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Encyclopedia of
Nursing Research, Second Edition
Joyce J. Fitzpatrick, PhD, RN, FAAN

Meredith Wallace, PhD, APRN-BC
Associate Editor

is the Elizabeth Brooks Ford Professor of Nursing, Frances
Payne Bolton School of Nursing, Case Western Reserve
University in Cleveland Ohio where she was Dean from
1982 through 1997. She has received numerous honors
and awards including the American Journal of Nursing
Book of the Year Award 18 times. Dr. Fitzpatrick is widely
published in nursing and health care literature. She is
senior editor of the Annual Review of Nursing Research
series, now in its 23rd volume. In 1998 Dr. Fitzpatrick
was senior editor of the first volume of the classic Encyclo-
pedia of Nursing Research as well as a series of Research
Digests, including Nursing Research Digest, Maternal
Child Health Nursing Research Digest, Geriatric Nursing
Research Digest, and Psychiatric Mental Health Nursing
Research Digest. She has coedited four books focused on nurses and the internet: Internet
Resources for Nurses (2000) and Nurses Guide to Consumer Health Web Sites (2001), Essen-
tials of Internet Use for Nurses (2002) and Internet for Nursing Research (2004). Dr. Fitzpa-
trick has provided consultation on nursing education and research throughout the world,
including universities and health ministries in Africa, Asia, Australia, Europe, Latin America,
and the Middle East.

nurse since she completed her BSN degree Magna Cum
Laude at Boston University in 1988. Following this, she
earned an MSN in medical-surgical nursing with a spe-
cialty in geriatrics from Yale University and a PhD in
nursing research and theory development at New York
University. During her time at NYU she was awarded a
predoctoral fellowship at the Hartford Institute for Geriat-
ric Nursing. In this capacity she became the original author
and editor of Try This: Best Practices in Geriatric Nursing
series. In 2001, she won the Springer Publishing Company
Award for Applied Nursing Research. She was the Manag-
ing Editor of the Journal of Applied Nursing Research
and is currently the research brief editor for the journal.
She is the author of numerous journal articles and book
chapters. Dr Wallace published Prostate Cancer: Nursing Assessment Management and Care,
in April 2002, which won the American Journal of Nursing Book of the Year Award. Preceding
this, she was the Associate Editor of The Geriatric Nursing Research Digest, which also won
the American Journal of Nursing Book of the Year Award in 2002. She is the recent recipient
of the Eastern Nursing Research Society/John A. Hartford Foundation junior investigator
award. Dr. Wallace is currently an Associate Professor and the Elizabeth DeCamp McInerney
Chair in Health Sciences at Fairfield University School of Nursing, in Fairfield, CT.

Fitz ENR title pps 8/3/05 4:10 PM Page 1

Encyclopedia of
Nursing Research, Second Edition

Copyright © 2006 by Springer Publishing Company, Inc.

All rights reserved.

No part of this publication may be reproduced, stored in a re-
trieval system, or transmitted in any form or by any means, elec-
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the prior permission of Springer Publishing Company, Inc.

Springer Publishing Company, Inc.
11 West 42nd Street
New York, NY 10036

Acquisitions Editor: Ruth Chasek
Production Editor: Sara Yoo
Cover design by Joanne Honigman
Typeset by International Graphic Services, Inc., Newtown, PA

05 06 07 08 09 / 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

Encyclopedia of nursing research / Joyce J. Fitzpatrick and
Meredith Wallace [editors]. — 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-8261-9812-0
1. Nursing—Research—Encyclopedias. 2. Evidence-based nurs-
ing—Encyclopedias. I. Fitzpatrick, Joyce J., 1944- . II. Wallace,
Meredith, PhD, RN.
[DNLM: 1. Nursing Research—Encyclopedias—English.
2. Evidence-Based Medicine—methods. WY 13 E5632 2006]
RT81.5.E53 2006
610.73'072—dc22 2005017674

Printed in the United States of America by Maple-Vail Book
Manufacturing Group.


Advisory Board vii

Preface ix

Contributors xi

List of Entries xxxiii

Encyclopedia of Nursing Research A-Z 1

References 637

Appendix: Contributors to the First Edition 755

Subject Index 767



Patricia Archbold, PhD, RN, FAAN Joanne S. Stevenson, PhD, RN,
Professor FAAN
School of Nursing Professor Emerita
Oregon Health Sciences University College of Nursing
Portland, OR The Ohio State University and
Rutgers University
Marie J. Cowan, PhD, RN, FAAN Columbus, OH and Newark, NJ
Professor and Dean
School of Nursing Diana Taylor, PhD, RN, FAAN
University of California Los Angeles Professor Emeritus
Los Angeles, CA School of Nursing
University of California, San
Barbara Given, PhD, RN, FAAN Francisco
Professor San Francisco, CA
College of Nursing
Michigan State University Nancy F. Woods, PhD, RN, FAAN
Lansing, MI Professor and Dean
School of Nursing
Angela Barron McBride, PhD, RN, University of Washington
FAAN Seattle, WA
School of Nursing
Indiana University
Indianapolis, IN


This second edition of the Encyclopedia of Nursing Research (ENR), like the first, is a
comprehensive, yet concise and authoritative guide to existing nursing research literature. It
charts the course of nursing research since 1983 when the first edition of the Annual Review
of Nursing Research (ARNR) was published.
The original edition of ENR, published in 1998, grew from a long-standing commitment
of the publisher, Dr. Ursula Springer, to the field of nursing, and my commitment to nurse
scholars around the globe. The original encyclopedia followed 15 years of publication of the
ARNR series. This second edition of ENR follows publication of 22 volumes of ARNR and
incorporates the research topics included in the ARNR series. Through these formative years
of nursing science, I have had the privilege of serving as editor of the ARNR series and
witnessing the rapid growth of knowledge and expertise in nursing research. Having served
as editor for the first edition of ENR, I am joined in this edition by Meredith Wallace, the
Associate Editor.
Nurse researchers and graduate students in nursing will be the primary audience for this
edition of ENR. Yet, as with the first edition, nurses in all phases of education, from basic to
doctoral, from formal university and college-based programs to continuing education offerings,
within all health systems, will find this an important introduction to current nursing research
topics. The alphabetical list of entries is provided to assist the reader in quickly finding the
relevant term. While every effort was made to include the most comprehensive list of entries,
based on both a literature review of key terms in journals and the ARNR series and the expert
advice of the Advisory Board members, we are cognizant of the fact that some terms may
have been overlooked. Thus, we encourage readers to advise us of new terms that should be
added to the already extensive list.
This project has been one of the most rewarding endeavors of my professional career. It
has been met with a great deal of professional interest and, most importantly, an extra measure
of enthusiasm by students at all levels. The References section lists the most critical references
on each topic. It is this attention to key references that may be of most use to graduate students
who wish to pursue a topic in more depth.
This publication would not have been possible without the experts in nursing research who
authored the hundreds of entries. Each author, some of whom have contributed multiple
entries, deserves thanks for the written entries, for the willingness to respond to strict guidelines
and page and reference limitations, and, of course, for adhering to a very demanding time
line for publication. Distilling one’s life work into a few hundred words is often the most
difficult accomplishment.
We also are indebted to the colleagues who served as members of the Advisory Board for
both the first and second editions of ENR. I thank each of you for your input into the terms
to be included here, the suggestions of potential contributors, and your willingness to plunge
into yet another publishing project with me.



As with any large continuing project such as this, a true team effort is necessary for a
quality project. First, my thanks to Dr. Ursula Springer for conceiving the project and asking
me to undertake the editing at a time when my commitments were at a peak. I am glad that
I did not hesitate. To the Springer staff who facilitated the production at the many levels, I
owe a huge thank you, most especially to Ruth Chasek, Senior Nursing Editor, who saw the
project through its many stages. I also acknowledge the endless energy, dedication, and
expertise of Meredith Wallace, Associate Editor for this edition. There was never too daunting
a task for Meredith as we worked tirelessly over the past 2 years to complete the project. A
number of students assisted Meredith and me in our activities for this edition of ENR. I would
like to thank Ali Salman and Yi-Hui Lee, PhD candidates at Case Western Reserve University,
Frances Payne Bolton School of Nursing, and Kara Diffley, Lindsey Neptune, and Christine
McGurk, undergraduate students at Fairfield University School of Nursing. I am certain that
there are numerous other graduate students who assisted the authors in completing their
entries. We hope that this edition of ENR will continue to be rewarding to them in their
future academic and professional careers.

Joyce J. Fitzpatrick


Lauren S. Aaronson, PhD, Donna L. Algase, PhD, Ida Androwich, PhD,
Professor Josephine M. Sana Professor
University of Kansas Collegiate Professor of School of Nursing
School of Nursing Nursing Loyola University Medical
Kansas City, KS University of Michigan Center
Data Analysis; Fatigue; School of Nursing Maywood, IL
Grantsmanship; Ann Arbor, MI Nursing Informatics;
Sampling Activities of Daily Nursing Information
Living Systems
Faye G. Abdellah, EdD,
ScD, RN, FAAN Elaine J. Amella, PhD, Karen J. Aroian, PhD, RN,
Dean & Professor Emeritus APRN, BC FAAN
Uniformed Services
Associate Professor and Katharine Faville Professor
University of the Health
Associate Dean for of Nursing Research
Research Wayne State University
Graduate School of
Medical University of College of Nursing
South Carolina Detroit, MI
Bethesda, MD
College of Nursing Immigrant Women
History of Nursing Charleston, SC
Research Carol A. Ashton, PhD, RN
Ivo L. Abraham, PhD, RN, Director of Nursing
FAAN Gene Cranston Anderson, Research
Visiting Professor PhD, RN, FAAN LDS, Cottonwood, and
University of Pennsylvania Edward J. & Louise Mellen Alta View Hospitals
School of Nursing Professor of Nursing Salt Lake City, UT
Philadelphia, PA Case Western Reserve Research Utilization
Applied Research; University
Experimental Research; Frances Payne Bolton Joan K. Austin, DNS, RN,
Quasi-Experimental School of Nursing FAAN
Research Cleveland, OH Distinguished professor
Kangaroo Care Indiana University
Raeda Fawzi AbuAlRub, School of Nursing
PhD, RN Indianapolis, IN
Assistant Professor
Jordan University of Attitudes; Chronic
Science and Technology Conditions in Childhood;
College of Nursing Epilepsy
Irbid, Jordan
Social Support


Kay C. Avant, PhD, RN, Suzanne Bakken, DNSc, Sandra C. Garmon Bibb,
Associate Professor Alumni Professor of Assistant Professor
University of Texas Nursing & Professor of Uniformed Services
School of Nursing Biomedical Informatics University of the Health
Austin, TX Columbia University Sciences
Concept Analysis; School of Nursing Graduate School of
Nursing Diagnosis New York, NY Nursing
Bethesda, MD
Formal Nursing
Cynthia Guerrero Ayres, Languages; SNOMED Leininger’s Theory of
PhD, RN International; Unified Culture Care Diversity
Director Language Systems and Universality;
Health Systems and Population Health
Collaborations—New Jane Barnsteiner, PhD, RN, Carol E. Blixen, PhD, RN
Jersey FAAN Senior Nurse Researcher
American Cancer Professor and Director Cleveland Clinic
Society—Eastern University of Pennsylvania Foundation
Division School of Nursing Department of Nursing
North Brunswick, NJ Philadelphia, PA Education and Research
Clinical Preventive Online Journal of Cleveland, OH
Services Delivery Knowledge Synthesis for Osteoarthritis
Terry A. Badger, PhD, Ella Blot, MA, RN, GNP
APRN, BC Mara M. Baun, DNSc, New York University
Professor FAAN Division of Nursing
University of Arizona Lee & Joseph D. Jamail New York, NY
College of Nursing Distinguished Professor Urinary Incontinence
Tucson, AZ University of Texas Health Rebecca J. Bonugli, MSN,
Depression in Families Sciences Center at RN
Houston Clinical Instructor
Judith A. Baigis, PhD, RN, School of Nursing
FAAN University of Texas Health
Houston, TX Science Center
Associate Dean for
Pet Therapy School of Nursing
Research and Scholarship
San Antonio, TX
Georgetown University Cheryl Tatano Beck,
School of Nursing and Serious Mental Illness
Health Studies Professor Joan L. Bottorff, PhD, RN
Washington, DC University of Connecticut Professor and UBC
Health Conceptualization School of Nursing Distinguished University
Storrs, CT Scholar
Tamilyn Bakas, DNS, RN University of British
Associate Professor, Meta-Analysis;
Department of Adult Phenomenology;
School of Nursing
Health Replication Studies Vancouver, British
Indiana University Colombia
School of Nursing Canada
Indianapolis, IN Nurse-Patient
Stroke Interaction; Nurse-
Patient Relationship

Contributors xiii

Meg Bourbonniere, PhD, Helen Kogan Budzynski, Jeeyae Choi, RN, MS
RN PhD, FAAN Doctoral Student
Assistant Professor Faculty Emeritus Columbia University
Yale University University of Washington School of Nursing
School of Nursing School of Nursing New York, NY
New Haven, CT Seattle, WA Formal Nursing
Physical Restraints Biofeedback Languages
Diane K. Boyle, PhD, RN Vern L. Bullough, PhD, Norma J. Christman, PhD,
Associate Professor RN, FAAN RN, FAAN
University of Kansas Distinguished Professor Associate Professor
School of Nursing Emeritus Emeritus
Kansas City, KS State University of New University of Kentucky
Job Satisfaction York College of Nursing
Barbara Braden, PhD, RN, Stony Brook, NY Lexington, KY
FAAN Gender Research; Sex Preoperative
Professor and Dean, and Gender Psychological
Graduate College Preparation for Surgery
Andrea Calaluce, BSN, RN
Creighton University
Yale New Haven Hospital Deborah A. Chyun, PhD,
Medical Center
New Haven CT RN
School of Nursing
Adult Pulmonary Medicine Associate Professor
Omaha, NE
Milford, CT Yale University
Computerized Decision School of Nursing
Support Systems Parkinson’s Disease
New Haven, CT
Geraldine Britton, PhD, Sara L. Campbell, DNS, Angina; Cardiovascular
FNP RN, CNAA, BC Disease
Assistant Research Associate Professor and
Professor Associate Dean Amy Coenen, PhD, RN,
Decker School of Nursing Illinois State University FAAN
Binghamton University Mennonite College of Associate Professor
Binghamton, NY Nursing University of Wisconsin
Bloomington, IL College of Nursing
Feminist Research Milwaukee, WI
Dorothy Brooten, PhD, Methodology International
FAAN Classification for
Professor Suzanne Hetzel Campbell, Nursing Practice
Florida International PhD, APRN, IBCLC (ICNP®)
University Assistant Professor
School of Nursing Fairfield University Marlene Zichi Cohen, PhD,
Miami, FL School of Nursing RN, FAAN
Clinical Trials; Fairfield, CT John S. Dunn, Sr.,
Transitional Care Breast-feeding Distinguished Professor
in Oncology Nursing
Emma J. Brown, PhD, RN Victoria Champion, DNS, University of Texas Health
Associate Professor and RN, FAAN Science Center at
Chatlos Endowed Chair Associate Dean of Research Houston
University of Central Indiana University School of Nursing
Florida School of Nursing Houston, TX
School of Nursing Indianapolis, IN Descriptive Research;
Orlando, FL
Breast Cancer Screening Nursing Assessment
Urban Health Research:
Nursing Research in
Urban Neighborhoods


Kathleen Byrne Colling, Barbara J. Daly, PhD, RN, Danielle Deveau, BS, MPS
PhD, RN FAAN Research Analyst
Assistant Research Scientist Associate Professor California State University,
University of Michigan Case Western Reserve Fresno
School of Nursing University Central California Center
Ann Arbor, MI Frances Payne Bolton for Health & Human
Middle-Range Theories School of Nursing Services
of Dementia Care Cleveland, OH Fresno, CA
Karen Corcoran, BSN, RN Critical Care Nursing HIV Symptom
Staff Nurse Management and
Greenwich Hospital Jennifer P. D’Auria, PhD, Quality of Life
Greenwich, CT RN, CPNP
Associate Professor Mary Jo Devereaux
Family Satisfaction With
University of North Hospital Librarian
End-of-Life Care
Carolina Chapel Hill Community Medical
Inge B. Corless, PhD, RN, School of Nursing Center
FAAN Chapel Hill, NC Scranton, PA
Professor Bibliometrics Orem’s Self-Care Deficit
Massachusetts General Nursing Theory
Hospital Sabina De Geest, PhD, RN
Institute of Health Director Elizabeth C. Devine, PhD,
Professions University of Basel RN, FAAN
Boston, MA Institute of Nursing Science Professor
Hospice; Terminal Illness Basel, Switzerland University of Wisconsin-
Cynthia L. Corritore, PhD Applied Research; Milwaukee
Associate Professor Medications in Older College of Nursing
Creighton University Persons Milwaukee, WI
College of Business Patient Education
Administration Alice S. Demi, PhD, RN,
Omaha, NE FAAN Nancy Diekelmann, PhD,
Professor RN, FAAN
Computerized Decision
Support Systems Georgia State University Helen Denne Schulte
Byrdine F. Lewis School of Professor
Colleen Corte, PhD, RN Nursing University of Wisconsin-
Postdoctoral Research Atlanta, GA Madison
Fellow School of Nursing
Delphi Technique; Grief;
University of Michigan Madison, WI
School of Medicine
Ann Arbor, MI Karen E. Dennis, PhD, RN,
Self-Concept FAAN Rose Ann DiMaria-Ghalili,
Disturbances and Eating Professor PhD, RN
Disorders University of Central Assistant Professor
Jessica Shank Coviello, Florida West Virginia University
MSN, RN School of Nursing Robert C. Byrd Health
Lecturer Orlando, FL Science Center
Yale University Obesity as School of Nursing
School of Nursing Cardiovascular Risk Charleston, WV
New Haven, CT Factor Nutrition in the Elderly
Angina; Cardiovascular

Contributors xv

Fabienne Dobbels, MSc Jacqueline Dunbar-Jacob, Janet Enslein, MA, RN
Katholieke Universiteit PhD, RN, FAAN Assistant Professor of
Leuven Dean and Professor Nursing
Center for Health Services University of Pittsburgh St. Ambrose University
and Nursing Research School of Nursing School of Nursing
Leuven, Belgium Pittsburgh, PA Davenport, IA
Medications in Older Adherence/Compliance; Ethnography
Persons Behavioral Research Carol Diane Epstein, PhD,
Joanne McCloskey Patricia C. Dykes, DNSc, RN, FCCM
Dochterman, PhD, RN, RN Associate Professor
FAAN Senior Nurse Fairfield University
Professor Informatician School of Nursing
University of Iowa Partners HealthCare Fairfield, CT
College of Nursing Wellesley, MA Critical Care Nursing
Iowa City, IA Clinical Judgment W. Scott Erdley, DNS, RN
Nursing Interventions Clinical Assistant Professor
Classification (NIC); Karen L. Elberson, PhD,
University at Buffalo
Taxonomy RN
School of Nursing
Associate Professor and
Buffalo, NY
Moreen Donahue, DNP, Associate Dean
RN Uniformed Services Electronic Network
Sr. Vice President Patient University of the Health Lois K. Evans, DNSc, RN,
Care Services Sciences FAAN
Greenwich Hospital Graduate School of Viola MacInnes/
Greenwich, CT Nursing Independence Professor
Clinical Judgment Bethesda, MD in Nursing
Capitation; Health University of Pennsylvania
Sue K. Donaldson, PhD, Indicators School of Nursing
RN, FAAN Philadelphia, PA
Dean and Professor Jennifer Harrison Elder, Physical Restraints
Johns Hopkins University PhD, RN, FAAN
School of Nursing Associate Professor Melissa Spezia Faulkner,
Baltimore, MD University of Florida DSN, RN
Basic Research College of Nursing Associate Professor
Gainesville, FL Department of Maternal-
Dianna Hutto Douglas, Child Abuse and Neglect Child Nursing
DNS, RN, CNS University of Illinois at
Associate Professor Marsha L. Ellett, DNS, Chicago
Louisiana State University RN, CGRN Chicago, IL
School of Nursing Associate Professor Diabetes
New Orleans, LA Indiana University
Jacqueline Fawcett, PhD,
Empathy School of Nursing
Indianapolis, IN
Annemarie Dowling- Professor, College of
Enteral Tube Placement Nursing & Health
Castronovo, MA, APRN,
BC Veronica F. Engle, PhD, Sciences
Assistant Clinical Professor GNP, APRN, BC, FAAN University of
New York University Professor Massachusetts-Boston
Division of Nursing University of Tennessee College of Nursing &
New York, NY School of Nursing Health Sciences
Memphis, TN Boston MA
Gerontological Advanced
Practice Nursing Newman’s Theory of (Dorothy) Johnson’s
Health Behavioral System Model

Rights of Human Professor Ageism University of Illinois at Subjects Chicago Joseph M. Head University CS New York University Frances Payne Bolton Adult Health Nurse Division of Nursing School of Nursing Practitioner New York. PhD. PhD. University Research in Nursing RN. PhD. PA Ethics. PhD. Filakovsky. Health Services Mental Health Services Administration Research . College of Nursing MSN. FAAN Chicago. PhD. Fisher. RN Assistant Professor Associate Professor Professor Emeritus Indiana University University of Texas Austin School of Nursing School of Nursing School of Nursing University of Virginia Indianapolis. Emily Fox-Hill. Family Branch (Imogene) King’s Health Galveston. IN Austin. PhD. Elder Computer-Aided Boston. MA Marquis D. IN Boston College Psychiatry Community Health School of Nursing The Pennsylvania State Chestnut Hill. RN. PhD. RN. Frey. FAHA The Erline Perkins McGriff Delirium Professor and Division Doctoral Student Case Western Reserve Frances Foster. RN Robin Fleschler. TX Conceptual System and Evidence-Based Practice Theory of Goal Donna Fick. Department of Indianapolis. PhD. Luce Professor of Associate Professor of School of Nursing Nursing Ethics Medicine. MI School of Nursing Medical Family Care. CCNS.xvi CONTRIBUTORS Suzanne L. PhD. PhD. RN RN. CNS. Gaskamp. OH Massachusetts General Acute Care of the Hospital Elderly. Ellen Flaherty. Feetham. APRN. NY Newman’s Theory of Chicago. Health and Human Professor FAAN Development Indiana University Henry R. NY Cleveland. CNAA. Bureau of Primary Health Director of Research and RNC. BC Associate Professor Professor Emeritus Director of Quality University of Tennessee University of Illinois at Improvement College of Nursing Chicago Village Care of New York Memphis. RN Attainment Associate Professor of Beverly C. FAAN University Park. NP Care Advanced Practice Assistant Professor Health Resources and Children’s Hospital of University of Texas Services Administration Michigan Medical Branch Bethesda. Patterns Carol D. RN. TX School of Nursing Cost Analysis of Nursing Charlottesville. Flynn. MA Mistreatment Instruction Functional Health Mary L. FAAN Sara T. MD Detroit. Nursing. Terry Fulmer. Fox. Fry. RN. MS. FAAN APRN. TN College of Nursing New York. PhD. VA Quality of Life Care. PhD. BC RN Jeanne C. PhD. Foreman. College of RN. IL Geriatric Health Director of Division of Interdisciplinary Teams Clinical Quality Maureen A. IL CS.

RN Program. Library Binghamton. Mentoring Professor Data Analysis. UT Sheila Grossman. FAAN Associate Professor Director Professor and Dean Ursuline College National Institutes of Emeritus Breen School of Nursing Health Rutgers University Pepper Pike. PhD. CIC Osteoporosis Nurse Consultant Bobbe Ann Gray. IN University Frances Payne Bolton Family Theory and School of Nursing Research Cleveland. PhD. IL RN Informatics Mother-Infant/Toddler Professor School of Medicine Relationships University of Alberta University of Utah Faculty of Nursing Salt Lake City. DNS. PhD. FAAN RN. MI Classification System. Sigma Michigan State University Theta Tau International Sarah Hall Gueldner. Chatham. OH Music Therapy. RN. RN. PhD. MSN. Goldrick. Patricia A. Health. Nosocomial Infections Assistant Professor CS Wright State University Clinical Specialist Marion Good. PhD. Hurdis M. Deborah Gross. DNSc. Representation Professor Nursing Workload of Knowledge for Fairfield University Measurement Systems. RN. Haber. NY MPH. Pain. MD Clinical Preventive National Institutes of Services Delivery. College of Nursing RN. FAAN East Lansing. PhD. Secondary Genetics. RN. CS RN. Giovannetti. ScD. Griffith. Graves. College of Nursing and Veterans Affairs FAAN Health Northern Indiana Health Professor Dayton. Deborah L. Pain Management: A Mid-Range Theory . Grady. Computational Modeling School of Nursing Patient Classification in Nursing: The Arcs© Fairfield. Dean and Professor Family Care Virginia Henderson Binghamton University International Nursing Decker School of Nursing Barbara A. FAAN Milwaukee. Department of Medical Chicago. Gentile. MA RNC Linda C. Alberta Canada Bibliographic Retrieval APRN Systems. PhD. WI Professor. FAAN RN. CT Barbara Given. PhD. DSN. Contributors xvii Rauda Gelazis. National Current Procedural RN Institute of Nursing Terminology-Coded Doctoral Student Research Services University of Wisconsin- Milwaukee Judith R. Edmonton. OH Care System Case Western Reserve Childbirth Education Fort Wayne. College of Professor Patient Education Nursing Rush University Adjunct Associate Professor College of Nursing Phyllis B. OH National Institute of College of Nursing Individual Nursing Nursing Research Newark. PhD. College of Nursing Nursing Research RN. NJ Therapy Bethesda.

FAAN Services Carolina at Chapel Hill Professor Emeritus Hartford Hospital School of Nursing University of Connecticut Hartford. Patricia A. RN. RN. DrPH. CS Professor of Pediatrics RN. Review MSN. GA Wellness Cancer in Children Advanced Practice Eileen M. Cleveland. PhD. NC Cardiovascular Risk The Theory of Nursing Factors: Cholesterol. PhD. Nutrition in Infancy and Nurse Staffing. CT Bowel Elimination Parenting Among Older Adults Infection Control Barbara J. RN. DrPH. PhD. PhD. Nursing Childhood Marilyn Hockenberry. RNC. PhD. Cardiovascular University of North RN. Martha N. SC Depression in Women. Thermal Failure to Thrive (Adult) Balance . Associate Professor of Edward J. BC FAAN Professor Emeritus Associate Professor Professor and Dean Medical University of University of Virginia John Hopkins University South Carolina School of Nursing School of Nursing College of Nursing Charlottesville. Diane Holditch-Davis. FL Carolina Chapel Hill New York. Hypertension Reminiscence and Life Mental Health in Public Sector Primary Care Mary Angelique Hill. FAAN LCP. DNSc. Director Georgia Southern University Center for Nursing University Frances Payne Bolton Research Center for Rural Health School of Nursing Texas Children’s Hospital and Research Cleveland. Critical Care Nurse Professor Educator. MD Charleston. OH Houston. FAAN Nursing RN. FAAN Gail A. Hermann. RN. RN. Halloran. CPN Laura Hayman. PhD. APRN. NC School of Nursing Storrs. RN Professor Emeritus RN Assistant Professor University of Texas Health Doctoral Student Case Western Reserve Science Center The Ohio State University University School of Nursing Columbus. Holtzclaw. MHS PhD. Higgins. as Caring Henderson’s Model. RN. Krainess. CT Chapel Hill. VA Baltimore. Emily J. FAAN Professor Lake City Community Associate Professor New York University College University of North Division of Nursing Lake City. Haight. CS. Hanson. NY Boykin & Schoenhofer: School of Nursing Chapel Hill. Harkness. RN-CS.xviii CONTRIBUTORS Barbara K. EdD. Studies Index PhD. PNP. RN. Nurses BSN. TX Statesboro. Hill. TX Smoking Cessation School of Nursing Fever/Febrile Response. MS. OH Shivering. Hauenstein. OH Frances Payne Bolton San Antonio. FAAN Charlene M. Marion Hemstrom. FAAN Assistant Professor Baylor College of Medicine Professor Case Western Reserve Nurse Scientist. FAAN Gretchen Harwood.

Content Analysis. FAAN Exploratory Studies. Quality and Research Systems Delivery. University of Alabama Boston College RN. FL Grounded Theory. Ingersoll. VA New York. Clinical Practice (Qualitative) Professor Guidelines Program New York University Kathleen Huttlinger. MD Organizational Redesign Associate Professor and Health Services Research Pamela Magnussen Deputy Director Ironside. Holzemer. CA Brookline. Health Carole P. PhD. RN. University of Virginia Division of Nursing RN Charlottesville. RN. Jacobson. Mental Status Sharol F. RN. MA Nursing Education. Hughes. to Illness Kent. Research and Practice Examination RN. PhD. RN. FAAN School of Nursing William F. PhD. Substruction Measurement: The Mini. RN Assistant Professor University of Wisconsin. Contributors xix William L. WI Rockville. for Health Disparities Austin FAAN Research School of Nursing Professor & Director of University of Pennsylvania Austin. NY Urban Neighborhoods Staff Member Agency for Healthcare Evaluation. FAAN FAAN BSN. OH PhD. RN. NY Professor Pain Breast Cancer: Kent State University Psychosocial Adjustment College of Nursing Loretta Sweet Jemmott. Research and Ethics MHS. FAAN van Ameringen Professor in Susan Houston. FAAN Research Interviews RN. FAAN Director. AL of Nursing University of Florida Cultural/Transcultural Chestnut Hill. Carol Noll Hoskins. RN. Michele Freeman Irwin. Jennings. RN Professor and Associate Executive Director New York University Dean Center for Excellence in Division of Nursing University of California Nursing Practice New York. and Co- Professor Participant Observation Director of the Center University of Texas at Gail L. PhD. FAAN and Professor Professor Sally A. RN. PhD. PhD. School of Nursing Nursing Research in MPH. NY San Francisco Brigham and Women’s Neuroleptic Use in School of Nursing Hospital Nursing Homes San Francisco. Connell School Professor Tucsaloosa. PhD. MD Hermeneutics Health Policy Patient Safety . MA College of Nursing Focus Postpartum Depression Jacksonville. Ann Hurley. RN Center for Health Policy. FAAN Rockville. TX Clinical Nursing School of Nursing Managed Care Research Philadelphia. PhD. DNSc. Psychiatric Mental CNAA. EdD. College of Nursing and Senior Health Scientist Health Science Administrator Madison School of Nursing George Mason University Agency for Healthcare Fairfax. RN. FAAN Rochester. Ada Jacox. PhD. Ronda G. Hutchinson. FAAN Mental State Associate Dean for June Andrews Horowitz. PhD. RN. PA University of Rochester Urban Health Research: Heddy Bishop Hubbard. Health Nursing. PhD. VA Research and Quality Madison.

FAAN Hesook Suzie Kim. Norway Evanne Juratovac. Iowa City. BSN William F. MI Qualitative Research Patterns. FAAN Ethics Professor Primary Health Care Boston College Lisa Skemp Kelley HaeSook Kim. PhD. UT Cleveland. PhD. CNM Professor Benchmarking in Health Clinical Assistant Professor University of Michigan Care. Homelessness and University University of Utah Related Mood Disorders Frances Payne Bolton College of Nursing School of Nursing Salt Lake City. Lecturer and Project Ursuline College Discourse Analysis. OH University Center on Aging Karin T. PhD. Johnson. RN Professor Emeritus Hemodynamic Cerebral Ischemia. RI School of Informatics Atlanta. GA Professor Indianapolis. Mary E. PhD. NY UCLA Medical Center University of Pittsburgh Surgery Department of Nursing School of Nursing Los Angeles. Nursing Activities of Daily Living Practice Models Susan J. Family Caregiving and and Health RN. IN Grandparents Raising Buskerud University Telehealth Grandchildren College Kongsberg. PA Marion Johnson. PhD. IL RNc. IA Shake´ Ketefian. CCRN FAAN Professor Emeritus Clinical Nurse Specialist Professor and University of Rochester Transplant/Surgical UPMC Health System School of Nursing Specialties ICU Chair of Nursing Science Rochester. Maureen Keckeisen. CS Associate Professor Action Science. RN. University of Iowa Monitoring Nursing Diagnosis College of Nursing Gwen Brumbaugh Keeney. Dean and Professor RN BC Assistant Professor College of Health and Professor Emerita Indiana University Human Sciences University of Rhode Island School of Nursing and Georgia State University Kingston. RN. PhD. MA School of Nursing Iowa City. RN. FAAN the Seriously Mentally Case Western Reserve Professor Ill. Josette Jones. RN. Jones. Kempe. Kirchhoff. Coordinator Breen School of Nursing Narrative Analysis Prentiss Care Networks Pepper Pike. OH Nurse Researcher in the Disparities in Minority Clinical Setting Mental Health . RN. RN PhD. Kelley. RN. EdD. MI College of Nursing Dorothy A. PhD. Nursing Outcomes University of Illinois at School of Nursing Classification Chicago Ann Arbor. RN. IA Functional Health Ann Arbor. CA Pittsburgh.xx CONTRIBUTORS Jean E. Alice R. FAAN MN. PhD. CS MSN. Kerr. Connell School University of Iowa Graduate Student of Nursing College of Nursing University of Michigan Chestnut Hill. EdD. RN. Research in Nursing Chicago.

RN Graduate School of Emeritus Doctoral Candidate Nursing University of Nebraska University of Arizona Bethesda. C Associate Professor Richmond VA Yi-Hui Lee. MSN. Management and Communication: Nurse. NE Spirituality Research Careers . ME Health HIV Symptom Interpersonal Irene Daniels Lewis. DNS. PhD Cleveland. NY Medical Branch School of Nursing Judith A. CA Division of Nursing University of Texas Ethnogeriatrics New York. APRN. MS. PhD. FAAN Choices. PhD. CS Associate Professor of Associate Professor Assistant Professor Nursing University of Southern Kent State University California State University. Louis. BC Greensboro. End-of-Life Planning and RNC. ND. FAAN APRN. Wendy Lewandowski. Maine College of Nursing Fresno College of Nursing and Kent. RN School of Nursing Assistant Professor Eugene Levine. FAAN Quality of Life Patient College of Applied Sciences Mia Kobayashi. RN University of Akron Genetics PhD Candidate College of Nursing Patricia Liehr. Dizziness in the Elderly University of the Health FAAN Sciences Dean and Professor Cheryl A. San Jose State University Doctoral Candidate RN. School of Nursing RN. Larson. MD Medical Center College of Nursing College of Nursing Quantitative Research Tucson. OH University Doctoral Education Frances Payne Bolton Helen Lach. RN. Unlicensed Galveston. OH St. Pregnancy School of Nursing RN. CA Portland. OH Professor and Director of University Comfort Frances Payne Bolton Doctoral Program Heidi V. Contributors xxi Kenn M. APRN. Marjorie Thomas Lawson. Deborah F. FAAN School of Nursing New York University Professor San Jose. PhD. PhD. OH College of Nursing Associate Professor West Palm Beach. PhD. Louis University School of Nursing Professor Emeritus Grounded Theory St. Failure to Thrive College of Nursing Case Western Reserve (Child) Columbus. Lindsey. and Arts CNM Regina Placzek Lederman. FL HIV Risk Behavior University of North Middle-Range Theories Carolina at Greensboro Elizabeth R. BC. FAAN Cleveland. AZ Omaha. Krowchuk. APN. School of Nursing Florida Atlantic University RN. FNP RN. RN. Lewis. RN Case Western Reserve Akron. PhD. NC Dean and Professor Assistant Professor of Child Lead Exposure Ohio State University Nursing Effects. TX Professor Assistive Personnel Maternal Anxiety and Virginia Commonwealth Adaptation During University Katharine Kolcaba. PhD. MSN. PhD. Kirksey. Lenz. OH Department of Nursing Health Professions Community Mental Fresno. RN. Lindell. MO Uniformed Services Ada M. BC PhD. PhD.

Lotas. CS-GNP Associate Professor Services and Director New York University University of Texas Health BSN Program Division of Nursing Science Center at San Associate Professor New York. Prevention of Preterm Psychiatric Mental Health CRNP. NY Antonio Case Western Reserve Acute Care of the School of Nursing University Elderly San Antonio. PhD. PA University of Virginia School of Nursing Clinical Decision Making School of Nursing Augusta. NY Linda Manfrin-Ledet. College of Nursing Virginia Pless Center for RN. IA Nursing Research Professor Nursing Outcomes New York University University of California Classification Division of Nursing San Francisco New York. FAAN FAAN Organizational Culture. VA Primary Care Doris Troth Lippman. RN. OH APRN. FAAN Iowa City. FAAN and Low-Birthweight Nurse Practitioner Associate Professor Births Cape Cod Hospital University of Pennsylvania Courtney H. IN Health Psychosocial Interventions (PSI) Job Stress. RN Kiran Mangrola. Marion. PhD. Lyon.xxii CONTRIBUTORS Adrianne D. Baltimore. CT School of Nursing College of Nursing and Indianapolis. Stress Dayton. Meridean Maas. Stress. LA Violence . PhD. Lyder. PhD. Clinical Setting. PhD. Professor Brenda L. FAAN Workplace Violence Excellence Associate Professor University of Iowa Director. Associate Professor Emeritus Professor and Research Dissemination University of Maryland Director of the John A. MSN. RN. School of Nursing Hartford Center of Linda J. APRN Patricia A. School of Nursing Postpartum Depression APRN San Francisco. PhD. PhD. RN Associate Dean for Student RN. Linton. DNS. GA Charlottesville. PhD. Mayberry. Marilyn J. PhD. MD Geriatric Nursing RN. RN. Pressure Ulcers PhD. Lipman. CA Assistant Professor of Immigrant Women Nursing Nicholls State University Department of Nursing Thibodaux. Martin. ND Emergency Nursing School of Nursing University of Virginia Pediatric Nurse Practitioner Medical Center Lucy N. RN RN Fairfield University Professor Dean and Professor School of Nursing Indiana University Wright State University Fairfield. FAAN Terri H. PhD. TX Frances Payne Bolton Wandering School of Nursing Anne Manton. Cleveland. Lipson. DNS. OH Management Nurse Researcher in the Jane Lipscomb. Muriel and Juliene G. Division of Endocrinology Professor of Nursing FAAN Children’s Hospital of Professor of Internal Professor and Dean Philadelphia Medicine and Geriatrics Medical College of Georgia Philadelphia.

WV Health Sciences Center Methodology. Omaha. Validity Florence S. PhD. CT Vegas Chronic Illness Pulmonary Changes in School of Nursing Elders Las Vegas. in Nutrition Madison. Meek. Susan H. Deborah Dillon McDonald. McBride. School of Nursing PhD. RN Stanford University Associate Professor Mary J. Wald Professor Chairperson of Nursing Quinnipiac University Sue E. McCrone. PhD. McNamee. CA Office of Student Equity Health Care and Multicultural Affairs Ethnogeriatrics Communication University of Nebraska Medical Center Maureen P. CS Reliability. Melen R. Elizabeth McGann. Nursing Intensity RN PhD. FAAN Madison Hospital and Austin. NE DNSc. RN. BC. Contributors xxiii Angela Barron McBride. EdD. Yale University Department of Nursing APRN. FAAN RN. RN. AZ Ruth McCorkle. FAAN Senior Vice President. PhD. McCausland. GNP Assistant Professor School of Nursing School of Health Sciences University of Nevada. Instrumentation. BC Distinguished Professor and Associate Professor Associate Professor and University Dean Emerita West Virginia University Director. CT Director Palo Alto. RN. Jr. PhD. Las New Haven. Stanford Geriatric University of Connecticut RN Education Center School of Nursing Associate Professor and School of Medicine Storrs. McDougall. FAAN PhD. FAAN RN RN. FAAN Professor and Associate Development and Professor Dean Nutritive Sucking New York University University of Illinois at Division of Nursing Chicago Paula M. FAAN Neurobehavioral PhD. Nursing Officer and University of Texas at Research Careers Patient Care Services Austin Barbara Medoff-Cooper. PhD. Byrd Health Development and School of Nursing Science Center Extended Studies Indianapolis. PA Sandee Graham McClowry. EdD. IN School of Nursing University of Colorado Feminist Research Morgantown. NY College of Nursing Assistant Professor Mental Disorders Chicago. Women’s Coronary Artery Bypass School of Nursing Health Graft (CABG) Surgery Denver. Chief Professor Homeless Health. Professional Indiana University Robert C. Graham J. RN. PhD. RN New York. TX Helen M. McHugh. University of Wisconsin. PhD. Philadelphia.. DNSc. NV Gastroesophageal Reflux Disease . WI Self-Efficacy University of Pennsylvania Primary Nursing School of Nursing Beverly J. Shearer Professor Clinic Cognitive Interventions. RN. RN. CT Hamden. McElmurry. CO Artificial Intelligence. Mary L. Meiner. IL University of Arizona Prevention Primary Health Care College of Nursing Tucson.

University of North PhD. PhD. Parental Response to the Watson’s Theory of Birth and Hospitalization Human Caring of a High-Risk Infant. Metzger. MI RN. Chapel Hill PhD. CA Newark. FAAN FAAN Stanford Cardiac Associate Professor Dean of Nursing Rehabilitation Program University of Medicine and University of Pennsylvania Stanford University Dentistry of New Jersey School of Nursing Medical Center School of Nursing Philadelphia. Complementary and Schizophrenia RNC Alternative Practices and Assistant Professor Rita Monsen. VA Cleveland. Associate Director RN. Unlicensed Observational Research Assistive Personnel Design Nancy Houston Miller. Pregnancy. PA Credentialing Professor Commission. SC School of Nursing Fitzpatrick’s Rhythm Chapel Hill. EdD. NY School of Nursing Medications in Older End-of-Life Planning and Houston. Health Professions Genetic Nursing RN. PhD. Assistant Professor Carolina. PhD. Mitty. PhD. KS Frances Payne Bolton University of Virginia Job Satisfaction School of Nursing School of Nursing Charlottesville. RN Margaret Shandor Miles. RN Victoria Menzies. RN RN. Afaf Ibrahim Meleis. NJ Immigrant Women. FAAN Time Series Analysis Kenan Professor of Nursing Kristen S. FAAN University of South School of Nursing Professor Carolina Chapel Hill. MS. Miovech. Genetics Ann Arbor. Transitions Factor Violence.xxiv CONTRIBUTORS Janet C. OH Susan M. Miller. RN Ethel L. Belgium New York. MPH. FAAN Philadelphia. PhD. Koen Milisen. NC University of North College of Nursing Carolina at Chapel Hill Uncertainty in Illness Columbia. Meininger. RN Wanda K. PA Palo Alto. RN Research Coordinator Center for the Study of Doctoral Student University of Kansas Case Western Reserve Complementary and School of Nursing Alternative Therapies University Kansas City. PhD. Intimate and Health Partner Violence Peggy A. NC Model. MSN. Parenting . PhD. DSN. Mohr. RN. NY School of Nursing Merle H. TX Persons Choices. PhD. Inc. University of Michigan Fetal Monitoring Keuka Park. Mishel. FAAN Center for Health Services Adjunct Clinical Professor Professor and Nursing Research of Nursing University of Texas Health Katholieke Universiteit New York University Sciences Center at Leuven Division of Nursing Houston Leuven. RN Mary Moller. Smoking/Tobacco as a Children Exposed to International Nursing Cardiovascular Risk Intimate Partner Research. Montgomery. Products (CAPPs) Holy Family University RN School of Nursing & Allied Interim Executive Director Bonnie L. BSN.

