

Retrospective study is comprised of all cases (N = 78) by a single gynecologic oncologist (July 2017 to July 2019) that involved a robotic-assisted total hysterectomy (RTH) with bilateral salpingo-oophorectomy (BSO) and total pelvic ± para-aortic lymphadenectomy for endometrial cancer. Categorical and continuous variables were analyzed using the Chi-square test and two-sided t-test respectively. Multivariate correlation analysis was utilized to determine risk factor influence on length of stay. Factors that may affect same-day discharge: surgery time, estimated blood loss, time of day (start of surgery after 15:00), cystoscopy, complexity of surgery, comorbidities, FIGO grade from endometrial biopsy pre-operatively, FIGO stage.

Setting:

Community hospital in El Paso, TX, a borderland city primarily comprised of a Hispanic population.

Patients:

78 patients who underwent robotic total hysterectomy with bilateral salpingo-oophorectomy and total pelvic ± para-aortic lymphadenectomy for surgical treatment of endometrial cancer.

Measurements and Main Results:

Total of 78 women with a median age of 61.8 years-old underwent RTH + BSO + surgical staging, and 56 (71.8%) of patients were successfully discharged the same day (< 24 h) despite no ERAS protocol. Number of comorbidities, body mass index (BMI), FIGO grade, surgery time of day, and surgery length did not have a statistically significant effect on length of stay. Of the same-day discharge cases, 20 (35.7%) were immediately discharged following post-op recovery (within 4 h). Patients were more likely to stayed longer than 24 hours if they were older (> 60 y), higher estimated blood loss (> 30 cc), higher surgical complexity (para-aortic lymphadenectomy and/or omentectomy performed), or higher FIGO stage (> IB).

Conclusion:

Same-day discharge is feasible following minimally invasive robotic surgery for endometrial cancer, despite multiple comorbidities, later surgery time of day, and higher FIGO grade.

Keywords: Same-day discharge; Minimally invasive gynecologic surgery; Endometrial cancer; Gynecologic oncology

Introduction

Endometrial cancer is the most common gynecologic cancer in women and 9

^th

most common cancer in women overall [1-2]. Moreover, incidence and mortality of endometrial cancer in the United States are increasing with an estimated 63,230 new cases and 11,350 deaths in 2018 [2-3]. Endometrial cancer is typically diagnosed in postmenopausal women who present with vaginal bleeding. First-line treatment for early–stage endometrial cancer is primary surgical resection via total hysterectomy with or without bilateral salpingo-oophorectomy and possible lymphadenectomy [4]. This surgery was traditionally performed via laparotomy, but now a minimally invasive approach has proven to be feasible and preferred with fewer surgical complications and shorter hospital stays [5-19].

To our knowledge, there are no consensus recommendations at a national level that endorse same-day discharge for minimally invasive surgery for patients with endometrial cancer. As the field of robotic surgery has grown significantly since its FDA approval in 2000, more and more physicians advocate for same-day discharge due to smaller incisions, better-controlled pain, and quicker recovery [7-8]. In gynecologic surgery, simple minimally invasive oophorectomies and ovarian cystectomies commonly have same-discharge. In comparison, many gynecologists admit their patients for overnight observation after more complex surgeries, like minimally invasive total hysterectomies [8]. The reasoning behind overnight observation is to detect potential perioperative complications, such as hemorrhage or unintentional injury to other pelvic structures, such as the ureters [5].

However, multiple studies have recently demonstrated feasibility and safety for same-day discharge status post minimally invasive hysterectomies without the need for reoperations or hospital admissions caused by perioperative complications [5, 8-17]. While some institutions have reported same-day discharge rates following minimally invasive hysterectomy as high as 93%, the national incidence is < 10% [5, 9]. Patients even report same or greater satisfaction with same-day discharge compared to 23-hour overnight observation in the hospital [8-9, 12]. Excluding high-risk patients with pre-planned hospital admission, some studies have found that longer operation time, later surgical end-time in the day, higher surgical complexity, increased age, and non-minimally invasive approach decrease the likelihood of same-day discharge [5, 8-9, 15-17].

