Multiple Mediation Analysis and Binary Mediators: A Methodological Brief

Event Abstract Back to Event Multiple Mediation Analysis and the Path Processes between Stress and Learning: A Methodological Contribution to an Emerging Field John Taverniers1, 2*, Joris V. Ruysseveldt1 and Jasper V. Grumbkow1 1 Open University of the Netherlands, Faculty of Psychology, Netherlands 2 Royal Military Academy, Department of Behavioural Sciences, Belgium Many studies in the broad field of behavioral neurosciences depend for their statistical analyses upon basic two-variable relationships. Significant two-variable relationships, however, remain a methodologically necessary though insufficient condition to establish causality. Restricting analyses to bivariate correlations may even restrain the field to identify processes, to gain knowledge, and to refine theoretical paradigms. Moreover, from an advanced scientific point of view it is often even more important to explain via which paths processes such as learning occur. This implies the idea of (multiple) mediation analyses; techniques that go beyond mere description because they establish process identification. Or, as Rosenberg [(1968, p. 63). The logic of survey analysis. New York: Basic Books] already stated: "In the absence of such mediating or intervening mechanisms, one ends up with facts, but with incomplete understanding". The current study balances on the intersection between stress research, behavioral neuroscience, and cognitive psychology (memory and learning), and puts forward a strategy for more sophisticated statistical designs. Via an illustrative example – derived from psychoneuroendocrinological stress research, it subsequently demonstrates how traditional bivariate analyses can be extended through multiple mediation designs that involve asymptotic and resampling strategies. In doing so, the current statistical analysis is the first to provide arithmetic support for the generally accepted thesis in psychoneuroendocrinology that cortisol secretion in itself, rather than subjective strain or the experimental treatment, affects cognitive performance. Given that understanding path processes and methodological sophistication are fundamental to the advancement of any psychological field, the authors sincerely believe that strategies for multiple mediation analyses may contribute to the "emerging" field of educational neuroscience. Conference: EARLI SIG22 - Neuroscience and Education, Zurich, Switzerland, 3 Jun - 5 Jun, 2010. Presentation Type: Poster Presentation Topic: Motivation and emotion Citation: Taverniers J, Ruysseveldt JV and Grumbkow JV (2010). Multiple Mediation Analysis and the Path Processes between Stress and Learning: A Methodological Contribution to an Emerging Field. Front. Neurosci. Conference Abstract: EARLI SIG22 - Neuroscience and Education. doi: 10.3389/conf.fnins.2010.11.00021 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 28 May 2010; Published Online: 28 May 2010. * Correspondence: John Taverniers, Open University of the Netherlands, Faculty of Psychology, Heerlen, Netherlands, john.taverniers@ou.nl Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers John Taverniers Joris V Ruysseveldt Jasper V Grumbkow Google John Taverniers Joris V Ruysseveldt Jasper V Grumbkow Google Scholar John Taverniers Joris V Ruysseveldt Jasper V Grumbkow PubMed John Taverniers Joris V Ruysseveldt Jasper V Grumbkow Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Transit use and walking as potential mediators of the association between accessibility to services and amenities and social participation among urban-dwelling older adults: Insights from the VoisiNuAge study

Introduction:Public service provision is one of the keys to reducing inequalities in the utilization of dental services. Given the increase in the aging population, there should be a focus on older adults’ oral health. However, this is often overlooked.Objectives:This study investigates the effectiveness of public services in reducing income-related inequalities in dental service utilization among older South Australians.Methods:A multiple counterfactual mediation analysis using the ratio of mediator probability weighting approach was used to explore the proposed mediation mechanism using a South Australian population of older adults (≥65 y). The exposure variable in the analysis was income, and the mediators were concession cards and the last dental sector (public or private). The outcome variable was the time of last dental visit.Results:Half of the older adults with high income (≥$40,000) owned a concession card, and 10% of those who attended public dental services belonged to this group. Interestingly, only 16.3% of the study participants had visited the public dental sector at their last dental appointment. Results showed a negligible indirect effect (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.85–1.05) and a significant direct effect (OR, 3.09; 95% CI, 2.24–4.87). By changing the potential outcome distributions to the counterfactual exposure distributions and taking the mediators’ distribution as a counterfactual exposure distribution, the odds of dental visits occurring before the past 12 mo approximately tripled for low-income compared to high-income individuals.Conclusion:Income inequalities were associated with relatively delayed dental visits in older South Australians, and provision of public services could not improve this pattern. This might happen due to inequitable access to concession cards and public services. A review of policies is required, including addressing income inequalities and implementing short-term approaches to improve service utilization patterns in older South Australians.Knowledge Transfer Statement:The findings of this study can enable policymakers for informed decision-making about the provision of public dental services for older Australians. This study emphasizes the importance of reviewing the current public dental services and subsidies and implementing short-term approaches to reduce income inequalities for older Australians.