NY College of Nursing Frances Payne Bolton HIV/AIDS Care and Iowa City. Registered Nurses University of Maryland RN. Moore. RN. MSN. PhD. OH Classification. OH School of Nursing Hartford Foundation Parse’s Theory of San Antonio. Cleveland. RN Associate Professor Hunter-Bellevue School of Associate Professor Case Western Reserve Nursing University of Iowa University New York. Moral School of Nursing Quantitative Research Reckoning Cleveland. PhD. PhD. Care Caregiving to Frail RN. Denver. CO New York. FAAN Mid-Range Theory. PhD. PhD. FNP. Novotny. PhD. CT University of Colorado Professor Nursing Education Health Sciences Center New York University School of Nursing Division of Nursing Cassandra Okechukwu. CUNY Sue Moorhead. PA Independent Consultant School of Nursing Transitional Care San Antonio. FAAN School of Nursing Associate Professor Yolanda Narvaez-Edwards. TX Seattle. Quality of Cohort Design. Contributors xxv Shirley M. MPH Funding Substance Abuse and Research Coordinator/ Addiction Among Clinical Instructor Diana Lynn Morris. PhD. IA School of Nursing Treatment Nursing Outcomes Cleveland. Statistical Mary Duffin Naylor. PhD. LMSW. FAAN FAAN APRN. Minority Women Disaster Nursing RN. RN. Murphy. FAAN University of Pennsylvania Susan K. PhD. MA Morgantown. Musil. Nokes. Naegle. WA Kathleen M. Moral Distress. GNP. CS School of Nursing Science Center Associate Professor. Offenders School of Nursing Watson’s Theory of Radford. Barbara Munro. WV Frances Payne Bolton Data Management. DSN. VA Human Caring Ethnography . TX Gerontology Fellow Nursing: Human Minority Women Radford University Becoming Theory. RN. RN. Shirley A. Fairfield University FAAN Madeline A. RN Hunter College. PhD. NY RN. FAAN Offenders Professor Carol M. OH Methodology. FAAN Fairfield. PhD. MD Case Western Reserve RN. PhD. Alvita Nathaniel. BSN Workplace Violence University Graduate Student Frances Payne Bolton University of Texas Health Lisa Onega. Baltimore. School of Nursing Professor and Dean APRN-BC. Moore. Pilot Study Dean and Professor Patricia Moritz. Pain Management: A Techniques RN. Professor Theoretical Framework RN. Professor Emeritus School of Nursing ACP University of Washington Philadelphia. FAAN Elders. BC Professor and Associate Dean and Professor Assistant Professor Dean for Research Boston College West Virginia University Case Western Reserve School of Nursing School of Nursing University Chestnut Hill. Family Jeanne M.

RN John R. FNP Program University of Central Assistant Professor Agency for Health Care Florida Graduate Program of Research and Quality Orlando. PhD. Palmer. Porche. College of Nursing Division of Nursing PhD. Case Western Reserve New York University RN University School of Education Associate Dean of Frances Payne Bolton New York. Jin-Hwa Park. FAAN RN Homelessness Associate Professor. RN Prostate Cancer Humanalysis. KS PhD. Inc. PA Tucson. O’Sullivan. BC. Adolescent Clinical Nursing Lorrie L. Kansas City. Powel. Community Partnerships CINAHL Information RNC. FAAN Associate Professor Professor Professor University of Missouri University of Pennsylvania University of Arizona School of Nursing School of Nursing College of Nursing Columbia. Director of Research/ Associate Dean for Professional Liaison Mary H. Popkess-Vawter. APRN. NC President Jana L. OH Science of Unitary Louisiana State University Health Persons Health Sciences Center Conceptualization. PhD. FAAN RN.xxvi CONTRIBUTORS Ann L. RN Weight Management Assistant Professor Professor Emeritus Demetrius J. AZ Widows and Widowers Adolescence. Polit. PhD. Massachusetts Institute of Prostate Cancer Caring. MA Joanne M. OK New York. MA. Porter. PhD. MD Cancer Survivorship. LA Nursing: Human Violence Becoming Theory. RN. PhD. College of Nursing Data Collection Methods University of Oklahoma GNP New York University Sue A. PhD. PhD. PhD. RN CRNP. PhD. Linda R. NY Research & Evaluation School of Nursing (Martha E. Pohl. Phillips. ARNP Oklahoma City. School of Nursing Parse’s Theory of New Orleans. Preparedness Research Public Affairs APRN. Roy Adaptation Model .) Rogers and Professor Cleveland. DNS. PhD. Pressler. Assistant Dean for Saratoga Springs. Professor. NY Professor Fitzpatrick’s Rhythm Chronic Gastrointestinal University of Kansas Model Symptoms School of Nursing Mary T. PhD. RN Pregnancy and Research Associate Professor Parenting. PhD Chapel Hill. MI Cumulative Index to Carolina at Chapel Hill Nursing Centers Nursing and Allied School of Nursing Health Literature Denise F. Nursing Process Health Professions Boston. RN School of Nursing Director of Bioterrorism College of Health and Joanne O’Sullivan. Quinn Griffin. FAAN University of Michigan Systems Umphlet Distinguished School of Nursing Glendale. Infant Injury Sally Phillips. RN. BC. CA Professor in Aging University of North Ann Arbor. Phillips. Eileen J. NY Research. Diane Shea Pravikoff. MO Philadelphia. FL Nursing Rockville.

CPNP Services. OH School of Nursing Queens Medical Center Orem’s Self-Care Deficit Baltimore. RN Advanced Practice Nurse Carol A. DNS. Karen R. and Curtis F. Denial in Medical College of Georgia Assistant Dean for Student Coronary Heart Disease School of Nursing Affairs Atlanta. Mary Anne Rizzolo. Beverly L. University CRNP. FAAN Associate Professor and Virginia K. Rains. Information Systems and Hospitals and Clinics Garvin Professor of Quality Assurance Iowa City. FAANP Immunity and Frances Payne Bolton Associate Professor Inflammation School of Nursing University of Maryland University Hospital Cleveland. WI Nursing Centers Nursing Information Systems . RN. Chapel Hill. Romano. Injury and Stress Nursing Informatics. Rosenkoetter. Retirement Communities PhD. FAAN. MD University of Arizona Cleveland. Terminology-Coded Professor RN. Nursing Occupational School of Nursing Home Health Systems. PhD. EdD. MS. RN Dean and Associate Director for Professional Assistant Professor Professor Development University of Texas Health Indiana University East National League for Science Center Division of Nursing Nursing School of Nursing Richmond. FAAN PhD. Robinson. FAAN. DNS. IA Nursing Warren Grant Magnuson Ethnography Frances Payne Bolton Clinical Center Pamela G. Institute of Infection. RN Peplau’s Theoretical Non Clinical Lecturer in Doctoral Student Model. Riesch. Roberts. IN New York. Spirituality Gastroenterology Case Western Reserve Barbara Resnick. FAAN School of Nursing and University of North Professor. IN Safety and Health Distinguished Scholar. Norma Martinez Rogers. United Nursing Theory Continuing Care Kingdom Marlene M. Saba. NY San Antonio. PhD. LNCC. DNSc. TX Collaborative Research Research on Interactive Minority Women Video Offenders Barbara Rakel. Madison. School of Nursing National Institutes of FAAN Case Western Reserve Health Professor University Bethesda. RN. OH Data Stewardship College of Nursing Falls. FGSA Director. RN RN. DC School of Public Health University of Wisconsin. FAAN PhD. Reed. FACMI Indianapolis. Pediatric Primary Care Adjunct Education and Research Susan K. Nursing University of Iowa Arline H. FAAN. EdD. GA Associate Professor Bonnie Rogers. NC Home Health Care Madison Classification System. Retirement Indiana University COHN-S. Contributors xxvii Joanne W. School of Nursing Director. AZ Eileen Virginia Romeo. Supervisor RN. PhD. Functional Health Tucson. MD Nottingham. MA. Center Georgetown University RN. FAAN Current Procedural Virginia Richardson. School of Health Studies Carolina at Chapel Hill Nursing Washington. Occupational RN. RN. PhD MSN.

TX Depression and Joan L. VA RN Manchester. MD. PhD. PA RN George Mason University Assistant Professor College of Nursing and Transitions and Health St. Tempe. KS Schools of Medicine and Associate Professor of Nursing Nursing Caregiver. FAAN Case Western Reserve Consultant. Schaag. Schwarz. RN. PhD. Massachussetts Patient Contracting ARNP Amherst. PhD. Shimono. Home Care Assistant Professor College of Nursing (Martha E. PhD. FAAN University of Pennsylvania School of Nursing Caryn A. OH Houston. AZ Persons RN Peplau’s Theoretical Assistant Professor Mary Cipriano Silva. Schumacher. WA Carol E. MSN. RN. Shaver. Endotracheal Suctioning Cardiovascular Diseases. CNA. CT Parenting. FAAN in Newborns: NICU Hypertension Professor and Dean Preterm Infant Care University of Illinois at Helen A.xxviii CONTRIBUTORS Ali Salman. Sheehan. RN Judith Kennedy Schwarz. Quality of School of Nursing Life Adolescence. BC Kansas City. RN Chief. Shearer. Seattle University Philosophy of Nursing MPH. Department of Nursing Fairfax. NY Caregiver. Ethics and Associate Professor University End-of-Life Care University of Texas Frances Payne Bolton New York. Schlenk. Adolescent Pregnancy and Storrs. PhD. NH Clinical Professor Assistant Professor Pender’s Health School of Public Health University of Pittsburgh Promotion Model and Health Sciences School of Nursing University of Pittsburgh. PA University of Connecticut Technologies. School of Nursing University of Pennsylvania RN. PhD. RN. MBA College of Nursing Deputy Physician-in-Chief Seattle. Center Kansas City. Chicago Elaine K. PhD. MSN. Model RN. PA Mary Shelkey. RN.) Rogers Technologies Arizona State University Science of Unitary Karen L. MA. Craig-Dalsimer Alzheimer’s Disease Professor Division of Adolescent University of Kansas Medicine Deborah Shelton. Professor Emeritus Philadelphia. MA Assistant Professor Ethics of Research. NY Health Sciences Center School of Nursing Advance Directives School of Nursing Cleveland. IL Clinical Director Research Study Sleep Psychiatry Care Center University of Kansas Mount Sinai Medical School of Nursing Nelma B. CPAP Chicago. Smith. MA College of Nursing RN Project Director. RN Shiao. Home Care Philadelphia. PhD Candidate PhD. MD. Infant Injury Child Delinquents . PhD. PhD. Shyang-Yun Pamela K. Anselm College Health Science Elizabeth A. Donald F. KS RN New York.

FAAN Sheri Stucke. AHN-C. PhD. Patricia W. FAAN RN MPH. PhD. WV RN. Caring RN. Stone. Professor Emeritus Kresge Center Research RN. PhD. FAAN Morgantown. RN Dependence. FNP Susan M. Byrd Health Medications in Older Measurement and Scales Science Center Persons School of Nursing Neville E. PhD Ann Arbor. Theresa Standing. Alcohol Hussein A. Karen Farchaus Stein. NY Bethesda. RN. Contributors xxix Marlaine C. OH Denver. FAAN Ohio State University Assistant Project Officer College of Nursing Decker School of Nursing National Library of Columbus. PhD. RN Professor and Associate Assistant Professor Assistant Professor Dean for Academic Case Western Reserve Columbia University Affairs University School of Nursing University of Colorado Frances Payne Bolton New York. CO Triangulation Ora L. Stalter. OH Binghamton University Medicine and Binghamton. NY Health Sciences Center School of Nursing Patient Safety School of Nursing Cleveland. PhD. RN. NJ Adult Health. PhD. OH New York-Presbyterian Ohio State University Vulnerable Populations College of Nursing Hospital Columbus. PhD. MD Rutgers College of Nursing Osteoporosis Electronic Network Newark. NY Endotracheal Suctioning Case Management . PhD. RN Emory University Professor and Associate and Nursing Research Katholieke Universiteit Nell Hodgson School of Dean for Graduate Nursing Academic Affairs Leuven Leuven. RN. MI Professor University of Pennsylvania Self-Concept School of Nursing University of Iowa Disturbances and Eating Philadelphia. Strickland. PhD. Wright State University Cardiovascular Services Kathleen Stone. Nursing Director of the Center for Middle-Range Theories University of Michigan Gerontologic Nursing School of Nursing Science Bernard Sorofman. Drug RN. PA College of Pharmacy Disorders Iowa City. FAAN Els Steeman. RN. Ann M. Smith. MS. PhD. OH New York. College of Nursing and Columbia University FAAN Health Medical Center Professor Emeritus Dayton. Belgium Atlanta. CNA Clinical Instructor Abuse. Sparks. Strumpf. PhD. Geriatrics Director of Nursing. GA West Virginia University Robert C. IA Physical Restraints Ethnography Joanne Sabol Stevenson. MSN Center for Health Services Professor Mary Jane Smith. Tahan. DNSc. FAAN Edith Clemmer Steinbright Drinking and Driving Associate Professor of Professor in Gerontology Among Adolescents.

IA Instrumentation. Consortial Research Anita CONTRIBUTORS Hsin-Yi (Jean) Tang. Assistant Professor San Francisco Doris C. DNSc University of California. Associate Professor FAAN RN. NJ Wright State University Job Satisfaction. Professor and Associate University of Washington Department of Family Dean School of Nursing Health Care Nursing Duke University Seattle. PhD. PhD. RN. Connie Vance. MS. EdD. Barbara S. CA Special Projects Consultant National Yang-Ming Menstrual Cycle. DNSc. KS School of Nursing Assistant Professor Newark. Dayton. AZ School of Nursing Iowa City. FAAN Sara Torres. BSN Florida Atlantic University Director of Nursing Staff Nurse—Cardiac Unit Boca Raton. Susan Dale Tannenbaum. RN Kansas City. Research Associate College of Nursing FAAN University of Maryland Brigham Young University Professor. Diana L. School of Nursing RN. RN. Verran. PhD. NY Senior Scientist FAAN Mentoring University of Kansas Dean and Professor Medical Center University of Medicine and Patricia E. Tiedeman. VA Ethnography. School of Nursing Dentistry of New Jersey PhD. EdD. RN. FAAN FAAN Study of Complementary Professor and Associate Professor and Alternative Dean University of Arizona Therapies University of Iowa College of Nursing University of Virginia College of Nursing Tucson. Children Exposed to School of Nursing and Outcome Measures Intimate Partner Health Ann Gill Taylor. WA Adjunct Professor. Qualitative Reliability. FAAN Teaching Associate Professor Emeritus. RN. RN FAAN RN. Center for the RN. Mount Sinai Hospital University Premenstrual Syndrome New York. MD Provo. Vermeersch. PhD. OH Violence. Validity Complementary and Research Alternative Practices and Products (CAPPs) . Center School of Nursing Biofeedback for Reproductive Health Durham. Taylor. RN. NC Policy & Research Informed Consent Siew Tzuh Tang. FL Research Johns Hopkins University Kaiser-Permanente Center School of Nursing Case Study as a Method of Research for Health Research Baltimore. Intimate FAAN Delirium Partner Violence Betty Norman Norris Professor of Nursing and Toni Tripp-Reimer. PhD. RN RN Associate Professor. Charlottesville. CS Barbara Valanis. New Rochelle. Turner. OR Hypertension Mary E. H. PhD College of Nursing San Francisco. RN. NY Taipei. PhD. MD Portland. Taiwan Patient Satisfaction Chronic Illness Debera Jane Thomas. Tarzian. Joyce A. DNS. PhD. School of School of Nursing College of Nursing Nursing Baltimore. UT The College of New Descriptive Research Rochelle Roy Adaptation Model Roma Lee Taunton. Director. Vahey. PhD.

Measurement: The Mini. West Lafayette. Margaret A. OH Frances Payne Bolton Ann Arbor. Center for Health University of Akron Case Western Reserve Promotion College of Nursing University University of Michigan Akron. FGSA East Lansing. Wheatley. FAAN Celia E. MI Graduate School of Professor and Mental Health in Public Nursing Associate Director. FAAN RN RN. School of Nursing Health Disparities Quasi-Experimental Cleveland. Case Geriatrics Center Research Management. Rural Health Carolyn A. OH Dean and Professor Associate Professor Uniformed Services Smoking Cessation Michigan State University University of the Health Ann Whall. WI Danny G. Contributors xxxi Antonia M. MSN Professor Assistant Professor Instructor Director. FAAN School of Medicine Sharon A. PhD. Wasserbauer. RN Columbus. PhD. PhD. Bethesda. PhD. RN. OH Research Disparities in Minority Ladislov Volicer. PhD. Marquette Eau Claire Populations and University College of Nursing and Aggregates Marquette University Health Sciences Milwaukee. Wilkerson. Professor School of Nursing PhD. PhD. SC. LA Professor Ohio State University Violence Patricia Hinton Walker. Mental State RN. Boston University RN. KY Provost. PhD. Willis. Wills. PhD. MD University of Michigan Mental Health Services Capitation. RN. RN. DNSc. Professor & Director Boston. Neuman University of Michigan Systems Model School of Nursing Ann Arbor. MD Mental Health Clarann Weinert. MA Bozeman. RN. RN University of Wisconsin. Nursing Practice School of Nursing MPH. WI Eau Claire. MA RN Center for Research on Geriatric Research Associate Professor of Chronic Health Education and Clinical Nursing Conditions in Rural Center Dwellers Purdue University Edith Nourse Rogers College of Nursing School of Nursing Memorial Veterans Montana State University. MI Middle-Range Theories of Dementia Care . Villarruel. FAAN (ICNP®) New Orleans. MT Behavioral System Model Mental Status Longitudinal Survey. Lexington. College of Nursing Sciences FAAN. Dean and Professor RN University of Kentucky Madeline Musante Wake. PhD. College of Nursing PhD. IN Hospital Bozeman (Dorothy) Johnson’s Bedford. Sector Primary Care. Williams. Lynn I. MN International Coping Doctoral Candidate Classification for Louisiana State University Mary Ellen Wewers. FAAN Examination Joan Stehle Werner. RN. MI Experimental Research.

OH School of Nursing Physiological Monitoring Cleveland. CT Research Interviews Structural Equation Bowel Elimination (Qualitative) Modeling Among Older Adults. RN. PhD. FAAN APRN Professor Emeritus Professor Lecturer and Clinical University of California Florida International Coordinator San Francisco University Community Health School of Nursing School of Nursing Nursing San Francisco. Zauszniewski. PhD. PhD. FGSA Resourcefulness Dean and Florence Cellar Professor of Gerontological Nursing Director. University Center on Aging & Health Case Western Reserve University Frances Payne Bolton School of Nursing Cleveland. Zurakowski. RNC. FL Yale University Grounded Theory. FAAN PhD. PhD. WI Scientific Development PhD. Factor Analysis. OH Depression in Older May L. OH Depression in Older Adults . RN Renzo Zanotti. FAAN. New Haven. FAAN School of Nursing RN Kate Hanna Harvey Philadelphia.xxxii CONTRIBUTORS Holly Skodol Wilson. Youngblut. Zembrzuski. University of Pennsylvania Chris Winkelman. Cora D. PhD. Italy Tamara L. JoAnne M. Adults. RN. PhD Dehydration in Older Associate Professor Professor Adults Marquette University University of Padova College of Nursing Padova. PhD. Causal Modeling. PA Assistant Professor Professor of Community (Florence) Nightingale Case Western Reserve Health Nursing University Case Western Reserve Frances Payne Bolton University School of Nursing Frances Payne Bolton Cleveland. CA Miami. RN. Wykle. Milwaukee. Wilson. CRNP Death and Dying Lecturer Jaclene A. Hydration and Sarah A.

LIST OF ENTRIES A C Community Mental Health Complementary and Action Science Cancer in Children Alternative Practices and Activities of Daily Living Cancer Survivorship Products (CAPPs) Acute Care of the Elderly Capitation Computer-Aided Adherence/Compliance Cardiovascular Disease Instruction Adolescence Cardiovascular Risk Computerized Decision Adolescent Pregnancy and Factors: Cholesterol Support Systems Parenting Caregiver Concept Analysis Adult Health Caring Consortial Research Advance Directives Case Management Content Analysis Advanced Practice Nurses Case Study as a Method of Continuing Care Ageism Research Retirement Communities Alcohol Dependence Causal Modeling Coping Alzheimer’s Disease Cerebral Ischemia Coronary Artery Bypass Angina Child Abuse and Neglect Graft (CABG) Surgery Applied Research Child Delinquents Cost Analysis of Nursing Artificial Intelligence Child Lead Exposure Care Attitudes Effects Critical Care Nursing Childbirth Education Cultural/Transcultural B Children Exposed to Focus Basic Research Intimate Partner Violence Cumulative Index to Behavioral Research Chronic Conditions in Nursing and Allied Benchmarking in Health Childhood Health Literature Care Chronic Gastrointestinal Current Procedural Bibliographic Retrieval Symptoms Terminology-Coded Systems Chronic Illness Services Bibliometrics Clinical Decision Making Biofeedback Clinical Judgment D Bowel Elimination Among Clinical Nursing Research Data Analysis Older Adults Clinical Preventive Services Data Collection Methods Boykin and Schoenhofer: Delivery Data Management The Theory of Nursing Clinical Trials Data Stewardship as Caring Cognitive Interventions Death and Dying Breast Cancer: Psychosocial Cohort Design Delirium Adjustment to Illness Collaborative Research Delphi Technique Breast Cancer Screening Comfort Denial in Coronary Heart Breast-Feeding Community Health Disease xxxiii .

xxxiv LIST OF ENTRIES Depression and Family Health HIV Risk Behavior Cardiovascular Diseases Family Satisfaction With HIV Symptom Depression in Families End-of-Life Care Management and Depression in Older Adults Family Theory and Quality of Life Depression in Women Research HIV/AIDS Care and Descriptive Research Fatigue Treatment Diabetes Feminist Research Home Care Technologies Disaster Nursing Methodology Home Health Care Discourse Analysis Fetal Monitoring Classification (HHCC) Disparities in Minority Fever/Febrile Response System Mental Health Fitzpatrick’s Rhythm Home Health Systems Dizziness in the Elderly Model Homeless Health Doctoral Education Formal Nursing Languages Homelessness Drinking and Driving Functional Health Homelessness and Related Among Adolescents Functional Health Patterns Mood Disorders Drug Abuse Funding Hospice Dysphagia Hydration and G Dehydration in Older E Adults Gastroesophageal Reflux Elder Mistreatment Disease Hypertension Electronic Network Gender Research Emergency Nursing Genetics I Empathy Geriatric Interdisciplinary Immigrant Women End-of-Life Planning and Teams Individual Nursing Therapy Choices Geriatrics Infant Injury Endotracheal Suctioning Gerontological Advanced Infection Control Endotracheal Suctioning in Practice Nursing Informed Consent Newborns: NICU Grandparents Raising Instrumentation Preterm Infant Care Grandchildren International Classification Enteral Tube Placement Grantsmanship for Nursing Practice Epilepsy Grief (ICNP®) Ethics of Research Grounded Theory International Nursing Ethnogeriatrics Research Ethnography H Interpersonal Evaluation Communication: Nurse- Health Care Evidence-Based Practice Patient Communication Experimental Research Intimate Partner Violence Health Conceptualization Exploratory Studies Health Disparities Health Indicators J F Health Policy Job Satisfaction Factor Analysis Health Services Job Stress Failure to Thrive (Adult) Administration (Dorothy) Johnson’s Failure to Thrive (Child) Health Services Research Behavioral System Model Falls Health Systems Delivery Family Care Hemodynamic Monitoring K Family Caregiving to Frail Henderson’s Model Elders Hermeneutics Kangaroo Care Family Caregiving and the History of Nursing (Imogene) King’s Seriously Mentally Ill Research Conceptual System and .

List of Entries xxxv Theory of Goal Neurobehavioral Osteoarthritis Attainment Development and Osteoporosis Nutritive Sucking Outcomes Measures L Neuroleptic Use in Nursing Homes P Leininger’s Theory of Newman’s Theory of Pain Culture Care Diversity Health Pain Management: A Mid- and Universality Nightingale (Florence) Range Theory Longitudinal Survey Nosocomial Infections Parental Response to the Nurse-Patient Interaction Birth and Hospitalization M Nurse-Patient Relationship of a High Risk Infant Managed Care Nurse Researcher in the Parenting Maternal Anxiety and Clinical Setting Parkinson’s Disease Adaptation During Nurse Staffing Parse’s Theory of Nursing: Pregnancy Nursing Assessment Human Becoming Measurement and Scales Nursing Centers Theory Medications in Older Nursing Diagnosis Participant Observation Persons Nursing Education Patient Classification Menstrual Cycle Nursing Informatics Patient Contracting Mental Disorders Nursing Information Patient Education Prevention Systems Patient Safety Mental Health in Public Nursing Intensity Patient Satisfaction Sector Primary Care Nursing Interventions Pediatric Primary Care Mental Health Services Classification (NIC) Pender’s Health Promotion Research Nursing Occupational Model Mental Status Injury and Stress Peplau’s Theoretical Model Measurement: The Mini. Nursing Outcomes Pet Therapy Mental State Classification Phenomenology Examination Nursing Practice Models Philosophy of Nursing Mentoring Nursing Process Physical Restraints Meta-Analysis Nursing Studies Index Physiological Monitoring Middle-Range Theories Nursing Workload Pilot Study Middle-Range Theories of Measurement Systems Population Health Dementia Care Nutrition in Infancy and Populations and Aggregates Minority Women Childhood Postpartum Depression Offenders Nutrition in the Elderly Pregnancy Moral Distress Premenstrual Syndrome Moral Reckoning O Preoperative Psychological Mother-Infant/Toddler Preparation for Surgery Obesity as Cardiovascular Pressure Ulcers Relationships Risk Factor Prevention of Preterm and Music Therapy Observational Research Low-Birthweight Births Design Primary Care N Online Journal of Primary Health Care Narrative Analysis Knowledge Synthesis for Primary Nursing National Institute of Nursing Prostate Cancer Nursing Research Orem’s Self-Care Deficit Psychosocial Interventions National Institutes of Nursing Theory (PSI) Health Organizational Culture Pulmonary Changes in Neuman Systems Model Organizational Redesign Elders .

xxxvi LIST OF ENTRIES Q Scientific Development Thermal Balance Secondary Data Analysis Time Series Analysis Qualitative Research Self-Concept Disturbances Transitional Care Quality of Care and Eating Disorders Transitions and Health Quality of Life Self-Efficacy Triangulation Quantitative Research Serious Mental Illness Quantitative Research U Sex and Gender Methodology Shivering Uncertainty in Illness Quasi-Experimental Sigma Theta Tau Unified Language Systems Research International Nursing Unlicensed Assistive R Research Classification Personnel System Urban Health Research: Reliability Sleep Nursing Research in Reminiscence and Life Smoking Cessation Urban Neighborhoods Review Smoking/Tobacco as a Urinary Incontinence Replication Studies Cardiovascular Risk Representation of Factor V Knowledge for SNOMED International Computational Modeling Social Support Validity in Nursing: The Arcs© Spirituality Violence Program Statistical Techniques Virginia Henderson Research Careers Stress International Nursing Research Dissemination Stress Management Library Research in Nursing Ethics Stroke Vulnerable Populations Research Interviews Structural Equation (Qualitative) W Modeling Research on Interactive Substance Abuse and Wandering Video Addiction Among Watson’s Theory of Research Utilization Registered Nurses Human Caring Resourcefulness Substruction Weight Management Retirement Suicide Wellness Rights of Human Subjects Surgery Widows and Widowers (Martha E.) Rogers Science Women’s Health of Unitary Persons T Workplace Violence Roy Adaptation Model Taxonomy Rural Health Telehealth S Terminal Illness Theoretical Framework Sampling Schizophrenia .

it can be applied to organizational theories-in-use refers to theories that are actu- behaviors and organizational intervention. able to articulate their theories-in-use except intentionality in action. I theories-in-use as a type that seals prac- tics. Scho¨n. used to teach new skills and create new cul- sional practice is concerned with “knowing ture. (b) a theory of intervention that 1983). (b) human Argyris and Scho¨n (1974) and Argyris. Es- primarily oriented to studying individual poused theories of action are the rationale practitioners in their practice and generation expressed by practitioners as guiding their of knowledge from individuals’ practice. and Smith (1985) identified Model of behavioral norms and institutional poli. 1985. Scho¨n contrasts action science as ad. Argyris (1987) suggests further that action science is Action science is an approach to generating an interventionist approach in which three knowledge for practice by engaging prac. prerequisites must be established for the re- titioners in that process through reflection search to ensue: (a) a creation of normative on their own behavioral worlds of practice models of rare universes that are free of defen- (Argyris. action sci. Action science is use as two types of theories of action. Model ating knowledge. Theories-in-use are only R. and Smith (1985) through reflection that fulfills the functions identified espoused theories and theories-in- of discovery and change. Putnam (1992) suggests that action sci. Action science thus is a II theories-in-use are proposed within action method and philosophy for improving prac. Putnam. and propositions and are the design in their practice may be limiting. Although know. rou.” whereas action science is oriented to Action science holds that actions in profes- “knowing how” in practice. and (c) the epistemology of practice calls titioners from learning and produces routin- for the engagement of practitioners in gener. inferable from the actions themselves. actions in a situation of practice. positivistic science. which he calls technical and (c) a theory of instruction that can be rationality. A Action Science tice and generating knowledge. basis on which practitioners’ behavioral tinized. ally used in practice. Putnam. ization and ineffectiveness in practice. what practitioners actually cepts. the perspective of human agency. & Smith. and normativity from through careful reflection and self-dialogue. Theories of action are of knowledge that is not available from tradi. Hence. and self-sealing. sional practice are based on practitioners’ ing how in practice contributes to the creation theories of action. Argyris. schemata. and ence is based on three philosophical premises: practitioners usually are not aware of or not (a) human practice involves meaning making. from the present to a new desirable universe. whereas however. learned and organized as repertoires of con- tional research. practice goes on in an interdependent milieu Putnam. worlds are created in specific situations of ence addresses generation of knowledge practice. sive routines. science as an intervention for Model I theo- 1 . can move practitioners and organizations vanced by these authors with the traditional. that. Technical rationality for profes.

health disciplines and professions across a Such session. and to evaluate practice face-to-face discussion (interview) outcomes. HESOOK SUZIE KIM tion. ties. The research pro. On the other hand. practice knowledge that informs their ap. nursing practice by freeing nurses from self- ing of new theories-in-use through reflective sealing practices and engaging them in the practice and practice design. to deter- transcripts or narratives by a researcher inde. the situation (Kim. The general aim of ac- ence generates knowledge regarding the pro. Transcriptions of actual practice by the researcher or narratives of actual practice Activities of Daily Living by the practitioner are analyzed together in order to describe and inform reflectively the Ability to care for oneself and meet basic nature of practice and theories-in-use. Reflection and learning are the two service that occurs in the context of health key processes necessary for the transforma. search goals. ADL are evaluated for many purposes. Through action science. aims to clients problems but also in terms of orga- to engage both practitioners and researchers nizational elements of the health care envi- in this process of transformation through the ronment. or response to intervention. from the most basic of human skills (e. Nursing practice is a human-to-human mitment. Through such sessions. R. mine care requirements. ADL are generally viewed hierarchically ing and doing that were involved in the prac. informed choice in action.g. also acts as an interventionist by engaging the pass principles of valid information. practice but has to be derived and designed Knowledge of practitioners’ theories-in from the nurse’s knowledge of and responses use and espoused theories provides a descrip. designed and enacted. the researcher ability to feed oneself) to somewhat higher . tice. process of learning and participatory re- Research process in action science calls for search. Nursing practice is not based sim- creation of a normative model of rare uni. practitioners en.2 ENCYCLOPEDIA OF NURSING RESEARCH ries-in-use. discovery of theories-in-use. ADL are useful to many between the researcher and the practitioner. vide opportunities for reflection on the think. and internal com. cess is not oriented to the analysis of action such as to assess current capabilities. Model II theories-in-use encom. Thus. In addition. then. wide range of health care settings and popula- structed reasoning of practitioners regarding tions for addressing both clinical and re- critical moments of the practice and to pro. and inter- vention. action sci. to the competing and complex demands of tive understanding about the patterns of in. Nurses practice within on-line condi- tion from Model I theories-in-use to Model tions that are complex not only with respect II theories-in-use. nursing practice in poused theories recalled in actual practice. tion science for nursing is then to improve cess involved in self-awareness and the learn. as the consistencies between theories-in-use and es. 1994). the cooperative participation of practitioner and researcher through the phases of descrip. may be entrenched with routinization or fro- gaged in Model II theories-in-use produce zen within Model I theories-in-use. as well as particular nursing actions. Action science. care. needs is fundamental to maintaining health nam (1996) suggests the use of the ladder of and independence. Put.. general. It involves a post. free and practitioner to move toward new learning. The term “activities of inference as a tool to discover practitioners’ daily living” (ADL) is used to refer to the set modes of thinking and action as revealed in of skills that constitute these essential abili- transcripts or narratives. action scientists suggest. cal knowledge that governs the situation of tion and instruction. ply on linear translations of relevant theoreti- verse and application of theories of interven. are used to get at the recon. a great deal of nursing proach to practice without routinization or as practiced may be exemplary and creatively the self-sealing mode. to gauge progress pendent of the practitioner. In addition.

their needs for assistance in support of contin- mant’s knowledge of the individual’s abilities ued independence. Generally. appropriate clothing is substantially more cially important in determining not only the useful in supporting a higher level of indepen- dimension of ADL to be assessed. Dichoto. best when the most commonly affected ADL pose and breadth of the assessor’s goals. such as diffi. the assessment can be targeted toward the way skills are rated. physical.. which generally encompasses when possible. what the community. ability to bathe and dress oneself). This higher level skill set is usually may not actually correspond with one an- distinguished from the more basic ones by other (Smith & Clark. such as cognitive and social (e. For example. An also part of the broader concept of functional evaluator should take care to note. Further. and managing one’s vidual is expected to do. cogni. not only in the range and known for a given population. a health professional. when conducting and interpreting assess- sure ADL and IADL. used are the Katz Index of Activities of Daily The application of ADL and IADL mea- Living. assessment of ADL may be most beneficial in Although ADL and IADL assessments have a clinical context where prescriptions for the been used for many years. Particular approaches to and any motivations of the informant that assessing ADL and IADL should be selected . derstanding the impact of illness or injury on or research staff.g.. or control assessment. the Barthel Index. knowing that a ease) or type of support (e. it is also im- Higher still are those more complex skills portant to distinguish between what the in- necessary to maintain independence in the formant says the individual can do. a family member and research because they are valuable in un- or informal caregiver. to. that the person needs help with sequencing mous and ordinal scaling approaches are the steps involved in selecting and donning most common. One disadvantage of specifying ADL assess- els has led to only a limited understanding of ments to particular populations is that the the pattern of ADL and IADL change over narrowed view may result in a failure to iden- time for various patient populations.g. much as quality of life measures have encompassing IADL can be used alone. and related performance limitations are ADL scales vary. such as using the telephone. may color responses. new approach that is beginning to gain no- dresses basic ADL. all of which may or finances. ADL and IADL are performance. dichotomous and broad ordinal scaling mod. This approach to the determining the scale’s sensitivity to change. but also in dence for the individual. the prevalence of kinds and levels of ADL assistance are made. tify uncommon areas of difficulty.g. accuracy can be a problem. or in combination with other mea. Among the most widely ments of ADL performance. single person selves independently is useful. and the Functional sures to particular clinical populations is a Independence Measure.g. sonal factors (e. each scale the most relevant ADL and scaled more measures along one dimension. In sum. ADL scales can be used to elicit informa. and per- functioning. and noise).. ADL and IADL are widely used tion from various informants including the concepts in nursing and health care practice individual being assessed. Many scales have been developed to mea. Such specific ADL measures may be applied sures of function. familiarity. In these situa- complexity of skills they include. 1995).g. individual actually can do. These and similar scales tice. Activities of Daily Living 3 ones (e.. person with dementia is unable to dress them- tive) or level of assistance (e. To obtain accurate ADL a person’s everyday life and in determining ratings it is essential to consider the infor. fatigue or depression).. performs with encountered. The scaling model is espe. but knowing assist) needed to perform a skill. gether. both environmental factors more domains. depending upon the pur. do.g. each of which ad. Even when ob- use of the term “instrumental activities of taining ratings of actual rather than reported daily living” or IADL. and what the indi- ing household chores. glare. but also in tions. been specified to various clinical populations.. meaningfully to the nature of the difficulty culty in performing a skill (e.

1993a. but intensive effort needs to be fo- wal. A widely cited study conducted care. Nursing research a 33% rate of readmission within 3 months that defines the evidence for practice inter. func- ten as younger individuals. For example. & Smith. Scherb. ence at least one iatrogenic complication For example. when other variables are held constant. & Weber. Sochalski. patient and staff satisfaction. 70 years and older were enrolled in a geriatric Data for acute care are also found in re- care program which used a geriatric resource. In a prospective DONNA L. 1993b). In another study. Salyer. and improved quality indicators (Inouye et Lake. and complications such as acute confusion ventions is needed for patients of all ages. For example. and iatrogenic complications. and pressure-ulcer prevention were some information regarding outcomes for the used (Palmer. which are com- especially for the elderly (Fulmer & Mezey. elderly. On average. Individuals older than 65 years of age are more likely to be admitted to acute care Older people have a greater prevalence of from the emergency department than other chronic diseases and disorders that lead to age groups. and the length of tional decline. Siegler. people over 65 an increased risk for poor outcomes such as are hospitalized more than three times as of. Palmer Gergen. Kresevic. Fifty-eight percent sis for best practice for hospitalized elders is of patients who are hospitalized will experi- often embedded in interdisciplinary studies. hos- care received by the hospitalized elderly. tafson. Careful consideration should be strated that ACE units reduce the institution- given to factors that may affect ADL and alization rate of hospitalized elders. Gus- the quality of information available from in. and Lee (2002) found that the com- ment can be made. models of patient and nursing administration proved care through the use of an ACE (Acute also have been examined (Mark. and Jacobsson (2000) also demon- formants. 1998). readmissions. Acute Care of the Elderly 2002). Kovner & al. Ged- Care of the Elderly) unit. in which protocols des. in one study. Sloane. The pital staff has been shown to make a differ- intervention decreased patients’ length of stay ence in patient outcomes (Aiken. 1998. mon among the elderly. Glick. 1994). son. IADL ratings so that the most accurate assess. search that looks at “nurse sensitive” indica- nurse intervention to improve the quality of tors for patient outcomes. ALGASE study of 804 patients 80 years of age or older. Rapp. & Maas. & Ko. Nurse accountability and and colleagues were able to demonstrate im. Tailored approaches for monality of the ACE unit was their interdisci- specific patient populations are emerging as plinary care and focus on functional improve- the next advancement in ADL measurement. 244 patients aged (Hart).. 1999.4 ENCYCLOPEDIA OF NURSING RESEARCH based on the purpose of the assessment and likely to be institutionalized. John- for skin care. such tivities of daily living (ADL) and were less as premorbid conditions? Such parameters . tween outcomes for younger individuals ver- comes among older patients who have been sus older individuals in the case of hospital hospitalized. and re- duction of length of stay. There is that of younger individuals. Landefeld. HAESOOK KIM 42% of the elderly patients with no baseline dependencies at admission had developed one or more limitations within 2 months (Hart. urinary-incontinence manage. and and nosocomial infections. resulting in increased 2002). morbidity and mortality. 1998). their stay is estimated to be 50% longer than as compared with other age groups. do older adults have dif- by Landefeld. cused on understanding the differences be- ACE units have shown improved out. The hospitalized elderly are at hospitalization. increased length of stay. Nursing research that provides the ba. Palmer. ment. These studies provide ment. Asplund. and Kresevic (1995) ferent cardiac output after coronary artery demonstrated that patients admitted to an bypass surgery than younger individuals ACE unit were more likely to improve in ac.

structured databases with the term compli- Historically. survival investigators view the terms as synonymous rates 4 to 6 months after discharge were ex. little systematic attention of 65 were excluded from surgical intensive was given to this phenomenon until the care units. Today individuals in their 80s and ture was published in Nursing Research 90s undergo open-heart surgery and require (Marston. The most study. One of the first reviews of the litera- patient. such as bilateral bruis. However. is frequently over. For example. The literature suggests that fewer part of acute care of the elderly and need to than 20% of patients with medication regi- be addressed with rigorous research studies. The national phar- therapeutic regimen (Haynes. or is adherence a patient responsibility? This looked when elders come into the hospital argument presumes that the patient is aware with severe symptoms. histories incompatible with injuries. as it was felt that the cost-benefit 1970s. Adherence is defined as the degree to which The problem of nonadherence is costly in behavior corresponds to a recommended terms of dollars and lives. if there though there is a smaller body of literature is an insufficient number of beds in an inten. individuals over the age of Plato. of his or her own behavior and has con- ing. The KIRAN MANGROLA most common reasons given by patients for lapses in adherence are forgetting and being too busy. the severity of the illness was a pre. therapeutic alliance. One of the issues that continues to arise dividuals before they are used to care for the in discussions of patient adherence is patient elderly? Further. 1994). when there was a proliferation of re- was not going to be in favor of the older search. elders were not considered to ance. Those patients who have be replicated among older adults to discern decided to follow the regimen but do not differences between the age cohorts. 1970). & macy council estimates that nonadherence to Sackett. a serious and autonomy. including com. mately $100 billion annually (Grahl. The majority of the research Ethical issues abound regarding elders has been focused on patient adherence. on the adherence of research staff to clinical sive care unit. Since that time there has appropriate postoperative care that only a been a profusion of research from a variety surgical intensive care unit can provide. These issues are a regimen. and independent of the decision to engage in amined in patients aged 45 and older. elder abuse. . Are scarce resources allocated to younger in. Numerous terms have been pharmacological therapies costs approxi- used to describe this behavior. complete literature can be obtained from dictor of ICU outcome. Taylor. been discussed in the literature since the days In the early 1970s. most patients after ICU hospitalization. should older individuals be sent protocols and a growing body of literature on out to the floor before younger individuals? provider adherence to treatment guidelines. A study conducted by Kleinpell operation. and sciously decided not to follow a treatment overt fear of caregivers. Adherence/Compliance 5 are needed for the improvement of care for pliance. be “suitable candidates” for surgeries and Adherence to health care regimens has treatments that today are considered routine. 1979). al- during a hospitalization. mens consciously decide not to engage in a Studies involving younger individuals need to treatment program. carry it out are unaware of episodic lapses in behavior or have difficulty in integration of TERRY FULMER the health care regimen into their lives. Although the literature is filled and Ferrans (1998) explored functional sta. with discussion of the acceptability of these tus and quality of life outcomes for elderly terms and the differences between them. of disciplines. Is nonadherence a patient right potentially fatal syndrome. In this a particular therapeutic regimen. and patient co- the elderly. This group comprises on average Adherence/Compliance 40% to 50% or more of patients in a treat- ment regimen. age was not.

on the data source. The Guide to Clinical Research on adherence has been focused Preventive Services (U. Failures to quit smoking. on health outcomes and costs (Dunbar-Ja- Poor adherence then is a significant prob. Most clinical studies have re. Just 1/3 of the inter. Hospital. mortality is high. ventions to improve medication adherence ages 20 to 24. to avoid adherence to treatment regimens with atten- excess alcohol. ventions were found to have an effect on both The actual number of adolescents and adherence and outcome. and office nurses provide education regarding treatment plans. ages 15 to 19. population is in- showed effectiveness were those that included creasing. and make important educational and these used general educational or behavioral occupational decisions that will shape their counseling interventions. Home health and community nurses provide education and assistance in carrying out health care advice. lescents will likely continue to increase in size. The ity as well as to early mortality. Nurse practitioners may prescribe or recommend JACQUELINE DUNBAR-JACOB therapies. There is a Census. meaningful approach to this stage is to sepa- ing factors. cence. At what age nurses prepare and support patients in the the label adolescence is appropriate depends conduct of treatment regimens. Most of ability. There is a need for Adolescence is a developmental stage distinct intervention studies that will guide practice as from childhood and adulthood. heavily on the determination of the extent of 1996a) uses ages 11 to 24 years. ages 15 and 19 years (U. to exercise regu. being used to obtain better information. Thus. (b) middle adoles- ized controlled studies have evaluated inter. adolescents reach physical and sexual matu- dicators as outcomes. Adolescence clinic. develop more sophisticated reasoning ined adherence to lifestyle behaviors. Further data research would benefit from theoretical ap- suggest that nonadherence to pharmacologi. 2003).6 ENCYCLOPEDIA OF NURSING RESEARCH Although the cost of nonadherence to non. and hanced attention by health professionals.S. as electronic monitors. 1996). Preventive Services. adult careers. Of the adolescent popula- One problem in evaluating interventions tion. proaches to the problem of patient adherence cal as well as nonpharmacological therapies and the design of intervention strategies. lem of direct relevance to nursing. the contribution to morbidity and nologies. Future research on adherence should ad- to lose and maintain weight. dividuals do not report accurately and those According to Day (1996) reasons for this in- reports are biased toward an overestimate of crease include the fact that “baby boomers” performance. Recent reports by the Cochrane rate adolescence into three periods: (a) early Collaboration suggested that just 36 random. PDAs and other tech- mated. rity. adolescence. 14. As a result.2% in 2002. 1996). the cohort of ado- growing body of evidence indicating that in.S. such pharmacological therapies has not been esti.9% in 1993. ages 10 to 14. tion directed toward various age groups. cob & Schlenk. non-White . and regimen behaviors. The most the problem and on predictors or contribut. population in 1990. 13. those between ages 10 and 14 years and identifying relevant predictors is that of represent 53% compared to 47% between measurement. Fewer still have exam. This group represented 14% of the components of self-management and/or en. Ef- contributes to excess hospitalization and fective strategies delivered by nurses have complication rates (Dunbar-Jacob & considerable promise of a favorable impact Schlenk. Bureau of the lied on self-report of adherence. clin- ute significantly to declines in functional abil. Strategies that their proportion in the U. ical populations. dress strategies by which nurses can improve larly. During this transitional period and examine both adherence and clinical in. alternative strategies are are having children later in life.S. to engage in safe sex practices. and to use seat belts contrib. and (c) late adolescence.

referral is re. Also. risks: suicide. Researchers rates. high-risk violent or self-injurious behavior or smoking. Adoles. therefore. personality). the health of adolescents. and most of the leading health problems. it is crucial for nurses to be cultur. Parents’ concerns include be mortifying experiences. eating disorders. 2001. period influences behavior. and gambling behaviors. and biobehavioral (neurohormonal.” The authors con. the percentage of adolescents how parental health attitudes and behaviors. American Medical Association. nurses tion. (a) how adolescents organize their lives and fore is preventable. and pros. experience the negative consequences but we quired. and 1% (norms. one’s feelings and one’s immortality. Many behavior patterns pattern their behavior in ways that put them developed during adolescence continue into at lower or higher risk for serious health adulthood. personality.6% Asian/Pacific Islanders. Hence.5%) or affect teenagers. driving fast. self-centeredness is the “personal fable. There is still much to learn regard- lescent population between the ages of 10 ing cognitive aspects (attitude.” lems.7% Blacks. appearance and behavior. Elkind (1984) de- Common concerns by adolescents and scribed the “imaginary audience” as one con- their parents have been documented sequence of adolescent egocentrism. psychosomatic issues. Before working with adolescents.. the health practices of adolescents. psychosomatic prob. problem solving. Romer (2003) offered an excellent over- health care providers. and a large number of immigrants are in are making some progress in understanding their 20s.2% Whites not of ceptions). must understand how the egocentrism of this 1999). often describe this belief as “It won’t happen cluded that any adolescent concern should to me”—the story we tell ourselves. persist. con- Hispanic origin. In the past 10 years. safety which is a set of beliefs in the uniqueness of issues. In 2001. moods. that other people may a severe or chronic disorder. within the White population (12. that is. When problems involve having sex without protection. environment. per- and 19 consisted of 63. emotional quence of the adolescent egocentrism and lability. whether lead to assessment. and mass media than that within the Hispanic (17. Others lems. and specific beliefs of adults and how these beliefs influ. medical prob. or other community re. Two important Most adolescent mortality and morbidity concepts related to adolescent lifestyles are results from behavior and lifestyle and there. 15. alcohol and other substance ence health-related behaviors. Adolescence 7 populations are experiencing high fertility become a focus of investigations. by discussion and reassurance with family.g. cents (Health Research Service Administra. depression. major advances decision making. 14. emotional aspects (feelings. safety. Another conse- acting-out behaviors.6% His. peer influences. and “wasting time. the ado. adolescence has increasingly have their origins in environmental or behav- . view of research on risk reduction to promote sources. As our focus use. & Sherer. social effects panics. status). Research topics included ing). risk-taking. culture. is watching them and is concerned about their peer interpersonal concerns. ing the life span. smok. cerns. drug and alcohol use. Eskimos.1%). lifestyles. has turned to the early origins of health beliefs Most of the health problems of adolescents and behaviors. and Aleuts. 3. school. the assumption that everyone around them cents’ concerns include parental conflicts. peer and have been made in understanding the health parental influence.8%) is lower social norms. Other issues can generally be handled will not. Radzik. lengths to avoid what they are convinced will pects for the future. (Neinstein. sexual activity. identity. beliefs. 2002). sexual activity. health-related beliefs and Black populations (17. and (b) how these patterns de- problems of adults are those associated with velop. socioeconomic American Indians. very self-conscious and often go to extreme lems. psychoneuroimmunological) influences on ally competent in order to care for adoles. or drinking. they are social situations. academic prob. or cease at different times dur- behaviors initiated early in life (e. peer pressures.