The goal of this study is to present a cases series endorsing same-day discharge for minimally invasive surgery for endometrial cancer and to determine predictive factors. There is supporting data from multiple institutions that demonstrates feasibility and safety of same-day discharge for women undergoing minimally invasive hysterectomy.

Methods

Participants

All patients of single gynecologic oncologist who underwent a robotic-assisted total hysterectomy (RTH) with bilateral salpingo-oophorectomy (BSO) and pelvic ± para-aortic lymphadenectomy for endometrial cancer between July 2017 and July 2019 were retrospectively reviewed for potential inclusion (N=78). The initial cohort was evaluated for chronic pelvic pain as an exclusion characteristic, though none matched this criterion. By study design, patients who underwent a non-robotic-assisted approach were excluded.

Surgical Methods

The underlying indication for RTH was a positive endometrial biopsy (EMB), though 4 (5.1%) patients did not undergo EMB prior to surgery. The RTH and BSO was performed using four ports, one of which was utilized as an assistant-port. Local anesthesia was injected at the port sites prior to incision and after closure. All specimens were removed via the vagina.

Recovery Protocol

No strict Enhanced Recovery after (gynecologic) Surgery (ERAS) protocol was followed. Patients were encouraged to ambulate and advance diet as tolerated. Foley catheter was removed immediately following surgery in most cases. Patients had standard anesthesia care. Postoperative analgesia consisted of hydrocodone/acetaminophen 5/325 mg quantity 10-15, unless patient pain threshold necessitated further management in PACU.

Variables Recorded

Baseline demographic variables recorded were age and body mass index (BMI). Clinical characteristics noted were comorbidities, FIGO (International Federation of Gynecology and Obstetrics) grade, preoperative diagnosis, postoperative diagnosis, surgical procedures performed, surgery start time, and surgery length. Surgical outcomes documented were estimated blood loss (EBL), FIGO stage, surgical complications, reasons and length of hospital stay.

Statistical Analyses

Sample size was calculated using alpha set at 0.05, power set at 90%, and known population incidence set at 10% [5]. Minimum of 4 subjects were required for analysis to achieve statistical power. Continuous variables were calculated using two-sided t-tests and are expressed as

median (range).

Categorical variables were computed with the Chi-square test and are written as

number of cases (percentage of occurrence).

Multivariate analyses were executed using logistic and linear regression models. These regression models evaluated the correlation between the demographic and clinical variables compared to length of stay. Statistical significance was set at

p

<0.05 prior to data collection, and significant values are denoted with an asterisk. Statistical analyses were performed using GraphPad Prism version 8.0 for Windows (GraphPad Software, San Diego, CA) and JASP version 0.9.2 (University of Amsterdam, Department of Psychological Methods, Amsterdam, The Netherlands).

Results

A total of 78 patients underwent surgical management for endometrial cancer between July 2017 and July 2019. The demographic and clinical characteristics by length of stay were not significantly different between the groups of same-day discharge (≤ 24 h) and admitted (> 24 h); however, age becomes significant when dichotomized above and below age 60 (Table 1).

Table 1
Demographic and clinical characteristics by length of stay
Characteristic						≤ 24 h(N = 56)	> 24 h (N=22)		p value
Age, y						62.25 (28 – 91)	61.09 (40 – 88)		0.628
≤ 60, > 60						20 (36.0%), 36 (64.0%)	14 (64.0%), 8 (36.0%)		0.025*
BMI, kg/m 2						35.22 (21.79 – 55.78)	32.26 (18.44 – 50.07)		0.129
≤ 30, > 30						17 (30.4%), 39 (69.6%)	10 (45.5%), 12 (54.5%)		0.207
Comorbidities									0.788
≤ 1, > 1						17 (30.4%), 39 (69.6%)	6 (27.3%), 16 (72.7%)
Histologic grade									0.122
I, II – III						26 (46.4%), 30 (53.6%)	6 (27.3%). 16 (72.7%)

In this study, surgical complexity is distinguished by the performance of additional staging procedures.

Simple

indicates that only pelvic lymph nodes were dissected.