Background: The aim was to examine the mediating role of basic psychological needs and job satisfaction in the relationship between the gender effect on health problems and psychological well-being for health professionals in Europe in 2015. Methods: Two multiple partial mediation analyses were conducted in order to test the partial mediation of both basic needs and job satisfaction, with gender as the independent variable and health problems or well-being, respectively, as the dependent variables, with a sample of health professionals. Results: Women reported lower psychological well-being and more health problems than men. The total effect of gender on both well-being and health problems was found to be significant. Regarding multiple mediation analyses: (a) the effect of gender on well-being was fully mediated by global basic need satisfaction and job satisfaction, such that gender did not present a significant direct effect and (b) the effect of gender on health problems was partially mediated by global basic need satisfaction and job satisfaction, such that the direct effect remained significant. Conclusions: The fulfillment of basic needs for autonomy, competence, and relatedness, as postulated within self-determination theory, was hypothesized to play a mediating role in the relationship between gender and well-being. Since significant gender differences in basic need satisfaction were observed, such a mediator should be controlled in order to achieve a significant relationship between gender and well-being when basic needs comes into play. The current study adds to the research emphasizing the need for satisfaction as a promising mechanism underlying for female health professionals’ well-being.

Bulimia, which means a person has episodes of eating a very large amount of food (bingeing) during which the person feels a loss of control over their eating, is the most primitive reason for being overweight and obese. The extended literature has indicated that childhood emotional abuse has a close relationship with adverse mood states, bulimia, and obesity. To comprehensively understand the potential links among these factors, we evaluated a multiple mediation model in which anxiety/depression and bulimia were mediators between childhood emotional abuse and body mass index (BMI). A set of self-report questionnaires, including the Childhood Trauma Questionnaire (CTQ), Beck Anxiety Inventory, Beck Depression Inventory (BDI), and Eating Disorder Inventory (EDI), was sent out. Clinical data from 37 obese patients (age: 29.65 ± 5.35, body mass index (BMI): 37.59 ± 6.34) and 37 demographically well-matched healthy people with normal body weight (age: 31.35 ± 10.84, BMI: 22.16 ± 3.69) were included in the investigation. We first performed an independent t-test to compare all scales or subscale scores between the two groups. Then, we conducted Pearson correlation analysis to test every two variables’ pairwise correlation. Finally, multiple mediation analysis was performed with BMI as the outcome variable, and childhood emotional abuse as the predictive variable. Pairs of anxiety, bulimia, and depression, bulimia were selected as the mediating variables in different multiple mediation models separately. The results show that the obese group reported higher childhood emotional abuse (t = 2.157, p = 0.034), worse mood state (anxiety: t = 5.466, p < 0.001; depression: t = 2.220, p = 0.030), and higher bulimia (t = 3.400, p = 0.001) than the healthy control group. Positive correlations were found in every pairwise combination of BMI, childhood emotional abuse, anxiety, and bulimia. Multiple mediation analyses indicate that childhood emotional abuse is positively linked to BMI (β = 1.312, 95% CI = 0.482–2.141). The model using anxiety and bulimia as the multiple mediating variables is attested to play roles in the relationship between childhood emotional abuse and obesity (indirect effect = 0.739, 95% CI = 0.261–1.608, 56.33% of the total effect). These findings confirm that childhood emotional abuse contributes to adulthood obesity through the multiple mediating effects of anxiety and bulimia. The present study adds another potential model to facilitate our understanding of the eating psychopathology of obesity.