& Gwyer.4%). within the programs that have correlated those 15–17 years and those 18–19 years. In 1991. Regardless of the (DiCenso. and male-focused efforts. to revisions in Census population estimates occupational. Second is that .000 young women was higher than that for Hispanics (105/ 1. The Human Development have recently begun to 2002 rate of 42. on issues ranging from abstinence. The rate in 1999 was 86..000 or the non-Hispanic Human adulthood refers to the stages or White rate of 30/1. O’SULLIVAN change for welfare support for young moth- DONALD F.000 compared with the non-Hispanic Black rate of 74 births/1. Programs have declined for all racial and ethnic groups have not yet begun to look at the processes and for all age subgroups: those under 15. In addition. 2003).000). O’SULLIVAN panic Whites or Blacks. especially older adults. In contrast. & Stewart-Brown. it is essential that all nurses under. Much research has been focused on under. Successful programs have included both group and indi- The incidence of adolescent pregnancy has vidual interventions. 2002). and health care young woman or her infant (Geronimus. Abma. intellectual. hormonal contraceptive and condom use. public policy ANN L. Guyatt.000 tion at a center or institution. the mass me. spiritual. Willan. economic. families. the Black DONALD F. Physical. Parenting Barlow. nursing for two reasons. and Native American ple stages of adulthood. 2003). growing evidence suggests that parenting interventions may make a differ- Adolescent Pregnancy and ence in outcomes for teens’ infants (Coren. First is that adults. since 1990 when home-based and those that require participa- rates peaked at 116.9 births per 1. 2002. 2003). with success by the infants. the rate the National Institute on Child Health and of births to adolescents has decreased. mains about whether a single birth to an ado- ple settings. health-related changes characterize the multi- Asian/Pacific Islander. 2003). communities. MacDorman. lescent has negative effects on the life of that dia. and in 2000.000. legislation that prevents 2003). alcohol.8 ENCYCLOPEDIA OF NURSING RESEARCH ioral factors.000 adolescent women phases of the life cycle after childhood and (Child Trends. Since 1990 the rate of decline in births has been slower for Hispanics than for non-His. 2002. SCHWARZ teen birth rate at 118/1.3 pregnancies per 1. This effect is greatest for Hispanic. Early Head Start programs funded by 1.000 young show promising outcomes with respect to women was 31% lower than the 1991 rate maternal school attendance as well as child of 61. Adolescent birth rates development (Love et al.000 (a decline of 25.8 births/1. Also controversial is whether adoles- adolescents’ access to cigarettes. & that involve both majority and minority Henshaw. The changes that adolescent girls (Arias. ANN L. settings. Reducing adolescent morbidity and birth and on the development of pro- and mortality requires strategies that involve grams to prevent pregnancy. Kirby.7/ teens. Some of the declines adolescence. take place in adulthood are of importance to ino. social. Mosher. Elfenbein & Felice. Controversy re- multiple approaches delivered through multi. Strob.S. and programs teenage women (Ventura. 2003). & Griffith. programs that are declined steadily in the U. stand how to provide culturally competent These programs have tended to focus broadly health care for adolescents. approach. comprise the largest standing the impact of adolescent pregnancy population served by nurses. It is the longest period of the in rates across all groups have been attributed life course. By 2001 the Hispanic rate was 86/ Adult Health 1. SCHWARZ ers. and cent parenting prevention programs work guns can promote health. educational. including schools. Similarly.

hand in hand with social. and as end product to be obtained at some definable one stage folds into the next. health researchers. anger.” this implies avoiding chronic dis- . Thorndike were two early 20th actualizing and maximizing human potential century scholars of the adult years. tioning. not an outcome or of adulthood has normative patterns. In mid. rarely are nursing actions designed nurse investigators. do not study health or to fit within the specific life stage. These stress tire life course. the maximum positive benefit for clients. professionals. Adults make up the The conditions are rarely perceived or treated “family” that is the basic unit of nursing care. good health is viewed as a resource that goes duce anxiety. G. One notable ex. and representatives redefined health as a “re- discontinuity over the life course. they are the direct or indirect clients for adults are decontextualized by health care essentially all of nursing care. in- study of adult life stages and critical situa. or acute or chronic illness. ostensibly because attributable to Dubos (1965). Furthermore. L. care phenomena within the context of the mental stage. 1993). frustration. who defined people did not live long enough to merit in. formed self-care. caregivers of elders. through the pursuit of three sub-goals: mak- 20th century. WHO spective focuses on change. The life-span per. Rather thus. providers in the form of accidents. Stanley of higher-level wellness embodied the idea of Hall and E. and physio. longer. changes is necessitated. who treat the immediate symp- Ideally. optimization of inherent and acquired human ment and aging is oriented to the scientific potential through goal-directed behavior. According to the highly influen- changes occur and integration of these tial WHO Ottawa Charter (Kaplan. nursing care and client education toms or condition while ignoring the adult about self-care would be designed to produce context in which it occurs (Stevenson. of adult clients. having an open-ended expanding class norms of the 1940s and 1950s. continuity. 1992). and adolescents and the informal abuse. According to Pender’s thesis. and progressing nately. The goal is to “live long and responses frequently present to health care die short. One conception of the health of adults that The study of adult development is a 20th has wide appeal in the medical community is century phenomenon. he lived long enough to revise them toward a more integrated and mature human and add additional stages as people lived ever existence through the entire life course. This process may pro. and harmony. entitled A Treatise on Man and the cept of higher-level wellness. within the context of the environment. on adult development. Adjustments are made as needed goal to maximize quality of life for as much to maintain structural integrity and harmony of the life span as possible. adaptation. Fortu. violence. Dunn (1980) went beyond ception was a treatise by Queletet published mere equilibrium and devised the new con- in 1842. within the developmental context. quiry in previous centuries. goal to seek a fuller potential. Erik Erikson (1959) published ing progress toward a higher level of func- a set of life stages that expressed the middle. Neugarten Pender (1996. chemical children. 2002) attempted to incorpo- (1968) and other investigators at the Univer. and satisfying relationships tions that most closely fits within the nursing with others. From 1960 through 1980. health as a state of equilibrium. health is the The life-span perspective of adult develop. and per- logical stress responses during the transition sonal development. economic. rate both Dunn’s actualizing focus and Du- sity of Chicago generated much of the work bos’s concept of health as maintaining stabil- that serves as the foundation of extant theory ity through adaptation to the environment. and it is a critically im- while the conflicts between the old and the portant resource for attaining and main- new self are resolved and the changes are taining a high-level quality of life for the en- integrated into the self-system. Adult Health 9 adults are the parents or guardians of infants. including However. Each stage source” for everyday life. or personal contextual reality adult life course. develop. Dunn’s concept Development of His Faculties. personal point in time.

catastrophic in research on adult health. There is a rise in cognitive abilities lumps three or more distinct adult stages into in young adulthood that does not peak for one group (e. prewomen’s decades of the 21st century. even in third world and for the development of intellect.g. Findings would be more valid old age and to peak near death for the cogni- and reliable. Emotional and spiritual de. and idiosyncratic middle years encompass the years from 30 to tendencies. 25 to 45. environment. Different aspects of development are dom. the environment. or the frail childhood occurred during the early years of age. 1993). Americans have been does not. great difficulty in trying to separate the im- The prevailing theories about physical pact of lifestyle from what is ultimately possi- normality and the adult stages have changed ble for adult health under ideal conditions. and exercise. In the ideal world. studies the theorist. but everyone experiences the most nursing research either erroneously decline.g. This ideal assumes that the necessary knowledge base exists. to expecta- from either 65 or 70 to 75. Nurse researchers were challenged to do ological efficiency in organ systems occurs more of their adult health research contextu- during the next 7 or 8 decades. the core or traditional ences. and gender-expectation inant in different stages of adulthood. Cultural. Even now. fat or carbohydrate intake. The latter three ages television versus the internet age). adult health status in light of varying mores the old-old age designation will move upward about smoking. Young adulthood lasts from tural expectations. 25 to 60) or makes up anti- most until middle age. is 85 and beyond. and old-old age. even about purely physiological tively and emotionally healthy. mal for men or women during the major the new middle years cover the years from stages of adult life is open to criticism as being about 51 to either 65 or 70. cohort.g. creativ- countries.g.. 20s. lifestyle. since the 1960s. 1993).. and 65 and above). but it Since the early 1970s.10 ENCYCLOPEDIA OF NURSING RESEARCH eases and disabilities and dying of old age at Although much has been learned. those whose extends to 85. Any of these phenomena. or other significant situa- tions.. encouraged to complete advance directives to . The prolongation of physical This is true not only for the biological possi- well-being has become a norm as humans bilities but also for the socioemotional realm are living ever longer. and then a very gradual decline in physi.. there is the natural end of the human life span. What is generally considered nor- 50 (50 was the average life span in 1900). The rate of ally tied to the specific adult ages and stages of change is mediated by genetics. as the baby liberation or sexual liberation). if scientifically based adult life norms may be altered for individuals by ge- stages were used as the grouping categories netics.g. Young old age covers the period done in the 1950s or the 1980s). decline at an even slower rate than the physi. middle old age tions within an age cohort (e. The biases can be overcome to some extent with biological self reaches its peak in the middle cross-cultural or cross-sequential designs. Developmental cal parameters. or to physical boomers move into the higher age brackets. and begin at age 90 or higher.. mental or physical illness. Much of the extant research differ by theorist. 45 to 65. differences that were influenced by prevailing ing. and wisdom. health professionals JOANNE SABOL STEVENSON would be cognizant of the developmental stage of each adult client and formulate care to match the needs and context of that stage Advance Directives (Stevenson. and their subjects (Stevenson. depending on tied to specific historical periods (e. emotional events. and these abilities then developmental age categories (e. to gender are relatively new designations and are evolv. the middle stages have been is plagued by the inability of researchers to expanded to accommodate the acceleration disentangle the overlay of familial and cul- of longevity. It is quite likely that during the first 3 values and expectations (e. cohort-specific life experi- about 18 to about 29. and situational confounders abound in data categorized and analyzed in this anti-theoreti- velopment is postulated to continue well into cal manner. Although the stages of adulthood ity.

This instructions in living wills is invariably con. making known as “substituted judgment. cision not to attempt cardiopulmonary resus. durable power of statutory recognition of these documents. in the event that the patient taining her life.” clinicians observe that they are often unavail- Some state statutes combine written and ap. religious medical system that ignores their personal groups.. robs them of privacy and engaged in a vigorous debate about the ac- dignity. discontinue the tube feedings that were sus- sures be used. and those viduals at the center of these early “right-to- involved in health care policy maintain that. and left no writ- their current autonomy into the future by ten documentation or clear verbal instruc- participating in advance care planning and tions about their end-of-life treatment wishes. Researchers are now examining how ADs citation is another form of ADs and is usually actually function in various clinical settings. completing advance directives (ADs). decisionally capable adults can extend result of a traumatic injury. members of the public. Their family members had to petition the There are two general forms that these courts in order to stop unwanted life-pro- legal documents take. The instructive direc. a standard of decision Even when patients have completed an AD. educators. Since 1976. Despite a great deal of effort and subsequent son to function as a surrogate decision maker publicity that included syndicated newspaper and make all medical decisions in the event columns by Ann Landers and “Dear Abby” that the patient loses decision-making capac. A de. Congress passed the which ADs become operational. Federal legislation requires all health care in- tingent upon a clinician’s determination that stitutions to inform newly admitted patients the patient has lost decisional capacity and about ADs and offer them assistance in com- that he or she has a “terminal” or “incurable” pleting a directive. Treatment decisions made by the surro. honoring the Patient Self-Determination Act of 1990. or not applicable in many situations pointment directions in one document. 2000). Others are questioning ther be medically futile or extraordinarily the very relevance of ADs to advance care . ment and allowing death to occur. In 1990. life treatment wishes. when the first so-called “right- ticipate in decision making. Both of these qualifying conditions tures have provided additional support for require a medical judgment to be made. in the event that they become unable to par. when the physician deter. the United States tive (i. able. and health care professionals have goals and wishes. The indi- Health care providers. zan’s wishes before permitting her family to monly.e. made by a surrogate following a physician and are exploring whether the presence of an recommendation. requesting that all life-extending mea. and prolongs their dying with painful ceptability of stopping life-prolonging treat- and ineffective technological interventions. or less com. die” cases were almost always young adults in order to avoid unwanted end-of-life situa. all 50 states have completed some form The proxy directive (i. involving critically ill adults (Tonelli.. Many Americans to-die” case involving Karen Ann Quinlan fear becoming trapped in a dehumanizing was decided.e. often as a tions. standard that required “clear and convincing ing a preferred course of action such as the evidence” of the then vegetative Nancy Cru- refusal of particular therapies. to range from 4% to 25% (Perkins. loses the ability to directly participate in In order to better inform the public about health care decisions. competent patient. Although each state the expected benefits of advance directives stipulates and defines the conditions under and encourage their use. 1996). vate the public about these documents. ADs. among other attempts to educate and moti- ity. who had lost decisional capacity. com- gate are expected to be consistent with those pletion rates for advance directives continue that would have been made by the now in. of attorney for health care) designates a per. living will) aims to direct future Supreme Court upheld Missouri’s evidentiary medical interventions by stipulating in writ. longing treatments. Individual state legisla- condition. AD ensures compliance with patients’ end-of- mines that a resuscitation attempt would ei. Advance Directives 11 ensure that physicians and family members burdensome in light of the patient’s current will know their end-of-life treatment wishes condition.

ing three face-to face counseling sessions Clearly. because of the limitations as- ACP intervention on the completion of ADs sociated with the use of instructive directives.12 ENCYCLOPEDIA OF NURSING RESEARCH planning (Perkins. 1996). they do not ensure that a those judgments. and uncertainty regarding the meaning discussions. meant” (Tonelli. Ditto and colleagues also found cult medical decisions each patient faced in that family members’ predictions of what the the course of their illness and treatment. Drought & Koenig. hospital-based that end-of-life interventions conform with physicians. with the result that the benefits of to seek information from others in the at- palliative or hospice end-of-life interventions tempt to determine what the patient “really were underutilized. Although the rate of completion (Dexter. Rubin. (ACP) and end-of-life care for nursing home Many commentators noted the following residents who were hospitalized during the last 6 weeks of life. and nurses are ideally situated to . truly direct care. quently resist advance care planning. Thiel. health care professionals have consistently Another group of researchers compared demonstrated widespread support for the the accuracy of substituted judgments made idea of ADs as an effective means to ensure by primary care physicians. (2001). it was subsequently noted that to explore whether ADs facilitate good end- 23% of the completed ADs were deemed le. Happ and colleagues difficulties associated with use of instructive (2002) found that the primary focus of ACP directives: incomplete information. surveys of patients and 2000). it did in- with chronic illnesses. Drought and Koenig (2002). Smucker (2001) found that familiarity with In a study by Tierney et al. conducted an ethnographic. and explored the effec- while ADs are reassuring to patients who tiveness of ADs in improving the accuracy of complete them. longitudi- that accurately reflected the patient’s end-of.. but a second study crease the accuracy of the judgments made found that having an ‘instructional’ AD did by hospital-based physicians. shown that ADs significantly facilitated end- In a study by geriatric nurse researchers of-life decision making. approv- hold values other than autonomy as im- ing life-sustaining treatments the patient portant. patient would want were correct less than These researchers concluded that shared deci- 70% of the time. Ditto. and patient’s end-of-life wishes will be followed. nal study of terminally ill patients with solid life wishes as stipulated in the AD (Ditto et tumor cancer or AIDS that explored the diffi- al. Eck- for ADs went from 16. Wolinsky. & Singer. not increase the likelihood that family deci. or that aimed to explore advance care planning saved resources at the end of life. 2000.g. 2002).7% follow. investiga. By so limiting ACP tions. Nonetheless. Tonelli and others searchers aimed to evaluate the effect of an concluded that. and family surrogates on behalf patients’ wishes. Coppola. Studies have found that of elderly outpatients. of substituted judgments for primary care proved the care satisfaction of elderly patients physicians or family surrogates. nurse eth- sion makers would make treatment choices icists. 2003. and patient satisfaction among persons with proxy directives are the preferred form of AD HIV/AIDS. & Tierney.. there is a need for further research about ADs. the in- in the nursing home was on cardiopulmonary ability to anticipate future medical condi- resuscitation preferences. 2001). ert. Danks. In another study. problems of interpretation require clinicians simplified. of-life care. and treatment as under-treatment—e. terminal patients fre- three times as likely to make errors of over.4% to 40. the patient’s AD did not improve the accuracy tors found that discussions about ADs im. re. end-of-life treatment choices and intent of written instructions. 2000. Perkins. and families were two to sion making is illusory. They cited substantial support for would not have wanted under the circum- their observations that no studies to date have stances. gally invalid (Ho. Gramelspachar. Tonelli). These were inappropriately constrained and over.

and vanced nursing practice research. 1996). specialized clinical area of the larger discipline Health policy–based nursing research that ex- of nursing (Hamric. roles. expert after providers of primary and specialty care for clinical practice. with emphasis important research agenda for the decade. suggests that . 1999). and ethical deci. based research networks that allow for data gen- nosis. of managed care and interdisciplinary. change agency. diag. according to geriatrician Robert But- of APNs (nurse practitioners. Spross. is an undisputed expert nurses who have expanded the bound. and certified registered nurse anesthetists. Advanced practice nurses Ageism is defined as a negative attitude or work within the designated scope of practice and bias toward older people that can lead to a collaborate with or refer to other professional belief that older people cannot or should not colleagues those patients and problems that fall participate in certain activities or be given beyond the expertise of APNs. Research into the education and tice nursing role. Nursing research focused in the realm aries and scope of the practice of nursing. consultation. sought- ated by the ability to carry out direct. using APNs to improve access to health care. Conceptu. certified nurse ler in his book Why Survive. One of the hallmarks of advanced practice Ageism nursing is the commitment to collaboration with other disciplines. plores workforce demographics. These competencies include evaluation of APNs is critical to health policy skills in expert clinical practice. certified registered nurse anesthetists. Ad- on health promotion. collabo- Advanced practice nurses (APNs) need basic rative approaches to care is a highly sought after core competencies to fulfill the advanced prac. standing of these documents. the use of expert nurses as competent. Advanced practice nurse researchers who en- collaboration. gage in clinical practice are the key to most of sion making. currently the role of the APN is limited to nurse practitioners. forecasting and workforce planning. as a part of education of patients and families. Advanced nursing as a whole. reimburse- The history and evolution of advanced practice ment. research. data need. Although advanced practice the American people. CHARLENE M. Clinically mous decision making in the assessment. disease prevention. cost. & Hanson. teaching and coaching. the research topics outlined above. Ageism 13 direct and participate in furthering under. HANSON clinical nurse specialists. the same opportunities as younger persons Advanced practice nursing and the practice (Holohan-Bell & Brummel-Smith. Advanced practice nursing is described as the which evidenced the safety and satisfaction of application of an expanded range of practical. who provide direct clinical care for patients. and clinical nurse specialists) serve as a rich and comprehensive base for nursing research. as well as the creden- nursing is a tapestry of patient care provided by tialing and regulation of APNs. The overused Of- fice of Technology Assessment study of 1986. the practice is nursing-based. and evaluation of the four groups Ageism. APNs offer high levels of autono. nursing is an evolving field. and privileging. JUDITH KENNEDY SCHWARZ Patient-centered outcomes research that ex- plores outcomes of patients served by APNs is central to the health care system that is un- Advanced Practice Nurses folding in the United States. leadership. and management of patients. midwives. theoretical. certified nurse mid- wives. offers researchers the ability practice nurses must have a graduate degree in to explore new and expanding areas that support nursing in a chosen specialty and are differenti. commodity. eration on patient outcomes are the single most ally. and research-based therapeutics to can no longer be cited as the only research phenomena experienced by patients within a support for the education and practice of APNs. issues.

health promotion and preventive screening. art. and has high- prevention of ageism. 1998. speak. Research by Beck and others has all health care personnel will find themselves helped explain aggressive behaviors in per- at one time or another caring for the elderly. Older persons may be lighted the need for greater resources to care discriminated against because of the way they for older adults with mental illness (Rice. Mezey & Fulmer. 1997. & Shekelle. look. Fick & Foreman. clinical care. et al. The diagnosis of de- By 2030. and beauty. however. or function in a society that val. 1998. Several search. Volicer. affect attitudes (Wilhite & Johnson. Researchers must de- screening or primary prevention programs. This has promoted met. the lack of trained profession. 1988. ues productivity. As these challenges are heimer’s disease patient. 1997. 2003. dementia. Bo. 1998). Ageism will influence both the type care. and bio. Alliance for berg. 1997. quality of life. 1999. resource utilization in the older adult. nursing home care and of student attitudes toward aging and care of organizational studies. Sher- youth. and informed consent research. Evans. . & Cam- gardus. Stew- dromes (Haight. Other How to define aging and the aging process research on dementia has advanced the un- is a controversial topic. dementia care. 1976. 1994. 1975). Frengley & Mion. it is projected that over 20% of mentia often stigmatizes both the patient and the population will be 65 and older. Allen-Taylor. Minnick. Almost the family. and the under. This research is seen on a personal level when a nurse or other important as it forces the reexamination of health care worker has low expectations of stereotypes held about older persons with de- an older person’s ability to perform a task. a lack of qualified personnel to Strumpf. and the need for more and the care of the disabled older adult. and mental retardation. mentia. Beck et al..14 ENCYCLOPEDIA OF NURSING RESEARCH there is a deep and profound prejudice against are persons with mental illness. & Sands. older people (Butler. decision making student and practicing nurse’s attitudes. 2002). of ethics. 2000. Ageism may also be Agostini. Researchers have agreed that past experi- The older population that is at the greatest ences with the elderly and faculty role models risk of prejudice and stereotyping.. symptom re- normal aging and disease processes. and influences both care and treat- Ageism may lead staff to perceive that an ment of older persons. Fick. Ageism may exist on a population level of research that is done and the public dissem- when older adults are excluded from disease ination of research. workplace studies. of older adults in clinical trials. early nursing studies highlighted the problem barriers to treatment. rell. Buckwalter. mental health. health care. sons with dementia by illustrating the need In fact. speed. als in gerontology. & Dias. Aging Research. Leipzig. & Palmer. Brod. Beck. Yneh. the underrepresentation Buckwalter. economic wealth. 1997. age alone. recognition of geriatric problems and syn. genetics. Maas. the majority of nurses will spend most for individualized care and behavioral sys- of their career caring for older adults in a tems theory to understand aggression in Alz- variety of settings. Mion. Hurley. socio-political issues. Anderson. 1997. research in gerontology. & Buckwalter. & Reed. logical issues such as the differentiation of cancer. 2003). Christ. biomarkers of aging. it is necessary to continually examine autonomy and personal control in the care the development of attitudes and roles in the of persons with dementia. 1999. Prejudice and stereo. & Stevenson. older adult does not “know what is going Ageism will continue to be important in on” and individuals may be excluded from almost every area of geriatric nursing re- decision making during hospitalization and search. derstanding of persons with dementia and has typing may lead to policies for rationing exposed myths often held about this popula- health care: withholding treatment based on tion (Strumpf & Evans. presentations of disease. & Inouye. 1998. scribe the relationship of ageism with qualita- Nursing research in ageism has centered tive and quantitative research in the areas on several main areas including education. Lamb. Sherrel & care for older adults.

cardiac arrhythmias. Alcohol Dependence 15 Chaisson. 1994) diagnostic term for alcoholism is Although many survey instruments and alcohol dependence. 1996). number of drinks consumed in a week or a month. of binge episodes during the past month/year. Alcohol is a solvent that permeates all 1984. but has chological. search challenges. Generally in the tional linkages. hypertension. wine. and environmental acceptable sensitivity and specificity primar- causal influences that have not been ade. including the blood-brain barrier. but does and physical damage to health. is valid and reliable for men and women. and occupational sta. and continued abuse leads to negative psy- home care. emotional. Fulmer & Abraham. cardio- tice nurses and basic gerontology content in myopathy. volving craving for. and other drinks may contain differing inent in other relevant arenas (intergenera. of research. erate drinking decreases fatty plaques in ing and attractive specialty for practicing blood vessels and thus decreases the risk for nurses. The excessive intake of alcohol dependence. and the number The DSM-IV (American Psychiatric Associa. & Mead. reveals intake within recent hours. of 80 proof distilled spirits. is much less valid for older men and for . liver damage. memory decrements. lifestyle. 5 oz. approxi- Perhaps the most lasting and powerful way mately 12 grams of pure alcohol per drink. It is a primary disease with genetic. Fox & Wold.” Alcohol effects of alcohol intake. Several govern. and through active dia. 1998. standard drink. increased risk for all types of accidents. and nursing home nurses. interpersonal/ not inform about recurring or chronic intake. nurses must be prom. plex.S. it quately differentiated to date. Alcohol is a depressant drug care of the elderly.) of challenge stereotypes of aging and promote beer or wine cooler. no single approach dependence is a chronic relapsing disease in. bringing national attention to nursing heart attacks.. hemorrhagic stroke. and Nursing has had a vital role in combating risk for suicide.5 oz. it is crucial to determine the logue with older persons. of wine. a standard drink is 12 ounces (oz. loss of control over. 1980. body cells. 1999). Ludenia. It is this moting positive attitudes toward older adults latter quality that leads to findings that mod- by showcasing geriatric nursing as a challeng. Penner. baccalaureate nursing programs (Abraham et distortions and errors in conceptual thought al. the number of drinks consumed in one drinking episode (binge drinking is defined as five or more Alcohol Dependence drinks for a man and four or more for a woman during one episode). appropriate views and care of older adults. tion. percentages of pure alcohol. ageism and continues to be in a key position Measuring alcohol intake presents re- to minimize ageist attitudes in the future. 1999. and tolerance for alcohol. Titler & processes. or for differentiating ical dependence on. depression. that is. ment and privately funded programs are pro. phys. to combat ageism is through the mentoring Collecting data about alcohol intake is com- of other practicing nurses. or 1. The amount of alcohol in Nurses must be involved in future studies to a standard drink differs across countries and investigate these important and relevant areas is made more complex by the fact that beer. Although many people biomarkers exist to measure the amounts and still use the older term “alcoholism. alcohol abuse. nurses in training. and higher than normal among binge drinking. psy. and has lipid-dissolving qualities. about longer term heavy drinking. across age groups. In addition. ily for young adult and middle-aged men. Blood alcohol level only alcohol over time leads to social. familial relationships. global attitudes on aging) that U. Mentes. Carbohydrate deficient transferrin informs tus. reaching out to hospital. and chological and physical detriments including illustrating the need for more advanced prac. in addition to the basic measure of a and young adults. the duration of the current and any DONNA FICK prior patterns of alcohol intake.

especially men. and (Connor & Streissguth. More controversial is the hy. & Tan. There are also physical stig. that the drinker experience the full conse- ate drinking of two standard drinks per day quences of the drinking without being res- for young and middle adult men and one cued so that continued denial of the effects standard drink per day for non-pregnant of the drinking becomes impossible. based interventions should be developed and stract thinking.S. and self-help groups—primarily longing the half-life of pure alcohol in body Alcoholics Anonymous and the 12 Step Pro- systems. port groups. problems among ethnic minorities. Fre- of studies are contaminated by the presence quent heavy drinking is much less prevalent of subjects with alcohol-related sequelae (i.S. cial features and other anatomical alterations women. intelligence. it is essential to separate out 1984 to 12% in 1995). The reasons have not been clearly U. have higher rates of heavy but are at higher risk for negative effects of drinking than those who immigrated to the alcohol. binge drinking. The research opportunities in this field are Fetal alcohol syndrome (FAS) and alcohol. and Hispanics who were heavy drinking. tano. ication regimens (especially for detoxifica- hol dehydrogenase. Theory- nation. behavioral. have the depending on where they were born.16 ENCYCLOPEDIA OF NURSING RESEARCH women of all ages. Whatever the cause. include impaired at.e. in their drinking histories and at much lower Family solidarity is required to stop all cover- quantities compared to men. thus increasing the time tion). who have alcohol problems are much less tent and less muscle mass are generally ac. college binge drinking mothers. The negative effects are merit considerably more research attention. 1998). gram.S. but simply three main ethnic groups in the U. sult from alcohol ingestion by the mother The reasons for the excess risk among women during pregnancy. among elders. individual and family counseling. white men. 1996). and other to get the drinker back into treatment and system dysfunctions and psychological dis. and cultural studies are in brain growth spurts and continue during the order to address the many unanswered ques- postnatal period for breast-fed infants of tions about adolescent drinking. At the fundamental science level re- related birth defects (ARBD) are manifesta. and ab. sup- necessary for first pass metabolism and pro. myriad. elderly persons. Most other biomarkers Alcohol consumption differs among the are not specific to alcohol effects. cepted facts. Consequences of FAS. women of all ages and elderly men. memory. and Pacific Islanders. Blacks and Hispanics explicated. Unfortunately. and drinking. In the area of measurement. women experi. referral. motor coordi. Asians. decreased among White men (from 20% in parison groups. Relapses are common. and differential risk for alcohol tention. complex problem solving. Clark. tested to enhance the case finding. especially marked during periods of fetal Social. but has remained “sick quitters” from lifelong abstainers or stable among Black and Hispanic men (15% very low quantity users. Within- sick quitters) in the abstainer group. In general fre- matological contents. after-care following each relapse and eventu- tress (depression and suicide attempts) earlier ally sobriety can be attained and maintained. These findings ups on behalf of the drinker. the . quent heavy drinking and binge drinking has surement issue related to abstinence in com. (Cae- report abnormalities in liver enzymes or he. highest rate of drinking. born in the U. Alcohol dependence is treatable with med- pothesis that women produce much less alco. search is needed on the root causes of alcohol tions of neuro-developmental insults that re. minorities. dependence including the role of genetics. likely to seek treatment compared to Whites. liver. but lower body water to lipid con. late onset alcohol dependence the milder form ARBD. among all groups of women (2–5%). Otherwise the results and 18% respectively in both years). but the key is ence higher levels of cardiac. and successful treatment for adolescents. group differences exist for ethnic minorities Young adults. There is also a mea. It is important led to the NIAAA (1995) guideline for moder. mata that attend FAS including abnormal fa. Women at all ages drink less.

& Schultz. Dr. Bienias. symptoms worsen. Alzheimer’s Disease 17 current paper and pencil survey instruments AD. including mental status testing. finding. such the disease progresses. with AD sufferers often and aphasia (impaired communication). cult to determine.8 cific for women and for older adults. & Ev- ans. These million) of people over 85 years of age were are but a few of the many areas available for estimated to be afflicted with the disease. drome) that results in impaired cognition. AD causes se- tive links between these factors and the ill. New biomarkers doubling every 5 years in people over 65 must be developed that are sensitive and spe. and families are ness. memory changes. vere cognitive impairments. such as wandering. physical and verbal ag- formed an autopsy and discovered clumps— gression. such as brain tu. 2003). and a published case report on a 52-year-old pa.. This care is other causes of dementia. agnosia (impaired sensory perception). nonsteroidal anti-inflammatory ingly burdened in trying to provide care. whether to resuscitate or the associated difficulties in diagnosing early. Pharmacologic treatments in- 60 years of age) exists the disease is more clude medications to improve cognition. tangles—in the patient’s brain (Dharmara. or treat behavioral symptoms . primarily uncompensated and includes emo- mors. Tennstedt. treat prevalent as people age. the initial apraxia (impairments in carrying out tasks). despite decades hour care. ance of advance directives. or infection. Bennett. often forced to make decisions for the AD Due to the lack of a diagnostic marker and sufferer (e. Although a rare familial Treatments for AD are multiple and vary form of AD (afflicting people between 30 and by illness stage. physical. functionally disabled. The average length of Alzheimer’s disease (AD) is a progressively the disease is 8 years. tional. In the severe stage. 1999). severe. As the disease progresses. and impaired word loss. 1998). Death usually results from an in- of research. and apolipoprotein (apoE) al. Yee. 2000). affects only 1% of those between 60 and are biased toward white men and toward the 64 years of age. the next 50 years is expected to show a three- JOANNE SABOL STEVENSON fold increase in the number of people with AD (Hebert. 1995). developing increased behavioral problems After the patient’s death. suffering adverse personal physical and psy- leles. often medication. symptom progression is typically di- heimer (1906) first described the disorder in vided into three stages: mild.S. or cure for the disease. there remains no known etiology fectious process such as pneumonia. families are increas- as estrogen. whether to institutionalize). course. In 2000. and resistance to personal care senile plaques—and knots—neurofibrillary (grooming and hygiene). metabolic disorders. researchers continue to discover defini. a result of the rapidly aging U. and an estimated 75% of older adults examination. population. Scherr. (Beers & Berkow. The diagnosis relies Care is provided primarily by family mem- on a thorough clinical history and physical bers. Alois Alz. memory loss. AD. Alzheimer’s Disease Alzheimer’s disease has a protracted downward trajectory. Dr. As future inquiry. 40% (1. the AD sufferer is profoundly cognitively and jan & Ugalino. behavior. Alzheimer per. Mild symptoms consist of personality tient who suffered from psychosis. As a result of its progressively degenerative mood. 2003). and function. Dementia. 20 years (National Institute of Aging. Hoffman.g. moderate. without the guid- stage AD. typically requiring 24- One hundred years later. have been speculatively associated with chosocial consequences (Ory. notably depression. with the number of cases young and middle aged. As Many genetic and nongenetic factors. precise prevalence rates are diffi. but it can span up to degenerative neurological disorder (syn. with dementia are cared for at home (Dun- both to establish a diagnosis and to rule out kin & Anderson-Hanley. and financial assistance.

2000). verbal aggressiveness. Capo. paired cognition (e. & Hass. thinking past events ated with increased confusion. dering. such as physical aggression or agi. The rapidly aging U. remi- AD sufferers may turn on stoves and then niscence therapy. in particular the Alzheimer’s and minimizing additional disability.S. tention also needs to be taken to provide im- pines are generally not useful for the control plements such as hearing aides or glasses.. including music therapy. & Graham. tion and are not associated with a decrease in sion is a common comorbid condition with falls (Strumpf. requiring early recognition and treat- be encouraged. Individual and family therapy should AD. thus. to pharmacologic therapy. Wagner. short evaluation periods. activity remain highly successful strategies to tors are indicated in the mild to moderate deal with problems related to the AD suffer- stages of AD to slow the progressive cognitive er’s short. to of behavioral symptoms and have been asso. However. confused older adult’s expressions of im- tions. Validation therapy symptoms. In communi- careful risk-benefit analysis and ongoing cating with confused older adults. 2002) is the preferred behavioral symptoms. Be. and therapy animals. strategies to prevent wan- forget to turn them off. to assist families in planning ment—both pharmacologic and non-phar- and preparing for the sufferer’s future needs. hospice is another source of personal grooming) do not respond favorably family support. treatment. or resistance to stage of AD. and do not have the unfa- respective needs of each person. are also an excellent source Certain behavioral symptoms (e.18 ENCYCLOPEDIA OF NURSING RESEARCH (e. may require antipsychotic medica. society and subse- Many assisted living and skilled nursing facil. For instance. cal. In institutional settings. behavioral strategies have been researched memory loss or lack of insight/judgment). quent increase in the number of people with .. They may inadver. are needed to ensure the person’s safety.g.. Some families have reported that ity orientation is often unsuccessful. Each AD sufferer needs limitations of the studies (small sample sizes. and therefore require a with acceptance and empathy.g. physical aggression or agitation). support groups.and long-term memory loss. strategies require careful tailoring to meet the typically successful. better havioral strategies. Robinson.g. vorable side-effect profiles of many of the Researchers have discovered decreased medications used to treat behavioral symp- levels of acetylcholine in the brains of AD toms.g. macologic—aimed at maximizing function Support groups. attempting to uncover a cause. unique confluence of symptoms. of. ables) affect the scientific rigor of these find- similar types of environmental modifications ings (Beavis. and reported to be clinically successful in ten results in unsafe behaviors. these drugs often are associ. so vali- these drugs resulted in some amelioration of dation therapy (Feil. or a cure for the illness. to be evaluated for possible sources of injury. wan- of information and assistance. sampling bias. Many combined with other cognitive deficits (e. 1998). & Evans. Depres. 2002). Benzodiaze. In the latter dering. treating AD. AD sufferer’s agnosia. and and strategies must be initiated to safeguard lack of consideration of confounding vari- living environments. the methodological increasingly unsafe. treatment Behavioral strategies are extremely varied. ciated with increased falls in older adults Physical restraints typically increase agita- (Frenchman. techniques include carefully attending to a tation. compensate for sensory losses. These symptoms AD research is overwhelmingly biomedi- require environmental modifications and be. acetylcholinesterase inhibi. Simpson. Diversion and redirection to a preferred sufferers. resulting in are occurring in the present) and responding decreased function. Real- decline. ities have dedicated units designed to address cause each person with AD experiences a the specific needs of this population.. careful at- evaluation of their effectiveness. Driving becomes behavioral strategies. Certain behavioral form of communication. Although posi- tently drink toxic substances or step into a tive results have been reported in utilizing bathtub of scalding water.

diagnosis (Tresch & Alla). In men aged 70 and older tion. and educational interven- equivalents (jaw pain. to delay in seeking treatment and in Families interface with the health care deliv. 1999. Individuals may often present with dyspnea. caregiver reactions to symp- nosis. underdiagnosis of CHD. an important role in studying dissemination farction (MI) are common the prevalence in. Since prompt recognition tlemark et al. & King. Pearson et . gastrointestinal (GI) symptoms. for example. a major manifestation of process causing an increase in demand or a myocardial ischemia. The presence of chest pain with MI of Cardiology (ACC)/American Heart Asso- may occur in fewer than 20% of the elderly ciation (AHA) to the elderly and their health presenting with MI. Angina 19 AD afford unique nursing opportunities and absence of symptoms may not only lead to challenges. of medical management. and MI may not even be suspected. or back pain. health care provider recognition. (Gibbons. & Spence.7% of decrease in flow. factors that delay decision to oxygen supply and demand. left seek treatment (perception of symptoms and ventricular hypertrophy and aortic valve ste. 1991. Dracup. dyspnea. there. Nursing has with atypical presentation of myocardial in. syncope. toms.7%. fre. Funk. imple- fore. vention established by the American College 2001). prevention has been shown to be lacking and Atypical angina manifested by nontypical health care provider noncompliance with es- chest. pul. Although issues central to atypical presentation (Reilly. 1999). Moser. However. Myocardial ischemia. Fagot. is found in 13. the presence of angina tive marker of myocardial ischemia. Atypical symptoms or care providers (Smith et al... faintness. women and 21% of men aged 65–69 (Mit. 2001. is neither a reliable nor sensi. however. Griffiths. giddiness. monary edema. must be directed at these different mentation of primary and secondary CHD CHD presentations. An. such as intercurrent illness. and cardiac arrhythmias Eldridge. Dracup & derlying coronary heart disease (CHD). of MI. MI may also be the result of another primary Angina pectoris. Bachulis. & cardial ischemia can result from a variety of Chyun. angina usually indicates the presence of un. 2001) such as: identification of angi- conditions that lead to an imbalance between nal equivalents. This may contrib- ery system at various points in time along the ute to a higher morbidity and mortality trajectory. The individual who has suffered an unrecognized MI days to weeks earlier may in fact present to the hospital in Angina heart failure (HF) or with recurrent angina. transient left ventricular dysfunction). It is then that nurses. & Allen. Nursing research. shoulder. a sole marker of CHD. as- quently occurs in the absence of angina or its sessment strategies. but in the setting munity and are cared for by their families. 2001). Dattolo. expectations). myo. dyspnea. tions aimed at reducing delay in seeking treat- fatigue. stroke. or HF.3%. it is vital that nursing research address the prevalence of angina is 27. 1993). tablished guidelines is high (Feder. or nonspecific symptoms related to ment. Naum. numbness. along Campagna. (Tresch & Alla). GI bleed. and adoption of guidelines for secondary pre- creasing with increasing age (Tresch & Alla. Rolka. can pro. to manage in the face of this devastating ill. Despite the limitation of using angina as gina. Milner. ness. In women aged 70–84 and treatment of MI is crucial to limiting the prevalence is 19% and in those 85 and infarct size and preserving myocardial func- older it is 24. or restlessness. in collabora. confusion. Differentiation of atypical tion with people in other disciplines. weak- MARY SHELKEY ness. 1994. symptoms from other chronic conditions is vide needed assistance to families struggling difficult. Most AD sufferers live in the com. therefore. & Narayan. Many supports the diagnosis of CHD and is useful elderly have atypical findings or have totally in assessing disease progression and efficacy asymptomatic CHD.