Complex

denotes that para-aortic lymphadenectomy and/or infracolic omentectomy occurred. No intraoperative complications occurred during any of the cases.  Length of stay was significantly associated with surgery time, EBL, surgical complexity, and FIGO stage (Table 2). There was no significant difference in surgery start time between the two groups.

Table 2
Surgical outcomes by length of stay
Characteristic						≤ 24 h(N = 56)	> 24 h (N=22)		p value
Surgery time, min						150.98 (68 – 256)	170.36 (103 – 233)		0.048*
≤ 120 > 120						10 (17.9%), 46 (82.1%)	4 (18.2%), 18 (81.8%)		0.048*
Surgery start time									0.789
Before 15:00, After 15:00						9 (16.1%), 47 (83.9%)	3 (13.6%), 19 (86.4%)
EBL, cc						32.68 (10 -100)	51.59 (10-200)		0.021*
≤ 30, > 30						44 (78.6%), 12 (21.4%)	12 (54.5%), 10 (45.5%)		0.34*
Surgical complexity									0.004*
Simple, Complex						14 (25.0%), 42 (75.0%)	13 (59.1%), 9 (40.9%)
FIGO stage									0.009*
IA, IB-IV						36 (64.3%), 20 (35.7%)	7 (31.8%), 15 (68.2%)

Multivariate models for predictors of same-day discharge demonstrated statistically significant relationships with age > 60 y, EBL ≤ 30, lower surgical complexity, and FIGO stage ≤ IA (Table 3).

Table 3
Multivariate analysis for predictors of same-day discharge (< 24 h) after RTH
		< 24 h (N=56)
Characteristic		Coefficient	95% Confidence interval	p value
Age >60		0.253	0.451, 0.033	0.025*
Comorbidities ≤ 1		0.030	0.251, -0.193	0.791
BMI ≤ 30		-0.143	0.082, -0.193	0.212
FIGO grade ≤ 1		0.175	0.383, -0.049	0.125
Surgery start time  before 15:00		0.030	0.251, -0.193	0.792
Surgery length ≤ 120		-0.004	0.219, -0.226	0.974
EBL ≤ 30		0.240	0.439, 0.019	0.034*
Surgery complexity- only pelvic lymphadenectomy		0.322	-0.108, -0.509	0.004*
FIGO stage ≤ IA		0.294	0.485, 0.076	0.009*

Of the 56 (71.8%) patients discharged home within 24 hours, 20 (35.7%) patients were immediately discharged within 4 hours. Multivariate analysis showed slightly different predictors in this subgroup. Discharge within 4 hours was associated with well-differentiated FIGO grade, surgery start time prior to 15:00, EBL ≤ 30, and FIGO stage ≤ IA (Table 4).

Table 4
Multivariate analysis for predictors of immediate discharge (< 4 h) after RTH
		< 4 h (N=20)
Characteristic		Coefficient	95% Confidence interval		p value
Age >60		-0.076	0.312, -0.129		0.509
Comorbidities ≤ 1		0.007	0.229, -0.216		0.954
BMI  ≤ 30		0.005	0.293, -0.149		0.967
FIGO grade ≤ 1		0.227	0.428, 0.004		0.046*
Surgery start time before 15:00		0.250	0.448, 0.030		0.027*
Surgery length ≤ 120		0.031	0.252, -0.192		0.785
EBL ≤ 30		0.238	0.437, 0.016		0.036*
Surgery complexity- only pelvic lymphadenectomy		0.180	0.387, -0.044		0.114
FIGO stage ≤ IA		0.294	0.485, 0.076		0.009*

Following RTH + BSO + staging, patients stayed at the hospital a median of 53.7 hours, ranging from 29 minutes to 168 hours or 7 days (Fig. 1). Of the 22 (28.2%) patients that were discharged after 24 hours, 7 (31.8%) patients were admitted secondary to comorbidities (Fig. 2).

Fig. 1
Distribution of length of stay. 56 (71.8%) patients were discharged within 24 h. Longest hospital stay was 168 h or 7 days.

Fig. 2
Reasons for prolonged hospital stay > 24 h. N = 22. SIRS = systemic inflammatory response syndrome; UTI = urinary tract infection.