IntroductionChildhood emotional abuse (EA) is a well acknowledged risk factor promoting the association between any type of childhood maltreatment and eating disorder (ED) psychopathology.ObjectivesThis study investigated the association between EA and ED specific symptoms exploring multiple potential mediators to better understand this complex relationship.MethodsThe study sample included 151 individuals with Anorexia Nervosa (AN), 115 with Bulimia Nervosa (BN), and 108 healthy participants. Before entering treatment programs, participants completed the following questionnaires: the Childhood Trauma Questionnaire, the Toronto Alexithymia Scale, the Behavioral Inhibition System/ Behavioral Approach System, BAS, and the Eating Disorder Inventory-2. A multiple mediation model was run including EA as independent variable, eating symptoms as dependent variables, and ineffectiveness, sensitivity to punishment, alexithymia, and impulsivity as mediators.ResultsIn individuals with AN impulsivity emerged as mediator between EA and desire for thinness and bulimic behaviors. In those with BN sensitivity to punishment mediated the relationship between EA and dissatisfaction with body image. In both clinical groups ineffectiveness and difficulty identifying emotions were mediators of the relationship between EA and eating-related symptoms. No mediation effect was observed in healthy controls, although a total effect of EA on dissatisfaction with one’s body was observed.ConclusionsImpulsivity, sensitivity to punishment, ineffectiveness, and alexithymia may make individuals with childhood EA more vulnerable to ED psychopathology with some differences between AN and BN. Addressing these psychological problems and their connections with early emotional abuse may represent treatment targets for individuals with EDs and a history of childhood trauma.Disclosure of InterestNone Declared

Cancer-related cognitive impairment (CRCI) is one of the severe side effects affecting the quality of life of breast cancer (BC) patients. However, the mechanisms underlying CRCI are still unclear. The study aimed to examine the multiple mediating roles of resilience, social support, cortisol, and neutrophil-lymphocyte ratio (NLR) in the relationship between perceived stress and cognitive function. The study was a descriptive, cross-sectional study. The study investigated 450 BC patients with chemotherapy in China. Convenience sampling was conducted from February to August 2023. The study used the Perceived Stress Scale, the Connor-Davidson Resilience Scale, the Social Support Rating Scale, the Functional Assessment of Cancer Therapy-Cognitive Function, the Montreal Cognitive Assessment, salivary cortisol, and NLR. SPSS 25.0 and AMOS 26.0 conducted bivariate correlations and multiple mediation analysis. The correlations of magnitude variables ranged from no correlation to moderate level (r = - 0.002 to - 0.617). The multiple mediation path demonstrated that resilience and morning cortisol levels mediated the relationship between perceived stress and cognitive function, with a 95% confidence interval (CI) not including 0 for the direct, indirect, and total effects. The study confirmed that when BC patients endure physical and psychological stress during diagnosis and treatment, individuals' resilience can buffer the stress on cognitive function. Morning salivary cortisol levels, as the product and indicator of the hypothalamic-pituitary-adrenal (HPA) axis function, may play a significant role in the effect of perceived stress on cognitive function while incapable of finding NLR as the marker of individuals' immune inflammatory response and social support play a role in this relationship. The study, based on a stress perspective, explored the regulatory mechanisms by which perceived stress affects cognitive function in patients undergoing chemotherapy for breast cancer, providing intervenable targets for subsequent improvement of patients' cognitive function.