(DM). and unrecognized MI is common ical activity. While assessment and management of typ. van Eld. Silent isch- The importance and feasibility of optimiz. and medical management in individuals with ings. the in the elderly population. 2001) or know how to als with CHD (Stuart-Shor. & Hecht. in.. Silent episodes outnumber symp- contributing to inadequate CHD risk factor tomatic episodes in patients with chronic sta- control is urgently needed. Psychosocial and educational factors known CAD who also have asymptomatic have been linked to how individuals perceive myocardial ischemia may improve outcomes. lack of symptoms (Wackers et al. of life which may be affected by control of The asymptomatic nature of CHD. and secondary prevention as the large areas duction behaviors. Buselli. emia. ble angina. lifestyle.. so the true prevalence in the elderly contribute to CHD management and quality population is not known. 1999). and cultural influences which may plished. along with strate. Anxiety and depression. 2002) and psychological factors (Chyun.20 ENCYCLOPEDIA OF NURSING RESEARCH al. extent of CHD. however. (Rockwell & Riegel. Wide- motivation.. 2002. 2002. Sullivan.. is associated with an adverse often confronted with comorbidites and a prognosis. 2000. personal (self-efficacy. Williams et al.000 to 100. nursing research fo. 2001). angina. Although it has been roll. 2004). In addi. occur in the absence of known CHD and is tion. Gibbons. Spertus. their own health status and manage chronic little is known about the behavioral illness. unsta- cluded from intervention trials. et al. Asymptomatic ischemia may also lack of social and financial resources. the individual may not be motivated tance of depression and social support has to engage in control of CHD risk factors been well documented especially in individu. and smoking. myocardial ischemia and infarction can Chatterjee. with careful atten. obe. 22% have CHD in the absence of tion). symptoms. CHD. but have a role in the de. In addition. have been angina. Addi- . denial. have not been widely studied in the ularly in individuals with diabetes mellitus elderly population. kus. these require further study. however. and control of lipids. Not comes (Hegleson & Heidi. commonly found in these individuals. educational. unstable angina. few inter. asymptomatic ischemia tend to have a higher sociated with these interventions (Abete et incidence of asymptomatic MI. (Tresch & Alla. Individuals with sity.. Psychosocial cently. degree of left ventricular dysfunction. who are often ex. Melkus. following MI and in 3 million persons with cluding from a nursing perspective. 2001). Car. only are these individuals at risk for adverse LaCroix. Chyun & Mel- the influence of other comorbid conditions.000 persons ing self-management of CHD risk factors. the importance of detecting ischemia early in cused on provider and patient-related factors its course. atic CHD. 2003). et al. underscoring al. 1999. tomatic patients following MI. lems. presents a unique challenge in primary may not only adversely affect CHD-risk-re. along with side effects as. it has been shown that in older adults (social support and interactions and relation. beliefs and spread screening of the elderly for asymptom- past experience with management). but without cues such as eren. Additional studies are needed during daily activities. along with symptomatic ischemia demonstrated. has not been accom- mental. with type 2 diabetes (T2DM) without known ships between persons managing the condi. shown that intensive lifestyle interventions ventional studies have extended these find. partic- CHD. Maes.) that may contribute to control ical and atypical angina are important prob. & Dusseldore. environ. present in 50. of CHD risk factors in this population. also exist in the total absence of signs and tion to use of aspirin. HTN. CHD outcomes. and in asymp- gies to improve compliance with guidelines. consideration of psychosocial factors frequently found in individuals with lower specific to the elderly that influence CHD extremity arterial disease and diabetes. 1999). & Forman. and who are ble angina. 2002. of potentially jeopardized myocardium are velopment of CHD and adverse CHD out. modify their activities. encouragement of phys. The impor. along with (Chyun & Minicucci. Re- management is also warranted.

. Most contemporary (QOL) has been shown to predict long-term monitoring systems provide the capability to outcomes. fundamental principles and processes that are Although ST-segment monitoring has core to the nursing discipline and its central been shown to be a reliable measure of myo. cational interventions and document their ef- 1983). coff. 2003). Stuart-Shor principles and processes governing physical et al. asymptomatic myocardial ischemia. disease progression. and assisting the person to rec. et al. ongoing debate. DEBORAH A. the presence of asymptom. yet standardized autonomic testing is infre. one end. as well as play an active role in as- atic myocardial ischemia has been strongly sisting the individual in the recognition and linked to the presence of cardiac autonomic management of asymptomatic disease. neuropathy (Chyun. commitment by nursing staff (Drew & Kru- cardial ischemia (Chyun. types of research. On the lower on levels of nervousness. such as daily activities and tal/theoretical research to generate research mental stress. it is assumed that nursing apy or coronary angioplasty. and theoretical research are used to refer to ity scale—have been associated with silent research focused on discovering fundamental ischemia (Droste & Roskamm. not only to identify find such terms as applied. the scientific community Although research is limited in the area.. psychosocial factors. dominance.. of asymptomatic myocardial ischemia. CHYUN quently used in clinical practice. Nursing. clinical. asymptomatic myocardial isch- emia. quality of life the acute care setting. Khuwat. Recently. cultural. Further research utilizing per. however. as management of T2DM and CHD risk factors. is likely to receive increasing attention. ment. well as to correlate the presence of asymp- as well as interventions that will successfully tomatic episodes with precipitating factors. therefore. which. Young. fundamental. without extra to therapy. aimed at answering focused and problem- ognize other vague symptoms associated with specific questions. tend tain personality traits—those who score to fall into a discrete classification. and life phenomena. however. On the other end. reduce their burden of risk. it is assumed that there are ment of the condition. As current stud- tifying individuals with asymptomatic isch. and adverse outcomes. envi- ronmental. ies progress. uses a myriad of terms. 1999). patient. Identifying plication of the findings of basic/fundamen- ischemia triggers. 2003). it has not been draws on fundamental principles and pro- widely used in monitoring the elderly for cesses discovered in other disciplines to gener- . terms such as basic. Though it is the subject of ischemia may allow more aggressive manage. has several samrit et al. unique opportunities to participate in as- mined regarding the individual and health sessing elderly individuals with or at high risk care system factors that contribute to self. in individuals with known CHD un. and environ- cardial ischemia following thrombolytic ther. and higher on the masculin. and pathologic factors In an attempt to differentiate between various influencing the individual’s response to pain. Applied Research cardial ischemia and the psychosocial. practical. cer. and response monitor ST-segment changes. is warranted. tions. Nursing also JESSICA SHANK COVIELLO should share the responsibility for expanding the knowledge base of timing and circadian variation of episodes of asymptomatic myo. tenets of health. we sonality characteristics. ficacy. in pain perception may account for lack of Nursing must be prepared to implement edu- anginal awareness (Droste & Roskamm. Much needs to be deter. little is known regarding costs to the individual and with minimal time QOL in individuals with asymptomatic myo. 2003). These refer to the ap- patient education. Early studies suggested that a defect emia. nurse. In addition. and excitability. asymptomatic individuals but as a basis for and product research. Applied Research 21 tionally. even in dergoing revascularization. response to medica- Nursing also has an important role in iden.

(b) the computerization of ac- and questions about nursing care. case-based learning models. the University of about the cost-effectiveness of the interven. been variously defined as: the design and op- search may be categorized as applied research eration of computer systems capable of im- as well if it meets the general criterion of proved performance based on (a) experience being focused on concrete and practical issues (i. understanding the dynamics of clini. and families (Abraham. learning. et al. Artificial Intelligence gations to rigorous clinical trials. Georgia. The etymology of sary process of altering routine nursing prac- applied goes back to the Latin ad-plicare. tice to evidence-based nursing (De Geest et meaning to put something (a law. into practical operation. soning—have produced distinct lines of re- Borgermans. Clinical and cost comparisons of pre. Other major centers of ing the costs of care is a major issue in health AI development are located at Massachusetts care. enable successful communication in a human 1995). and (c) the development of computer plant patients and their relationship to the systems that exhibit what people describe as occurrence of adverse posttransplant events intelligence. Artificial intelligence has Yet nonintervention (or descriptive) re. etc. 1996). caregivers.. All three defined areas— in developing interventions to enhance adher. it must be pro- can be a source of considerable cost savings grammed with natural language processing to (De Geest. a test. tivities that people believe involve thinking stance. Abraham. Typical areas of AI research include cogni- ous cohorts of community-dwelling elderly tive models of human learning. and health care workers need evidence Institute of Technology. profiles for institutionalization among vari. implementation of commercial AI products). of these fields. a modified isolation protocol incorporating Four capabilities have been identified for a only those elements with supported effective. applied research provides additional data to support the neces- in nursing can be defined. Kesteloot. ter for Applied Research in Artificial Intelli- Currie. For in. ing). operative skin preparation procedures in cor- tient care.. or the ability to reason and learn helps nurses and other health professionals from experience. integration of a variety of rea- applied research in nursing also refers to cost soning to support complex decision making. Neese. it must have a strategy for . Second.e. IVO L. and rea- ence to prescribed drug regimens (De Geest. Yi. Dartmouth College. preventive strategies and models of care for and neural network research. and neural networks. computer to be able to produce an artificially ness in the care of heart transplant recipients intelligent product. and SRI International (produces tions used.. calculations of nursing interventions. refers to research aimed at con. onary artery bypass graft (CABG) patients Under these assumptions. The Navy Cen- patients. First. machine furthers the knowledge base for designing learning models. The most evident type of applied research is inter- vention research—from exploratory investi.) al. Steeman. (such as problem solving and decision mak- cal and subclinical noncompliance in trans. 1995). Manag. This type of applied research is aimed at providing an. Degryse. The term artificial intelligence (AI) was first swers to questions about the effectiveness and used in 1956 at a computer conference at efficacy of nursing interventions.22 ENCYCLOPEDIA OF NURSING RESEARCH ate new knowledge about nursing and pa. language. then. especially those of machine 1997). Applied research in nursing. ABRAHAM crete and practical issues and questions of SABINA DE GEEST concern to the delivery of nursing care. machine learning. learning). mous activity. gence conducts advanced research in several 1994. sensor-based control of autono- In addition to effectiveness and efficacy. Thompson-Heisterman. For instance. & Vanhaecke. Developing risk search. decision making. & Godderis.

pattern recognition and elabo. MEDICUS or GRASP systems. All expert sys- research areas in AI that hold the most prom. Thus. Primarily. intelligence. found. & Budjhardjo (1991) examined the use grammed problem-solving strategy. However. The and to change its decision-making strategies capacity to learn is what differentiates AI when performance success drops below pre. problem solving. Other types of expert systems accept data man thinking. such as the When machines are programmed to recog. Much work also has been done on nurse ration is defined as the nature of learning. tems reason. Machine learning requires and change their processing strategies in re- the machine to evaluate its own performance sponse to “experience” are said to learn. Sum. The the parameters of the problem and the defi- terms expert systems and decision-support ciencies of the old problem-solving pattern to systems are used interchangeably. The and learning from experience. In nursing the majority of publications protein-solving patterns is one definition of that list AI as a search keyword address com- learning. The AI literature discusses two solving strategies. staffing and scheduling systems. capacities of human intelligence: reasoning chine learning strategies programmed. from expert decision-support systems that do determined acceptability levels. Poison control centers use icant new knowledge and applications in the such systems to determine the lethality and defense industry. This area of research has produced signif. the term AI recognition is a major source of human un. more problem-solving algorithms. The confusion stems from differ- programming that provides it with one or ences among users in the meaning of the term more information-processing and problem. Some AI researchers add the require- cess that may not be known to all readers. it must have systems. Of greater interest to nurs. should be restricted to systems that both rea- derstanding. Fourth. and making changes in mental son and learn from experience. management. The new patterns these are systems that help support decisions are tested until a more successful pattern is about nursing assessment or care planning. Artificial Intelligence 23 knowledge representation so that it can store The term AI has been used to deter to both its own knowledge base as well as the infor. Grzymala-Busse. expert systems and true artificially intelligent mation input by the user. Decision-support systems may they are considered to exhibit machine learn. reasoning ability. not achieve the level of true intelligence. These are nize ineffectiveness of existing patterns and management decision support systems that to construct and test changes in those patterns could also be considered expert systems for until a new pattern proves more successful. When quirement needs further definition because humans perform this process. human reasoning and ways to improve hu. ers guide the user in the selection of one or pert systems in nursing. reason. it must have ma. and decision input from the user and provide a recom- making. It is this area of research focuses on pattern recog. typical to find the terms AI and expert system nition and pattern reconstruction. that is. expert systems. antidotes (if any) to a variety of substances ing. Learning has been defined as adap- puterized nursing expert systems. Computer systems that are sophisticated learning and reasoning in Defense Depart. ment for machine learning to the definition of Much work has been done on machine AI. which are tation to new circumstances by extrapolating usually clinical decision-support tools. newly constructed patterns. In general. Pattern used interchangeably. Woolery. Third. The latter . Still oth- of machine learning for development of ex. and knowledge en. mation provided by a user and produce ex- gineering and representation. they are using how a machine learns mimics a human pro. enough to analyze their own performance ment laboratories. they apply one or more ise for nursing applications are machine problem-solving strategies to specific infor- learning. mended course of action based on a prepro- mers. pert advice (or a decision) as a product. it also led to new understandings about considered to be poisonous to human beings. The fourth re. serve as an online reference without much ing.

in the sophisticated health care environment. This field seeks methods of rep. These responses are typically resenting (programming and storing) infor. mation and human thinking processes in the and behavioral (Eagly. model is that the process linking attitudes to When the requirements of a task exceed hu. studies focus on a component of knowledge Attitudes are dispositions to evaluate objects engineering. Artificial intelligence can social learning (e. 1988). 1992). Although attitudes had long easily exceed the ability of an unaided nurse been assumed to influence behavior. It was the inability simple survival conditions. cessing is exactly what modern science (and The rationale behind the expectancy-value the U.. attitudes have tools that expand their capabilities. Knowledge engi. early re- to use that information clinically. Unassisted. Cognitive re- computer. ated with an object. the power of the human hand. people must model (Fishbein & Ajzen. 1975). zen. systematic approach to the user’s own prob- lem-solving abilities. strat. the computer 1995). influence behavior through behavioral inten- ficial intelligence is one type of tool that can tions or the intention to engage in the behav- be developed to support and expand nurses’ ior.g. Affective responses experts mentally depict external reality consist of emotions such as positive or nega- (knowledge representation) and from study tive feelings associated with the object. An attitude object can be solving strategies. titude object that reflect favorable or unfa- Just as a hammer is a tool that expands vorable evaluations (Stroebe & Stroebe. not to integrate to predict behavior from attitudes that led to multiple. reflected in two models: expectancy- of work with an acceptable degree of consis. legal system) demands of nurses. behaviors is a reasoned one. classical conditioning greatly enhance the power of human cogni- and modeling) from other persons (Baron & tion. MARY L. 1994). Attitudes are thought to be acquired both directly through personal experience is a tool that can expand the power of the with an attitude object and indirectly through human mind. and approaches.S. highly complex. of thought about how attitudes affect behav- ables. The amount and complexity of infor- for nursing practice is their relationship to mation available for clinical situations can health behavior. people cannot do that kind iors. and to respond. 2001). affective. of information nor to calculate interaction Social psychology has two different schools effects and probable outcomes of many vari. According to this man performance parameters. cognitive abilities so that they can function tions but merely serve to support a logical. MCHUGH Another line of nursing scholarship in the field of AI involves knowledge engineering in nursing (Chase. technical sources new approaches to understanding attitudes. Yet that level of information pro. Attitudes neering is a subfield of AI that seeks to under- stand the ways in which nursing experts con. value and automatic attitude activation (Aj- tency. havioral responses are actions toward the at- egies. Arti. Knowledge is ultimately extracted sponses are beliefs or thoughts associated from study of the ways that highly successful with the attitude object. The human search failed to support a strong causal rela- mind evolved to function under relatively tionship between them. The knowledge base of health science Byrne. Knowledge representation anything that is discriminated by the person. has increased exponentially over the past 20 The primary reason attitudes are relevant years. The direct antecedents of these behav- .24 ENCYCLOPEDIA OF NURSING RESEARCH system may not offer action recommenda. divided into three types: cognitive. An attitude can be defined as the person’s ceptualize and define nursing problems and summary evaluation (like or dislike) associ- how they think about developing problem. Be- of experts’ problem-solving techniques.

. Attitude toward having a chronic condi- cult it will be to perform the behavior. the more readily the attitude is JOAN K. In contrast. provide frameworks on which to build nurs- The attitude-accessibility model. this model proposes that tude activation model will have implications attitudes are automatically accessed in mem. which ing interventions by providing an under- was developed by Fazio and Williams (1986). extension. The expectancy-value (taking hypertension medication) would be model of attitude has been used much more a better predictor of the behavior of taking extensively as a framework to guide health hypertension medication than would a more behavior than has the automatic attitude acti- global attitude toward maintaining a healthy vation model (Stroebe & Stroebe. tions to stop negative health behaviors (e. anything that which is the person’s perception of the extent would lead to an attitude becoming more ac- to which important others think that he or cessible would lead to behaviors that are con- she should engage in the behavior. Also relevant to with which attitudes can be brought from nursing practice are strategies for changing memory. An important component of this overeating) are not predictive of the behavior model is attitude accessibility. fluence on behavior. such as social influence and mes- the greater the strength of the association in sage-based persuasion (Wood. the attitude is derived from direct experience tional concepts. workers. the theory of planned behavior. The most popular revision is with the attitude object. AUSTIN . and Marston-Scott is that they do not account for other causes of (2001) used the theory of planned behavior behavior. it proposes is more rapid. perceived behavioral control. attitude accessibility the theory of planned behavior. tion has been found to be associated with nents of expectancy-value models point out adjustment. tion. that shape attitudes and subjective norms. 1995). Wilbur. habit. If the corre. The more accessible the attitude. attitudes toward epilepsy the specificity of the attitude and the specific. Blue. standing about the beliefs and perceptions proposed that attitudes are not carefully rea. atti. 2000). The expectancy-value model and its sonality traits. and the stronger the attitude’s in the behavior and (b) the subjective norm. attitudes. Current research focuses on these to study exercise behavior in blue-collar other causes such as past behavior. Therefore. For lifestyle. For monly intervene to assist persons in changing example. an attitude toward a specific object health behaviors. memory between the attitude object and its evaluation. Attitudes 25 ioral intentions are (a) the attitude toward activated. toms (Dunn. the person’s perception of how easy or diffi. The spondence between level of specificity of the attitude-behavior relationship is also relevant attitude and the behavior are similar. Austin. for nursing practice through improving the ory without conscious awareness and influ. in children with that the degree of correspondence between chronic epilepsy. attitudes and behavior is stronger (Eagly. 2001). understanding of circumstances when inten- ence behavior directly (Baron & Byrne. or the ease (Stroebe & Stroebe. 1995). Propo. when (1988) revised this model by including addi. 1994). soned as proposed in the expectancy-value With further development the automatic atti- model. for nursing practice because nurses com- tudes are stronger predictors of behavior.g. have been associated with depression symp- ity of the behavior is important. and self-identity (Ajzen. & Huster. per. For example. Ajzen sistent with the attitude. For example. 1999). The major criticism of these models example. and the relationship between an additional predictor of behavioral inten. which is 1992).

The discipline of nursing doctoral students in nursing pursuing a grad- is primarily applied rather than basic. 1996)? In contrast. Studies using animal arly work is best categorized as applied rather subjects are often applied rather than basic than basic research in that nursing research research in nursing. to Florence Nightingale (Woodham-Smith. search programs for nurses with doctoral de- As a discipline and a science. All clinical research in nursing is by defini- 1951). Hu. such as Nursing seeks knowledge from the perspec. social and biological. This edu- existence or elucidation of phenomena. Nurses with doctoral degrees in basic sciences Behavioral Research were prepared to contribute as basic research- ers. small numbers Basic research includes all forms of scholarly of nurses continue to pursue degrees in the inquiry for the purpose of demonstrating the basic sciences in the United States. Animal research is cate- has been conducted for the primary purpose gorized as applied research if the work is de- of solving problems related to human health.. White. as part of the U. 1978). signed to answer a clinical question. B Basic Research spite the growing number and popularity of doctoral programs in nursing. Maxwell. and nursing disciplinary knowledge Nurse researchers often engage in basic re- is integrated into the broader context of the search to generate knowledge that may lead whole of human knowledge. Another link between the basic sci- dress specific problems or real-world applica- ences and nursing has evolved as a result of tion of knowledge. rat) skeletal mus- tive of the human experience of health. & Crowley. cle adapt to non-weight-bearing conditions man perceptions and experiences of health equivalent to bed rest (Kasper.. nursing is in. Over time. K. grees in nursing are facilitated by nurses with formed by knowledge from basic and applied doctoral degrees in basic research disciplines. Basic cational path is used more often in countries where doctoral programs in nursing are not research is conducted without intent to ad- available. tion applied research. begun by examining what it is and differenti- 26 . intent of the study is to elucidate an inher- torally prepared in the basic sciences. Pub- SUE K. how does mammalian (e. the majority of the schol. and then they adapted their knowledge An examination of behavioral research is best and skills to conduct nursing research. research involving edge to solve problems through nursing care human subjects or human cells and tissue and practice.S. to new perspectives for applied research in The origins of nursing research trace back nursing. S. DONALDSON lic Health Service Nurse Scientist Training Program from 1962 until the late 1970s. research. might be basic research. & are studied with the intent to generate knowl. al- uate minor in a basic science or a postdoctoral though basic research is a part of the disci- fellowship in a basic science. These basic re- pline (Donaldson.g. both ent mechanism. particularly if the There is a cadre of nurses who were doc. De.

Intervention is then directed to the bition or desensitization in which anxiety is specific areas targeted by the initial assess- viewed similarly as a conditioned response to ment. In this case. identifies a cognitive feature as a major moti- ing. Numerous strategies have evolved tion in cardiac rehabilitation programs. Much of the re. Laws have been established that areas: (a) health-promoting behaviors such address the identification of reinforcers. deprivation or satiation with regard to rein- imen. The contracting and tailoring. and the con- istration of the chemotherapy (unconditioned sequent or reinforcing events that follow the stimulus). and adminis- field today. (unconditioned stimulus) may induce nausea The history of the behavior is of less interest and vomiting. As the operant model has expanded over ing theories that arose in the early part of the time. and strategies for the extinction of behavior. behavior. Another example is reciprocal inhi. the course of intervention and often through ation) is paired with progressively stronger a period following intervention to assess levels of the conditioned stimulus in order to maintenance or generalization. used in studies of patient adherence. immunization. diet. and mammography. motivation is seen as a state of behaviors such as adherence to treatment reg. developmentally delayed. the stimulus condi- prior to and independent of the actual admin. Self-effi- . In prostate examinations. blood glucose monitoring. which have been used in studies ing of the nature of behavior and health rela. on unit management with the mentally ill or tionships and to the modification of behav. It has been estimated management. forcers. than the factors that currently sustain the be- motherapy in a particular setting (condi. breast self-examination. Behavioral research has its roots in learn. Behav. tering self-reinforcement for success. the as exercise. Each of the cognitive-behavioral models With instrumental or operant condition. including but not limited to treatment-related appointment keeping. behavior is seen as arising from environ. An empirical model is used with an tioned stimulus). asthma. It is directed toward an understand. long-term regimens such as those for of a conditioned response. cise. cial case of contingency management. tions that precede the behavior. Studies may include the following behavior. mental stimuli or random exploratory ac- ioral research within nursing generally refers tions. self-management the individual is responsible erant conditioning and evolved into the cog. inhibit anxiety responses. participa. which has been used in the pro- that over half of premature deaths could be motion of treatment behaviors such as exer- prevented if health behaviors were altered. resulting in the development chronic. monitor- nitive-behavioral theories that dominate the ing progress toward those goals. An incompatible response (relax. self-management has evolved as a spe- 20th century. and (c) therapeutic this model. Classical or respondent condi. token lations. Self- conditioned stimulus is paired with a condi. With tioning was followed by instrumental or op. search emphasizes conditioned physiological In both of these models there is an empha- responses. beyond that of the chemotherapy. (b) screening behaviors such as initiation and maintenance of behavior. Behavioral Research 27 ating it from related areas of research. and from this work. the setting itself may induce assessment of the frequency or intensity of nausea and vomiting (conditioned response) the behavior over time. Detailed assessment continues through stimuli. and contingency iors that affect health. for establishing intermediate goals. chemotherapy reinforcing behaviors of significant others. which are then sustained by the occur- to the study of health-related behaviors of rence of positive reinforcement following the persons. and smoking schedules of administration of reinforcers for cessation. vational determinant of behavior. In classical conditioning an un. management has been studied particularly for tioned stimulus. economies. diabetes. An example is found in the study sis on behavior rather than motivation or per- of anticipatory nausea and vomiting during sonality or relationships. which have been research spans medical and psychiatric popu. havior. and cardiovascular disease. After several exposures to che.

The health belief model smoking behavior. mechanisms of addiction in toward the behavior. Al- including cognitive-behavioral studies. There tion and soon became popular in other indus- are studies in the community to modify health tries. In the classical and instru. the examination of health behavior change Behavioral research can be distinguished in the community. how. coping strategies. Benchmarking in Health Care like psychosocial studies. health Institute of Nursing Research grant (5 P30 promotion. compare.28 ENCYCLOPEDIA OF NURSING RESEARCH cacy theory postulates the role of perceived related behaviors of research participants. However. development of assessment instruments. and the role of biofeedback in such behaviors as pelvic floor muscle exercise in incontinence and heart rate variability. to intervene with behaviors that contribute mental models. and the etiological relationship emphasize adjustment and coping as well as between behavior and health and illness. The theory of reasoned action the relationship between behavior and dis- postulates that intention to engage in a behav. they may be of interest in determining practices of high-performing organizations reinforcers and stimulus conditions. and incorporate the best ever. Fur- predictor and moderator variables arising ther. influence intentions and subsequently modify those behaviors would benefit the in- behavior. the common sense model dividual as well as the population. In the cognitive-behavioral model. descriptive in nature or have focused on the vironment of the person. particularly in ness or treatment-related behaviors. childbirth and Institute grant (1 UO1HL48992). as well as the perception of the that adversely affect health and the manage- benefits and barriers to engaging in the be. provement (CQI). though few of the studies have examined how phasizes behavior. research to understand and havior. . such as studies of the role of ior is significant and is influenced by beliefs exercise on the maintenance of function in regarding behavioral outcomes and attitudes the older adult. stressed. which tends to clinical trials. maternal behaviors. sexual behaviors. Lung. Behavioral research. many of the studies in nursing have been from the psychological state or the social en. Benchmarking is a structured process used to nomic status are not primary interests. and the effect of neuro- postulates that one’s perceptions about the transmitters on eating behaviors. discover. The introduction of benchmarking in behaviors within populations and studies industry was aligned with total quality man- within multicenter clinical trials that attempt agement (TQM) and continuous quality im- to influence the health behavior or protocol. JACQUELINE DUNBAR-JACOB tions. Given the prevalence of lifestyle behaviors ceptibility). behavioral symptoms of dementia. Within nursing much of the behav- ioral research has addressed participation in This paper was supported in part by a National treatment. for the purpose of improving the benchmark- There is an additional body of behavioral ing organization’s performance. exercise. ease etiology. There is of illness proposes that the individual’s own a need for nursing research to expand into model of the illness influences his or her ill. ment of illness. this research would be useful to better direct both observable and covert behaviors are interventions with patients. observable behavior is to the development or progression of illness. breast self-examination and NR03924) and a National Heart. self-management in chronic condi. Also there is a broad set of studies to identify ous conditions. Un. It was first research that tends to be interdisciplinary in used in the late 1970s by the Xerox Corpora- nature and is of relevance to nursing. and Blood mammography utilization. the interdisciplinary arenas. factors such as per- sonality. studies within multicenter from psychosocial research. capability to engage in a behavior under vari. When used correctly. illness in terms of its threat (severity and sus. em. stressed. management of alcohol or drug depen- dency. and socioeco.

being benchmarked in the organization using ing is often used in conjunction with TQM. External benchmarking Truly effective benchmarking requires in- may be conducted with like organizations in depth. other quality assurance programs. it is process that is repeated until performance important that the organization identify key goals have been reached and maintained processes for improving performance. a number of pitfalls must be sions within the organization. It has been used to improve business to identifying practices in the comparison or- processes. ough description of the operational process marking. management processes. with recog. and adoption of new pro. tices is a necessary prerequisite to the analy- duced in an organization with a preexisting sis. marking. Analysis requires two discrete sets of data: tional quality improvement methods. & Williams-Brinkley. . ongoing process that requires tion’s performance. personal examination of the reasons a geographical region. followed by reevaluation of the se- tified during the planning phase. or tions. Benchmarking in Health Care 29 benchmarking offers the opportunity for ex. Processes to be benchmarked are iden. quires that performance and productivity nized high performers in health care. and inade- sulting group or benchmarking clearinghouse quate preparation of the organization for that does benchmarking for health care orga. Implementation of oper- planning. Identification of these “best” prac- Benchmarking is most effectively intro. Perfor. The organization may ductive if used inappropriately or improperly. quantum improvements in operational and Selection of organizations to benchmark delivery systems. As in other industries. and customer satisfaction. inadequate data analysis. ganizations that enable them to be high per- cal processes in health care organizations. This operational description is often competitive analysis in health care organiza. and (2) a thor- care organizations began to adopt bench. nizations and has access to data from similar ponential improvement rather than the incre. health care. over time. with sures. care. benchmark. it also has the potential to against is another major decision during the increase stress and cost and to be counterpro- planning phase. referred to as process mapping and is essential tions. to be used in comparing the bench- enormous pressure to increase efficiency. ational processes identified through bench- cesses. Prob- performers is costly and time consuming and lems also may arise from an inadequate study may be more efficiently handled by a con. It that can improve the benchmarking organiza- is a continuous. It also re- tions in a collaborative project. or with findings the benchmarks (performance measures) and from research literature. and clini. choose internal benchmarking to compare Because benchmarking is in its infancy in performance of similar operations or divi. is a cyclical benchmarking costs can be significant. and adoption of practices culture of process orientation and analysis. mental changes most frequent with tradi. organizations recognized as high performers. with similar organiza. performance and how it differs from the ternal benchmarking and comparisons with benchmarking organization’s performance. analysis. not looking at the process to find out how However. identification. design. As (1) the benchmarks. mance data to be used as benchmarks must Although benchmarking has the potential be identified and available for analysis and to assist health care organizations to make comparison with selected high performers. within one op. and because lected performance measures. Identification and comparison with high Leighty. for the high performer’s success. benchmarking. health the selected high performers. to reap the full benefit of bench. or with measures be consistent with the philosophy high-performance industries outside health and objectives of the organization (Smeltzer. benchmarking and the comparison organiza- CQI. or performance mea- health care became more industrialized. other organizations. avoided. 1997). the high-performing organization achieves marking the organization must move to ex. A common problem is comparing eration or division over time. formers. marking organization’s performance against quality.

1996) and patient populations mary developer of the classification system (Clare. When the classification search software logic with which searches are system is accompanied by an alphabetical list done facilitates certain types of searches and . bibliographic classifiers organize the trieval is a function of all three elements. and operating room use. Other document types ganizations. lary). ber. 1996) are reported in the literature services that provide access to multiple biblio- and often contain cost information as well as graphic databases. admissions process. (b) a database of documents indexed ever. how. Computerized bibliographic ples of business and management processes databases based on specialty-subject thesauri studied include workers’ compensation pro. Abstracts are usually included. and pages). through a search service offered by the pri- Czarnecki. Fees for such services patient outcomes. are available for many other reference disci- cess. Many of these studies are reported as case The major bibliographic classification studies that provide information about the schemes dealing with the nursing literature process being used. sociology. more evaluative article author. Citations commonly include the in health care organizations. nizations have accumulated comparative A bibliographic retrieval system is a special data from the organizations they service. scheduling systems. Other data that help to locate a specific document—for example. if incorporated in the system. Moxley. Classifying knowledge in books and other Computerized bibliographic retrieval sys- documents is in the domain of library and tems have three components: (a) the classifi- information sciences. cation system. accession number and author address—will be added Bibliographic Retrieval Systems to the database by the producer of the system. Terms from used to index the literature and thus serves the controlled vocabulary must be accurately a purpose of location and retrieval of the assigned to the documents in the field. and so forth. videos. Sargent. Access to bibliographic databases is either Daughtridge. The in- information may surface in the literature formation that is stored (and retrieved) pro- slowly. 1992).30 ENCYCLOPEDIA OF NURSING RESEARCH Benchmarking studies have only recently of terms with cross-references. the organizational are implemented in computerized biblio- changes made. plines of psychology. title. cation system for the field of knowledge (sub- ments are considered “physical objects” that ject headings. and the exact location of studies are needed to assess the effectiveness the article (the title of the journal in which of benchmarking for improving the cost and it is published. vary considerably. etc. The knowledge produced by the scientists (Land. Whereas sci.). it is called a been published in health care literature. Although consulting orga. journal volume and issue num- quality of services provided by health care or. and the outcomes achieved graphic database retrieval systems for nursing through the benchmarking process. marking with clinical processes (Bankert. & Colburn. have descriptors appropriate for that MARION JOHNSON document type. The quality of re- the field. (books. 1992). this type of information retrieval system. & Forthman. or is licensed for use by bibliographic retrieval Lauver. controlled vocabu- can be classified in a number of ways. The classification system is sent the literature in the field. and medicine. education. Studies of bench. and (c) the retrieval system entists in a field identify the knowledge of search engine (software). To determine the usefulness vides citations of documents represented in of benchmarking for achieving improvements the system. subject classification is considered the with the controlled vocabulary of the classifi- most significant characteristic. Books and other docu. controlled vocabulary must adequately repre- gridge. The indexed documents. 1995. 1996. thesaurus. Meehan. if at all. thesaurus (Landgridge. Exam.

1987). research by nurses that is tem makes available. such as nursing theoretical frame. The opera- names as keywords by researchers is of little tors. begins with. The operator and causes all the signed subject heading is a research variable documents containing one term. Sys. First. the published litera- Nursing has long been dissatisfied with ture fails to reflect adequately the knowledge bibliographic databases that index the nurs. logic used by the search system and how it The results section of research articles. R. & is a way of combining sets of things—in this Fuller. The strategy or “logic” that software uses sent the new nomenclature in a field. The identification of variable case. Because variable names are not used by bibliographic retrieval systems in always included in bibliographic classifica. cannot assign terms to adequately represent Generally. This is the invisibility of knowledge to the discipline because variable names are sometimes so far but results in a significant waste of resources out on the classification tree that they are to duplicate work that has already been done usually not suitable for subject headings. meta-analysis strategies. which for assigning index terms (Horowitz. where the variable names reside. These to search databases determines how docu- new terms are frequently renamed or incor. literature. excludes. there is no way to tell whether the documents containing the terms will be an author-identified term or a classifier-as. Second. Third. be combined and thus yield valuable new Another long-standing disappointment in knowledge. ing available. This set of docu- of interest to researchers (Weinberg. and all name or just another topic the article is documents containing another search term.” It is fair to say that “aboutness” y. that are not indexed by the database develop. In part. Cost of publishing ing literature. B.. and availability of reviewers limit the number cabulary used by major systems has not satis. ments is called the search result. makes sense because variables usually repre. x and y. Frequently. search terms in documents. S. the concepts of sensitivity and specificity of . is implemented in the database of interest.. Although other search strategies are becom- bility than is characteristic of research vari. This or to identify work that needs to be done. called Boolean operators. ments can be retrieved and how accurately porated into another term or they may disap. Accuracy is a generic term that refers to ers in the domain. combined. With more focus on statistical medicine. to be combined into the set of documents indexing has a serious impact on retrievals that contain both x and y. bias against small studies with nonsignificant tems oriented toward nursing literature over. “about. Other common operators are not. findings and perhaps of parochial interest come some of this difficulty by classifying works against publication of clinical research things of importance in nursing but not in in nursing. being generated in a field. the primary search strategy able names. Vocabularies need more sta. of articles that can be published. if a controlled vocabu. is rarely used Boolean logic is based in set theory. the more Boolean operators a sys- documents. dictate how use. bibliographic data. nursing and related fields is based on Boolean tions. lary is inadequate for any reason. The searcher must fully understand the of variables studied in the research. pear altogether. H. The operator or results in a set of docu- Research document representation in ments that have either the term x or y. the document set of interest can be retrieved. this is because the vo. 1982). The consequence of large the profession has been the inability to locate amounts of fugitive research lies not just in nursing research by variables studied. Publication factorily reflected nursing terminology. Bibliographic Retrieval Systems 31 hinders others. thereby affecting the quality bases are limited to the published research of the retrieval. Currently. these studies might works. the more accurate the published outside the field may be in journals search that can be performed. articles are not indexed by the names logic. includes. indexers adjacent. x. It nursing-related databases is a problem for includes the set of documents that have both several reasons.

the Registry of Nursing Research accessible the references of research journal articles are by directly indexing the studies by variable analyzed in bibliometric studies. H. B. The ies and are generally collected from bibliogra- Virginia Henderson International Nursing phies. Biblio- names as well as by researcher and by subject graphic attributes such as authors. 1990). All that can be obtained tists and their work. and com- pending on the complexity of the search. Shirley. and across disciplines (Borgman. The accuracy of field. and primary journals. munication networks in specialty areas. & Gilman. and whether the article is about humans model of science. de. It has been used successfully to evaluate these searches can be extremely low. cita- Library makes the nursing research that is in tion indexes. infor- or other animals. Cita- lished.32 ENCYCLOPEDIA OF NURSING RESEARCH the search result. Wein. sensitivity and national Nursing Library”). bibliometric search should not be part of a literature classi- studies may provide insights into the histori- fication system because the results are the cal and sociological evolution of nursing sci- knowledge. change. 1986. from a bibliographic database search is a list Bibliometrics is a useful research method- of citations of documents or perhaps the full ology for describing and visually representing text of some documents that may or may not the communication structure of a scientific contain research findings. Using bibliometrics. research knowledge can be community. When that have influenced the intellectual develop- viewed this way. Or perhaps this was and is the trieval systems in nursing. perhaps the results of re- ment of a scientific field. (c) evaluation of scholarly contribu- Weiner. however. They also can be used to knowledge produced after it has been embod- identify prominent scientists or documents ied in documents (Landgridge. (b) evolution of a scholarly com- indexed by its variables (Graves. 1997.. abstracting and indexing services. reports represent relationships among scien- berg. bibliographic tific fields) that have driven the genesis of a classification is done to organize the scientific new scientific field. These characteristics can mation scientists assume that published re- be used to further delimit a search. Typically. . In addition to Boolean operators. 1992). 1987). In Boolean search systems headings (see “The Virginia Henderson Inter- of bibliographic databases. 1969). munity. GRAVES relevant but includes most that are relevant or it results in a few of the most relevant documents being found but fails to turn up Bibliometrics others of relevance. Bibli- ometric methods have been helpful in identi- The scientific knowledge is the research fying the foundational fields (i. 1981) and tions. categories: (a) characterization of a scholarly Nonetheless. for example. the dissemination history of the study tion data are often used in bibliometric stud- (bibliographic citations) can be provided. not documents (Doyle. citations. and (d) diffusion of ideas from within linked to its source (the researchers). such things as emergence. search documents reflect new knowledge in Researchers are interested in scientific a scientific field and that references in these findings. Thus. other scien- result or findings. specificity are inversely related: the search ei- ther results in many documents that are not JUDITH R.e. if pub. only legitimate method available to library Research questions addressed by biblio- and information scientists when approaching metric studies generally fall into one of four the literature of all disciplines. Bibliometric language the article is written in. the plinary field (Pritchard.. document research methods are based on a literary type. common Bibliometrics is broadly defined as the appli- bibliographic database retrieval systems will cation of mathematical and statistical meth- have tags that identify other salient features ods to published scientific literature in a disci- of documents in the field. not the document with the ence as well as the design of information re- knowledge. Stowe.