Discussion

Our data support the feasibility and safety of same-day discharge after RTH + BSO + staging for endometrial cancer. This study suggests that younger (age ≤ 60) patients whose staging is limited to pelvic lymphadenectomy and with less invasive endometrial cancer (FIGO stage IA) are more likely to be successfully discharged within 24 hours. Of the 22 (28.2%) patients who stayed longer than 24 hours, 7 (31.8%) cases were associated with comorbidities, which included cardiovascular disease, pulmonary disease, renal disease, and seizure disorder. Of the same-day discharge cohort, only 1 (1.8%) patient had a reoperation for vaginal cuff dehiscence and 1 (1.8%) patient had a readmission for abdominal pain and leg edema.

Furthermore, our study demonstrated that immediate discharge within 4 hours is achievable for endometrial cancer patients after surgical management. Similar to same-day discharge, immediate discharge within 4 hours was associated with EBL ≤ 30 and FIGO stage IA. To our knowledge, one other study presents data for immediate discharge within five hours following total laparoscopic hysterectomy for benign indications [13]. In this study, patients received preoperative counseling by the surgeon and anesthesiologist on postoperative pain management and recovery. It also endorses early pain relief as necessary, quick mobilization, food within 2 hours, and no urinary catheter upon termination of surgery.

In our study, we also excluded chronic pelvic pain patients. Potentially, chronic pelvic pain patients undergoing surgical management for endometrial cancer may lead to longer hospital stay. One study found that patients undergoing hysterectomy indicated by chronic pelvic pain were admitted for an average of 2.5 days [20]. Perhaps it can be extrapolated that chronic pelvic pain patients undergoing more a complex hysterectomy for malignant reasons may have an even longer hospital stay.

Preoperatively, our patients were counseled on surgical procedure and recovery expectations, including discharge immediately after surgery. Multiple retrospective studies endorsing same-day discharge have encouraged these discussions, ensuring that the patient is mentally prepared and can also coordinate transportation and supportive care after surgery [8, 10, 15, 20]. These doctor-patient interactions act as a placebo, effectively manipulating the self-appraised symptoms, such as postoperative pain [21].

This study also presents some limitations. This is a retrospective study of a relatively small sample size treated by a single surgeon. Additionally, no formal ERAS protocol was implemented for this cohort. The ERAS guidelines encompass perioperative care elements to augment post-op recovery. These elements include thromboembolism prophylaxis, postoperative fluid control, postoperative serum glucose management, pain management, perioperative nutrition, early mobilization [22].

Despite these limitations, the robotic surgery was performed by a high-volume surgeon with relatively low rates of adverse outcomes [23]. Moreover, the majority of these cases were performed in less than 160 minutes. Less time in the OR may translate to less pain, fewer anesthesia effects, and quicker recovery and discharge.

Conclusion

This study demonstrates the feasibility of discharging patients directly from PACU after undergoing minimally invasive robotic surgery for endometrial cancer. In certain instances, patients required 23-hour observation postoperatively due to multiple comorbidities, some of which were anesthesia-related. Further clinical studies may show that ERAS protocol affects length of stay after RTH indicated for endometrial cancer. Although minimally invasive surgery is well documented for decreased length of stay and use of postoperative pain management [15], the use of consensus recommendations may be helpful in the management of this patient population postoperatively.