BackgroundMapping expression quantitative trait loci (eQTLs) has provided insight into gene regulation. Compared to cis-eQTLs, the regulatory mechanisms of trans-eQTLs are less known. Previous studies suggest that trans-eQTLs may regulate expression of remote genes by altering the expression of nearby genes. Trans-association has been studied in the mediation analysis with a single mediator. However, prior applications with one mediator are prone to model misspecification due to correlations between genes. Motivated from the observation that trans-eQTLs are more likely to associate with more than one cis-gene than randomly selected SNPs in the GTEx dataset, we developed a computational method to identify trans-eQTLs that are mediated by multiple mediators.ResultsWe proposed two hypothesis tests for testing the total mediation effect (TME) and the component-wise mediation effects (CME), respectively. We demonstrated in simulation studies that the type I error rates were controlled in both tests despite model misspecification. The TME test was more powerful than the CME test when the two mediation effects are in the same direction, while the CME test was more powerful than the TME test when the two mediation effects are in opposite direction. Multiple mediator analysis had increased power to detect mediated trans-eQTLs, especially in large samples. In the HapMap3 data, we identified 11 mediated trans-eQTLs that were not detected by the single mediator analysis in the combined samples of African populations. Moreover, the mediated trans-eQTLs in the HapMap3 samples are more likely to be trait-associated SNPs. In terms of computation, although there is no limit in the number of mediators in our model, analysis takes more time when adding additional mediators. In the analysis of the HapMap3 samples, we included at most 5 cis-gene mediators. Majority of the trios we considered have one or two mediators.ConclusionsTrans-eQTLs are more likely to associate with multiple cis-genes than randomly selected SNPs. Mediation analysis with multiple mediators improves power of identification of mediated trans-eQTLs, especially in large samples.

Causal mediation analysis is a popular approach for investigating whether the effect of an exposure on an outcome is through a mediator to better understand the underlying causal mechanism. In recent literature, mediation analysis with multiple mediators has been proposed for continuous and dichotomous outcomes. In contrast, methods for mediation analysis for an ordinal outcome are still underdeveloped. In this paper, we first review mediation analysis methods with a continuous mediator for an ordinal outcome and then develop mediation analysis with a binary mediator for an ordinal outcome. We further consider multiple mediators for an ordinal outcome in the counterfactual framework and provide identification assumptions for identifying the mediation effects. Under the identification assumptions, we propose a regression-based method to estimate the mediation effects through multiple mediators while allowing the presence of exposure-mediator interactions. The closed-form expressions of mediation effects are also obtained for three scenarios: multiple continuous mediators, multiple binary mediators, and multiple mixed mediators. We conduct simulation studies to assess the finite sample performance of our new methods and present the biases, standard errors, and confidence intervals to demonstrate that our proposed estimators perform well in a wide range of practical settings. Finally, we apply our proposed methods to assess the mediation effects of candidate DNA methylation CpG sites in the causal pathway from socioeconomic index to body mass index.

Introduction: The Hypertension Control Program in Argentina (HCPIA), a cluster-randomized trial of a community health worker-led multicomponent intervention on blood pressure (BP) control in low-income patients in Argentina, previously reported a significant reduction in systolic BP in the intervention compared to the control group over 18 months (6.6 mm Hg net difference; p&lt;0.001). Understanding which elements of a multicomponent intervention are important contributors to its success is critical for future BP control efforts. We conducted a mediation analysis to determine the contributions of seven measured intervention targets to the systolic BP intervention effect. Methods: HCPIA randomized 18 primary healthcare clinics treating uninsured patients to either a multicomponent intervention, consisting of health coaching, home blood pressure monitoring, blood pressure audit and feedback, physician education, and a mobile health intervention, or usual care. A total of 1,357 hypertensive participants completed the trial and are included in the mediation analyses. Changes in seven potential mediators over the 18-month intervention were assessed: medication adherence score, medication adjustments (addition of new medication or dose titration), waist circumference, physical activity, fruit and vegetable consumption, sodium consumption, and alcohol consumption. Generalized estimating equations were used to compare changes in potential mediators between intervention groups. Path analytic models were used to test single-mediator and multiple mediator indirect intervention effects using the Lavaan package in R statistical software. Mediation was considered significant at p&lt;0.10. Results: All potential mediators were significantly improved in the intervention group compared to the control group. Fruit and vegetable consumption, medication adherence, physical activity, and salt consumption are each significant mediators accounting for 4.3, 3.8, 3.3, and 3.2%, respectively, of the intervention effect in single-mediator models. The multiple mediation model explained 15.5% (1.3 mm Hg) of the total intervention effect. Changes in fruit and vegetable consumption and medication adherence remained significant mediators in multiple mediation analysis, responsible for 3.8% and 4.3% of the net reduction in systolic BP, respectively. Other potential mediators did not account for a significant proportion of the intervention effect. Conclusions: Increases in medication adherence and fruit and vegetable consumption were responsible for the largest proportions of the explained intervention effect.