No subjective judg. guide for scholarship for doctoral students gated. and interpreting citation data in the field of ments are made by the researcher about what nursing. including other bibliometric strategy based on the anal- author co-citation analysis. At this point in the development of nursing cialty area. that is. shaping the generation of scientific informa- niques used in the analysis of citations. Bibliometrics 33 and textual content are used as variables in Review of Research bibliometric research. Citation analysis is the best-known biblio. Wil- documents are cited together in the reference ford (1989) used citation analysis techniques lists of later publications. it is important that the investigator studies will provide nurse scholars with a clearly delimit the specialty area to be investi. to demonstrate ysis of co-occurrence of keywords used to index documents or articles. Co-word analysis is an- used citation analysis techniques. nursing will provide a baseline for describing line electronic databases. The findings of bibliometric fore. conducted literature in a scientific field. and researchers in the field of nursing that and interpret citation data in conjunction may differ from information that has been with other sources of information relevant to passed down as traditional wisdom. an information scientist. using citation data from 1981 to data. Thus. the identities of nurse scientists and scientists In addition. bibliometrics does not have a from other disciplines whose interests are theory that integrates the methods and tech. In bibliographic coupling. literature best defines a scientific field or spe. the findings of bibliometric studies will open . Fur- Bibliometric strategies are practical and ther bibliometric analyses of the research lit- may be applied to citation data that are erature from the general field or subfields of readily accessible on citation indexes and on. There. It is a set of strategies for vestigations of the nursing literature. Garfield studying relationships among cited and citing (1985). Messler of references two articles have in common (1974) conducted a citation analysis investi- reflects the similarity of their subject matter. Bibliographic a journal citation study on core nursing jour- coupling and co-citation analysis use citation nals indexed in the 1983 Social Sciences Cita- analysis to demonstrate linkage of citation tion Index. Bibliometric methods can provide what the scientific community in a field of a way to track disciplinary influences and study has recognized by way of publication. citation data can portray only the field. John- such as cluster analysis and multidimensional son (1990) conducted a bibliometric analysis scaling. the area of interest. be familiar with the field of interest. However. gating the growth of maternity nursing In co-citation analysis the focus is on the cited knowledge as reflected in published nursing literature. ways to increase the visibility and retrieval mine the intellectual base of the specialty of scientific information being generated in area. using graphical display techniques dissertations from 1947 to mid-1987. The unit of analysis for co-citation using the technique of keyword analysis to analysis studies can also be journals (journal describe the evolution of the holistic para- co-citation analysis) or authors (author co- digm in the field of nursing. There have been at least five bibliometric in- metric strategy. the number conducted by nurse researchers. This method is the feasibility of using author co-citation useful for mapping content in a research field analysis for identifying emerging networks of or for tracing the evolution of networks of researchers in the subfield of maternal and problems in a disciplinary field. tion in nursing. the focus is 1983. Four bibliometric studies have been on the citing literature. it is critical that nurse scholars create publish in the scientific literature that deter. child health nursing from 1976 to 1990. D’Auria (1994) citation analysis). the number of times two practice literature from 1909 to 1972. that is. It is the scholars themselves who science. Sets of co-cited doc- to study citation patterns depicted in the ref- ument pairs may be grouped together and erences of a random sample of 310 nursing mapped.

Eriksson et al. There are untold other nurses through operant conditioning. as has way of repairing organs. It is. Leavigtt. & Gage. rigorous and systematic biblio. Early evidence ute working models of the development of of the possibility of generating growth or re- nursing science that could be used to evaluate growth in neural tissue was reported by Mar- scientific progress. 1997. Kuhn. & Macklis. back and light/sound stimulation. such as atten- systems through which all bodily activity is tion deficit disorder. the electrical-biochemical with target chronic problems. Evaluating the degree of scientific activ. While on the to practice settings. epilepsy. migraines. and other symptom neural pathway acknowledges the mind-body patterns. search (often in universities) have little access lar research in the recent years.. As the nursing research literature contin. ues to grow. It will also pro. To focus on the brain/ head injury.34 ENCYCLOPEDIA OF NURSING RESEARCH up new avenues for debate and hypotheses in tracing evidence of the capability of the generation in regard to the evolution of nurs. There are over 100 nurse professionals in While in the past. Budzynski and Budzynski (1997) to ity in research areas would help nurse schol. They disease process. exciting biofeedback/neurofeedback work ment. metric research of citation data may contrib. Diamond stimulated brain growth in older nurse scholars can identify underdeveloped rats by enriching the environment. practice privately alongside multiple other The use of biofeedback and its accompa. The nursing biofeedback one hand. Magavi. to develop research based pro- in research has realized exciting possibilities grams for specific target clinical problems. body to perform neurogenesis and neuroplas- ing science. and those who are doing re- states has been greatly impacted by the cellu. By managing appropriate change in the EEG or the brain’s electrical activity. D’AURIA only can rid itself of chronic symptoms but can also heal itself. But they practice outside the main- interface and the centrality of the brain in the stream of nursing’s institutions of care. stroke. ticity (Kempermann. 2000). these practitioners are not inclined to under- regulation of body function and optimum take research. another movement medicine. health disciplines. nursing. after all. Other schisms are that nying belief in helping persons master self. From this or neglected areas of research in nursing sci. These new directions for intervention are reaching consumers of Biofeedback health care. disciplinary and interdisciplinary linkages. improve cognitive functioning of elderly hu- ars determine if research resources are allo. By discovering trends in ion Diamond (1988). . mans by enhancing the brain with neurofeed- cated correctly as well as assist them in de. common to consider the brain and central Many of these practitioners are performing nervous system as the central focus of treat. mild finally determined. In these early studies. 2000. Bjorklund & Lindvall. 1999. field could advance markedly if these activi- plored the progress of using stem cells as a ties and professionals could merge. 1998. biofeedback for chronic the Biofeedback Certification of America symptom patterns has been thought to be (BCIA). of nerve tissue together with reports of im- vide an avenue by which nurse scholars may provement of body functioning through neu- access scientific information and prevent the rofeedback suggested that changes in bodily loss of information generated in the field of functioning can be reached through the brain. groups of neuroscientists have ex. (1996). Kempermann & Gage. termining the need for new journals and Results of studies on cellular restoration books in the field of nursing. now it is more practicing without current certification. study were derived the studies by Budzynski ence. the body not JENNIFER P. the certifying body for biofeedback/ simply training muscles and body functioning neurofeedback.

The stage is set for offering feedback motility of the digestive tract (Vogelzang). HSIN-YI (JEAN) TANG Selection of the same foods is common. 2001. progressive relaxation. and colo- individual efforts to inform the field of their rectal cancer (American Cancer Society. In addition. 2002). have been shown to affect the older popula- These publications predominantly indicated tion: constipation. to any number of chronic problems which Older adults living at home may be at an have heretofore been neglected. sudden cardiac arrest. West. heart a primary reason for constipation. and heart rate variability training.000 in 40% of older Americans. and endo- symptoms. & Ossip- change. even higher risk for overdose related to self- the new President of the Association for Ap- medication with over-the-counter drugs (Vo- plied Psychophysiology and Biofeedback. respiratory problems have been studied and consistently training. inconti. limited income influ- nurse. According competitive in nonnursing journals. 2000. to name cations have been shown to adversely effect a few. laxatives have It is informative to point out the following: become the most commonly sought treatment Chronic symptom patterns such as advanced for constipation. and elderly cogni. defined as the accumulation have been generated in nursing publications. Research findings demonstrate viously been treated with feedback training. Bowel Elimination Among Older Adults 35 Nursing biofeedback research has shown Bowel Elimination Among Older effective changes in patient symptoms Adults through application of complementary tech- niques. Robinson & Rosher. Klein. is to make the nervous the older adult’s diet. recognized the dominance of the brain in feedback by quoting William James on the ences the quality of food purchased and the latest cover of AAPB Biofeedback: “The degree of fiber-rich foods incorporated into greatest thing. fewer biofeedback studies Constipation. training during childbirth. incontinence. & Fletcher. of feces in the lower intestines with difficulty But there is evidence that research methods evacuating this waste. a gelzang). CO2. Berkow. ans. 2002). lead- . blood in nursing home residents. then. to Annells and Koch (2002). is the most common and physiologic measurement has markedly complaint among older adults (Abrams. gastrointestinal and musculoskeletal of tension with EMG training. Vogelzang. leav- ing them limited funds for groceries. hand warm. that increasing fiber and fluid in the diet sig- Physiologic indicators with a psychological nificantly decreases the need for laxative use self-care orientation are used to demonstrate and stool softeners (Howard. adults use weekly laxatives to reduce strain nence following surgery. reduction crine. 2003. A review of biofeedback/self-manage- Bowel elimination is the end process of diges- ment training research by nurses prior to 1997 indicated favorable patient outcomes tion resulting from interactions of the central when performing management of stress and autonomic nervous systems. proliferated. Multiple medica- allowing researchers to trace change in bodily tions (polypharmacy) had been identified as and psychological processes—EEG. Also. Annual income is less system our ally instead of our enemy. Over the 2003a. and respiratory activity. Most do HELEN KOGAN BUDZYNSKI not take advantage of funded food programs. blood sugar levels. especially rate variability. respective specialized treatments. but recently the kinds and quality of non. indicate that programs of care by nurses have 1999). Lynda Kirk. ber. Memorial Sloan-Ket- years since then. and enhance fecal elimination (Reiss & Ev- tive decline as listed above have not pre. improved—many articles using feedback are Beers. More than one third of older heart failure. These above studies are few in num. Vogelzang (1999) cited seven reasons for invasive instrumentation on the market are constipation in the elderly. there is very little shift to tering Cancer Center. Three major bowel elimination ing. Six or more medi- flow. 1995). Hogstel.” than $6. systems.

1998). There exists over 50 years old in an ambulatory clinic a strong correlation between urinary and fe. (2) neurolog. In 50–60 year olds than on 60–70 year olds. The study upper digestive tract (Caygill. tive effect against colorectal cancer. against both colorectal and breast cancer. & duce risk by up to 75% (Donovan.8% were risk for colorectal cancer increases (Borum). occur in public. and Hill (1998) investi- in a long-term care setting identified five risk gated the relationship between intake of high factors associated with fecal incontinence: (1) fiber and risk of breast and bowel cancer. also counteracts appetite as well as bowel Approximately 90% of individuals with regularity. Dietary habits of patients (1. (c) colonoscopy fiber. Huseboe. urgent sensation to quickly reach the toilet.186 older adults 60 years of age and older Caygill. ounce glasses of water/day). every 5–10 years (American Cancer Society. and La Vecchia (1998) researched or liquid stools. Titler. They also experienced an fiber intake and the risk of colorectal cancer. fecal incontinence and overall poor health in Non-healthy snacking throughout the day older adults. The described as a concern. Another carcinogens. Negri. The food due to unclean food preparation. Screening can re- creased activity (Hinrichs. study showed cereal and vegetables protect ical disease. Charlett. Fecal incontinence associ. the more likely the chance of cancer. a survey conducted by Giebel and colleagues. 2001). and/or polyps should be screened at a tribute to decreased social activity (Giebel. Women had more of a problem with pasty Parpinel.154 most problematic.6% Diet plays an important role in the preven- experienced at least one type of incontinence. 1. (3) poor mobility. and (5) age greater than 70 Fruit had no protective effect on colorectal (Chassagne et al. Those with a family history of colon cancer Fecal incontinence has been shown to con. unable to control solid stool. Controlling flatus was also with no history of cancer) were studied. 2003a).). Findings suggest that data indicated that dietary fiber has a protec- the lack of control associated with bowel hab.225 with colon Men described soiling their underwear as cancers. High fi- its plus the reduction in activities necessitate ber diets may protect against colorectal can- interventions aimed at education about intes. done in the older elderly than the younger many responded to a questionnaire about elderly.. Lefering. Franceschi. As aggressive screening diminishes. so they tend to limit outside A retrospective chart review of 200 patients activity with friends and family. along with in. or breast cancer. 728 with rectal cancers. whereas 19. Constipation can yearly fecal occult blood test. cer by allowing brief mucosal exposure to tinal health and dietary change. 1998). showed that more rectal exams were done on cal incontinence (Chassagne et al. adequate hydration (at least 6–8 eight. nitive decline. (4) severe cog. & Syngal). (b) flexible sig- be controlled by a well-balanced diet high in moidoscopy every 5 years. Charlett. Tang. The history of urinary incontinence. However. and 4. Troidl. tion of colorectal cancer. Older Borum (1998) evaluated the relationship adults are embarrassed that incontinence may of age with screening for colorectal cancer. fruit was shown ated with impaction and diarrhea occurred to be more protective against cancers of the in 234 (20%) of the sample. These results indicate that less screening is 500 randomly selected older adults in Ger. 1999). physical colorectal cancer are over 50 years of age inactivity. and United States Preventive Task Force recom- inadequate cooking skills also have been mends individuals beginning at age 50 be identified as contributing factors to risk for screened for colorectal cancer as follows: (a) constipation (Vogelzang). & Blochl.36 ENCYCLOPEDIA OF NURSING RESEARCH ing to a poorly balanced diet (Vogelzang). nausea caused by contaminated (American Cancer Society. bowel habits. Donovan & Syngal. & showed an association between permanent Hill). younger age and more frequently. Lack of social interaction. It was found that 4. . The longer stool remains in the study done on fecal incontinence enrolling intestine.

• personhood is enhanced through partici- pating in nurturing relationships with car. Boykin. characterized by altruistic actions and vanced age. Schoen- tual framework for the nature of nursing as a hofer. p. admin- . as caring in areas of nursing practice. Parker. educa. regardless of ad. 2001a). St. providing a meaning of lived caring. and the understand- structure for practice. Boykin et al. 2003). both as a discipline and as a profes- which may be associated with the physiologi. Jean. increased activity. “involves the nurturing of persons living cal changes occurring with advancing age and and growing in caring” (Boykin & Schoen- lack of screening. 2001) provides a concep. Embodying element of the theory acknowledges the need the aesthetic and personal realms of knowing for a paradigm shift from the traditional top- in nursing (Carper. & Schoenhofer. (Boykin & Schoenhofer. & Aleman. 14). Diets high in fiber. mutuality and respect found within nurse- pathic aspects of nursing situations as per. and education between the nurse and the nursed. Qualitative re- • persons are caring. 13). client collaborative partnerships. 2001a. represents Theory of Nursing as Caring the circular nature of caring grounded in the valuing of one another (the nurse and the The theory Nursing as Caring (Boykin & nursed) as unique caring individuals (Boy- Schoenhofer. nursing. 12). manness Bingham. An integral component of Nursing as Car- Boykin & Schoenhofer: The ing. development of middle-range theories that sion address more specific phenomena of nursing (Boykin & Schoenhofer. p. a personal EILEEN M. the Dance of Caring Persons. & Hutchins. administration. care organizations to circular structures of the theory incorporates the artistic and em. HERMANN connection encounter between the nurse and the nursed “within which personhood is nur- tured” (Boykin & Schoenhofer. sion. Central concepts include to be done on all elderly. 1993. the caring between nurse and nursed en- hances personhood” (Boykin & Schoenhofer. This caring discipline and profession. Chinn & Kramer. the nursing programs encourage prevention of complica. older adults are at risk for The focus of Nursing as Caring is that developing bowel elimination complications. moment to moment search methodologies grounded in dialogue • persons are whole and complete in the and description and interpreted as themes moment characterize research into the value experi- • personhood is a process of living ground- enced in nursing situations (Boykin & ed in caring Schoenhofer. kin & Schoenhofer. adequate hy. Boykin & Schoenhofer: The Theory of Nursing as Caring 37 In summary. 11). 2001a. 2001b. Screening for cancer needs hofer. 1998). Smith. 1978. down hierarchical structures present in health 2004. sonal caring connections between the nurse Research approaches developed within the and the nursed as they occur in the moment. oped the synthesis of meaning (Schoenhofer. Boykin. “a shared lived experience in which tions. p. the recognition of value and connectedness dration. CORA D. Research participants generated data in focus group settings and also devel- • persons are caring by virtue of their hu. A qualita- Major assumptions/fundamental beliefs tive group phenomenology approach was uti- underlying the transformational model of the lized to provide insight into the meaning of theory of Nursing as Caring include: lived caring. context of the theory of Nursing as Caring The theory of Nursing as Caring is essential include focusing on the discovery of the to the core essence of nursing. ing of value experienced in nursing situations tion. Nursing as Caring guides research by pro- ing others viding a broad conceptual framework for the • nursing is both a discipline and a profes. and research.. ZEMBRZUSKI p. 2001a. 2003). 1994). situation. and the caring between. caring.

1995). 1995). stress than others. 1996). and surviving cancer based nursing model that grounded an acute from a family perspective. The factor of time is reflected agnostic and immediate postoperative phases in longitudinal studies of emotional and phys- are particularly stressful (Northouse. reclaiming life. symptoms related to the disease MARY ANGELIQUE HILL and treatment. Although the di. 1992. Examples of devel. 1997. Funk. 2003). and social (Tulman & Fawcett. tional distress and mood disturbance among Although adjustment has been commonly the spouses at 3-days post-surgery differed conceptualized as quality of life. In general. mul- focuses on caring processes. as compared to patients. and Eaton (1999) conducted a include the theory of technological compe. phases characterized by more demands and Northouse. sis. altered with resultant interpersonal tension veys & Klaich. cus of quality of life to breast cancer survi- ing (Boykin et al. months. & Steeves. emotional distress (Hoskins et al. of breast cancer extend over time. sexual function for as long as 3 years. physical (Given & Given. self-esteem. the breadth significantly from population norms. body image. and need for infor. Acceptance of the diagno. and include the development of new methods of Garcia (1998) concluded that adjustment in- nursing inquiry appropriate to the study of volves demands across the physical. 2001a). in both patients and partners (Lewis & Ham- Magill. Similarly. Usual roles are mation and support are ongoing issues (Lo. tiple losses.. may continue mance (Derogatis. In their seminal study of 50 newly diagnosed distress from side effects (Walker et al. it is agreed that the broad domains of adjustment to Breast Cancer: Psychosocial breast cancer may be conceptualized as psy- Adjustment to Illness chological (Walker. social. 1998. adjustment among spouses (Given & Given. Nail. & Schwartz. 1996b. and the caring. ized in many ways. 1991). ical adjustment in both patients and partners. The adjustment process has a strong effect lated to physical change and loss. Wyatt & Friedman. Grant. The dis- of the broad conceptualization inhibits defin. Ferrell. Dow. Cohen. life purpose. 1992). As the person most (Lasry. 1996). 1996b). Higher emotional distress and lower Adjustment has. uncertainty. including role perfor. emotional symptoms (Hoskins intimately involved in the events related to et al. and struggles with fear of the cancer. Classified as a chronic disease. Dunphy’s (1998) “circle of caring” struggle among independence-dependence.38 ENCYCLOPEDIA OF NURSING RESEARCH istration. 1990. the partner function (Cimprich. control.. Walker. however. & Charron-Moore. treatment decisions. 1997). tress and disturbance continued to 18 itive studies of its dimensions and predictors. psycho- Nursing as Caring allowing for research of logical. Nail. with some 1998). kinds of cancer and identified themes of 1998). Otis-Green. qualitative study of 687 survivors of various tence as caring in critical care nursing (Locsin. 1990). 1983). breast cancer patients and spouses. To address the issue of multiple opments of such mid-range theoretical mod. and limitations in role performance house and Swain (1987) noted that the emo- and sense of control may last longer. the demands Kahn. cognitive the patient’s illness and treatment. been conceptual.. psychological functioning. and education. 1998). and social functioning. Aaronson (1990) recognized the rience of the nursing situation (Boykin & multidimensionality of quality of life and pro- Schoenhofer. Nort- 1996). Larsen. Narrowing the fo- care unit in the perspective of nursing as car.. model for advanced practice nursing which wholeness. Future directions vors. posed the four major dimensions of func- tional status. arty. alterations on the family as a system (Cooley & Mori- in lifestyle. Pasacreta. Ferrell. 1991. els based on the theory of Nursing as Caring Haberman. Germino. mond. emotional distress re. & Croyle. the meaning of nursing within the lived expe. Dorris. and spiritual domains. interpretations and dimensions. demands . 1999).

1990). 1999). both the American feelings of being ineffectual. Breast of mammography screening. raphy were higher. initial agreement. Budin. mammography recommenda. crease for mammography have included clini- side effects and associated distress (Wilson & cal breast examination.. increases in mammography may report BSE practice as frequently as screening have influenced breast cancer mor. although increasing. Moore. identified mammography does not magically become by the patient as the person most intimately effective at age 40 or 50 or 60. breast cancer screening by 1993). age (Lehto & ates artificial boundaries that cause much Cimprich. phy. perceived nation is not as clear as that of mammogra- support (Northouse. Roberts. 1991). intervals are not good. The rates for consistent 211. dations for screening. Rates form of cancer mortality for women. Dorris. and indications are that vantage. & Reddy. but the independent Morse.800 will die. Recent data indicate that women Stage I tumors. Williams. Now that the American Cancer 1999). To date. and almost 39. the wide variety of predictors of aged 40 to 49 with women 50 and over cre- adjustment include life stress. When discovered early. Society and National Cancer Institute are in Crooks. victims may anticipate a 97% chance for It is obvious that breast cancer screening complete cure. retrospective studies have found that BSE may detect an earlier stage Breast Cancer Screening of disease or smaller tumor size. in 1996 for clinical breast examination and mammog- an overall decrease in mortality was reported. 1996b). addition. and 40 to 49. Rates for mammogra- Although breast cancer remains a significant phy in 2000 ranged from 57%–72%. Laten. & Charron. In (Christman. previous diagnosis of cancer (Nort. & Browne. Cancer Society and the National Cancer Insti- calate. Breast Cancer Screening 39 placed on personal life (Samms. breast cancer ciency scores. stage of disease (Zabalegui. Minority rates for fol- Recently. Hoskins et al. & Osoba. and one mis- involved in the breast cancer experience are take that fueled controversy was comparing rare and require furthur resources. Studies in which the partner. although it is currently recommended. one decade to another. This health-promoting detection . age 40. and access to care is a tions have been expanded to include women real issue. seven to eight times a year but have low profi- tality. 1991. Obviously. particularly in cancer screening rates. prospective mortality-based trials. increased depression among partners tute now recommend screening beginning at affects marital adjustment (Zahlis & Shands. Consequently. confusion. While screening rates may approach the incidence will remain high. 1998). rates are lower for minorities Cancer Society estimates that more than and women over 65. and uncertainty effect of the latter has not been studied. energy may be focused on other emotional status (Iscoe. 1996a. Despite its apparent effectiveness. time since diagnosis (Irvine. The American 70% to 74%. 1991). issues. Comparing women Finally. As demands es.3% Because treatment is extremely effective with and 69%.300 women were diagnosed with breast mammography screening at recommended cancer in 2003. 1999). Brown. breast Breast cancer is a disease for which there is cancer screening is not used to its fullest ad- no foreseeable cure. 1991). low-up are dismal. The effectiveness of clinical breast exami- house. and therefore are not optimal. 1995). the efficacy of breast self-examina- tion (BSE) has been documented although not CAROL NOLL HOSKINS in randomized. ranging between 37. 1995. women 50–70 years of age. Some studies demonstrating a mortality de- social integration (Loveys & Klaich. Most problematic is the fact most organizations recommend periodic that women do not follow current recommen- screening beginning at age 50. Prospective mortality-based has the potential to reduce mortality and studies have demonstrated the effectiveness morbidity from this dreaded disease.

Nurses are in an optimal particular demographic characteristics. barriers have been significantly related to ior.. Interventions to promote cade have used various models to predict mammography and teach BSE can be carried mammography screening. beliefs and (b) social influence. was added to the health Instead. pliance has been physician recommendation. which postulates that two ma. surement of outcomes. previous health habits. Subjective norms. Social influ. women who were taught personally belief model. descriptive research embedded in models. tualized in the early 1950s to predict preven. A major dict breast cancer screening have included problem with BSE research has been the mea- Fishbein and Ajzen’s (1975) theory of rea. predict behavior (Prochaska et al. fear of radiation. the vari- and barriers to taking a preventive action ables of perceived susceptibility. predictors of mammography use have been phy and BSE. Recently. dicting mammography by postulating that lated. benefits spanned the past 2 decades. and were predicted to influence the health behav. and inconvenience. Research has shown that there beliefs of significant others and the influence is often little correlation between reported of significant others on the individual. In many earlier studies soned action. or not thinking about included the concepts of risk of contracting mammography. The health belief model was initially concep. Actual measurement of BSE proficiency This model defines the outcome in terms of also has been problematic. and per- ical breast examination is a skill that should ceived barriers to screening have been pre- be learned by all nurse practitioners and con. 1994). clinical breast examina. the trans- tive behaviors such as influenza inoculations theoretical model has been used for pre- (Rosenstock. A number of studies spanning over a de- tion. In 1988. In general. and this was used as screening: (a) beliefs and evaluations of these the operational measure of compliance. mammogra. Again. . and BSE). which precontemplation. A less significant prediction of BSE com- perceived confidence in carrying out a pre. or BSE. The best studies stages of preparedness to engage in a health. Clin. the concept of self-efficacy. time. identified in the theory of reasoned action. The most consistent cancer screening—in particular. Later. workers (1992) found that perceived pros Several important theoretical variables (benefits) and cons (barriers) varied across have been tested for relationships to breast stages of mammography. benefits. and position to increase all three screening meth. pain. The theory that has generated physician recommendation and barriers. women were asked how many times they ex- jor concepts are related to breast cancer amined their breasts. as suggests that breast cancer screening is influ. In addition to the factors either complete BSE or identify silicon lumps involved in these models. all areas of practice. raphy over time. The the most research is the health belief model. to maintenance of mammog- the disease (perceived susceptibility) and per. In addition. self-report proficiency scales were ence is also composed of two components: widely used.40 ENCYCLOPEDIA OF NURSING RESEARCH activity is of primary importance to nurses in enced by knowledge. the health belief model included the women move through a series of stages from variable of perceived threat to health. ity. health care systems. indicating that recently. dictive of mammography. attitu- out during general health promotion or while dinal variables such as perceived susceptibil- women are being seen for other reasons. they may not be tested with mammography use and found to doing it proficiently enough to detect lumps. the transtheoretical model has been even if women practice BSE. 1966). found to comply at higher rates. As originally formu. Rakowski and co- ducted yearly on all women aged 20 and over. have used trained observers to watch women promoting activity. perceived benefits to screening. fear of results. ods (mammography. ventive behavior. sonal cost should the disease be contracted Descriptive studies to predict BSE have (perceived seriousness). and returned a demonstration have been Other theories that have been used to pre. latter have included perceived lack of need. cost. Most frequency and proficiency.

Intervention research for both mammog. Descriptive and intervention studies based raphy and BSE has systematically built on the on similar theories of breast cancer screening descriptive studies of earlier decades. and barriers. Many of the interventions use educa- tional strategies. The ventions have ranged from multistrategy major difference in relation to promoting community interventions to individual pa. Physician recommenda- dividually focused interventions targeted per. the set of skills needed to com- lems. or Hispanic ing. Many of the in. and both cognitive self-examination has been one of the strong. these costs. BSE teaching. recommendation. Breast-feeding continues to be the gold stan- phlets to one-to-one teaching sessions with dard for feeding infants. in increasing mammography. Access mography. to identify lumps have been the most vigor- lations between attitudinal variables and ous. African American. is related to mammography and because an strategy interventions often targeted physi. telephone delivery. benefits. Perceived benefits and barriers to both mam- cess-enhancing interventions have included mography and BSE also should be addressed the use of mobile vans. especially those skin protection and adherence to low-fat diets based on sound theory. Preventive behaviors such as the use of women. Most return demonstrations. Peer implications for increasing other health be- leaders can sometimes be important links for haviors. have been successful can also be targeted for intervention trials. We phy screening. Ac. Multi. If this perceived sus- organizations (HMOs) consistently have ceptibility is unrealistically low. For both BSE and mam- postcards. do patients in private medical practice. order may be necessary to obtain a mammo- cian recommendation. Breast-Feeding 41 have been predictive in some studies. cess for all people. A major future di- agencies such as the American Cancer Society rection related to mammography will be to and Little Red Door have helped to defray increase interval compliance. Perceived confidence for completing tions. Interven- tions have ranged from handing out pam. Various ways of delivering now know enough about breast cancer messages have been tried. Finally. as shown the individual’s perceptions about her suscep- by the fact that persons in health maintenance tibility to breast cancer. such as colorectal or prostate screen- low-income. Studies using models research has identified low to moderate corre. although ciency will be important. tion is important both because medical advice ceptions of risk. tailored letters or for nursing practice. which provide easier and individualized strategies developed. screening to make certain recommendations dia. as it provides nutri- . clinicians must take into account has been identified as a problem. mammography is the addition of physician tient-oriented interventions. For access for women with transportation prob. personal teaching has been to be an important predictor of mammogra. efforts must higher rates of mammography screening than be made to paint a more accurate picture. Costs of mammography for indigent plete this exam and observation of profi- women continue to be a problem. tice. increase in proficiency. and in-person counseling. VICTORIA CHAMPION related to the theoretical constructs of per- ceived susceptibility. including the me. have extended over the past 2 decades. and barriers. For BSE. Inter. with or without counseling. which had been found gram. nurses must actively encourage pub- Interventions addressing BSE often focus lic policy decisions that increase screening ac- on teaching women the correct skills for prac. Social network interventions have Breast cancer screening research has broad been effective with minority groups. Most interventions. Studies that include personal demonstra- BSE. and personal instruction evidence the greatest est predictors. found to be a most important predictor. Many studies have used reminder systems or Breast-Feeding self-prompts to increase practice. guided feedback. benefits.

race. identify women at risk for complications tween breast-feeding and a decreased risk of early on. effect on initiation and short-term duration especially lactation consultants. are still un.. 50% breast-feed. More research is negative attitude toward breast-feeding and needed into nurses’ influence on the decision low confidence in their ability to breast-feed. on breast-feeding initiation and duration of: tunity for health promotion and disease pre. There continues to be a large The advent of the Breastfeeding-Friendly discrepancy in the United States between Hospital Initiative in 1997 in the United breast-feeding rates. & Grummer-Strawn. care behavior. (UNICEF) encouraged the identification of luwalia. however. ported. 1990-2000. 2003). of breast-feeding. Investiga- cently. has led to the benefits and risks of not breast-feeding the recognition that breast-feeding is a health should be in the forefront in nursing research. experts. 6 months postpartum experienced perceived amined the policies and practices that impact difficulties with breast-feeding. These studies breast-feeding initiation. to breast-feed and their roles in promoting chological benefits for young children. terials for artificial infant milk (Auerbach. Bibb. Dennis (2002) examined breast- lates to promotion. terdisciplinary focus. provision of gift packs with promotional ma- Breast-feeding has an international and in. especially according to States by United Nations Children’s Fund income. cluded that mothers who weaned prior to Breast-feeding researchers in nursing ex. They cessity to the health of humans (Heinig. Re. and reinforcing women’s decision. Once seen as a personal lifestyle feeding in areas such as: breast reduction/ choice. 2003). 75% ings. In a thorough review of the literature from jority of nursing breast-feeding research re. labor medications. Nurses have intimate contact did increase both short and long-term dura- with women at key times to make a difference tion (Guise et al. although support programs derutilized. education. and ethnicity (Ah. failure of nurses to frequently assess breast- ing at 6 months. and drugs. delayed feed- (2000) national health objectives target. Riordan. The Healthy People 2010 early introduction of pacifiers. medical breast-feeding to the health and well-being conditions. protection. ineffective positioning. documentation of the superiority of augmentation surgery. need to be aware of new research on breast- 2001). a meta-analysis of over from various arenas of health care and the 35 studies demonstrated that breast-feeding sciences are interested in lactation and the educational programs had the greatest single field continues to grow. Hsia.42 ENCYCLOPEDIA OF NURSING RESEARCH tional.. Many professionals 2000). children. HIV status. nurses have an oppor. and psy. When breast-feeding is examined as Studies have demonstrated the negative effect a health care behavior. 2001). Nurses and unreplicable living tissue transferred to need updated education based on research to infants and children through breast-feeding. Nurse scientists identified those least likely to breast-feed as: continue to develop instruments to assess young. full-time employed women with a Miller. affect all of society. use of supplements. Morrow. supporting its importance and ne. forc- vention among mother-child dyads which can ing baby to breast. so that interventions can be initiated illness and health problems in infants and and referrals made in a timely fashion to pre- children. and 25% breast-feeding chil. initiation of breast-feeding. immunological. . routine separation of mother and baby. 2002. and dren until 1 year of age. 2003). and support feeding initiation and duration and con- of breast-feeding. In contrast. a burgeoning body of research in the tors have demonstrated the importance of immunological and biochemical sciences has health care professionals’ recommendations continued to identify the unique properties to mothers (Ahluwalia et al. practices that impact breast-feeding duration. serve the breast-feeding relationship. Careful assessment of of infants. cognitive. unsup- breast-feeding (Dennis. feeding encounters. and to These studies have made the connection be. and women. The ma. & Rawlins. ethnic minority. low income. in their breast-feeding experiences. vigorous suctioning. provide this support at critical times.

the private). ing met. the shift from knowledge to practice feeding include three major areas: the lack of is painful and takes time (Hong. sources of support providing inaccurate and The influence of the health care delivery sys- inconsistent advice (Dennis). expensive than artificial milk supplementa- ceptability of breast-feeding (both public and tion and more environmentally friendly. and most importantly the culturally relevant is. 2003). 45% report ever breast-feeding (compared to Although breast-feeding is now recognized 66% and 68% of Hispanic and white as a right of mothers. In con- theory using the concept of self-efficacy. ing. the health belief model. especially women of color within this bility and validity studies of major breast- group. & consistency in the definition of breast-feeding Schwartz. and ecologi. 2003). com.6 million out historical-cultural approaches. and trast. phenomenological studies.. 27 projects (7. work or school. feeding for all women and ways in which munication-related barriers. Only 13. These results tem. a health care behavior women) (Bentley. & Meier. 2003). Nurses need port. and prenatal and postnatal interven. national breast-feeding goals are far from be- ing the infant close. (Brown. a lack of social ac. (e. to be at the forefront in protecting.g. and lack of support. breast-feeding and cir- professionals who lacked knowledge related cumcision. Breast-Feeding 43 Partners and nonprofessionals were most Clinical issues being explored by nurse sci- supportive.1 million) in- the social ecological framework. Re. Nurses are volved the use of human milk composition exhibiting a stronger role in publishing stud. SUZANNE HETZEL CAMPBELL sues that influence breast-feeding choices. sup.. Rea. exclusivity). and society/culture cannot provide a target population for intervention be ignored. Federal funding for breast-feeding Nurse scientists are using different meth. HIV and breast-feeding. making comparison of A major population needing attention fo. and health care feeding to the mother. and supporting breast-feeding for the searchers have demonstrated the importance health of society. Theoretical frameworks funds from 1994 to 1996 were awarded to used to explore the health behavior of breast.4 million available) of federal research cal perspectives. Callister. promot- tions to support the mother and infant. projects having an impact on the Healthy feeding include the theory of planned behav. and indicate that even as knowledge has Challenges related to the study of breast- grown. 2003). of $40. and randomized controlled trials. less include: embarrassment. including: incongruity with the national priorities for ethnographies. the need for comprehensive at all levels support or interfere with breast- breast-feeding education and support. the ways that cultural norms and structures tal interventions. the difficulty cused on breast-feeding are low-income measuring cross-cultural effects (lack of relia- women. the effect of hospi. and positioning and attachment. Dee. community.5% or $4. the effect of values and practice. . and technologies to improve artificial milks ies examining breast-feeding education. the difficulty keep. studies tedious if not impossible. breast-feeding. issues. social cognitive dence and duration of breast-feeding. & Jensen. entists include: biological benefits of breast- rimental to breast-feeding. lactation to breast-feeding were seen as negative mastitis. socioeconomic nursing can make a difference. African-American women have feeding instruments with various cultures). among the lowest rates of breast-feeding in and the development of prospective designs the United States (Ahluwalia et al. research in the United States demonstrates an odologies to study breast-feeding. hospital routines were often det. This will require exploring of peer and social support. People 2000 goals for increasing the inci- ior. Bair.7% ($5. contributing to the reduction of infant and sons given by women for not breast-feeding maternal morbidity and mortality rates.

agents such as exposure to ionizing radiation The annual incidence of childhood cancer have been found to cause cancer in children is 15. Cancer Statistics Working Group. nursing care proce- males (14. Major areas of pediatric oncology nursing 2003). A review than 20 years of age diagnosed each year by Hinds. For published studies were on nursing care proce- children of all ages.000).5 per 100. have yet to be explored. C Cancer in Children congenital anomalies. Wilms tumor grief and loss experienced by the parents and is associated with an increased incidence of siblings of children who died of cancer. Strobino. 2002). and Schum (2002) with cancer (Smith & Gloeckler Ries.5% of the McDorman. While increased attention on nursing more common in Caucasians. leukemia is the most fre.g. of the child and family. Only 5. dures. Despite the lack of knowledge about the vival. Tumors of the kidney published in nursing journals and of those. 2002). there is some information agnosed with malignant neoplasms will sur. 2002). and man- mately 12. the numerous advances in the diagnosis Bondy.S.2%) were mors and lymphomas.6 per 100. due to the Chromosome abnormalities have been found improvement in childhood cancer survival. How. Environmental Reis. found that the majority of published studies Childhood cancer is the third leading cause (70%) are related to psychosocial care needs of death in children ages 1 to 19 years (Arias. fessional issues. creased incidence of cancer (Gurney & ever. and soft tissue are more common in African 67% were published in cancer nursing jour- Americans. There is a slightly higher incidence in research include psychosocial care needs. Most studies (78. Wilms tumor. on risk factors that increase the likelihood vive more than 5 years (Smith & Gloeckler of children developing cancer. The emphasis on psychosocial care needs blastoma demonstrate patterns of inheritance of children with cancer and families has that suggest a genetic basis for the disorder. Children with syn- dromes caused by abnormal numbers of chro- Pediatric oncology represents only a small mosomes (e. dures. cer. followed by brain tu.000) compared to fe.. Hockenberry. There are approxi. years (U. Down syndrome) have an in- fraction of the discipline of oncology. ciencies are at greater risk for developing can- sulted in significant improvements in sur. origin of cancer. and less than 5% were on nursing pro- quent type of cancer. changed over the past 20 years. Re- 44 .6 per 100. research has occurred over the past 10 years. lar retinoblastoma. The cause of childhood cancer is not many areas of pediatric oncology nursing known. 2003). Children with immune defi- and treatment of childhood cancer have re. in particu. whereas tumors of the bone are nals. and neuro. males (16.400 children and adolescents less agement of health care resources. Some childhood cancers. & Guyer.000 children ages birth to 19 (Gurney & Bondy). nursing professional issues. physical impact of cancer. Approximately 75% of all children di. in acute leukemia and lymphoma as well as Nursing research in the 1980s focused on in other pediatric solid tumors.

Limited research is nous access. alence of this symptom confirms the need to tions of clinical trials and understanding of explore the interrelationships between fa- the consent process. Docherty (2003) recently completed a re- Skolin. child and their families (Hedstrom. Interventions designed to minimize the adverse effects of central ner- have addressed distressing cancer events and vous system therapy are now being con- symptoms from the specific perspective of the ducted. management research focus is the evaluation ents facing the loss of a child. 2003) should continue to be agement issues. a major research focus. the National Insti. pain. Fatigue has been found to be one of ness and its impact on the child and family the most distressing symptoms experienced living with a cancer took center stage. use of conceptual models or theories. Fatigue prove and childhood cancer survivors move measurement instruments have been devel- toward adulthood. blood product infusion methods. cancer. Hedstrom et experiences of children and adolescents with al. enced by children with cancer. nition and acknowledgment of the beliefs and ment. Woodgate & Deg- view of the published literature on symptom ner. Depression. children cannot be over emphasized. and lack of appetite. Nursing studies have documented the ad- symptoms of cancer and its treatments have verse effects of central nervous system (CNS) not kept pace with new advances in the causes treatment on cognitive. nursing investigations are focus- ment in Cancer: Pain. cough. and Fa. while continuing to eval. complications of central ve. during childhood cancer treatment. to improve. drowsiness. chronic ill. Haglund. ing on survivorship issues and quality of life tigue (NIH. nausea.. garding cancer-related symptoms (Wood- Nurse researchers have evaluated pain man. 2000). The review of existing following the diagnosis and treatment of can- research revealed that efforts to manage cer. lives. found regarding assessment of pain in chil- and chest tube care. academic. 2003. This review revealed no longitudinal of distress in a group of 121 children with symptom management study designs. Three landmark studies chosocial functioning. Cancer in Children 45 searchers studied how care was provided in Also. and no attention to the 35%) in a group of 160 children with cancer impact of these symptoms on the children’s as lack of energy. and psy- and cures for cancer. fre- and fatigue. This symptom Adolescent risk-taking behaviors is a new re. has been evaluated from both qualitative and search area as survival rates continue to im. The families felt unrelieved or uncon. Longitudinal studies evalu- . In re. and terminal of fatigue in children and adolescents with care costs. Multi-center trials have been implemented to rent research on symptom management in evaluate this symptom in children with individuals with cancer. Collins et al. described the most quent adaptation of adult instruments as common physical symptoms (prevalence > symptom measures. The im- of 39 children and their family members and portance of striving for symptom relief in found that these individuals expected to expe. In order to evaluate the status of the cur. & von Essen. limited cancer were treatment-related pain. 2002). discovered that the most common causes cancer. Recog- rience suffering as part of the cancer treat. nausea. quantitative research perspectives. a relatively new area of symptom the home care environment. dren with cancer. 2003. expectations of children and their parents re- trolled symptoms were necessary for cure. Woodgate and It is evident from the recent childhood can- Degner evaluated expectations and beliefs cer pain literature that there is still much to about childhood cancer symptoms in a group be gained from continued research. As survival improved. tigue and other symptoms commonly experi- uate stress and coping in the child and family. the needs of par. oped and tested during the past 5 years. gate & Degner. cancer. tutes of Health recently held a State of the As survival for childhood cancer continues Science Conference on Symptom Manage. Collins et al. The prev- cent years researchers have evaluated percep.