References

1. C. Corzo, N. Barrientos Santillan, S.N. Westin, et al. “Updates on conservative management of endometrial cancer.” Journal of Minimally Invasive Gynecology. 25.2 (2018) 308-313.
2. M.E. McDonald & D.P. Bender. “Endometrial cancer: Obesity, genetics, and targeted agents.” Obstetrics and Gynecology Clinics of North America. 46.1 (2019) 89-105.
3. “Cancer stat facts: Uterine cancer.” National Cancer Institute. 2018. https://seer.cancer.gov/statfacts/html/corp.html. Accessed February 10, 2019.
4. “NCCN Clinical Practice Guidelines in Oncology: Uterine neoplasms.” National Comprehensive Cancer Network. 2018. https://www.nccn.org/professionals/physician_gls/pdf/uterine.pdf. Accessed February 10, 2019.
5. J. Lee, Y. Aphinyanaphongs, J.P. Curtin, et al. “The safety of same-day discharge after laparoscopic hysterectomy for endometrial cancer.” Gynecologic Oncology. 142 (2016) 508-513.
6. C. Bourgin, E. Lambaudie, G. Houvenaeghei et al. “Impact of age on surgical staging and approaches (laparotomy, laparoscopy, and robotic surgery) in endometrial cancer management.” European Journal of Surgical Oncology. 43.4. (2017) 703-709.
7. C.N. Criss & S.K. Gadepalli. “Sponsoring surgeons: An investigation on the influence of the da Vinci robot.” The American Journal of Surgery. 216 (2018) 84-87.
8. LT. Gien, R. Kupets & A. Covens. “Feasibility of same-day discharge after laparoscopic surgery in gynecologic oncology.” Gynecologic Oncology. 121 (2011) 339-343.
9. C.R. Fountain & L.J. Havrilesky. “Promoting same-day discharge for gynecologic oncology patients in minimally invasive hysterectomy.” The Journal of Minimally Invasive Gynecology. 24.6 (2017) 932-939.
10. S.J. Lee, G.J Gardner, A. Mays et al. “The feasibility and safety of same-day discharge after robotic-assisted hysterectomy alone or with other procedures for benign and malignant indications.” Gynecologic Oncology. 133 (2014) 552-555.
11. A. Melamed, J.L. Katz Eriksen, E.M. Hinchcliff, et al. “Same-day discharge after laparoscopic hysterectomy for endometrial cancer.” Annals of Surgical Oncology. 23.1 (2016) 178-185.
12. L. Bruneau, M. Randet, E. Evrard, et al. “[Total laparoscopic hysterectomy and same-day discharge: satisfaction evaluation and feasibility study.]” Journal de Gynécologie Obstétrique et Biologie de la Reproduction. 44.9 (2015) 870-876.
13. O. Donnez, J. Donnez, M.M. Dolmans, et al. “Low pain score after total laparoscopic hysterectomy and same-day discharge within less than 5 hours: results of a prospective observational study.” Journal of Minimally Invasive Gynecology. 22 (2015) 1293-1299.
14. J. Gale, C. Thompsom, K.J. Lortie, et al. “Early discharge after laparoscopic hysterectomy: a prospective study.” Journal of Obstetrics and Gynecological Cancer. 40.9 (2018) 1154-1161.
15. C. Rivard, K. Casserly, M. Anderson, et al. “Factors influencing same-day hospital discharge and risk factors for readmission after robotic surgery in the gynecologic oncology patient population.” Journal of Minimally Invasive Gynecology. 22 (2015) 219-226.
16. M.B. Schiavone, T.J. Herzog, C.V. Ananth, et al. “Feasibility and economic impact of same-day discharge for women who undergo laparoscopic hysterectomy.” American Journal of Obstetrics & Gynecology. 5.207 (2012) 382-e9.
17. G. Moawad, P. Tyan, V. Vargas, et al. “Predictors of overnight admission after minimally invasive hysterectomy in the expert setting.” Journal of Minimally Invasive Gynecology. 26 (2018) 122-128.
18. Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, Barakat R, Pearl ML, Sharma SK. Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study. Journal of Clinical Oncology. 30.7 (2012). 695.
19. Walker JL, Piedmonte MR, Spirtos NM, Eisenkop SM, Schlaerth JB, Mannel RS, Spiegel G, Barakat R, Pearl ML, Sharma SK. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. Journal of Clinical Oncology. 27.32 (2009). 5331.
20. Chen I, Thavorn K, Shen M, Goddard Y, Yong P, MacRae GS, Nishi C, Matar A, Allaire C. Hospital-associated costs of chronic pelvic pain in Canada: a population-based descriptive study. Journal of Obstetrics and Gynaecology Canada. 39.3 (2017) 174-80.
21. Kaptchuk TJ, Miller FG. Placebo effects in medicine. New England Journal of Medicine. 2.373.1 (2015). 8-9.
22. Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Antrobus J, Huang J, Scott M, Wijk L, Acheson N. Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—Part II. Gynecologic oncology. 2016. 140.2 (2016). 323.
23. Mowat A, Maher C, Ballard E. Surgical outcomes for low-volume vs high-volume surgeons in gynecology surgery: a systematic review and meta-analysis. American journal of obstetrics and gynecology. 215.1 (2016) 21-33.