Background: In our previous study investigating mediators of the Black vs. White disparity in breast cancer survival for women in Florida, the two most important factors explaining the disparity were advanced disease stage at diagnosis and nonreceipt of surgery. Model assumptions of the multiple mediation approach used in that study prohibited examination causally prior (proximal) mediators. The purpose of this study was to: 1) quantify the excess risk of advanced disease stage at diagnosis and nonreceipt of surgery for Black vs. White women, and 2) use multiple mediation analysis to investigate the degree to which insurance status and high neighborhood poverty explain the racial disparity in these two outcomes. Methods: The study population was comprised of women in Florida diagnosed with breast cancer between 2004 and 2015 and who were reported to the Florida Cancer Data System. The potential mediators consisted of insurance status (Medicaid/Uninsured: yes/no) and census tract poverty level (High poverty [≥ 20% of households in poverty]: yes/no). The two outcomes of interest were advanced stage of disease at diagnosis (stages III/IV) and nonreceipt of surgery. The log-binomial model was used to obtain risk ratios (RR) with 95% confidence interval (CI) for the association of race with these two outcomes, adjusted for age. The multiple mediation approach of Yu et. al. was used to obtain log odds ratios (OR) to quantify direct effects, indirect effects, and the relative % of the total effect mediated. Results: There were 101,872 women available for analysis. African American women were 55% more likely to be diagnosed with advanced disease stage (RR = 1.55: 95% CI, 1.50-1.60) and 97% more likely more likely to not receive surgery (RR = 1.97: 95% CI, 1.90-2.04). The results of the multiple mediation analysis revealed that insurance status and high poverty explained 20.2% and 6.8%, respectively, of the racial disparity in advanced stage of disease at diagnosis. For the disparity in nonreceipt of surgery, insurance status explained 14.4% of the race effect and high poverty explained 5.2% of the race effect. Conclusions: Mediation analysis can provide insight into the mechanisms by which racial disparities in health outcomes occur. As was the case in this study, mediation analysis can also lead to new hypotheses concerning the most important factors causing disparities. To wit, contrary to our initial hypothesis, neither insurance status nor high poverty mediated the majority of the racial disparity in advanced disease stage at diagnosis or nonreceipt of surgery. Future research is required to obtain a better understanding of the barriers to screening mammography and receipt surgical treatment in Black women diagnosed with breast cancer. Citation Format: Robert B. Hines, Xiang Zhu, Eunkyung Lee, Bradley Eames, Karolina Chmielewska, Asal Johnson. Insurance status and neighborhood poverty as mediators of the racial disparity in advanced disease stage at diagnosis and nonreceipt of surgery for women with breast cancer in Florida [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr C003.