. Founded in 1986. survivorship. Such effects include a plethora victimized by cancer to people living with and of physical. 1980).000 20-year-olds is a child- mainder of life (NCI. the efforts of the NCCS as well as other grass- ration of the most effective drug regimens roots organizations. An- drew von Eschenbach of the National Cancer As we move forward in the new millennium Institute identified areas of focus for survivor- more people are living with cancer than dying ship research. social.e. Since its inception the OCS tive. as a result of velopment and evaluation. these MARILYN HOCKENBERRY novel efforts have provided important struc- ture for a small but rapidly increasing field of cancer survivorship research. pubertal. ac. creative methods for dissemination of has funded initiatives geared towards the our knowledge of cancer pain and its manage. Finally. setting public policy priorities on behalf of ship with cancer center staff need further de. cussed. and vorship (NCCS). For most people and therefore represent important areas for this means that cancer has gone from a death future research as the number of cancer survi- sentence to a chronic disease. cancer survi. eas are uniquely relevant to nursing practice lion cancer survivors (NCI). psychosocial. Moreover. 2004). that arise after completion of therapy. stimulation of research on long-term cancer ment must be explored. it was may result in physical. and emotional established to refocus attention from people consequences. 2003). These ar- years after diagnosis. to outlive. Dr. Recent statistics indi- sis and treatment of cancer through the re. & the physical. people with cancer. to live more (Merriam. unstudied needs. low-up of childhood cancer survivors and is- 2003). sues faced by cancer survivors from un- 63% of adults treated for cancer are alive 5 derserved populations (NCI. and follow-up care among both pediat. 2003). in 1996 the NCI created and methods of delivery should be pursued the Office of Cancer Survivorship (OCS) in for children experiencing all types of cancer recognition of the large number of individuals pain. It encompasses hood cancer survivor (Meadows. for pediatric cancers. ing from 3 decades of successful treatment vorship is the period of time after the diagno. M. 2003). Thus. Belasco. Thus. as well as the poten- . Continued explo. utilization of research findings now surviving cancer and their unique and in the clinical setting is lacking. More innova. Indeed barring death by other causes. They included long-term fol- from it (National Cancer Institute [NCI]. Krejmas. i. although the concept of cancer survivorship is relatively young. side effects that do not resolve or of the National Coalition for Cancer Survi. The word survivor is derived from the Cancer survivorship research originated Middle French survivre. cate that 1 in 1. the same treat- quelae of cancer diagnosis and its treatment ment that produced successful response rates and issues related to health care delivery. adult survivors of pediatric cancers culminat- Webster Online.. (Smith. can also cause long-term adverse effects cess. accounting for 10 mil. This success vors increases in the coming decades. & Hare. and repro- surviving cancer (NCCS. intellectual. For many pediat- ric and adult survivors of cancer (NCI). The NCCS ductive manifestations. and economic se. 2004). survivorship is marked The current focus on cancer survivorship by the occurrence of treatment-related late is in large part a result of the visionary efforts effects. The effective use of pain management what is now a formidable advocacy group teams in hospital settings and their relation. Ironically. and from from studies conducted with adolescent and the Latin supervivere. Cancer Survivorship In his annual report to the nation. Find- has resulted from continued advances made ings of studies related to these foci will be dis- both in the laboratory and at the bedside. ric cancer survivors.46 ENCYCLOPEDIA OF NURSING RESEARCH ating the trajectory of pain over time are not evolved from a peer-support organization to found.

Mott. In a review of the current state of knowl- naires including items related to organ system edge of cancer survivorship among ethnic mi- functioning. determinants of cancer decision making. fertility. As increasing numbers These effects represent a lifelong risk that of people from underserved populations are often negatively influence quality of life and diagnosed and treated for cancer. auro. those with gies to promote optimal health status in survi- low income and educational levels. these over 14. including smoking and to patterns of cancer-specific survival and rel- consumption of alcohol. completed baseline and follow-up question. and meaning of cancer Study (CCCS). 8%) (Mitby et of literature on sociocultural and behavioral al. psychosocial norities and medically underserved groups. 2002). of cancer. 2004).. (c) culturally relevant mea- important findings provide insight into a vari. cause of their genetic predisposition and pre. ferences have implications for the adaptation multi-institutional. Swartz). Tes. As a result of this work. factors may be complicated by poorer overall vors initially diagnosed between 1970 and health status as a result of comorbidities or 1986. health. (Shavers & Brown. ied. (b) reduced general ship is needed. and second malignancies. Andersen. Some of their findings in- physical and mental health. Cohen. ducting research that improves the under- hood cancer survivors. (Brandeis. cost of treatment combe. (Phillips. demiology and End Results [SEER]. These dif- cer Institute. survivors vors of cancer. significant may be linked to the practice of high-risk differences have been reported with respect lifestyle behaviors.. These populations and. & Litwin. 2002. the CCCS The number of people with cancer is ex- has laid the groundwork for further examina. Moreover. Aziz and Rowland (2002) found that research Highlights of four studies reporting initial related to the impact of ethnic and minority findings were: (a) a statistically significant groups on issues of survivorship is largely excess of secondary malignancies. Survivors who participated in the study lifestyle. health habits. Aziz. and research on the impact of cancer .6 million by the year 2050. (c) increased cers were conducted on Caucasian survivors use of special education services when com. 1999).. 2001). thyroid cancer. practices that are ative risks of cancer death (Surveillance Epi- further complicated in this population be. & Moses. 2001). tervention studies that develop or test strate- lations may include the elderly. standing of cancer survivors. sarcoma. survivors. An important vehicle for addressing some 2001). 1999). access to educational and emotional of these and other childhood cancer survivor support services (Wilson. tion into other issues that will provide addi.. information on survivors of from ethnic and cultural minorities. & concerns is the Childhood Cancer Survivor Meischke. the most related to epidemiologic analysis of cancer common being breast cancer. the CCCS is a collaborative. 2003). Thus. research related to meningioma.500 5-year childhood cancer survi. there is a growing emphasis on con- tionally important contributions to child. (b) while there is a growing body pared with siblings (23% vs. risk and survival. and (d) increased reports of de. and bone cancer issues of the underserved and cancer survivor- (Neglia et al. & Hunt. few pressive and somatic distress when compared studies explored interventions in underserved with siblings (Zebrack et al. and activity and cluded the following: (a) a majority of studies functional limitations when compared with of late effects of treatment of secondary can- siblings (Hudson et al. and those cancer who have previously been understud- who live in remote areas (Rowland. Henning. Pashos. 2002). longitudinal survey of to and survival of cancer. as well as other issues such as access to care vious exposure to cytotoxic agents (Lar. 2003). sures that capture concerns of cancer survi- ety of concerns relevant to childhood cancer vors were largely absent. Thus. & Feuer. Needed are in- Cancer survivors from underserved popu. Cancer Survivorship 47 tial for secondary cancers (Swartz. pected to reach 2. 2000). Funded by the National Can.

Nurse new. This form of payment is a change from providers. or evaluation out of the need to control escalating health research. Research related to capitation in the con- ture and terminology of health care delivery text of managed care is health systems re- to managed care. tation) for health services. Capitation payments are usually cal. 2001). Holzemer and Reilly (1994) used care costs and has become accepted as an the term variations research as an important inevitable way for health care to be delivered. and enrollees (members) were also fee-for-service payments as a method of com. market. is usually associated with managed generated above expenses could be shared by care. or on visits and unexpected admissions is key to expected high utilization of service based on success in a capitated managed care system. settings offer opportunities created by man- Although health care reform as a legisla.48 ENCYCLOPEDIA OF NURSING RESEARCH on the family (Rowland et al. In many cases. strategy designed to improve the quality of Managed health care organizations are not care while controlling costs. Implemented in the 1970s. Managed care has grown search. Providers (pri- marily physicians) were offered the choice of collecting a fee for service from the patient Capitation or having the HMO pay the physician directly out of a prepaid per capita payment (capi- Capitation. and primary care provider in community-based so forth. In some cases. HMO providers first shared the risk of financing health care LORRIE L. 1996). health services research. rate such as $x PMPM may exist for primary ber regardless of how expensive the services care services. and lengths of stays. and coordina- of the enrolled members. with an additional capitated are or whether the member actually received pool of #xx for referral services. 76). selected chronic illness. of people who live with cancer. risk. providers or provider organizations in place that covers care across the contin- receive the same amount of dollars every uum. one capitated payment is tation. driven reform is rapidly changing the struc. and $xxx services. period of time (Knowlton. when prepaid plans were implemented in nificant contribution to improving the lives health maintenance organizations (HMOs). Many forms of managed care providers (Schramm. a form of payment for health ser. They grew out of the private sector researchers have the potential to make a sig. the tion of care in order to reduce unplanned capitation rate is also based on risk. but (1995) defined capitation specifically as “pre. health promotion. Kongsvedt care organizations besides HMOs exist. within specific limited resources. In other situations. Capitation costs from the current fee-for-service systems can also be defined as a fixed payment per and through capitation to improve the quality health plan enrollee being paid to a provider and coordination of care across the con- for a defined set of services for a prescribed tinuum. Capitation culated on the capitation equivalent of aver. POWEL for an enrolled population. Awareness of the value of and vary according to the age and gender prevention. a blended capitation month (PMPM rate) for each enrolled mem. the challenge for all these provider organiza- payment for services on a per member per tions is to remove inefficiencies and reduce month (PMPM) basis” (p.. from the staff nurse in acute care or provider organization (based on actual or to the home health nurse to the primary care existing data for the population of interest) nurse practitioner. for inpatient or institutional care. Any excess revenue vices. affects nurses in all care settings across the age fee-for-service revenues of the provider continuum. 1996). able to save health insurance premiums by pensation to capitation for services and to reducing unnecessary hospital admissions negotiation of reduced payments to health. aged care and challenges to manage care tive agenda is no longer relevant. or on specific conditions such as use New nursing roles of case management and of illegal drugs. Under capi. They proposed .

an important issue is educating ers (such as advanced practice nurses vs. Despite the importance of CHD. the majority of cases of HF are attributable Use of information systems to obtain data to CHD with approximately 22% of men and related to costs and other outcomes from or. ELBERSON PMPM). etc. variability of interventions or pro. 38% of women will die within 1 year of their ent characteristics that influence outcomes of MI (AHA). and patient/provider satis. with 84% of quality outcomes (functional and clinically all CHD deaths in those 65 years of age or relevant changes) in the client and client satis. These companies desire cause of death in the elderly. phy. Nonetheless. coronary heart disease (CHD). the provider or provider prevalent form of CVD is HTN. risk. Finally. assessment of risk for population-based care More current literature suggests that pro- and determining the appropriate capitation viders are turning to fee-for-service charges based on variability within different popula.). practicing nurses. Cardiovascular Disease tween hospital and home or the use of case management models to reduce inappropriate Cardiovascular diseases (CVD). Risk adjustment of outcomes is complex valvular dysfunction and other conditions. The Outcomes research is of great interest to man. The Second World Assembly on Aging . of CHD. Although the most client characteristics. sicians). Community health assessment per. cost. older (American Heart Association [AHA]. 2002). gender. but must be addressed in variations research. and cli. which in- utilization of care. current nurse researchers. The rapid increase in managed care or- costs. sudden death and myocardial a cost-effective manner. the different uses and types of providers or processes of care needed to achieve required PATRICIA HINTON WALKER outcomes at a particular price (capitation rate UPDATED BY KAREN L. and capitation is of paramount importance. (Dalzell. Finally. heart failure (HF) are major contributors to Nurse researchers may study the client and mortality and morbidity. (age. ganizations and systems has introduced new faction). the majority system. of CVD deaths are attributed to CHD. cost savings. 46% of women disabled by heart failure post- ganizational databases must be addressed. to make up revenue lost under capitation tions. prevention and management of CHD are only tion and use of proxies to handle missing beginning to be studied in the elderly popula- data is a relevant issue for health systems tion. Cardiovascular Disease 49 an outcomes model (based on the work of researchers who study the impact or effective- Donabedian) that allowed for measurement ness of capitation in the context of man- of variability related to client or population aged care. specific interventions. care. Variations research infarction (MI) are the major manifestations is an attempt to control confounding vari. terms and concepts into medical and nurs- Research related to capitation may involve ing language. even though formed by community health nurses may be health care on a fixed. and they want them in 2001). clude stroke. Although HF may result from care. per-capita budget has used for these types of assessments. Angina. Research lost favor of late. arrhyth- The unit of analysis in research related to mias. and qual- cess of care. variability of provid. 2002). The issue of decisions related to data substitu. MI (AHA). hypertension (HTN). or outcomes. severity of illness. Twenty-five percent of men and ables such as risk. for example. prevalence and incidence of CHD increase aged care companies that are implementing dramatically with age and CHD is the leading capitation models. transitional models of care be. many trends are cyclical related to capitation may involve study of just as this trend may be (Dalzell. and future students in the risk. faction with the care. and variability in outcomes of ity issues related to capitation in managed care (which may include quality indicators. the research may focus on the cost savings of a particular intervention.

and the role of conven.. as well as identifying new risk following MI. along with reasons for any 2003). ination of guidelines for primary prevention brinogen levels. Much of our cur. Large multicenter hypertension trials discrepancy. agement of diet and exercise may pose special uals. recent trials of lipid-lowering agents have a survival benefit—ACE inhibitors. care can be targeted. Nursing also has an important role elderly individuals. Man- studies conducted with non-elderly individ. Efficacy of monitoring for compli- cardiac risk factors. and methods to prepare individuals tional cardiac risk factors remains controver. studied. psychosocial factors is warranted. consideration of Guidelines. have not been widely risk score in the Framingham Risk Profile. HTN. however. however. 2003) do not make guidelines cial influences. Discrep- patient management of cardiac risk factors is ancies between other medications known to limited. ducing risk of CHD (Puddey. therefore. within a sial. with increasing age yielding a higher risk factors. drug interactions is increased in the setting demia (Adult Treatment Panel III [ATP III] of polypharmacy.50 ENCYCLOPEDIA OF NURSING RESEARCH in 2002 addressed the international issue of of aggressive hypertension treatment in re- supporting patients in both primary and sec. which may contribute to con- specific to different adult age groups. along rent knowledge. Knowledge of diabe. Al. Awareness of prognostic factors can alent (ATP III). Psychoso- banian et al. In addition. quitting smoking. Although coronary revasculari- have also begun to demonstrate the efficacy zation procedures—angioplasty or bypass . lowering agents—may also exist and need to bidity and mortality (Mostaghel & Waters. be documented. medications to treat hypertension CHD and subsequent MI are potentially and lipid abnormalities may not be well-toler- preventable conditions. obesity. Glad. however. and younger adults are classified by their risk which may be affected by control of cardiac factors. uals who are eligible for aspirin or beta- term outcomes. 1997. The recent publica. as well as to long. delivered to. Chyun et younger and elderly individuals regarding al. such measures (Williams et al. not only or weight reduction are not yet established to the public. 2002). term mortality so that interventional nursing and death following MI. 1997. Many individ- ment of CHD and MI. of prognostic factors for short-term mortality Age-related differences exist between is available (Normand et al. preventive interventions. and smoking need to be determined. cations. shortened hospital stay.. HF. studied in the elderly population. although information regarding these medications upon discharge. Finally. Older trol cardiac risk factors. and a beginning understanding factors specific to the elderly population. is limited. is still based on with side effects of these interventions. Nevertheless. 2002). 2001) and hypertension (Cho.. teristics that contribute to better risk factor tality and morbidity in both middle-aged and control. Levels of physical ac- appear to be warranted (Kannel.. exercising of CHD established by the AHA. blocker therapy following MI do not receive Secondly. Identifi- ondary prevention of CHD and HF that are cation and evaluation of the efficacy of other so prevalent in the geriatric population. tivity and control of lipids. Diabetes is also associated assist in identifying patients at risk of short- with an increased risk of recurrent MI. need to though control of hypertension and dyslipi. however. diabetes mellitus is a preva. 2001). dish & Rajkumar. Research aimed at prevention must address Advanced age is known to be associated the importance of established risk factors in with an increased risk of in-hospital death the elderly. and quality of life. ated and the potential for side effects and tion of the standards of care for both dyslipi. as well as individual charac- demia have been shown to reduce CVD mor. sessed in high-risk individuals. and their caregivers for discharge. lipid have demonstrated a beneficial effect on mor. but to health care providers in the elderly. be documented. challenges. the efficacy of other mea. in studying methods and adequacy of dissem- sures such as lowering homocysteine and fi. and as- tes management in relation to the of develop. and is considered a CHD equiv. need to be lent problem. 2000).

need to be identi. Pasquali. Despite im- ences (Stuart-Shor et al. has derly (Lavie & Milani. pression. both can be greatly improved through Older age has consistently been associated exercise rehabilitation. Educational strategies directed specifi. the stantial mortality and morbidity associated majority of older adults report having no reg- with CHD and MI. 2001). Bar- tested. focusing on coordina- . con. activity is central to management of CHD. 1995). Williams. bilitation have not been well defined. exercise tolerance and assist in control of car- 2002). The reasons term outcomes. therefore. Al. however. anxiety. information on post-discharge factors diac risk factors. walked a mile in the past year. de- are crucial prior to much-needed interven. gram. which has been linked to explored and strategies for improving access mortality require further study in the elderly and maintaining participation tested. Normal age-related higher levels of functional disability in the changes in the elderly also appear to affect elderly.. yet only limited infor. associated with decreased quality of life and and early functional limitations or mild im. been shown to predict subsequent functional nursing research is also needed to document dependence (Gill. & Peterson. Potential psychosocial ular exercise and most report not having factors that may contribute to poorer long. Therefore. Subjects at risk of management of underlying CHD. and fol- important prognostic factor after MI. population with CHD. 2003). older age has been shown to be after adjustment for other prognostic factors. diastolic. ization for acute MI or revascularization may prior to loss of function. therefore. despite mal systolic function. Cardiovascular Disease 51 surgery—are being used more frequently. 1997). re. These data provements in functional status. rather than systolic function. and economic factors. even lowing MI. mobility. Mendes de post-discharge complications and long-term Leon. few studies are that may have contributed to these outcomes. psychosocial. including exercise though acute MI-related prognostic factors rehabilitation. and CHF—following MI. such as the impact riers to participation. related to the development of HF despite nor- yet it has not been widely studied. a decrease in functional capacity. Alex- not been documented. sumption. Prevalence of HF in the elderly MI popula- Functional status has been shown to be an tion increases with increasing age. the elderly. are referred to and adverse outcomes. low levels with poorer long-term outcomes—death. While mul- pairments that are not evident clinically have tidisciplinary teams. that special efforts be made to overcome ob- Angina and psychosocial factors may con. but cally to the needs of the elderly and their probably result from a combination of physi- caregivers also need to be identified and cal. as well as link the individ. Functional loss appears to be pro. In addition.. Nor is it should be strongly encouraged to participate known what factors contribute to or prevent in exercise-based cardiac rehabilitation and successful CHD management in the elderly. at outset should not prohibit participation. available that address these issues in the el- as well as to use of health care services. participation in a cardiac rehabilitation pro- lowing discharge. It is unknown how ander. and enroll less frequently than younger indi- mation is available on these possible influ. that individuals do not enroll in cardiac reha- fied. Hospital. or if they and it is recommended that men and women participate in cardiac rehabilitation. Cardiac rehabilitation. Although physical patients manage their cardiac condition. mance and functional status may influence ual to a cardiac rehabilitation program fol. functional decline may be identified early. 1995. health care resource con- tional studies aimed at decreasing the sub. factors. Although physical perfor- CHD management. has been shown to improve are beginning to be identified (Chyun et al. viduals (Lavie & Milani. need to be of functional status. HF is ceeded by a decline in physical performance. tribute to long-term management of CHD particularly elderly women. and mortality with exercise. current MI. trol specific cardiac risk factors. so that interventions provide the only opportunity to maximize may be targeted. & Tinettit. stacles to entry and participation.

The most recent revision of these rioration in clinical status. on available epidemiological and clinical tient satisfaction. Coronary heart disease (CHD) is a major above optimal (100–129 mg/dl). 2004.. (ATP) issued the first guidelines for identi- Grady et al. Topol. the National Cholesterol Education al. 2004. Venner & Solitro-Seelbinder. Program (NCEP) Adult Treatment Panel Naylor et al.. 1994. Atherosclerotic-CHD processes acute coronary event) was associated with begin early in life and are influenced over time improved cardiovascular outcomes and by the interaction of genetic and potentially raised questions regarding the currently es- modifiable environmental factors including tablished cutpoints for LDL-C (Cannon et health-related lifestyle behaviors. In 1988. such as use of structured exercise continues to focus on LDL-C as the primary programs.52 ENCYCLOPEDIA OF NURSING RESEARCH tion of inpatient. Results of very recent clinical in men and women in the United States. guidelines (Executive Summary of the Third etary and fluid adjustment. As HF will con. 2001). lipid abnormalities are diagnosed and ity of life. Additional interventional studies confirmed that lowering LDL-C was im- are needed on management of common prob. target of risk reduction therapy.21 mmol/L) DEBORAH A. the major atherogenic percholesterolemia in children and adoles- .. referred to as ATP III. treated. al. length of stay. of CHD. lesterolemia. With continued emphasis on identi- failure (Hunt et al. Nissen et al. Stanley & Prasun. ATP derly population. nursing research should fo. di. and em- for HF. a new staging system expands the phasizes therapeutic lifestyle change (TLC) continuum of care to encompass prevention and pharmacological therapies for reducing and includes screening and treatment targets individual risk and the public health burden for people at high risk for developing heart of CHD. is recognized as an independent risk gram (NCEP) has not revised the 1991 defini- factor for CHD. high (160–189 mg/dl). cholesterol-lowering therapy. strategies. LDL-C levels are categorized as fol- Cholesterol lows: very high (≥ 190 mg/dl). fication of individuals at risk and more atten- tinue to be an important problem in the el. 2001). Hypercho. 1996. considers with the recent publication of new guidelines other lipid and nonlipid risk factors. In addition.. and prognostic factors fying and managing hypercholesterolemia in for readmission have been identified. elevated serum total cholesterol The National Cholesterol Education Pro- (TC). social support. CHYUN for individuals 20 years of age and older. Throughout the past 16 years.. portant in primary and secondary prevention lems in this population—monitoring for dete. medication. 1995. Report of the National Cholesterol Educa- and noncompliance—as well as in innovative tion Program. Low-density lipoprotein tions and guidelines for management of hy- cholesterol (LDL-C). 2000). 2002. III incorporates numerous roles for nurses cus on evaluating nursing interventions that and nursing across health care settings where reduce hospital admission and improve qual. results mains the leading cause of hospitalization in of numerous randomized controlled trials the elderly. and optimal cause of morbidity and premature mortality (< 100 mg/dl). adults.. ATP III continues to define hypercholes- JESSICA SHANK COVIELLO terolemia as TC ≥ 240 mg/dl (6. the trials suggested that LDL-C lowering beyond industrialized world. tion to adherence-enhancing strategies. in HF management. and quality of life (Rich et data. self-care knowledge. typically constitutes 60%–70% have demonstrated positive outcomes in of serum TC and is the primary target of terms of functional capacity. based readmission rates. and many developing 100 mg/dl in secondary prevention (after an countries. outpatient and home care lipoprotein. pa. HF re. borderline high (130–159 mg/dl). TC levels of 200–239 mg/dl are considered borderline high and < 200 mg/dl is considered Cardiovascular Risk Factors: desirable. 2004).

Results of a very recent secondary ≥ 140/90 mm Hg or on antihypertensive med- prevention trial suggested that early and con- ication). Variations in serum TC. diabetes) (Cannon et al. however. risk status. for adolescents with diabetes. the percent probabil. TLC diet include viscous fiber. hypertension (blood pressure turi. mately 15% of total calories from protein are LDL-C levels are targeted as the basis for recommended. years or older. Similar to adults. tributed to individual differences in biological C. nutrient [HDL-C]. In a meta-analysis of clini- ity of having a CHD event in 10 years) are cal trials.000. ATP III recommends the use of HMG- The Framingham projections of 10-year CoA reductase inhibitors (statins) as first-line absolute CHD risk (i. plant stanols/ stone of treatment. 2003).. increased out (and beyond) the duration of pharmaco- physical activity and normalization of body therapy. high-density lipoprotein cholesterol mechanisms. 1999). He. and soy protein. and triglyceride) should be ob. Less than 200 mg/ (170–199 mg/dl).e. LDL. Important components of the TLC ican Heart Association’s (AHA) recent diet are saturated fat (less than 7% of total guidelines for primary prevention are consis. the average reduction in clude: presence or absence of CHD and other LDL-C was 28%.. both calories from carbohydrates and approxi- lipid and nonlipid risk factors are addressed. cal agents currently used in treatment of dys- The intermediate risk category (10-year risk lipidemia in adults include bile-acid binding ≤ 20%) includes multiple (2+) risk factors resins. and fibrates. Relatedly. the type risk category (10-year risk < 10%) includes and dosage of agent to be used. family history of premature CHD. niacin. and adherence tained once every 5 years in adults aged 20 over time to the prescribed dietary regimen. ciga- ide averaged 13% (LaRosa. Other pharmacologi- has a goal of LDL-C defined as < 100 mg/dl. . Cardiovascular Risk Factors: Cholesterol 53 cents in the United States. risk determinants in- 5 years was 20%. A basic principle of prevention The first priority of pharmacological ther- is emphasized throughout ATP III: the inten. risk). 30. and age (men ≥ tinued lowering of LDL-C with an intensive 45 years. therapy are based on the individual’s baseline The cornerstone of treatment for hyper. 2004). diovascular events than a standard regimen cal forms of atherosclerotic disease. LDL-C levels ≤ 110 mg/ sterols. the Amer. elevated TC (≥ 200 mg/dl) day of dietary cholesterol. polyunsaturated fat (up to 10% of tent with NCEP definitions: acceptable TC total calories) and monounsaturated fat (up (< 170 mg/dl [4. Normally. The category lipid-lowering (statin) regimen provides of highest risk (10-year risk > 20%) includes greater protection against death or major car- CHD and CHD risk equivalents (other clini.4 mmol/L]). and the decline in triglycer- clinical forms of atherosclerotic disease. TLC continues through- phasis on dietary modification. baseline TC levels. the average reduction in TC in over used to identify and risk-stratify individuals. the patient’s response cholesterolemia and other lipid abnormalities is evaluated about 6 weeks after starting drug is therapeutic lifestyle change (TLC) with em. women ≥ 55 years). middle-aged men followed for over In addition to LDL-C. apy is to achieve the appropriate LDL-C goal sity of risk-reduction therapy should be ad. Decisions to initi- and has goal LDL-C as 130 mg/dl. & Vuppu- rette smoking. Other key components of the treatment decisions. LDL-C < been observed in males and females across 100 mg/dl is recommended for children and the life span. and the sched- 0–1 risk factors with LCL-C goal of 160 ule for monitoring individual response to mg/dl. low HDL-C (< 40 mg/dl). therapeutic agents. (as defined by the individual’s category of justed to an individual’s absolute risk. and TLC is the corner.. the lowest ate LDL-C lowering drug therapy. ATP III recom. therapy. Considerable varia- dl are considered acceptable for children and tion in response to dietary modification has adolescents without comorbidities. 50–60% of total (Kavey et al. example (ranging from 3% to 14%) are at- mends a fasting lipoprotein profile (TC. weight. borderline TC to 20% of total calories). calories). composition of baseline diets.

burnout in various illness populations such search build on and extend current programs as cancer care with home chemotherapy. car- of nursing and multidisciplinary research fo. Hayman. veals potential problems they experience. Di- Assessment and management of hypercho. 2002). The caregiver’s treatment. pectations for themselves and from others ical practice. however. taining decision making among appropriate tion. Directions for future re. 2002). Because the caregiver by definition is laden The term caregiver is defined as an individual with tasks and expectations. clude designating others to assist with patient tion. Sales.. the provider. secondary prevention of CVD across the life 1991). Usually lipid risk factors. medications. resolving uncertainty or guilt. releasing tension.54 ENCYCLOPEDIA OF NURSING RESEARCH Consistent with recommendations of the and does not receive monetary compensation 33rd Bethesda Conference on preventive car. and the suddenness and are optimized with case management by amount of the change in the patient’s need for nurses within the context of a multidiscipli. a caregiver is a person who not only performs Schron. housekeeper. rect patient care encompasses much more lesterolemia and other lipid abnormalities is than physical care. In addi. giver burden and negative outcomes on care- . pro- identifies and targets adherence-enhancing viding physical. social. symptoms. helps with a patient’s that the major area of research has been care- physical care. treatment outcomes illness severity. Delineating the role of the caregiver re- emia and other lipid abnormalities. & Schultz. including ATP III and the health care professionals (Smith. typically lives with the patient. diac rehabilitation. and technical care) but also ad- of the individual patient. financial interventions that consider the characteristics management.. exchanging information. consider both lipid and non. Pasternak. it also necessitates learn- an important component of both individual/ ing an extensive amount of information high risk and population-based approaches about illness. whether as breadwin- and emphasize TLC as the cornerstone of ner. LAURA HAYMAN grieving the loss of the health and personality of their loved one. and providing positive Caregiver regard for those with whom they interact. Caregivers also have numerous ex- strategies for effective implementation in clin. caregiving have been predictive of caregiver nary team approach. gencies and be capable to respond. Current evidence. nological treatments. sonal responsibilities. The caregiver ment by nurses within the context of multidis. Caregivers also must be prepared for emer- dren and youth. tech- to CVD risk reduction. around them to perform various psychosocial tasks such as coping with changes in role. & Dunbar-Jacob. systems and society as a whole. role is often anticipated in relationship to el- ciplinary team approaches is considered an ders. for the help.e. it is no wonder who assists ill person(s). the patient’s individual’s risk status. and cused on innovative models for primary and dementia victims (Biegel. muscle deterioration. 1995). Therapeutic regimens including relationship with the patient. AHA primary prevention guidelines for chil. and how to relate to based guidelines. and main- family-based approaches to CVD risk reduc. to therapeutic regimens for hypercholesterol. span and with emphasis on both quality and The indirect familial caregiver tasks in- cost as outcomes (Allen et al. or both. A more descriptive definition of diology (Ockene. minimal data exist regarding persons. the caregiver’s pharmacotherapy and TLC are based on the age and life developmental stage. spiritual. current recommendations emphasize care. and vocates for the ill person within health care systems of health care delivery. Case manage. target LDL-C in algorithms the caregiver must also maintain their per- for assessment and treatment considerations. yet rarely is there preparation for care- integral component of increasing adherence giving to one’s child or one’s spouse. ATP III common caregiver responsibilities (i.

included logical. Handler. Kleinbeck. of depression. 2002). & Pingree. and cardiovascular Martini et al. Kochinda. giving skill. demographic in. Policy and Research [AHCPR]. et al. peer support. For example.. Caregiver 55 givers’ physical. The state of the sci- vice use (Smith. wound healing. Wilkinson & sulting in complications and high health ser. social sup. & Given. experts. & Jackson. 1996). 1994. Nursing interventions have The majority of burden studies have been been found efficacious for caregiver problems descriptive and correlational and have re. and group with common problems (Shaw. & Martire. 2002). more successful problem-solving algorithms 1995). tion. 2002. information. pectations. pects of caregiving is being conducted by multi-perspective (psychological and physi- Smith under the concept of caregiving effec. Howard & Malone. immune status. Lustig. The tial and caregivers’ ability to solve problems Cochrane review and randomized trial results can avert patient problems (National Family concur. Di- greater fatigue. Given & Given. all tailored to a specific family provision of technical. 2002). 2002). include counseling.. 1998). coping. health services used resulted from patients’ ker. Effective caregiving is defined as booster repetition.. attitudes. easily-remembered steps. progressive decline (Col- function. high-qual- Numerous variables (e. Gustafson. Pace. Schultz. mental. 1991).g. Schultz & yet unverified approach is to provide guide- Beach. These interventions that are often measured as illness demands. social isolation. These caregiver prob.. yet only a handful of studies on prob. quality of life. ing and develop skills for solving stressful lems directly influence patient outcomes. A step-by-step approach is an essential care- vation with daytime sleepiness. Smith’s ence report on computer-based algorithms (1994) research indicated caregivers’ motives that aid patients to make step-by-step deci- for helping consistently explain variance in sions about treatment options concluded that their depression. 2003. lins.. emotional care that results in optimal patient McTavish. step decision aids had realistic treatment ex- 2000). catheter infections) Research should continue on the cultur- while maintaining the caregiver’s health and ally-related aspects of caregiving strategies . Federal Interagency Forum on Aging. Smith. cal) information. and financial health. adding that patients with step-by- Caregivers Association. health and quality of life and minimal techno. The lines to manage specific caregiving problems majority of caregivers experience depression. sleep depri. Wang. Step-by-step guidelines on com- cient use of family resources (Fitzgerald. use of algorithms (Agency for Health Care Problem-solving ability is lauded as essen. ity internet information. 1998. there is a dearth of port) that have been studied in relation to research on caregiving with lifelong technol- caregiver experience are influential yet not ogy dependence that begins unexpectedly in universally predictive of caregiver burden middle life (when teenagers and elder family (Biegel et al. 2000). Mynors-Wallis. long-term access. The most widely recommended clinical 2000.. Silver & Wellman. Research across disci. physical. and lower (Smith. 1996). Yee. 2000. & Par. Stommel. and ineffi. Hawkins. financial strain. caregiving and complex tech- acteristics of the care needed by the patient nology problem solving. and tiveness. logical side effects (e. Boyle. 1999. 1994). sleep deprivation.. mortality. social isola- sulted in identification of multiple factors rec. Unique research on the positive as. disease) (Beach. (Schultz. re.. developmental stage. 1998. satisfaction with care. The all had positive outcomes (Roberts et al. puter algorithms can guide systematic think- 2003.g. and contacts with formation. problems (Smith et al. 2002). members also need assistance) and continues plines identifies significant negative health on a trajectory of intermittent disease exacer- outcomes of caregiving (reduced physical bations and slow. and quality of life improved knowledge. and lack of access to evidence-based ognized as being significant for burden: char. and low- lem solving in caregiving were found and not ered anxiety (O’Connor et al. Schultz.

reviewed the research related to Watson’s theory of human caring. doing for. El. Smith (2004) the developmental life stage of the caregiver. In the U. the concept. as an ontology. anthropological (meaning of being a care of people with cancer. 1995). fied five processes by which caring is enacted: tions may reduce caregiver stress in a limited knowing. body of knowledge that can be referred to as Another contemporary focus in caregiving re. ethic of caring) questions to fully understand liott. summarized and categorized the research re- tivation to help (Smith. She in which burden and supportive interventions also defined caring as an ethic or moral im- have been studied. or a quality givers has come from the literature on aging of consciousness that potentiates healing. 1994a). the humanity of the person is preserved. Watson (2001) defined caring Historically. The studies 25 years theory and research on caring have were categorized into five levels: the capacity grown steadily. perative for relating with the other in which clude teaching mastery of caregiving tasks. contributing to a substantive for caring (characteristics of caring persons). being with.” protecting not only the hafer (1990) argue for a multidimensional patient but also the caregiver. extends to friends. whom one feels a personal sense of commit- comes of many of these intervention studies ment and responsibility” (p. . (Smith CE. 1995). In some ing literature as: (a) a human trait or condi- countries giving care is a way of life that tion of being human. and society. (b) a moral imperative.56 ENCYCLOPEDIA OF NURSING RESEARCH used in various ethnic groups (Picot. SMITH signs and methods have been used to investi- HELEN A. et al. and quasi- experimental designs using standardized Caring scales and physiological measurement. and books on caring pub- cept in the discipline of nursing. In the past lished between 1980 and 1996. In addition to the care. This term is translated analysis of caring theory. is an example of caring person). approach that poses ontological (meaning of Share the Care. both to the patient knowledge about caring is key to understand- and in support of the primary caregiver ing human health. (d) an interpersonal interaction. caring science. chapters. Interventions tested in. 1993b) and mo. ing way of relating to a valued other toward vices such as counseling and respite care. Swanson (1999) reviewed 130 databased Caring has been identified as a central con. While criticism has been levied search should be the caregiving family. a program designed for the caring). and ontical (function and mantlezork (Lakey. as against this body of literature for its lack of research has clearly indicated that multiple conceptual clarity. & Rajotte. Boykin and Schoen- as the “care cloak.. 165).S. surveys. and quality of life. the interven. 1996). One analysis (Morse. healing. In (c) an affect. enabling. Warnock. articles. a way of being. lated to caring in nursing science and Sher- search is needed to test more interventions wood (1997) reported a meta-synthesis of the and match the timing of the intervention with qualitative research on caring. SCHAAG gate caring including descriptive qualitative designs. caring have been published. She identi- indicated that in the short term. the caregiving neighborhood elaborated five perspectives of caring in nurs- or parish should be a focus of study. and way but the burden returns when the inter. In another to define caregiving. research on the topic of care.. there seems to be a grow- members of families are involved in providing ing international consensus in nursing that direct and indirect care. Singh. neighbors. Out. the Netherlands the term mantlezork is used and (e) a therapeutic intervention. Swanson (1999) source management (Smith. maintaining belief. Bottoroff. phenomenology. ventions cease. Research with midlife caregiv. social interventions such as support groups Swanson (1991) defined caring as “a nurtur- or telephone contacts. Three reviews of the research literature on ers reveals the need for interventions on re. Further re. and direct clinical ser. 1991) giving family. Many different de- CAROL E.

conditions the “taken for granted” nature of the instru- (what affects. enhances or inhibits the occur. and (e) the Caring Efficacy Scale were identified as person-centered and tech. In her summary of 30 qualitative tivities impact mood following miscarriage. It is important to note that while ories and other nursing conceptual systems patients rank behaviors such as knowledge (Watson & Smith. Watson’s (2002) compendium of instru- nity. Q-sort (CARE-Q) to measure perceptions of oblivious. International Journal in Human Caring pub- ing in nursing practice and education. fear. and therapeutic or healing outcomes. and evaluating outcomes of car. (d) the Nyberg Caring Attribute process. but patients do. and outcomes of caring for the recipients of care even blood pressure. studies that described outcomes of caring and patient satisfaction. nurse caring behaviors as perceived man Caring (IAHC) meets annually to dis- by clients and nurses. lished between 1988 and 2003 that focused The future of research in caring is promis- specifically on Watson’s theory of transper. enhanced ments to assess and measure caring is an im- healing. were: emotional and spiritual well-being (dig. and caring consequences (outcomes of Research is indicating that caring-based ac- caring). desperate. knowledge. This text pro- and feeling out of control. (CES) to measure the belief in one’s ability nical-physical. Important research and technological competence as the most questions center on the relationship between important nurse caring behaviors. (c) qualitative studies revealed four patterns of the Caring Behavior Assessment Tool (CBA) nurse caring: interaction. Scholars are examining the nurse caring behaviors as perceived by clients transtheoretical linkages between caring the- or nurses. measure patient perceptions of nurse caring Caring was defined within content. Caring 57 concerns and commitments (beliefs or values iors. the qualities of rank behaviors such as presence. caring actions (what caring differences. An international community of scholars sonal caring. human experiences and seminate the work of its members and the caring needs. and the Caring Assessment Tool (CAT) to tional response. ing. An expanding area of research means to nurses and clients and what it looks is related to evaluating outcomes of caring. Scale (CAS) to measure caring attributes of Two types of caring knowledge and skills nurses. Four major categories of re. frightened. like). mental activities by nurses might explain the rence of caring). self-control. nurses caring and healing outcomes. Nurses who care tions of work in which they were used. portant contribution toward the advance- quences of noncaring were humiliation. well-being. The lishes research and scholarship that expands highest number of studies were focused on caring science. and report a sense of personal and professional a copy of the tools. and enhanced relationships. These petencies and types of nursing therapeutics differences suggest that nurses do not con. that are caring-based. inten. honoring a caring consciousness. 2002). the ontological com- dignity. pain and symptom dis- noncaring relationships Swanson found that tress in patients with cancer. and the types of envi- sider competence with medical and technical ronments and communities that facilitate car- skills within the realm of nurse caring behav. and worn nursing caring behavior. and vulnerable. context. depressed. ment of research in the field. personhood). and therapeutic outcomes. and touch as most important. behaviors. to express a caring orientation and develop Smith (2004) reviewed 40 studies pub. Conse. helpless. Nursing is the discipline that is studying . vides background on 21 instruments. (b) the Caring Be- down. Patient vulnerability and that underlie nursing caring). Some of these tools are: satisfaction and fulfillment while noncaring (a) the Caring Assessment Report Evaluation is related to outcomes of becoming hardened. havior Inventory (CBI) to measure that which Sherwood’s (1997) meta-synthesis of 16 is associated with the process of caring. caring relationships. ing. The International Association for Hu- caring. cita- alienated. is actively building knowledge in caring sci- search were identified: the nature of nurse ence.

community. cluding rehabilitation and vocational coun- partments and outpatient clinics). Swanson. and insurance case management (Cesta & Ta- based centers. others see it as a process or oping clinical trials to test the effectiveness an approach to better care delivery and out- of caring-based therapeutics in promotion of comes. and how these relationships the discipline that employs it. Ritenbaugh. UPDATED BY MARLAINE C. God. pends on the setting and model that is used. health insurance organizations. core the fact that CM has been recognized as an functions identified are integration of care effective and desirable approach to care deliv. & Watson. etc. addresses the logical model for studying caring (Quinn. main issue(s) at that point in time. which resulted in the ab. 2003). coordination of services among providers. zation. subacute. and which professional variables that may confound the links be. seling). all share similar SALLY PHILLIPS aims: to improve health care delivery (access. and con- trol or reduce costs. There are multiple case management mod- els in use today. eliminate fragmen- tation and duplication of services. Some health- moving from studying the individual as unit care professionals view CM as a patient care of analysis to studying aggregates. tivities/elements of CM practice. who is best to assume the ity. There also sures of caring capacity. there continues to be little consensus and direct delivery of services to meet patient as to what CM is. identifying and measuring the competing case manager’s role. social case management. and the type affect health and healing outcomes. friends. on one episode of illness/care. it grates these multiple perspectives and ways tends to be narrow. long-term. however. those who ent outcomes of caring theory-based models assume the role of the case manager. when CM is viewed as a delivery ing questions in the field. It will be of personnel used to accomplish the functions important to study both caregiver and recipi. disability case management (in- acute. example. Multiple ways of system. primary care case manage- Case management (CM) is a growing patient ment. and devel. Research needs to move beyond The literature contains multiple definitions examining caring in nurse-patient relation. place in a specific care setting. as an approach to care or a process.58 ENCYCLOPEDIA OF NURSING RESEARCH the relationship between caring relationships sence of a standard or universal definition. examining the effects exists considerable confusion regarding what of nurturing and experience on caring capac. Different designs and in differences in the scope of CM practice. Models include private Case Management or independent case management. chronic care. This difference in perception results health and well-being. For methods must be used to capture the emerg. and takes Smith. and quality). 1997). telephonic case mented in almost all care settings including management. discipline owns or should own the account- tween caring actions and their outcomes. uum of care focus that transcends beyond quired to explore all dimensions of caring one care setting or an episode of illness. and palliative/hospice. How- phenomena. Swanson There is no clear agreement in the litera- (1999) offered several suggestions for future ture about the definition and component ac- research related to caring: developing mea. SMITH continuity. nursing case management. needs efficiently and effectively attending to . and focuses of knowing may be the preferred epistemo. of practice in different settings. ery for the patient and the health care organi. A model of research that inte. advanced care delivery structure that has been imple. ability for the practice of CM. (Cohen & Cesta. Despite han. Regardless of the model. that is. its scope is wide and entails a contin- knowing from empirics to aesthetics are re. practice case management. for CM. across the continuum. worker’s compensation. ever. short-term. and each definition frequently de- ships to caring in relationships with family. delivery system. consumer advocacy. ambulatory (emergency de. 2003). constitutes CM. and healing.

monitors. However. Around of care that may be used as one strategy to the turn of the 20th century. . case management has become a When attempting to define CM. the demands of the prospective payment sys- It is a participative process to identify and tem. Case services by the first Board of Charities in Mas. monitors use of patient care services keep veterans out of the hospital (Tahan). integrates and coordi- Major emphasis in the past was on the nates clinical services. 1998). 3) the proliferation of managed care. 2002) tients and resources in a cost-conscious and quality health care delivery system. in relation to the challenges of managing pa- (CMSA. one must dominant and desired approach to care and examine the views of two professionally cred. . This case management model empha- facilitate options and services for meeting sized early assessment and intervention. . an individual’s health needs through com. coordinates. cost savings in the context of market-driven ible and leading groups in the delineation of health care reform. collaborative practice. CM branched priate hospital length of stay and access to into the area of mental health especially to services. Although Case management as a concept and role managed care and case management are used function is not new. implements. A collaborative process which assesses. to achieve effective management of care. while decreasing prehensive care planning. p. care in the context of interdisciplinary and vices to meet the needs of the patient or client. is a process sachusetts (in 1863) (Tahan. . Case Management 59 cost and the use of resources (Cohen & Cesta. more recently (especially since the 1997. the case management model of today focuses on . These are the enhanced the use of case management during American Nurses Association (ANA) and the the 1970s by way of funding certain commu- Case Management Society of America nity-based demonstration projects. Managed care can be described as a of CM in the U. However. The ANA defines CM as: the nurse case management model was first introduced in 1985 as a relatively new out- . 1999. and service system fragmentation and duplication of care and referrals to specialty providers (Cohen & enhancing quality. (CMSA). 1997). and effectiveness of health services. public health nurses. . Cesta & Tahan). manager assuming the role of the gatekeeper and evaluates options and services to meet of health care delivery and services. Case management and managed care are munication and available resources to pro. In the early 1990s and due to [ANCC]. It has been used by men. interprofessional collaboration. the use of CM control costs and inappropriate use of re- became popular in the public health sector sources and services in a managed care sys- and in community-based social work services tem. . two dominant concepts in discussion today mote quality cost-effective outcomes . and enhances patient . A dynamic and systematic collaborative growth of primary nursing and as a strategy approach to providing and coordinating to counteract the nursing shortage and meet health care services to a defined population. The use terms. qual- (in 1860). based on type of client. . com- individuals’ health needs. mid-1980s). (American Nurse Credentialing Center Cesta.S. hence. fosters continuity of recipient of care and the coordination of ser. Nursing case management provides out- in the form of “case coordination. nursing case management models increasingly be- The CMSA defines CM as: came interdisciplinary in structure. on the other hand. costs. it is tal health providers. and in coordinating public human ity. .” After comes-oriented care with attention to appro- World War II and in the 1950s. management. goes back to the last quarter general system of care delivery that has re- of the 19th century in the provision of care placed fee-for-service systems of care for im- for the immigrants by the settlement houses proved management of resources. The federal government the knowledge base for CM. cost-effective outcomes . with the case plans. and important to differentiate between these two social services for about a century.