The article chosen to be critiqued is titled “Achieving Drug and Alcohol Abstinence Among Recently Incarcerated Homeless Women: A Randomized Controlled Trial Comparing Dialectical Behavioral Therapy-Case Management With a Health Promotion Program”. The abstract of the article is detailed and clearly outlines the different components throughout the article. The abstract written by Nyamathi et al. (2017), provides sufficient insight into the design of this study and enables the reader to build a clear of understanding of the issue being investigated.

Research Problem and Purpose

The research problem is not clearly defined in this study, however, within the introduction the reader can infer the issue the authors intend to study. The problem presented within the introduction highlights the vulnerability of recently freed drug offenders to reengage in inappropriate drug use and succumb to homelessness, and the lack of necessary resources to provide adequate transition back into the free world. The study utilizes a specific behavioral intervention to tackle the issue of unmanaged drug abuse among homeless ex-drug offenders (Nyamathi et al, 2017). The purpose of this study is clearly defined. The main purpose compares the effect of the dialectical behavioral therapy vs. health promotion program on aiding homeless ex-drug offender successful eliminate use of drugs when released (Nyamathi et al, 2017).

Review of Literature

This study identifies other literature sources that have utilize the dialectical behavioral therapy to improve outcome in patients with personality disorders. A study by Linehan et al., (2006) illustrated the effectiveness of dialectical behavioral therapy in suicidal patients. Another study highlighted in this article demonstrated that dialectical behavioral therapy can reduce impulsive aggressive behavior in female prisoner with bipolar disorder (Nee & Farman, 2005). The results of these two studies provides enough evidence that the use of dialectical behavioral therapy can successfully modify at risk behaviors.

Nursing Framework

The nursing framework or theoretical basis is discussed within this study. The study utilizes the comprehensive health seeking coping paradigm to construct their experimental design and lead decision made throughout the study (Nyamathi et al, 2017). This theoretical model utilized factors such as sociodemographic, situational, and social to effectively study the impact of dialectical behavior therapy on ex-offenders (Nyamathi et al, 2017).

Research Questions or Hypotheses

The hypothesis of this study is properly explained for this study. The researchers believe that the use of dialectical behavioral therapy correction –modified will work better at reducing use of drugs and alcohol in homeless female parolees when compared with the health promotion program (Nyamathi et al, 2017). The study also works to explore what initial determinants are necessary to achieve the goal of abstinence from drugs and alcohol (Nyamathi et al, 2017).

Research Variables

Nyamathi et al, (2017) experimental study consisted of a variety of measureable variables. Variables measured included the sociodemographic and situational status which provided insight into the participants’ history (Nyamathi et al, 2017).  Other variables including social support, depression levels, anger and hostility were evaluated using specific scale measure described in study. Participants’ ability to cope were also evaluated and abstinence was evaluated by assessing participant’s urine and by receiving self-reporting (Nyamathi et al, 2017).

Study Design

The study utilized a randomized controlled trial which included 130 female parolees/probationers with ages ranging from 19-64 (Nyamathi et al, 2017). Randomized controlled trials are noted to be the ideal study method for measuring effectiveness of an intervention (Grove & Gray, 2019). Also, the ability to reduce bias and error improves with randomized controlled trials. The study does not specify whether or not blinding was implemented so the risk for some bias can be present.

Population and Sample

In this study Nyamathi et al. (2017) selected participants by screening homeless ex-offenders from four different community based sites. The potential participants were screened using specific criteria sampling discussed in the study that allowed Nyamathi et al. (2017) to obtain their sample size of 130 participants to undergo the experimental study. Additionally, a sample size of 130 should be sufficient to allow for confidence in results obtain from study.

Procedures

The procedures in this study was adequately summarized. Nyamathi et al. (2017) details methods used to reach out to potential candidates which included the use of flyers and posters. Candidates then underwent criteria selection and then randomly designated to either the dialectical behavioral therapy group or the health promotion group (Nyamathi et al. 2017). Additionally, Nyamathi et al. (2017) details measures taken to ensure participation which included the use of monetary incentives.