BackgroundThe mechanisms underlying childhood overweight and obesity are poorly known. Here, we investigated the direct and indirect effects of different prenatal exposures on offspring rapid postnatal growth and overweight in childhood, mediated through cord blood metabolites. Additionally, rapid postnatal growth was considered a potential mediator on childhood overweight, alone and sequentially to each metabolite.MethodsWithin four European birth-cohorts (N = 375 mother-child dyads), information on seven prenatal exposures (maternal education, pre-pregnancy BMI, weight gain and tobacco smoke during pregnancy, age at delivery, parity, and child gestational age), selected as obesogenic according to a-priori knowledge, was collected. Cord blood levels of 31 metabolites, associated with rapid postnatal growth and/or childhood overweight in a previous study, were measured via liquid-chromatography-quadrupole-time-of-flight-mass-spectrometry. Rapid growth at 12 months and childhood overweight (including obesity) between four and eight years were defined with reference to WHO growth charts. Single mediation analysis was performed using the imputation approach and multiple mediation analysis using the extended-imputation approach.ResultsSingle mediation suggested that the effect of maternal education, pregnancy weight gain, parity, and gestational age on rapid postnatal growth but not on childhood overweight was partly mediated by seven metabolites, including cholestenone, decenoylcarnitine(C10:1), phosphatidylcholine(C34:3), progesterone and three unidentified metabolites; and the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth. Multiple mediation suggested that the effect of gestational age on childhood overweight was mainly mediated by rapid postnatal growth and that the mediating role of the metabolites was marginal.ConclusionOur findings provide evidence of the involvement of in utero metabolism in the propensity to rapid postnatal growth and of rapid postnatal growth in the propensity to childhood overweight. We did not find evidence supporting a mediating role of the studied metabolites alone between the studied prenatal exposures and the propensity to childhood overweight.

Protective factors like peer and teacher social support should be identified to mitigate or prevent the detrimental effects of exposure to psychological maltreatment, which can result in traumatic consequences in adolescents at a critical stage of development. This study aimed to assess whether trust in teachers and friendship qualities mediate the effects of psychological maltreatment on youth internalizing behaviours using a multiple mediation model. The study is an observational, questionnaire‐based, cross‐sectional study. The study was conducted between January and April 2022 with 810 adolescents aged 14–18 years in the paediatric outpatient clinics of a state hospital. To test the research hypothesis, a parallel multiple mediator model was conducted using the PROCESS macro in Mediation Analysis. The study was reported based on Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. The results of multiple mediation analyses revealed a significant direct effect of psychological maltreatment on young internalizing behaviour and a significant indirect effect of psychological maltreatment on youth internalizing behaviour through trust in teachers and friendship qualities. Both trust in teachers and friendship qualities partially mediated the relationship between psychological maltreatment and youth internalizing behaviour. The development of school‐based psychoeducational programmes, counselling services, and group‐based support interventions for nurses and educators in adolescent and family education may be guided by the mediating impact of teacher and peer interactions.

The impact of intimate partner violence, depressive symptoms, alcohol dependence, and perceived stress on 30-year cardiovascular disease risk among young adult women: A multiple mediation analysis

Missed nursing care (MNC) is a significant global issue in health care, especially in intensive care units (ICUs) where the complexity of patient care and high workloads increase the risk of errors and omissions. Nursing deficits impact patient safety, nurse efficiency and psychological well-being, yet the relationship between ICU nurses' perceptions of patient safety, their caring behaviour, professional self-efficacy and nursing deficits remains underexplored. This study aimed to examine the relationships between ICU nurses' perceptions of patient safety, caring behaviour, professional self-efficacy and nursing deficits through a multiple mediation model. A cross-sectional survey was conducted with 304 ICU nurses from general hospitals in Guangxi Province between January 2022 and January 2024. The study used validated instruments to measure patient safety perception, caring behaviour, professional self-efficacy and nursing deficits. Spearman correlation and multiple mediation analyses were applied to explore the relationships among these variables. ICU nurses reported average scores of 63.35 ± 8.06 for patient safety perception, 70.28 ± 12.14 for caring behaviour, 26.19 ± 4.57 for professional self-efficacy and 75.92 ± 17.68 for nursing deficits. Significant negative correlations were found between patient safety perception, caring behaviour, professional self-efficacy and nursing deficits (r = -.483, -.516, -.326, p < .01). Caring behaviour and self-efficacy mediated the relationship between patient safety perception and nursing deficits, accounting for 74.65% of the total effect. This study follows the STrengthening the Reporting of OBservational studies in Epidemiology guidelines. This study highlights that improving ICU nurses' perceptions of patient safety can reduce nursing deficits by enhancing caring behaviour and professional self-efficacy, offering a pathway to improve care quality in ICUs. Hospital administrators should focus on strategies that enhance ICU nurses' safety perception, caring behaviour and self-efficacy to reduce nursing deficits and improve patient outcomes.