The dominant research experimental or quasi-experimental designs. there seems to be a lack of base in CM practice and research methods. scope of services should be examined when ated with the design. to CM evaluation is the examination of cost process(es). processes of care (describing and differentiat- ity of the published studies are primarily de. Such confusion results from the CM models are rarely appropriately evalu- lack of theoretical underpinnings of CM ated. not an easy task. implementation. providers and emergency departments. The major. and outcomes of CM models is and quality outcomes employing perfor. Although in some the challenge of matching. access to care. and require the coordination of interventions or outcome measures/indica. outcomes of care that frequently include out- ing the effects of confounding variables (e. This efits of implementing CM strategies for the existing limitation may be attributed to the provision of care. i. process.. or cases structure. on outcomes. heightened. mised (Tahan. controlling for control and experimental ables are examined. 2003). con model frameworks. collection. 2003). and outcome vari. ment study designs. However. Such studies strong because of the lack of clear or stan. the ability to link these challenge of conducting a study that com- outcomes to the CM system has not been as bines the four types of variables. measures.” The dominant approach connectedness and relationships of structure. Examples may include decreased dence among multiple professionals includ. costly. Cesta & Tahan. a professional with specialized knowledge tors.e. The combi- it is evident in the literature that research nation of variables most commonly used is supports these goals and strengthens the ben. interdepen. especially be- cesses. can be approached by evaluation research. and sampling methods seem to be Designing a study that evaluates the inter- an “afterthought. The examination of these tions is dominant. comes indicators such as quality and cost denials and appeals management. 2003). enhance quality. evaluating the interrela. nonroutine visits to the results obtained. and control costs.. and . 2003). roles. randomizing. cance and utility of these studies are compro- 1997. or that integrate the different complication rate. clear theoretical frameworks that define the Other challenges are attributed to the confu- relationships between the structure and pro. Very rarely a combination of cost-effectiveness and quality care. theoretical underpinnings for these descrip. and outcomes. Therefore. quality. depending on the researcher conducting the The CM research literature shows that evaluation. The literature describing CM practice and Issues of cost. and evaluation of cause of the claim that they are implemented these CM models. variables is essential so that the implications sued the conduct of CM evaluative research of CM for health policy decisions can be to validate its value. Although these four variables is examined. ing CM models of care delivery) or on the scriptive in nature and tend to ignore examin. because of validating the value of CM.g. In definitions of the variables examined (Ta- most of the studies the research design. pro. the signifi. are also known to be complex. groups. cost and quality or access and quality. In addition. data han. studies are basically retrospective attempts at or qualitative methods. Nurse scholars have pur. and length of stay. which are defined as both cost and quality variables aspects of CM practice (Tahan. evaluating CM delivery models. such as readmission rate. structure. and its outcomes is focused on select areas associ. reduced hospitalization or re- ing the physicians) that may have influenced hospitalization rates. length of stay. Research related to CM mance improvement and outcomes-measure. quasi-experimental research is fre- tionships among the variables or how they quently used. time dardized definitions for either CM or CM consuming. sion of identifying the classification of the cesses of CM interventions and their effect variables studied. aims. or standard amined are loosely defined or measured. CM research may focus on the affect each other remains lacking. and in some instances the variables ex- practice. the absence of to improve access to care.60 ENCYCLOPEDIA OF NURSING RESEARCH and provider satisfaction (Cohen & Cesta. however.

Case Study as a Method of Research 61 consumer satisfaction. Research out attention to the specific structure (context of care delivery) and processes (tasks. the case-in- UPDATED BY HUSSEIN A. experimental. conducted ing ethical competence becomes as important within the context of the situation and exam- as clinical. Cohen and Cesta environmental characteristics. the ethics. 1986). fam- derserved populations. Data collection may be facilitated through about what a case study actually is. case study is defined significant issues related to the implementa. and history frequently use case study various models of CM require attention to as a teaching method. but works for. (c) resolving role con- ies from factual or interpretive to evaluative. Issues and Guba. ity to the unique needs of individual patients. is not a methodologic choice. affects practice and research is that of ethics. self-report study is described by some as a research instruments completed by those providing method (Yin. Disciplines such as nursing. examining a large aged by case managers. it has been difficult for educators to velopment of more sophisticated methods of clearly define core competencies of the case research. The level of analysis also var- (b) competing loyalties. Case studies must be conducted within the portant ethical issues are consumer advocacy. are educational preparation and ethical com. . element in defining and influencing the be- ers’ rights and safety are protected. flicts. a data collection CM services. R. istrative competence. (d) owning responsibilities to un- with the unit of analysis a single person. 236). descriptive. However. Today it is used practice arena continues to be changing rap. medi- manager and to be clear about the necessary cine. psychology. intellectual. Used as a research the structure of care. Another charac- . and the primary purpose of the because of the narrative nature of the case CM role. culture. less frequently in nursing because of the de- idly. financial. These issues impact the research study. it is often used as a qualitative method. and a reporting method (Lincoln & care provider agencies or payers. and (f) balancing care for others with appropriate self-care. atory. whom the case manager method. and admin.. and ensuring that consum. interactions (Bromley. the question of ensur. Case studies can be as simple as a single. sociology. or large data sets from health method. sonal biases. havior and experience of people. or explanatory. It is also used for hy- Another critical issue related to CM that pothesis testing and theory generation. Used as a re- dressed in practice and research as the role search method. and population man. . Case the use of patient questionnaires. not by methods tion of CM roles and research related to CM of inquiry” (Stake. designs and questions. anthropology. (e) identifying per- ily. Also. ining in-depth data about the background. and behaviors) of care that may influence the literature. community. or institution. To deter- mine if the conclusions of a case study can PATRICIA HINTON WALKER be applied to other situations. number of variables. level of educational preparation. Because this design for nursing research. and (1997) identified six challenges to be ad. but a choice of tions must be addressed. interpretive. activi- There are many references to case study in ties. but there is little agreement evaluation studies of CM practice. case study can be quantitative. case study can be explor- of case manager continues to evolve: (a) fidel. Thirty years ago case study was a popular petence of the case manager. context of the individual or group of individ- balancing access to care and services with uals because beliefs and values are an integral cost-effectiveness. case study is defined as an in- Because many case managers face competing tensive systematic study of an entity or enti- loyalties and priorities. by interest in individual cases. 1985). p. brief case or very complex. outcome Case Study as a Method of studies must not dominate the research with. depending on setting. TAHAN context must be delineated. Generally. Others argue that “case study considerations related to CM roles and func. ties with definable boundaries. Additional im. type of case manager. Two of the most object to be studied . 1994. 1989).

an explanation of the problem or issue and sources will be needed. there are few fixed formulas [for data analy- First. and explanation. To improve the rigor of the study. There are two basic designs in case study The standard measures of reliability and research. validity apply to case studies that are quanti- which is used when a case represents a typical. or revelatory case. Questions of what. Methods for guide the case study. transferability. which can contain tifies a plan for data analysis and reporting inferences about how these results fit with the the data. but most case studies include terviews. in. the intensive analysis involved whereby the reader can follow the research- in case study is appropriate to answer ques. the study. and phenomeno- The research process for case study design logical analysis.. Credibility of the in- the purpose of the study is theory generation. The protocol also iden. logs. “Unlike statistical analysis. etc. Multiple. The protocol may cesses surrounding the phenomenon under need to be modified as the study progresses investigation. from formal written narratives to sis must be clearly delineated. Methods for analyzing qualitative lem has been identified and a solution needs data include content analysis. . and a tentative time a detailed description of the context and pro- line for data collection. ten narratives. ety of ways. or event. p. . organi. Most case study zation. Clearly identifying the unit reports in nursing. how. The written product of case tion and the study protocol. and theory testing. R.or videotapes. . and care- why are appropriate for case study designs. the purpose and the research questions sis] . and own style or rigorous thinking . veloped. A discussion of the results is and problems emerge. . The protocol study is often artistic in its composition. existing literature and practice implications. such as why subjects coln & Guba. analysis can be an individual. family. critical. This helps identify as. videotape. Even though historical data about explanatory and descriptive studies. When ered to be trustworthy. tion. three the understanding of phenomena about principles of data collection are employed: which little is known. it is consid- terpretations from a group of cases. field observation. terpretations is supported by techniques such multiple-case design is appropriate. Other purposes of case study include audio. The case Data analysis in case study is not well de- study approach also can be used when a prob. analytic induc- to be found. narratives. and (c) an audit trail is evident For example. also included in the report. letters. description. The unit of creative montages of photographs. 1985). unique. should list how subjects will be recruited. When a qualitative study meets the extreme. . The data then can be (a) multiple sources of data are used. Case study reports are presented in a vari- At the outset of the study the unit of analy. ful consideration of alternative interpreta- A theoretical framework may be used to tions” (Yin. The first is the single-case design. er’s process from question to conclusion (Lin- tions of explanation. de- Multiple-case designs draw inferences and in. analyzing quantitative data are similar to sumptions that the researcher may have those in any quantitative study and would about the phenomenon at the beginning of depend on the research questions. documents. qualitative and often include both in the same One purpose of case study is to expand study. constant comparison. as triangulation of data collection methods.).62 ENCYCLOPEDIA OF NURSING RESEARCH teristic of case studies is that they are present. criteria for credibility. There are no rules or standardized ways to what constitutes data (documents. (b) a used to formulate hypotheses and plan larger case study base is developed using field notes. think or behave in certain ways. much depends on an investigator’s are developed. 1989. write a report. the entity being studied is included in the Data for case study can be quantitative or research. pendability. is similar to techniques used in other designs. and confirmability. tative. case designs also are useful to add depth to oriented. and arts and craft work. what re. however. the study focus is on the present. 105). are formal writ- of analysis has implications for data collec. studies.

Path analysis usually refers to a part of the indicator that cannot be explained model that contains observed variables rather by the latent variable is the error variance than latent (unobserved) variables and is ana. the terms exogenous and en- ture. and the final capture this uniqueness and afford a way to outcome variables. generally due to measurement. It is essential that the investigator model can be based on the observed correla- be open to the idea that there is more than tions in the sample. Exogenous variables are those whose DEBERA JANE THOMAS causes are not represented in the model. Because the mediating gain knowledge about human interaction and variables act as both independent and depen- behavior as it is situated within time and cul. Causal Modeling Causal models contain two different struc- tures. the causes of the endogenous variables are repre- sented in the model. The measurement model includes the Causal modeling refers to a class of theoreti. (observed variables). findings from empirically constructed models Case studies are essential to nursing be. statistical techniques the existing literature. programs such as LISREL or EQS. this practice is not recom- one “truth. and of how paths that are not theoretically defensible.” It is necessary for the researcher mended. Most causal models contain two or more cur. variances. A respondent’s sis. dogenous are used to describe the latent vari- ables. one of human beings. dent variables. Although the ambiguity. latent variables. and LISREL modeling to cause the observed responses on the empir- have slightly different meanings but often are ical indicators. The modeling. Causal Modeling 63 negative case analysis. Because nurses believe in the uniqueness stages. Path analy. case study is a method to or more mediating variables. cal indicators that are analyzed with iterative pretation with the participants themselves. and recommendations are sup. Empirically derived models capital- to be aware of his or her own assumptions. A causal model is composed of latent con- conclusions. When another person cannot overcome restrictions imposed by the is able to follow the researcher’s audit trail study’s design. structural equation modeling. The structural model specifies the relation- The other three terms generally refer to mod. cal or research evidence for the direction and searcher who is flexible and comfortable with sign of the proposed effects. gener. on the factor analysis model. The researcher con- dent. nomena within the context in which they oc. on the regression model. and checking the inter. lyzed with multiple regression procedures. their empirical indicators cal and methodological techniques for exam. Each of the endoge- . they have independent variables. among those concepts. The measurement model is based ally with nonexperimental data. covariance position on the latent variables is considered structure modeling. should not be interpreted without replication cause they are an excellent way to study phe. Confirmability is achieved when the results. in another sample. and associated error ining cause-and-effect relationships. A common Transferability (or fittingness) is an indica. so arrows point from the la- used interchangeably with the term causal tent variable to the empirical indicator. ize on sample variations and often contain preconceived ideas and values. vide weak evidence of causality regardless of then the study is considered to be dependable. Nonexperimental data pro- or the process and procedures of the inquiry. the analysis techniques applied. these impact data collection and analysis. ships among the latent concepts and is based els with latent variables with multiple empiri. misconception is that these models can be tion of whether the findings or conclusions used to establish causality with nonexperi- of the study fit in other contexts and fit with mental data. however. structs this model a priori based on theoreti- Conducting case studies requires a re. cepts and the hypothesized relationships ported in the data and the audit trail is evi.

similar to R2 in multiple regression. or dummy-. effect-. measures. zur. there are no dependent measure. Multiple regression is appro- models allows the researcher to divide the priate when each concept is measured with total effects of one latent variable on another only one empirical indicator. a unique so. to test theo- tus refers to the amount of information (vari- retical models specifying causal flow. the use of standard conventions. flow (CBF) adversely affecting various func- .64 ENCYCLOPEDIA OF NURSING RESEARCH nous variables has an associated explained Causal models can be analyzed with stan- variance.” In both cases. represent one latent variable’s influence on or βs) are estimated by regressing each endog- another that is not transmitted through a enous variable on the variables that are hy- third latent variable.” Cerebral Ischemia and a unique solution is not possible. causal modeling techniques provide a way to more fully represent the els is identification status. causal modeling enables inves- of parameters to be estimated. dard multiple regression procedures or struc- The paths between latent variables represent tural equation analysis programs. Nonre- cursive models are underidentified unless in. or orthogonally Nonrecursive models contain one or more coded categorical data for the independent feedback loops or reciprocal causation paths. the model is “underidentified” or “unidentified. (b) interval. Assumptions of multiple re- cepts or error terms. Direct effects cients (standardized regression coefficients.” If the strength and direction of the hypothesized amount of information exceeds the number effects. the model is “just identified. such as hypotheses about the relationship between LISREL or EQS (see “Structural Equation the variables. of the two latent variables in the reciprocal MacKenzie. The sever- causation relationship but only an indirect ity of ischemia depends on the severity and effect on the other latent variable) can be duration of the reduction in cerebral blood specified. The multistage nature of causal Modeling”). Recursive models have arrows sion: (a) interval or near-interval data for the that point in the same direction. JOANNE M. Thus. & McCulloch. 1982). With possible points for intervention. In summary. it provides information on the mated. Each latent variable can have many fied model with the total explained variance indirect effects but only one direct effect on of the proposed overidentified model (Pedha- another latent variable. and (c) 5 to 10 cases per indepen- Feedback loops can exist between latent con. Data requirements for path analy- Causal models can be either recursive or sis are the same as those for multiple regres- nonrecursive. If the amount of information causal modeling cannot be used to establish equals the number of parameters to be esti- causality. recursive models are almost always overidentified. the model is tigators to explore the process by which one “overidentified. Fit of effects of one latent variable that are trans. Identification sta- complexities of the phenomenon. Although estimated. Path coeffi- into direct and indirect effects. dent variable. gression must be met. Cerebral ischemia is defined as inadequate strumental latent variables (a latent variable blood flow to the brain to meet metabolic and for each path that has a direct effect on one nutritive needs of the brain tissue (Edvinsson. and to ances and covariances) available. variable might affect another and to identify lution for the parameters can be found. compared separate the effects of one variable on another to the number of parameters that are to be into direct and indirect effects. YOUNGBLUT When the amount of information is less than the number of parameters to be estimated. near-inter- feedback loops or reciprocal causation paths. An important issue for nonrecursive mod. Indirect effects are the pothesized to have a direct effect on it. val. 1993). the model is calculated by comparing total mitted through one or more mediating latent possible explained variance for the just identi- variables.

The technique was modified by Lassen and changed. If this thus dependent on a constant supply of oxy. or thrombosis. and loss stores no oxygen and little glucose. and Steele and Lavoisier made the con- of early symptoms of cerebral ischemia can nection that oxygen contributed to the pro- allow for intervention and minimize the prob. and an increase in the astrocyte processes sur. Nurses are responsible for flow of blood through the body. With the Kety & Schmidt. Cerebral Ischemia 65 tional and metabolic processes as CBF de. a highly diffusible gas. The first “measures” of ronal change during a low flow state and CBF involved direct and indirect observations provided evidence of the threshold for cere. & 1890). and by a specific organ over a unit of time (Fick. in ability of permanent damage. in the 16th century. there is neuronal shrinkage. anemia. Ames. Kowada. Global the lungs. inadequate energy to maintain the sodium Cerebral ischemia may be focal or global. oxygen. He observed and ible gas. that is taken up change” in 1922. 1870. oxygen was discovered by Priest- global cerebral ischemia. The brain production. and nucleolus remain un. recover from an ischemic challenge. hypoxia. of intracranial vessels (Roy & Sherrington. with a corresponding increase in lactic acid creases (Heiss & Rosner. As the nucleus continues sures. nial detectors traced the transit time of the changes within organelles in the cytoplasm. Focal cerebral ingly detailed the process in an attempt to ischemia occurs when a major cerebral artery identify and improve the brain’s tolerance to becomes occluded or constricted from arte. & Majno. emboli. duction of “heat” or energy. that one was able to described in further detail the process of isch. radiation from the Xe-133 as it flowed and the cell is further surrounded by through the brain. 1948). transit time. when Kety and Meldrum. providing focal CBF mea- astrocytic processes. nitrous oxide. the contour of cells. 1983). incrustations begin to form. Researchers have increas- the entire brain is ischemic. emic cell change (Brierley. astrocytes proliferate and lipid phago. 1973). Nearly 200 identifying individuals at risk for focal or years later. Brierley presented the time course for neu. estimate cerebral blood flow (Kety. such as oxygen. Global Servetus. 1972). metabolic derangement. energy sources change ery of xenon gas transit throughout brain from an aerobic to an anaerobic pathway. process continues unchecked. rial spasm. was injected into the internal carotid artery rounding the neurons. Brown. (Lassen & Ingvar. he was burned at the stake for his oxygen deprivation of the brain may also oc. ported Servetus’ findings by describing the or near drowning. Fi. For example. efforts. for example after cardiac arrest. first pre- ischemia occurs from an overall decrease in sented the idea that blood flowed through CBF. potassium pump across the cell membrane depending on whether a part of the brain or (Jones et al. or magnetic res- nally. Chiang. initial decrease in blood flow. (Spielmeyer. 1981). There is disruption of mitochondria Ingvar when Xe-133. 2001). to calculate vascular cytoplasm becomes increasingly homoge. William Harvey (1578–1657) sup- cur as a result of asphyxia. CBF in humans using vascular transit time. Nursing assessment ley. It was not until 1945. 1971. defined blood flow as the quantity of Spielmeyer first described “ischemic cell a substance. stable xenon-en- neous. PET. 1922). regions. there will be gen and glucose from the blood. as the incrustations disappear and the onance imaging (MRI). bral anoxic ischemia (Brierley. the nucleus. 1950. Obrist. Multiple extracra- cess continues. and/ Kety was the first person to measure global or glucose to the brain. Diffusible tracers are now combined to shrink and the cytoplasm becomes more with tomographic reconstruction such as amorphous. 1870. 1968). As the ischemic pro.” As the flow lowers and hardware and software and directs the deliv- the mitochondria fail. and is of ion and transmitter homeostasis.. Adolf Fick. Serial CT scans are conducted during . Schmidt applied the Fick principle to diffus- Wright. hanced CT scanning measures CBF via con- cytes form in preparation for removal of the ventional scanner interfaced with computer now “ghost cell. computed tomography.

the perfect tech- weighted perfusion imaging technique in. Child Abuse and Neglect son. All forms of child maltreatment ever. concerns as well as criminal activity (Gelles & ished electrical activity by evoked potentials Cornell. gadolinium). Hanks. & Niec. physical ered to be a threshold for synaptic transmis. Crockard. rebral ischemia. volves giving a bolus of paramagnetic con. 2003). KERR age from cerebral ischemia is generally de- fined as below 20 ml/100g of tissue/minute (Jones et al. from the radiology department to application vides an index of relative blood volume by nurses in the community or at the bedside (Grandin. & Brown. Sharbrough. 30% xenon. & Wynne. nique is not yet available. drug abandonment. MARY E. sexual abuse. administration. As blood volume. 1981). vices. CBF below this level al- Child abuse and neglect.e. dition. Sekhar. predict. & Michenfelder.66 ENCYCLOPEDIA OF NURSING RESEARCH the inhalation of a gas mixture containing that “noninvasively” detect. and room or treat cerebral ischemia. track changes in. Global brain ischemia Logue. and/or psychological sion (Astrup.. 30% to 60% oxygen. and society at large and are known to be Symon. air. Recent work focuses on methods tal well-being” (Nolan & Nolan-Haley. Department of Health and Human Ser- 100g/minute. The contrast clude the development of noninvasive tech- media is traced and the amount of signal at.” are produce energy. of the cerebral vessels combined with a mate cerebral blood volume is using a gradi. how. With a series of multi-slice techniques become increasingly more porta- measurements. Absolute CBF of cerebral blood volume. & Pasztor. Kaufman. Anderson. little impairment occurs. child maltreatment has been utes will result in permanent brain damage identified as a national emergency and one (Brierley.e. In the that is sustained for longer than 4 to 5 min- United States. The ultimate information in the evaluation of ce- dynamic contrast-enhanced susceptibility. 2001). Below 15 ml/100g/minute is consid.. Future directions in cerebral ischemia in- trast material (i. bral ischemia is only as good as the technique CBF is also estimated from measurement used to detect low flow states. 1981. John. One way to esti. abuse. niques to measure regional blood flow that tenuation is proportional to the cerebral have increased sensitivity and resolution. The serial images are stored and regional The determination and prediction of cere- flows are calculated. and the area under the curve pro. in terms of acts of commission (i. Below associated with a variety of mental health 18–20 ml/100g/minute evidence of dimin. The of our nation’s “most compelling problems” majority of studies show that above 23 ml/ (U. 1998). 1974). moral or men- threshold. neglect) (Cowen. 1999). However. . 1973). Studies show that the thresh- recognized as major social and mental health old for irreversible brain damage are volume problems throughout the world (Bonner. Hobbs. “Child abuse” is legally defined as “Any form tribute to the complexity of defining this of cruelty to a child’s physical. Yonas. & Gur.e. 1989). Meldrum. The threshold for irreversible brain dam. and time dependent. marker of tissue response would provide the ent-echo planar system on MR systems. and identify patients at risk adapted to CT scanners with the capability for cerebral ischemia.. factors including temperature. Similar techniques are to assess. below 20 ml/100g/minute symptoms of pose major threats to the integrity of families neurologic impairment develop (Branston. In ad. and individual variation con. Child maltreatment can be differentiated 1974). maltreatment) and caregiver omission (i. there will be a translation sity curve. often referred to by ters the functioning of the mitochondria to the broader term “child maltreatment. one may generate a time-den. 1999).. 1990. & Symon. ble and useable. Siesjo.S. for rapid sequential scanning. or electroencephalogram occurs (Sundt.

Examples of child abuse in. in turn. educational oppor. Noting how chological maltreatment was more strongly the commonly used term “ethnicity” is com- predictive of impairment in child develop. may be limiting as other important coexisting emotional abuse and neglect. 1016). p. 2003). child abuse victims are less likely to report. tence. particularly sexual abuse. 2002). ing the predictive effect of cultural factors on treated. and be modified to address maltreatment coexis- continue to be. perhaps be. example.. child emotional abuse and neglect cause females are traditionally more likely to refer to a caregiver-child relationship that is volunteer for research studies or because male characterized by patterns of harmful but non. the author defined three con- . treatment in three ethnic groups. in longitudinal studies of physical mission. difficult to detect. 239). Researchers are faced with the grabbing. burning.. & cally maltreated (Dong et al. Conyngham. plex and vague. and long-term is. However. Then efforts can be directed toward de- ing. to date. this emotional maltreatment is often example. cloth. Currently efforts are might be incorporated into prevention pro- underway to further define the concepts of grams and intervention development. and supervision” (Bonner constitute risk factors and how those findings et al. social. more physical abuse (Behl. ser. treatment more adversely affect child progno- 2003). literature suggests that females are publicly demonstrated (Glaser. p. termining if child and/or perpetrator gender tunity. there has of one type of maltreatment on another. The first step in addressing this glect” has been defined as the “chronic failure concern and other gender issues is to obtain of a parent or caretaker to provide children accurate gender-specific prevalence data. protection. cause professionals have difficulty recogniz. For example. For been increasing interest in other acts of com. the effect and interaction frequently coexist. ment than the severity of physical abuse (Gla- clude overt physical abuse such as hitting. risk factors. 2003). Giles. Fer- children who had been physically abused and rari (2002) provided a useful model for study- neglected had also been psychologically mal. experiences commonly co-occur with sexual Other related questions include whether co- abuse that need identification and interven. 2002) The relationship between the caregiver so that important research questions related and child is “nested” within the family that to the prevalence. perhaps be- speaking. existence of two or more types of mal- tion (Dong. Chil. sis than a single type of maltreatment. Clauseen of these personal. and shaking as well as challenge of clearly defining each type of mal- emotional abuse that may be more subtle and treatment so it can be studied separately. Dube. Child Abuse and Neglect 67 1990. to focus on sexual abuse alone. more likely to be victims of child sexual dren who frequently witness family violence abuse. as is the recent if possible. history as well as the social environment and Different forms of child abuse and neglect culture. physical interactions with the child. Yet. Unlike Gender differences are found in many areas other types of abuse that are performed in of psychology and child-related research. emotional abuse and neglect (Glaser. shelter. significantly influenced by each effects of this type of maltreatment can be an. May. under 18 with basic needs such as food. family member’s personal belief system and swered. and Child emotional abuse and neglect are very whether current treatment modalities should common but have traditionally been. sequelae of physical abuse versus trend. whereas males are more likely to suffer and abuse are also described as psychologi. For secret. mechanisms are needed to determine. “Ne. Anda. medical care. While reports of physical while also evaluating the potential influence abuse still dominate the literature. Male victims and perpetrators are also un- ing and defining these terms. 2001. & Felitti. Generally derrepresented in the literature. abuse. understudied. Another important factor worthy of parenting behaviors and definitions of mal- further investigation is the finding that psy. and cultural influ- and Crittenden (1991) found that 90% of ences have not been adequately studied. 2002).

there have been promising trends Although the number of cases involving of- in the development of relevant multidiscipli. Since the publication of olent. and ally recognized as needing services to prevent prevention programs for all forms of child them from becoming tomorrow’s serious. vi- maltreatment. for study. must also address important methodological age and race/ethnicity. These include developing and using lence include 2 or more hours of media vio- more standardized measures for identifying lence daily. ago (1962). crime victimization. fenses included in the FBI’s Violent Crime nary theoretical models and increased focus Index (criminal homicide. Nurses are edu. Silverman. Steele Droegenmuller. rob- for child maltreatment research. exposure to domestic violence.68 ENCYCLOPEDIA OF NURSING RESEARCH cepts associated with ethnicity (maschismo. Violent be- In addition to focusing on the previously havior has specific risk factors and more com- discussed knowledge gaps. forcible rape. Overall. However. an understanding of violence in tions of maltreatment. history of physical fighting. tors. 2001). (c) examination of proportion of these young child delinquents. treatment. The Kempe. violent act. measuring outcomes through re. and ethically well posi. and aggravated assault) decreased by several important knowledge gaps remain. the lives of children is necessary. for violent crimes increased by 45%. and (e) examination of cultural influ- To treat youth who have committed some ences upon child-rearing practices and defini. Health diverse children and families. 2003). tory of suicidal attempts. Measuring these components. Child Delinquents Child maltreatment is clearly a specific and challenging area of inquiry that is in need of Child delinquents (juveniles between the ages further research to develop and empirically of 7 and 12) constitute a population not usu- validate effective diagnostic. JENNIFER ELDER generational transmission of abuse among cultures. harsh and differentiating forms of child mal. child arrests and differentiation regarding the type of mal. (b) child delinquents arrested in 1997 were more likely to be charged with a violent crime. the author also examined the possibility of inter. valuing children) and defined them portant area of science. future research mon forms of violence that vary by gender. bery. for These include the need for (a) more specificity children under the age of 12. treatment that is studied and reported. academic attack at school. 1999). a more adequate conceptualization and re- weapons offense. clinically. and chronic offenders regarding both male victims and perpetra- (Loeber. and psychological adjustment. violent. weapons. tioned to lead the way in advancing this im- familism. A larger tional abuse and neglect. his- cidivism data. & Petechuk. Farrington. and sexual abuse (Brown & Bzos- and developing culturally sensitive diagnostic tek. be- forms of maltreatment. most violent behaviors demonstrated by de- and Silver’s seminal article over 4 decades linquent youth are homicide and sex offenses. (d) more information come serious. and chronic juvenile offenders. brain damage from shaken baby syndrome . fear of ies to evaluate the children’s health. Risk factors for vio- issues. or a drug law violation than search in the understudied areas of child emo- a property offense (Snyder. bullying. This is another area warranting con- tinued research. the coexistence and interaction of different as compared with later onset delinquents. and evaluative measures to ensure accurate For infants and young children. spanking as a form of discipline. consequences of abuse include permanent cationally. treatment. conducting longitudinal stud. carrying treatment. 2003). the pri- representation and assessment of ethnically mary locus of violence is in the home. 8% between 1997 and 1998 (FBI. mal- performance.

Child Delinquents 69

and homicide. The perpetrators are almost are more likely to suffer significant injury
always a parent or other relative. The homi- from such violence (Hawkins et al., 2000).
cide rate for infants is higher than for any age A public health strategy used for public
group up to age 17 (Gells, 2002). Surviving health risks should be applied to preventing
toddlers exposed to domestic violence experi- serious and violent juvenile delinquency, with
ence depression and psychological distress a focus on targeting early risk factors associ-
and are more likely than other children to be ated with persistent disruptive child behavior.
physically violent (Gells, 2003). Media vio- Because it is not possible to accurately predict
lence and violence in the schools, which in- which children will progress from serious
cludes bullying and physical fighting, are problem behaviors to delinquency (Loeber,
more common sources of violence in middle Farrington, & Petechuk, 2003), it is better to
childhood. Data indicate that chances of be- address problem behaviors before they be-
ing bullied in school are higher for 6th graders come more serious. Interventions delivered
than for any other group up to grade 12 early are most effective to prevent child delin-
(DeVoe et al., 2002). For teens, homicide and quency, whether these interventions focus on
suicide increase rapidly and the risk of being the individual child, the home and family, or
a victim of sexual assault, aggravated assault, the school and community.
and robbery also increases (Minino, Arias, The most promising prevention programs
Kochanek, Murphy, & Smith, 2002). for child delinquency focus on several risk
Differences in violence experiences by race domains at a time (Herrenkohl, Hawkins,
and ethnicity and by type of violence also Chung, Hill, & Battin-Pearson, 2001) in an
exist. These factors reflect social factors re- effort to shift the balance toward a greater
lated to family structure, income, education number of protective domains. To achieve
this effect, multisystemic programs designed
level, and neighborhood characteristics.
to target the child, family, school, peers, and
Black infants are four times as likely to be
the community have proven most effective.
murdered than Hispanic or white infants
These include parent training and family ther-
(Overpeck, Brenner, Trumble, Trifiletti, &
apy in combination with classroom and be-
Berendes, 1998). Black teens are twice as
havior management programs.
likely to be murdered as Hispanic teens and
The first step toward obtaining effective
about 12 times as likely to be murdered as
treatment is to provide families with access
white teens (Anderson, 2002). Black youth to mental health and other services. The delay
are more likely to have been abused (U.S. between symptom onset and help seeking
Department of Health and Human Services, contributes to poor behavioral health out-
2003a) and more likely to report being vic- comes. Awareness and use of culturally con-
tims of aggravated assault and robbery than gruent approaches reduce the challenges to
their Hispanic or white counterparts implementing interventions. Interventions
(Hawkins et al., 2000). must deal with the multiple problems stem-
As might be expected, there are variations ming from generations of dysfunctional fami-
in the types of violence experienced by males lies. To be effective, these public health inter-
and females. Females at any age are more ventions must address both the social condi-
likely to be victims of sexual abuse and rape tions and institutions that impact family func-
(Finkelhor & Hashima, 2001). Males under tioning.
the age of 8 are more likely to be victims While the very early detection of emo-
of physical abuse in the home, a trend that tional and behavior problems is a public
changes to female teens between ages 12 to health goal, results have been limited. Juve-
17. Both male and female students are equally nile justice systems continue to be dumping
likely to report dating violence, but females grounds for children who are inadequately


served by other institutions (Kupperstein, children within the last 30 years. The major
1971; Office of Juvenile Justice and Delin- sources of environmental lead exposure have
quency Prevention, 1995). been greatly decreased through the elimina-
tion of lead in gasoline, the banning of lead-
DEBORAH SHELTON based paint for residential use, and the elimi-
nation of lead solder from food and beverage
cans. Despite the success of these efforts, lead
Child Lead Exposure Effects poisoning continues to occur in about 5% of
children 5 years of age and younger, and
Childhood lead poisoning is recognized as much higher levels of lead poisoning have
the most important preventable pediatric en- consistently been documented among low-
vironmental health problem in the United income, urban, and African-American chil-
States. The adverse health effects of lead ex- dren living in older housing in the Midwest
posure in early childhood are well docu- and Northeast (Pirkle et al., 1994).
mented. Lead poisoning is defined as expo- Childhood lead poisoning was first de-
sure to environmental lead that results in scribed in the late 1800s by Gibson and col-
whole blood lead concentrations ≥ 10 µg/ leagues (Gibson, Love, Hendle, Bancroft, &
dL (micrograms/deciliter) (U.S. Centers for Turner, 1892), who encountered a case of
Disease Control and Prevention, 1992). Ex- peripheral paralysis in a young child and de-
posure to environmental lead begins in the scribed the similarities of the case to that of
prenatal period when physiologic stress mo- chronic lead poisoning in adults. Gibson
bilizes lead from its storage in maternal bone speculated that the source of the lead poison-
into the blood, where it easily crosses the ing was paint, and he described the long-last-
placenta and is deposited in fetal tissue. De- ing effects of the exposure. Unfortunately,
pending on the level of lead present in the most of Gibson’s observations were ignored,
environment, the exposure can continue as as the prevailing view of the time was that
infants and children develop. Absorption of once a child survived lead poisoning, there
lead is dependent on age and nutritional sta- were no lasting effects. It was not until the
tus; young children and those who have diets early 1970s that cross-sectional and longitu-
high in fats are most susceptible. Lead is most dinal studies of low-level lead exposure
commonly ingested through exposure to were conducted.
lead-contaminated paint and the resulting These early studies of lead exposure in-
dust, soil, and paint chips. Once ingested, volved comparisons of a lead-exposed group
lead is distributed in the blood and eventually and a comparison group on intelligence test
is deposited in bone and teeth. measures. As knowledge accumulated and re-
Whole blood lead levels (BLL) greater than search strategies became more sophisticated,
10 µg/dL put children at risk for developing researchers began to assess the influence of
a variety of health problems. At high level covariates, such as parental intelligence, so-
exposures (BLL > 20 µg/dL), damage to the cioeconomic status, and parental education
nervous, hematopoietic, endocrine, and renal level (Gatsonis & Needleman, 1992).
systems can occur. At lower level exposures, Though conflicting results were common,
these health problems include altered cogni- lead exposure and neurobehavioral deficits
tive and neurobehavioral processes. Re- remained significantly associated.
searchers have suggested that some of these Although few nurse researchers have in-
effects may be seen in children with BLL as vestigated the effects of low-level lead expo-
low as 5 µg/dL (Lamphear, Deitrich, Au- sure on the neurobehavioral development of
inger, & Cox, 2000; Landrigan, 2000; Nee- children, low-level lead exposure certainly
dleman & Landrigan, 2004). falls within the realm of the phenomena of
Direct results of primary and secondary concern to the discipline. Lead exposure is
efforts at prevention of lead toxicity have sig- unquestionably of clinical significance; until
nificantly reduced BLL among young U.S. all lead is removed from the environment,

Childbirth Education 71

clinicians will be faced both with screening Scientists criticized the work done by Nee-
children for lead exposure and treating the dleman and his colleagues (1979) because the
effects of this preventable public health prob- study lacked baseline data about early cogni-
lem. The deleterious effects of lead exposure tive abilities of the subjects. For instance, it
have been known for a hundred years; how- was proposed that the affected children may
ever, progress in prevention has been slow. have had neurological deficits at birth that
Some of the reasons for this are related to would lead them to certain behaviors (in-
society’s indifference to problems of poor and creased mouthing) that predisposed them to
vulnerable populations. Until recently, lead be lead exposed. To address this issue, subse-
exposure was thought to be a problem only quent studies were designed to follow large
for poor inner-city minority populations, and numbers of subjects from birth through early
parenting practices were thought to contrib- school age and major outcomes (e.g., IQ level,
ute to the problem. Also, many considered motor development, cognitive development)
the elimination of lead in gasoline and paint were measured, while large numbers of co-
sufficient to eradicate the problem of lead variates were controlled. Numerous investi-
poisoning. The Centers for Disease Control gators using comparable designs reported
(CDC), in 1992, issued comprehensive guide- similar findings; thus a solid consensus
lines for preventing and treating the problem among investigators began to emerge that
of childhood lead exposure. These guidelines lead was toxic at extremely low concentra-
were issued after the CDC accumulated large tions. Research with lead-exposed primates
amounts of scientific evidence from animal strengthened the consensus, and the toxic
and human studies that supported the hy- level of lead was redefined by the CDC as a
pothesis that the deleterious effects of lead BLL ≤ 10 µg/dL.
exposure occurred at levels previously Researchers continue to study the effects
thought to be harmless. of low-level lead exposure on the develop-
The earliest studies of lead poisoning were ment of children. While these efforts are
conducted on children who had BLL ≥ 60 µg/ worthwhile, future efforts could focus on (a)
dL and were symptomatic. During the 1970s, identifying mediators of lead exposure ef-
researchers focused on asymptomatic chil- fects, (b) investigating the effects of lowering
dren who had BLL in the 40–50 µg/dL. Con- blood lead levels (chelation) on the neurobe-
clusions about the effects of lead exposure havioral outcomes of children, (c) investigat-
were difficult to make from these studies be- ing the synergistic effects of other environ-
cause of their methodological shortcomings. mental exposures on neurocognitive develop-
In 1979, researchers conducted a major inves- ment, and (d) investigating the effects of pro-
tigation of large cohorts of asymptomatic viding educational materials about reducing
children and used shed deciduous teeth rather environmental lead exposure to families of
than BLL to measure lead exposure (Nee- low-level exposed children. Any efforts that
dleman et al., 1979). These researchers con- address the primary prevention of the prob-
trolled for major confounding variables and lem would help to protect thousands of chil-
concluded that BLL was associated with dren against the long-lasting effects of lead
lower IQ, decreased attention span, and poor exposure.
speech and language skills in the children
studied. Long-term follow-up of these chil- HEIDI V. KROWCHUK
dren led the researchers to conclude that the
effects of low-level lead exposure (equivalent
to BLL ≤ 25 µg/dL) persisted throughout Childbirth Education
young adulthood; failure to complete high
school, reading disabilities, and delinquency Childbirth education focuses on the learning
were behaviors exhibited by children who needs of expectant families and covers a
had elevated BLL at age 7 (Needleman, Riess, broad range of topics from the physical care
Tobin, Biesecker, & Greenhouse, 1996). needs of expectant women to the psycho-


socio-cultural needs of the new family. The conditioning methods to reduce both the fear
goal of childbirth education is to assist fami- and the pain became the basis for “natural
lies in acquiring the knowledge and skills nec- childbirth.” While philosophical differences
essary to achieve a healthy transition through still exist among childbirth education meth-
the childbearing process and initial phases ods, common aspects of all programs include
of parenthood. Classes range from courses education on: (a) the physical process of la-
designed for those considering pregnancy bor, (b) physical and psychological condi-
through courses dealing with infant care tioning methods, and (c) supportive assis-
needs and early parenting issues. tance during the birthing process.
Nurses are the professional practitioners A review of the Cumulative Index to Nurs-
who assume the primary responsibility for ing and Allied Health Literature (CINAHL)
teaching childbirth education classes within for the years 1997–2003 reveals 173 pub-
the United States. Nurses are in a unique posi- lished research-based articles listed under the
tion to serve as childbirth educators because keywords “childbirth education.” A wide va-
of their broad base of knowledge including riety of topics are covered including: (a) post-
both the behavioral and biological sciences. partum skills such as parenting and breast-
In addition, nursing’s focus on caring and feeding; (b) classes for special populations
emphasis on client education enable nurses such as grandparents, siblings, fathers, teens,
to guide families toward their childbirth goals disabled persons, and preparenthood cou-
with sensitivity using appropriate educa- ples; (c) effects of mother-friendly and baby-
tional methods. Nurses are the health profes- friendly hospital protocols; (d) self-care mea-
sionals within the hospital environment who sures during pregnancy and labor such as nu-
provide the majority of hands-on care and trition, fitness, pain control, breathing, and
labor support. Thus, nurses are in a strategic relaxation techniques; (e) effects of medical
position to act as patient advocates and to interventions such as epidural anesthesia, an-
provide anticipatory guidance regarding the algesics, and cesarean deliveries; (f) caregiver
decision making that is often required during effects focusing on the outcomes achieved by
a birth within an increasingly complex health midwives and doulas; and (g) childbirth edu-
care system. cator competencies and teaching methods.
Formal childbirth education in the United Expectant fathers are currently the focus
States began with the classes in hygiene, nutri- of many research efforts. Greenhalgh, Slade,
tion, and baby care provided by the American and Spiby (2000) reported that fathers at-
Red Cross. During the early part of the 20th tending childbirth education classes who
century, classes on childbirth and family care wished to avoid information perceived as
became increasingly available to American threatening had significantly less fulfilling
women. However, the classes provided little childbirth experiences than similar fathers
information regarding coping with the who did not attend classes. This finding ques-
stresses related to labor. With the shift from tions whether traditional mother-focused
the female controlled, social model of child- childbirth education classes meet the varying
birth to the medical illness model of child- needs of fathers, some of whom are eager to
birth that occurred during the first half of the participate in the childbirth experience and
20th century, the scientific community paid others who are reluctant to do so. Diemer’s
increasing attention to the control of pain (1997) quasi-experimental study comparing
during labor. Thus, classes initially focused traditional prenatal classes with classes using
on management of pain related to childbirth father-focused discussion groups found a de-
(Ondeck, 2000). crease in psychological symptoms and greater
Contemporary childbirth education dates improvement in spousal relationships for
back to the work of Dick-Read, Lamaze, and men attending father-focused groups. The
Bradley. The notion of pain during labor as need for attention to the special interests of
secondary to fear and the use of psychological fathers was also supported by the work of