Results

A variety of data analysis measures were utilized to determine results.  The characteristics of participants were compared by utilizing the Pearson’s χ2 test or the Fisher’s exact test (Nyamathi et al. 2017). The dialectical behavioral therapy group and health promotion group effectiveness in reducing or eliminating drug/alcohol use in participants were measured utilizing logistic regression modeling (Nyamathi et al. 2017). Findings from this study show that that both groups led to some degree of abstinence, however, the dialectical behavioral therapy group did have greater increase in the degree of drug abstinence (Nyamathi et al. 2017). Additionally, the study found that the dialectical behavioral therapy group were more inclined to be alcohol abstinent as well.

Validity of Research

Nyamathi et al (2017) discusses measurements methods used to analyze data. The use of dialectical behavioral therapy as a form of behavioral modification have also been supported by other studies discussed within this study which shows that reliability was used to properly form this study. The study overall participation/ completion percentage remain near to 90% for both groups. Additionally, the study addresses its own limitations which all speaks to the validity of this study.

Efficacy of the Study

The study by Nyamathi et al. (2017) was a randomly controlled experiment which is ideal for limiting bias and speaks to the efficacy of a study. The interventions used in the study were able to be measured and provided sufficient data that allow conclusions to be drawn. Furthermore, the meticulous nature of selecting participants for this study speaks the efficaciousness of this study.

Legal and Ethical Issues

The study by Nyamathi et al. (2017) indicates that it was approved by a University review board and registered with Clinical Trials.gov. Additionally, Participants in the study were provided with written consent forms which were obtained prior to inclusion into the study. Finally, the benefits of the study outweighed the risk because the ethical procedures used during the study protected the confidentiality of the participants and of the nurses and others involved in the study. This study was conducted in an ethical manner.

Cultural Aspects of Study

The study by Nyamathi et al. 2017 does not explicitly speak to the cultural aspect of their study, however, in this study the culture of female prisoner is brought to light. The culture that leads to female prisoner developing self-harming drug and alcohol addiction is discussed within this study. Additionally, the studies use of the dialectical behavioral therapy works to disrupt the damaging effects of drug and alcohol use among homeless female ex-offenders. Nyamathi et al. (2017), mentions the potential for their study to have a cultural impact on races such as African Americans, Latinas, and Whites in future studies.

Research Impact on Future Studies

Much of the nursing practice deals with providing patients with the capacity to take control of their health. Nyamathi et al (2017) study, manages to apply this aspect of nursing to a population of female ex-offenders struggling with drug and alcohol addiction. The components of this research can be applied to patients struggling with addiction to opioids and provide an intervention that grants patients the ability to retake control of their health. In this study, the researchers speak to cultural component that can be looked more closely and the need for larger sample sizes to further understanding and identify areas of improvement (Nyamathi et al, 2017).

Research Contribution to Nursing Student’s Practice

As a nursing student, a number of interventions are studied to aid patients in achieving better health and improving health outcome. This study addresses the important area of behavior and how adequate behavioral therapy can modify individuals that have very complicated issues such as female ex-drug offenders. Knowledge acquired from this study can go a long way in adding to the toolbox of nursing students and greatly improve nursing practice as it pertains to behavioral modifications.

References

• Nyamathi, A. M., Shin, S. S., Smeltzer, J., Salem, B. E., Yadav, K., Ekstrand, M. L., . . .Faucette, M. (2017). Achieving Drug and Alcohol Abstinence Among Recently Incarcerated Homeless Women. Nursing Research, 66(6), 432-441. doi:10.1097/nnr.0000000000000249
• Grove, S. K., & Gray, J. (2019). Understanding nursing research: Building an evidence-based practice. St. Louis, MO: Elsevier.
• Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, … Lindenboim N. Twoyear randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry. 2006; 63:757–766. DOI: 10.1001/archpsyc.63.7.757 [PubMed: 16818865
• Nee C, Farman S. Female prisoners with borderline personality disorder: Some promising treatment developments. Criminal Behavior and Mental Health. 2005; 15:2–16. DOI: 10.1002/cbm.33