Children Exposed to Intimate Partner Violence 73

McElligott (2001) and Smith (1999) who re- wishing to provide high-quality, yet conve-
ported men’s need for information about nient, classes for today’s busy families.
their unique contribution to the childbear-
ing experience. BOBBE ANN GRAY
Prenatal education related to breast-feed-
ing continues to be a major focus of research.
Cox and Turnbull (1998) reported that at- Children Exposed to Intimate
tending a breast-feeding workshop signifi- Partner Violence
cantly increased both women’s confidence
level and the length of time the women breast- Given the magnitude of this problem, there
fed their infants. Britton’s (1998) qualitative is a growing awareness of the potential harm
study of the sources used by women for to children exposed to violence within fami-
breast-feeding information identified discord lies. Following a 2-year analysis of violence
between women’s expectations of breast- and children, the American Academy of Pedi-
feeding and the reality of the experience. This atrics issued a policy statement indicating
study underscored the continuing need for that the U.S. is experiencing an epidemic of
prenatal breast-feeding education courses children exposed to violence. Despite recog-
and development of peer-support and self- nition that domestic violence seriously threat-
help groups. ens the health and emotional well-being of
A third area receiving continuing attention children, only recently have researchers fo-
concerns childbirth education methods and cused on children affected by domestic vio-
content. The need for use of adult learning lence. There has been intense advocacy and
principles and identification of specific legislative action to combat violence against
learner needs is continually reinforced. In ad- women; however serious concerns about
dition, extension of the traditional childbirth their children did not appear in the research
literature until recently (Mohr, Lutz, Fan-
education program to include gender-specific
tuzzo, & Perry, 2000).
information on early parenting skills is sup-
Children who live in homes where partner
ported (Callaghan, Jones, & Leonard, 2001;
violence occurs are at risk for developing a
Schmied, Myors, Wills, & Cook, 2002).
range of emotional, physical, and behavioral
Lamaze International (2002) presented a
symptoms. Research suggested that they are
position paper for the 21st century which
at serious risk of developing a host of aggres-
identifies the need to reshape the birth envi-
sive, antisocial, or fearful and inhibited be-
ronment to be supportive of women’s confi- haviors and deficits in social skills (Farrell &
dence, control, and comfort as well as main- Bruce, 1997). They are reported to have im-
taining rewarding family interactions paired concentration and difficulties in
through encouragement and support. With school performance (Schwab-Stone et al.,
the advent of the mother-friendly and baby- 1999; Delaney-Black et al., 2002) and higher
friendly initiatives, additional research is levels of alcohol abuse as adults (Dube, Anda,
needed to identify educational needs of both Felitti, Edwards, & Croft, 2002). They per-
consumers and practitioners that will support form overall at lower levels than nonexposed
cost-effective, collaborative policies and high children on a variety of measures of cognitive
levels of consumer satisfaction. In addition, and motor development (Jaycox et al., 2002).
continued examination of the traditional Children who witness domestic violence dem-
course content in light of the needs of fathers onstrated higher levels of depression and anx-
and special populations is required. Use of iety than counterparts in nonviolent homes
the internet as a media for childbirth educa- (Berman et al.; Hurt, Malmud, Brodsky, &
tion has not been reported in the literature. Giannetta, 2001; Cuffe et al., 1998; Jaycox
Online courses and support groups may pro- et al.). They see violence as an acceptable
vide a fruitful avenue for childbirth educators form of resolving interpersonal conflicts and


they are at risk for potential deviance in fu- gess (2002) conducted interviews with 13
ture social relationships (Hurt et al.). children ages 9 to 11 years during the initial
Children from families with domestic vio- 1 to 3 months after a family homicide and
lence are at risk of suffering physical violence provided insight into themes of bereavement.
themselves. The link between marital conflict A major finding in the study was that the
and child maltreatment has received much witnessing or hearing the news of a family
attention in the past 10 to 15 years. It has member homicide was a powerful associative
been observed that children of battered factor for childhood PTSD and for compli-
women are at an increased risk of being cated bereavement.
abused themselves, with estimates of an over- In sum, nursing research concerned with
lap between spousal abuse and child abuse victims’ children is scant when compared to
ranging from 30% to 60% (Hartley, 2002; what is being studied by psychologists, physi-
Dong et al., 2003). cians, and social workers. Findings in all cases
In addition, child exposure to family vio- comparing children exposed to domestic vio-
lence can be deadly. Dube et al. (2001) exam- lence with children from nonviolent homes
ined the relationship between the risk of sui- indicate that this exposure (a) has an adverse
cide attempts and adverse childhood experi- impact across a range of child functioning, (b)
ences and the number of such experiences. produces different adverse effects at different
The researchers conducted a retrospective co- ages, (c) increases the risk of child abuse, and
hort study of 17,337 adult health mainte- (d) is associated with other risk factors such
nance organization members who attended a as poverty and parental substance abuse.
primary care clinic in San Diego within a 3- However, comprehensive reviews of this liter-
year period (1995–1997). Subjects completed ature indicate no reliable information about
a survey about childhood abuse and house- the impact of particular types or frequencies
hold dysfunction, suicide attempts (including of domestic violence on children or the im-
age at first attempt), and multiple other pact of various degrees of exposure on chil-
health-related issues. The researchers discov- dren’s functioning and across time. Close in-
ered a powerful relationship between adverse spection of the child impact research indicates
childhood experiences and risk of attempted that it does not provide a substantial basis to
suicide throughout the life span. Alcoholism, inform strategic national policies and sys-
depressed affect, and illicit drug use, which temwide action due to many gaps and inade-
are strongly associated with such experiences, quacies. Some of these include retrospective
appeared to partially mediate this relation- analysis, no longitudinal studies unsubstanti-
ship. ated reports of child exposure or the violent
Finally, in a landmark intervention study, episode itself, exclusive use of the CBCL as
Stein and a multidisciplinary group of col- opposed to instruments that are more domain
leagues (2003) evaluated the effectiveness of specific, and others (for more in-depth discus-
a collaboratively designed school-based cog- sion on shortcomings of this literature, see
nitive behavioral group therapy intervention. Mohr, Lutz, Fantuzzo, & Perry, 2000). Yet,
The 10-session intervention significantly de- without accurate, reliable information about
creased symptoms of posttraumatic stress dis- the prevalence and nature of children’s expo-
order (PTSD) in students who were exposed sure to domestic violence, prevention and in-
to violence and experiencing distress. tervention efforts cannot be designed for, and
There is a dearth of research conducted public and private resources cannot be appro-
by nursing scholars on children exposed to priately targeted to the affected children.
violence. Some recent work has been pub- Effective responses and effective interven-
lished on the issue of children’s reactions to tions depend on responses to several ques-
exposure to family homicide, which may be tions. First, how many children are exposed
considered within the context of family or to domestic violence, and what is the nature
intimate partner violence. Clements and Bur- of these children’s exposure? Second, how

Chronic Conditions in Childhood 75

do these traumatic events uniquely affect the with chronic conditions at any given point in
course of healthy development for child vic- time, vary according to the definition used.
tims? Third, what factors increase risk for, Estimates of prevalence range from less than
or provide protection against, the potentially 5% to more than 30% (Newacheck & Tay-
deleterious effects of child exposure to do- lor, 1992); they tend to be higher when the
mestic violence? Fourth, what types of inter- definition is based on duration and lower
ventions can mitigate these specific negative when the definition is based on impact on
effects? Responses to these critical questions the child’s functioning. In 2001, more than
require a scientifically rigorous research 4 out of 5 children (83%) were rated as hav-
agenda, leading to the development of a trust- ing very good or excellent health by their
worthy database. parents; about 8% of school-age children
Nurses are often the first care providers were reported to have their activities limited
identifying and assessing not only adult vic- because of a chronic condition (Federal Inter-
tims but their children. Their presence in the agency Forum on Child and Family Statis-
area of adult victimology is laudable, but tics).
nurse scholars are relatively absent in the dis- Risk factors for health problems have been
cussion surrounding the child victims—as in- identified. Boys have more limitations from
visible as the children themselves a scant 2 chronic conditions than do girls. School-age
decades ago. children (ages 5–17 years) are twice as likely
to have a chronic condition as preschoolers
WANDA K. MOHR (under 5 years). Children living in lower-in-
SARA TORRES come families are less healthy than children
living in families of higher income. There is
also a trend for Black and Hispanic families
Chronic Conditions in Childhood to have poorer health than White, non-His-
panic children. In contrast, White adolescents
There is no one accepted definition of a child- have the highest rates of substance use such
hood chronic condition; however, a research as smoking cigarettes, drinking alcohol, and
consortium on chronic illness in childhood using marijuana (Brown et al., 1999). There
recommended that it be defined on two levels: are also changes in the prevalence of health
duration of the condition and impact on the problems experienced by children. For exam-
child’s functioning (Perrin et al., 1993). In a ple, pediatric AIDS cases are declining. In
definition based on duration, a chronic condi- contrast, asthma is increasing among all chil-
tion is one that has lasted or is expected to dren, with the highest increases in children
last more than 3 months (Perrin et al.). This who are under 4 years (National Center for
definition would include recurring acute con- Health Statistics).
ditions (e.g., repeated ear infections) as well A large amount of research has been car-
as those that are expected from the onset to ried out to investigate children with chronic
be long-term (e.g., diabetes). In a definition conditions. There is an increasing emphasis
based on impact on the child, a chronic condi- on assessing the health-related quality of life
tion would be one that limits the child’s func- of these children. This research has estab-
tioning or leads to the child’s receiving addi- lished that, compared to the general popula-
tional medical attention beyond that ex- tion peers, children with chronic conditions
pected for a child the same age. A recent are at risk for a poorer quality of life related
trend is to address morbidities that are often to physical, psychological, social, and aca-
associated with risk-taking behavior such as demic functioning. Moreover, the families of
alcohol use, substance use, contraceptive use, these children are at increased risk for adjust-
and being overweight (Brown et al., 1999). ment problems.
Prevalence estimates for childhood Two major approaches to sample selection
chronic conditions, or the number of children are used in research on children with chronic


conditions and their families: noncategorical tion, painless diarrhea, and fecal incontinence
and categorical. The major assumption be- (Talley et al., 2001)—may be common
hind the noncategorical approach is that among the public (Talley et al.), but for the
there are many commonalities in the experi- health provider they are also among the most
ence of families of children with chronic con- difficult conditions to read and treat. When
ditions. These researchers generally study a chronic gastrointestinal pathology cannot
samples in which many different chronic con- be identified, it is more generally diagnosed as
ditions are represented. In contrast, research- Irritable Bowel Syndrome (IBS) or Functional
ers using the categorical approach generally Bowel Disorder (FBD) (Heitkemper, Jarrett,
study samples that are homogeneous in re- Caudell, & Bond, 1998).
gard to chronic condition. An example of IBS is a recurrent disorder characterized
nursing research using the categorical ap- by chronic abdominal pain, bloating, and al-
proach is the research on behavior problems tered bowel patterns. It is the most common
in children with epilepsy (Austin, Dunn, & disorder treated by gastroentrologists (Amer-
Huster, 2000). Even though there has been ican Gastroenterological Association, 2002;
much discussion about which approach is Fass et al., 2001) and is more commonly
better to use, the current thinking is that the found among women than men. IBS has also
purpose of the research should determine the been found to contribute to lowering of eco-
approach used. In nursing, both approaches nomic and other quality-of-life factors. One
are needed to provide important information study showed that 15.4 million people in the
that will improve nursing care of children United States suffer from IBS regularly, with
with chronic conditions and their families. most missing three times as many work days
In the past decade there has been a strong as those without symptoms (13.4 days vs. 4.9
trend to study chronic illness from the per- days), costing employers $1.6 billion in direct
spective of the person who is chronically ill. costs and another $19.2 billion in indirect
Many of these nurse researchers use qualita- costs (American Gastroenterological Associ-
tive methods to learn about the illness experi- ation).
ence (Thorne & Patterson, 2000). This focus Although the etiology of IBS has not been
on the subjective experience is also reflected clearly identified, it is thought to be related
in a number of scales being developed to mea- to such factors as the following: (a) abnormal
sure chronically ill children’s perceptions of GI motility, described as high-amplitude
the quality of life. Another trend is the in- propagating contractions or delayed transit
creasing focus on interventions to help chil- of gas; (b) visceral hypersensitivity; (c) enteric
dren cope with a chronic condition. For ex- infection; (d) autonomic dysfunction; and (e)
ample, common interventions for children dysregulation of brain-bowel interactions. In
with diabetes include educational programs, addition, stress and psychological affliction
psychosocial interventions (e.g., coping skills are important psychosocial factors in IBS
training, psychotherapy, stress management, (American Gastroenterological Association,
and social support groups), and family inter- 2002; Fass et al., 2001); however, these are
vention (Grey, 2000). only partially correlated with symptoms and
are not sufficient to explain reports of
JOAN K. AUSTIN chronic, recurrent IBS. Although there are
several pathophysiologies of IBS based on this
etiology, further studies are needed to clarify
Chronic Gastrointestinal such findings.
Symptoms There are multiple potential causes for IBS,
and the diagnosis of each case must be based
Chronic gastrointestinal (GI) symptoms— relative to the symptoms (Rome criteria).
which include frequent bowel-related ab- Symptoms include at least 12 weeks of ab-
dominal pain, reflux, dyspepsia, constipa- dominal discomfort or pain in the preceding

Chronic Gastrointestinal Symptoms 77

12 months, accompanied by two or three of In cases in which individuals with IBS do
the following additional features: (a) the pain not respond to physiological treatments, psy-
or discomfort is relieved with defecation, (b) chological factors should be considered. Sev-
the onset of the pain or discomfort is associ- eral psychological procedures have been stud-
ated with a change in the frequency of the ied in IBS patient therapy trials, including
movement of stool, and/or (c) the onset of cognitive-behavioral treatment, stress man-
the pain or discomfort is associated with a agement, dynamic/interpersonal psychother-
change in the form of the stool. In addition, apy, hypnotherapy, and relaxation/arousal
cumulatively supportive symptoms include: reduction training (Ringel, Sperber, &
(a) abnormal stool frequency (for research Drossman, 2001; Drossman, 1995). Due to
purposes, “abnormal” may be defined as methodological limitations, however, there
more than three times a day and less than are as yet no comparative data demonstrating
three times a week), (b) abnormal stool form that one psychological intervention is supe-
(lumpy/hard or loose/watery stool), (c) ab- rior to any other for any given patient group
normal stool passage (straining, urgency, or or set of conditions (American Gastroentero-
feeling of incomplete evacuation), (d) passage logical Association, 2002). Several recent
of mucus, and (e) bloating or feeling of ab- findings in nursing research have focused on
dominal distention (Thompson et al., 2000). the relationship between gastrointestinal
Management of IBS is based on the domi- symptoms and women (Heitkemper et al.,
nant symptoms, their severity, and psychoso- 1998), the effects of coping with stress among
cial factors. It is also imperative in the man- women with gastrointestinal disorders
agement of IBS that the patient take responsi- (Drossman et al., 2000), differences in pa-
bility as an active participant in his or her tients’ and physicians’ perceptions about
treatment. Nurses can engage patients by en- women with IBS (Heitkemper, Carter,
couraging them to write down their symp- Ameen, Olden, & Cheng, 2002), and the
toms and times of occurrence in a diary, sense of coherence and quality of life in
which can also be used to monitor the daily women with and without IBS (Motzer, Her-
food intake, activities, and events of the pa- tig, Jarrett, & Heitkemper, 2003). These
tient in order to identify possible exacerbat- studies supply information suggesting that GI
ing factors. If, on examination of the diary, symptoms in some women are linked to the
symptoms prove mild, prescription medica- following: (a) reproductive cycling (increased
tion may not be needed, though in general GI symptoms at menses), (b) negative health
the patient will benefit from normal daily outcome due to maladaptive coping and de-
activities that include dietary and lifestyle creased self-perceived ability concurrent with
modification (Ringel, Sperber, & Drossman, or in response to a history of abuse, (c) dis-
2001). Once the patient has monitored symp- cordance between patients’ and physicians’
toms for 2 to 3 weeks by writing them in views about IBS, and (d) reduced sense of
the symptom diary, certain foods and other coherence and holistic quality of life.
agents that worsen symptoms can be identi- The care of patients with chronic GI symp-
fied and avoided. However, nurses should toms is particularly challenging because the
remind patients not to be overly restrictive in diagnosis is never assured and symptomatic
their diet to avoid the risk of malnutrition. treatments are not always successful. Diagno-
Some studies recommend a high fiber diet to sis and treatment tailored on the basis of indi-
resolve symptoms, even though it may ini- vidual need should be carefully performed.
tially cause bloating and flatulence. However, In addition, establishing an effective relation-
although helpful in treating constipation, ship between the patient and the health pro-
maintaining high levels of fiber intake is con- vider requires patience, education, and reas-
troversial when used to relieve diarrhea and surance for vital therapeutic management.
abdominal pain (American Gastroenterologi- Future studies are needed to determine the
cal Association, 2002). degree to which the modification of manage-


ment will improve symptom treatment, clini- From the societal perspective, living with
cal outcomes, and the patient’s overall quality a chronic illness is a major source of health
of life. Finally, the treatments that are consis- care utilization. In the United States, chronic
tently effective for all symptoms should be diseases account for three quarters of health
further investigated. care costs (Vlieland, 2003). Specifically,
Druss and colleagues (2001) indicated that
JIN-HWA PARK almost half of U.S. health care costs in 1996
were borne by persons with one or more of
five chronic conditions: mood disorders, dia-
betes, heart disease, asthma, and hyperten-
Chronic Illness sion. In addition, the nonmedical costs are
substantial due to lack of productivity. Druss
The practice of nursing has long been identi- and colleagues (2002) reported that the most
fied with the care and comfort of the chroni- expensive chronic illness at a population level
cally ill. It is apparent, however, that the was ischemic heart disease; at the per capita
health care delivery system, in general, has level it was respiratory malignancies. The
not adequately responded to the changing conditions with the greatest disability (in-
needs of the population, particularly in terms cluding bed days, missed workdays, and rates
of the increasing numbers of chronically ill of impairment in activities of daily living and
adults. Currently, in the United States, by age instrumental activities of daily living) relative
70, a majority of the U.S. population copes to expenditures were mood disorders,
with the effects of at least one chronic illness chronic obstructive pulmonary disease, and
(Nesse, 2002). Blendon and colleagues arthropathies.
(2001) reported that when asked what they The traditional approach to studying
thought were the most important health chronic illness has been limited, focusing on
problems facing the nation, over 80% of re- the medical model. A new health para-
spondents identified three chronic illnesses: digm—a care-oriented model of illness—has
cancer, human immunodeficiency virus emerged. The concept of health is more
(HIV)/acquired immunodeficiency syndrome readily measured in terms of maximizing
(AIDS), and heart disease as the top three. physical, psychological, social, and spiritual
Chronic illness includes a broad spectrum well-being. In this paradigm, a holistic health-
of diseases that differ significantly from one focused model has become accepted with a
another in their underlying causes, modes of resulting change towards care of the whole
treatment, symptoms, and effects on a per- person as well as the family. In addition, in
son’s life and activity. Chronic illness refers chronic disease management, all clinical deci-
to diseases that are caused by nonreversible sions need to be individualized, because they
pathology; are characterized by a slow pro- usually involve choices between possible out-
gressive decline in normal physiological func- comes that may be viewed differently by dif-
tion; are permanent with cure unlikely; and ferent patients. Vlieland (2003) recognized
require long-term surveillance, leaving resid- that a constant tailoring of care to the actual
ual disability (Hwu, Coates, & Boore, 2001). needs of individual patients as well as the
Families are drained physically, emotionally, complexity and long duration of the disease
and financially. There is often upheaval of are the distinguishing features of chronic dis-
relations among the patient, family, and other ease management. Another related frame-
members of society. Overall, chronic illnesses work that has emerged is the self and family
vary greatly in their developmental course. management in chronic illness (Grey, Knafl,
Some conditions improve over time, some Gilliss, & McCorkle, in press).
stabilize, and others are progressively degen- Pollock (1987) provided an initial review
erating and debilitating. of nursing research related to adaptation to

Clinical Decision Making 79

chronic illness. More recently, Fitzpatrick order to capture these complex relationships,
and Goeppinger (2000) edited ten chapters designs that include mixed methods will be
that reflected a variety of chronic illnesses essential.
and a full range of interventions to manage
them. Valuable contributions to increase our RUTH MCCORKLE
understanding have come from first-person SIEW TZUH TANG
accounts of patients’ experiences (Thorne &
Patterson, 2000). Other noteworthy efforts
have been expanded to families, including Clinical Decision Making
ethnically diverse families (Chesla & Run-
greangkulkij, 2001). Other important contri- Clinical decision making is the process nurses
butions have focused particularly on nursing use to gather patient information, evaluate
interventions. For example, Frich (2003) con- the information, and make judgments that
cluded that nursing interventions for patients result in the provision of patient care (White,
with diabetes can improve psychosocial and Nativio, Kobert, & Enberg, 1992). Clinical
health outcomes in terms of facilitating ad- decision-making ability is defined as the abil-
herence to regimens or behavior changes ity by which a clinician identifies, prioritizes,
(greater self-care skills), patient satisfaction, establishes plans, and evaluates data. Deci-
good clinical outcomes (reduction in plasma sion making is central to professional nursing
glucose, decreased blood pressure and choles- and has vital links to patient-care outcomes
terol), and cost savings. (Catolico, Navas, Sommer, & Collins, 1996).
Research related to improving the quality Researchers have investigated the process,
of life for people with chronic illness should types, and quality of clinical decision making.
be a national priority given that people are Catolico and colleagues (1996) studied deci-
living much longer and better with conditions sion making of practicing staff nurses. It was
that used to be fatal. The existing literature demonstrated that nurses with better commu-
is limited in several critical ways. Much of nication skills had a greater frequency of ac-
the research in chronic illness addresses a par- tual decision-making practices. Intuition was
ticular illness or disability. Findings may be a critical component of clinical decision mak-
applied too narrowly or too inclusively to ing in a qualitative study of 10 novice nurse
illnesses with markedly different demands. practitioners (Kosowski & Roberts, 2003).
The landscape of chronic illness is diverse and Some researchers have looked at approaches
complex, presenting a vast range of symp- such as informatics or algorithms to aid deci-
toms and trajectories, accomplished by a vari- sion making. Akers (1991) showed that
ety of demands over the natural history of nurses who used algorithms to aid their deci-
the diseases. Research to date has focused sion making utilized more thorough patient
on only specific phases of the trajectory of assessment and a more informed nursing re-
specific diseases, and not on the unfolding of sponse, which resulted in better patient man-
illness related to developmental tasks over agement. Another critical issue is the educa-
the entire course of an illness. The impact tional level and preparation of the nurses who
of chronic illness on the patient, well family are formulating decisions. Studies have ex-
members, and key caregivers differs and de- plored the decision-making process of stu-
pends on when an illness strikes in the family dent nurses, staff nurses, and nurse prac-
and on each member’s individual develop- titioners. A group of nursing students were
ment. Many complex management interven- given didactic and interactive teaching ses-
tions are eventually aimed at improving or sions on clinical decision making. Students’
maintaining the patient’s independent partic- decision making was in accordance with the
ipation in society. Outcome measures cov- decision making of experts significantly more
ering this dimension are rarely applied. In often than that of the student nurses who


did not receive the decision-making content chest pain are hospitalized less often than
(Shamian, 1991). A study in the United King- white patients (Pope et al., 2000). There was
dom demonstrated that nurses having a col- a significant difference in reports of suspected
lege education were significantly better at de- abuse after the evaluation of fractures be-
cision making than their colleagues educated tween minority and non-minority children
in diploma programs (Girot, 2000). Ad- (Lane, Rubin, Monteith, & Christian, 2002).
vanced practice nurses in specialty practices Competent clinical decision making by nurses
tend to generate fewer hypotheses in their requires being cognizant of potential biases.
clinical decision making. Those nurses must Decision making is critical to nursing prac-
be aware that formulating a diagnosis too tice. Gathering, organizing, and prioritizing
early in the data-gathering phase precludes data are major components of the process.
the possibility of considering all options (Lip- Continued research in this area can foster
man & Deatrick, 1997). the development of decision-making skills in
When investigating the decision-making novice nurses and cultivate high clinical deci-
process, researchers have utilized simula- sion-making ability in expert nurses.
tions, together with interviews regarding the
thought processes individuals use to reach TERRI H. LIPMAN
decisions. The quality of decision making is
defined as having the ability to make fre-
quently required decisions (Catolico et al.,
1996). That aspect of decision making has Clinical Judgment
been studied by using computer-assisted sim-
ulations requiring nurses to make decisions in Clinical judgment has been defined as the
controlled clinical situations. To investigate process by which nurses come to understand
clinical decision making by nurse prac- problems, issues, or concerns of patients, at-
titioners, the nurses care for patients via com- tend to salient information, and respond in
puter and interactive videos. To more objec- concerned and involved ways. Clinical judg-
tively assess student clinical competencies, ment occurs within a framework of clinical,
the clinical decision-making skills of nurse legal, ethical, and regulatory standards and
practitioner students were evaluated using a is closely aligned with phenomena such as
standardized simulated patient encounter critical thinking, decision making, problem
(Stroud, Smith, Edlund, & Erkel, 1999). solving and the nursing process (Benner, Tan-
Various factors have been shown to affect ner, & Chelsa, 1996).
clinical decision making, such as the experi- Expert clinical judgment is held in high
ence and the knowledge base of the nurse. regard by nurses as it is generally viewed as
Those with case-related experiences are more essential for provision of safe, effective nurs-
likely to choose appropriate interventions. A ing care and the promotion of desired out-
study of nurse practitioners by White and comes. Nursing research has been conducted
colleagues (1992) concluded that case con- on the processes of clinical judgment with
tent expertise is crucial for clinical decision the intent of better understanding how nurses
making from the aspect of understanding the identify relevant information from the vast
significance of the data acquired and in mak- amounts of information available and then
ing the correct decision. Nurses’ decision how information is used to make inferences
making is also affected by the sociodemo- about patient status and appropriate inter-
graphics of the patient. Age, sex, race, reli- ventions. The complexity of the clinical judg-
gion, and socioeconomic status can impact on ment process has brought about collabora-
decision making. Racial disparities in health tion of nurse researchers with multidiscipli-
care may be due to racial biases when formu- nary experts from a broad array of scientific
lating clinical decisions. Non-white patients backgrounds including cognitive psychology,
presenting to the emergency department with informatics, phenomenology, and statistics.

Clinical Judgment 81

The body of research on clinical judgment and involves the process of weighing cues and
generated by interdisciplinary collaboration employing mathematical models (generally
has been categorized into two disparate theo- made possible through expert systems) to de-
retical classifications: the “rationalistic” and termine the course of action most likely to
the “phenomenological” perspectives. In this produce desired outcomes.
context, the term “rationalistic” describes Corcoran (1986) used an information-
scientific inquiry into the deliberate, con- processing approach and verbal-protocol
scious, and analytic aspects of clinical judg- technique to compare care-planning strate-
ment (Benner et al., 1996). Examples include gies used by hospice nurses. She found that
research on the role of information pro- unlike novice nurses, the overall approach
cessing, diagnostic reasoning (Tanner, Pa- of expert nurses differed by case complexity
drick, Westfall, & Putzier, 1987) and deci- with a systematic approach employed for less
sion analysis (Schwartz, Gorry, Kassirer, & complex cases and an exploratory approach
Essig, 1973) in the clinical judgment process. for cases of greater complexity. In addition,
The term “phenomenological” refers to re- expert nurses generated more alternative ac-
search on the skill-acquisition component of tions during the treatment planning process,
clinical judgment as advanced by Benner et were better able to evaluate alternative ac-
al. in the Novice to Expert Model (Benner & tions, and developed better care plans than
Tanner, 1987; Benner et al., 1996). did novices.
Information processing theory and diag- Tanner et al. (1987) used verbal responses
nostic reasoning are based on the work of to videotape vignettes to describe and com-
Newell and Simon (1972b) and Elstein pare the cognitive strategies of diagnostic rea-
(Elstein, Shulman, & Sprafka, 1978) and col- soning used by nursing students and practic-
lectively describe problem-solving behavior ing nurses. They found that practicing nurses
and the effect of memory and the environ- were more likely to employ a systematic ap-
ment on problem solving. These theories hold proach and to be more accurate in diagnosis
that human information processing capacity than the students. Henry (1991) examined
is restricted by short-term memory and effec- the effect of patient acuity on clinical decision
tive problem-solving ability is dependent on making of experienced and inexperienced
adoption of strategies to overcome human critical care nurses using computerized simu-
limitations. Information processing theory lations. Findings suggest that inexperienced
and diagnostic reasoning have been applied nurses collected more data and had poorer
widely to the study of clinical judgment and patient outcomes than experienced nurses.
the use of information in the clinical judg- Salantera, Eriksson, Junnola, Salminen,
ment process. Published research suggested and Lauri (2003) employed simulated case
that nurses and physicians use a similar pro- descriptions and the think-aloud method to
cess for clinical judgment which involves in- compare and describe the process of informa-
formation gathering, early hypothesis genera- tion gathering and clinical judgment by
tion and then additional information gather- nurses and physicians working with cancer
ing to confirm or rule out a suspected diagno- patients. The authors found that while nurses
sis or clinical problem. According to the and physicians identify similar problems,
“rationalistic theories,” early hypothesis gen- they employ divergent approaches to infor-
eration “chunks” data and is an effective mation gathering and clinical judgment.
strategy for conserving short-term memory Unlike the objective, detached approach
(Corcoran, 1986; Elstein et al., 1978; Tanner to the study of clinical judgment characteris-
et al., 1987). While knowledge generated tic of the rationalistic perspective, the phe-
from work completed in the fields of informa- nomenological perspective holds that intu-
tion processing and diagnostic reasoning has ition is a legitimate and essential aspect of
been descriptive in nature, decision analysis clinical judgment and is the feature that dis-
is a prescriptive approach to decision making tinguishes expert human judgment from that


of expert systems (Benner & Tanner, 1987). models hold potential for bringing effective-
Benner’s work is based on the skill acquisition ness to EBP by providing a holistic evaluation
model advanced by Dreyfus. According to of patient systems. A holistic perspective
this model, there are six key aspects of intu- would serve as a guide to clinicians in the
itive judgment: pattern recognition, similarity care of individuals through identification and
recognition, commonsense understanding, application of evidence which is most rele-
skilled know-how, sense of salience, and de- vant at the local level and for individual pa-
liberative rationality (Benner & Tanner). tients.
Much of the research related to Benner’s
work and the Novice to Expert Model relates PATRICIA C. DYKES
to the relationships that exist between nurs- MOREEN DONAHUE
ing knowledge, clinical expertise and intu-
The Novice to Expert Model is based on Clinical Nursing Research
Benner’s early work where a phenomenologi-
cal approach was used to interview and ob- Clinical nursing research is both broadly and
serve nurses with varying degrees of clinical narrowly defined. Broadly, it denotes any re-
expertise. In the interview process, nurses search of relevance to nursing practice that
were asked to describe outstanding clinical is focused on care recipients, their problems
situations from their practice. Benner found and needs. This broad definition stems from
that a holistic grasp of clinical situations is a the 1960s, when a major change occurred in
necessary precursor to expert clinical judg- nursing science. Prior to the 1960s the re-
ment (Benner, 1984). Subsequent research search of nurses had focused on nurses and
has supported these findings and has teased the profession of nursing including major
out differences in clinical judgment between questions of interest related to nursing educa-
clinicians with varying levels of experience tion and the way in which nurses practiced
(Corcoran, 1986). In a six-year interpretive within care delivery structures (i.e., hospi-
study of nursing practice, Benner et al. (1996) tals). The reasons for these foci are many, but
identified five interrelated aspects of clinical for the most part they stem from the dearth
judgment: (1) disposition towards what is of nurses with advanced degrees at that time
good and right; (2) extensive practical knowl- and the fact that nurses with advanced de-
edge; (3) emotional responses to the context grees were educated in other disciplines
of a clinical situation; (4) intuition; and (5) (e.g., education).
the role of narrative in understanding a pa- In the late 1950s and 1960s a major shift
tient’s story, meanings, intents and concerns. occurred, driven by three factors. First, lead-
The authors suggested that these aspects play ers in nursing successfully lobbied for the in-
a significant role in clinical judgment and de- stitution of the nurse scientist program
serve equal consideration along with the as- through the federal government, which pro-
pects arising from the “rationalistic” perspec- vided financial support for nurses to be edu-
tive of clinical judgment cated in the sciences (e.g., physiology, biol-
Research on clinical judgment identified ogy, anthropology, psychology). Second,
two divergent but legitimate perspectives. nurse theorists such as Faye Abdellah, Vir-
The challenge for future research is to inte- ginia Henderson, Imogene King, Ida Or-
grate these perspectives to study the impact of lando, Hildegard Peplau, and Martha Rogers
integrated models on clinical reasoning and began to formulate conceptual models to di-
patient outcomes. Synthesis holds promise rect nursing practice, and attention was fo-
for promoting evidence-base practice (EBP). cused on designing research that more or less
Rationalistic models can be employed in the was guided by those models (or at least the
form of guideline-based tools to bring the best substantive areas circumscribed by the mod-
evidence to patient care. Phenomenological els). Third, as more nurses attained advanced

Clinical Nursing Research 83

degrees, doctoral education with a major in The next stage in the evolution occurred
nursing finally became a reality, and the focus with the realization that little was known
of nursing research shifted more firmly away about many of the phenomena of concern to
from nurses and nursing education to the nurses. This heralded a period during which
practice of clinical nursing. The broad defini- emphasis shifted away from experimental
tion of clinical nursing research, then, was methods to exploratory/descriptive methods,
originally formulated to differentiate be- such as grounded theory. Guided by the meta-
tween the research conducted by nurses prior paradigm of nursing (person, nursing, health,
to the 1960s, which focused on nurses, to the environment), nurse scientists began focusing
major shift in focus on practice. on discovering and naming the concepts of
Strongly influenced by the establishment relevance for study in nursing, delineating the
of the Center for Nursing Research (at pres- structure of these concepts, and hypothesiz-
ent the National Institute of Nursing Re- ing about the relationships of these concepts
search) in the National Institutes of Health in theoretical systems.
(NIH), clinical nursing research has recently More recently, clinical nursing research
taken on a narrower definition, modeled after has become clearly defined as a cumulative,
the definition of clinical trials (large-scale ex- evolutionary process. Investigators are still
periments designed to test the efficacy of advised to derive questions from clinical
treatment on human subjects) used at NIH. problems, but the focus is on knowledge gen-
This narrow definition limits clinical nursing eration, specifically the generation and test-
research to only those studies that focus on ing of middle-range theory (a theory that ex-
testing the effects of nursing interventions on plains a class of human responses), for exam-
clinical or “nurse sensitive” outcomes. ple, self-help responses, symptom experience
In addition to an evolution in definition, and management, and family responses to
clinical nursing research also has changed in caregiving. Because knowledge is viewed as
form and complexity over time. Early clinical cumulative, investigators usually study vari-
nursing research was characterized by a focus ous aspects of one particular concept or re-
on circumscribed areas of inquiry using ex- sponse; studies build on one another, and
perimental and quasi-experimental method- each study adds a new dimension of under-
ologies. Investigators were few and tended to standing about the concept of interest. This
work in isolation. Prompted by metatheorists approach to clinical nursing research requires
such as Dickoff, James, and Wiedenbach investigators to use multiple methodologies
(1968) and methodologists such as Abdellah in their programs of research, including (a)
and Levine (1965) and Mabel Wandelt inductive techniques to discover knowledge
(1970), nurse scientists were advised to derive from data; (b) deductive techniques to test
questions directly from problems encoun- hypotheses that are either induced or de-
tered in their clinical practice and to strive to duced; and (c) instrumentation to increase
develop and test interventions to solve these the sensitivity, reliability, and validity of the
problems. Often an investigator conducted measurement system designed for the con-
single studies on different problems rather cept.
than series of studies focused on different as- The methodologies being used include
pects of the same problem. As a result, study qualitative methods such as ethnomethodol-
results tended to be context-bound and lim- ogy, grounded theory, and phenomenology
ited in generalizability to other settings, sam- and quantitative methods ranging from tradi-
ples, or problems. The relationship between tional experimental methods and designs to
theory development and research was dis- less traditional methods, such as path analysis
cussed abstractly but not explicitly operation- and latent variable modeling. Because human
alized, and a philosophy of knowledge build- responses change over time based on contex-
ing, rather than problem solving, had not tual factors or treatments (independent vari-
yet developed. ables) applied by the nurse investigator and


because understanding the nature of change tion and testing while developing measure-
often is at the crux of the theory building, ment systems and using research methods
skills in measuring change also may be re- that capture the holism of the client and the
quired. This has resulted in the need for many holistic nature of the health care experience.
investigators to incorporate techniques such
as time series analysis and individual regres- LINDA R. PHILLIPS
sion into their research.
Understanding the human responses of
concern to nurses can also require an under-
standing of cellular mechanisms that are best Clinical Preventive Services
studied in animal models and a coupling of Delivery
biological techniques such as radioimmuno-
assay and electron microscopy, with psy- Empirical support of preventive health care
chosocial techniques such as neurocognitive and health promotion has grown consider-
assessment or self-report of psychological ably over the past decade, demonstrating that
states. In addition, measurement of different the short-term investment in preventive care
units of analysis (e.g., individual, family, or- could avert health problems and medical
ganization) may be required, along with strat- costs over time (U.S. Preventive Services Task
egies for understanding the effect of care con- Force, 2000). Many serious disorders can be
texts (e.g., social, physical, organizational en- prevented or postponed by immunizations,
vironments) on the human response of con- chemoprophylaxis, and healthier lifestyles, or
cern. Needless to say, single investigators detected with screening and treated effec-
rarely have all the skills needed to advance tively (U.S. Public Health Service, 1994).
the understanding of a particular concept. As However, many preventive care services are
a consequence, single investigators are be- frequently not being delivered by clinicians
coming more and more a thing of the past in practice.
as teams of scientists, including nurses and Despite the benefits of preventive care ser-
individuals from other disciplines, collabo- vices, such as cancer screening and immuniza-
rate in the knowledge-building endeavor. tions, utilization of specific preventive care
Nursing is concerned with human re- services in New Jersey remain below state
sponses and is based on the assumption that and national goals. Documented barriers to
humans are holistic and embedded in history the implementation of these services included
and various environments. Clinical nursing (a) clinician uncertainty about what services
research is about generating a body of knowl- to offer, to whom, and how often; (b) lack
edge on which nurses can base practice. It of reimbursement and associated time con-
is about assuring the efficacy and safety of straints; (c) clinician attitudes and lack of
nursing actions, substantiating the effect of knowledge about preventive services; (d) pa-
nursing actions on patient outcomes, and tient attitudes, confusion, and lack of under-
conserving resources (costs, time, and effort) standing about clinical preventive services;
while effecting the best possible results. It is and (e) lack of organized systems to facilitate
about identifying strategies for improving the the delivery of services (Griffith, Dickey, &
health of the population and promoting hu- Kamerow, 1995).
manization within a health care environment Clinicians are confronted with different
that has a natural tendency to be mechanistic, recommendations regarding preventive care
compartmentalized, and focused on short- practices from the HPs they contract with.
term rather than long-term gain. It is about Multiple recommendations for preventive
client advocacy, client protection, and client care sometimes conflict with each other, leav-
empowerment. The challenge of clinical nurs- ing clinicians confused about which services
ing research is to develop an understanding to provide. Literature shows that lack of a
of human response through theory genera- standardized approach to the delivery of clin-

cal directors were able to identify a subset of ing on managed care plans and integrated USPSTF guidelines that all HPs could endorse delivery systems. cluding three Delphi rounds and four coali- prove consistency. How. guidelines as the standard for which preven- ment the national guidelines.S. In meeting this objective. some medical directors decide what (Fox & Cuite. In either circumstance. cal directors. both scientific evidence tion meetings over the course of a year. and established a consistent to support the recommendation that the con- set of guidelines to which all of the nine dition be specifically considered in a periodic HPs agreed. health examination. nine NJ HP medical sent to the medical directors to assess their directors were brought together to form a HP’s level of agreement and/or disagreement coalition to identify a set of CPS guidelines with the USPSTF guidelines. the coalition should be recommended on their own. Medical directors discussed that are being held accountable for care provided.8 million New Jersey. agreed on the value of these evidence-based viewing original empirical research to supple. Medical directors from competing on scientific evidence and needs of their mem- HPs brought to the table expertise on CPS. immunizations. compen. medi- and clinical practice. livered and do not replace the clinicians’ judg- The New Jersey Association of Health ment based on patient risk. lines. A clinicians with information on the value of third questionnaire was then sent to the medi- preventive services to their patients. particularly because plans practice. The USPSTF. Their decision to include only discussed the current knowledge of evidence. Using consensus-building strategies in- Sisk (1998) discussed that initiatives to im. plementation. Pre- HP medical directors seek recommenda. ans that represent 98% of the state’s HMO Decisions made at each level were based market. a level of strength “A” . HP Seventy areas identified by the USPSTF for medical directors work independently from preventive care were reviewed by each medi- other HPs. were based on the evidence-based U. particularly for tive care should be delivered to the general newer or more controversial services (Fox & population. conducted comprehensive evalua- work with a committee of practicing member tion of the scientific evidence for CPS. 2001). individually through question- Through a partnership between the New naires and collectively through coalition Jersey Association of Health Plans and Rut. Positively stated that all plans could endorse as priorities for recommendations that the medical directors implementation. Clinical Preventive Services Delivery 85 ical preventive services (CPS) is a barrier to Agreed-upon guidelines of the coalition implementation (Griffith et al. imple- Plans and Rutgers College of Nursing collab. those guidelines with good to fair evidence based practice. screening tests. meetings. which preventive care services should be de- cians utilizing patterns. bers at large. Therefore.. ventive Services Task Force (USPSTF) guide- tions from government agencies and profes. Cuite. re. are increasingly focus. 1995).S. ommendations they should provide. However. 2001). tion. disagreed on were addressed at subsequent these HPs will be able to provide contracting coalition meetings to promote consensus. as priorities for implementation in clinician ment guidelines. a body of preventive care sional organizations in selecting CPS their HP experts convened by the U. cal director. Two rounds of questionnaires were gers College of Nursing. obtaining feedback regarding rec. and chemoprophylaxis ever. if not control. requesting them to rank order sating for uneven knowledge and skill that these guidelines according to priority for im- many clinicians have in the area of preven. HPs should be able to imple. Some medical directors Services. Public Health should recommend. ing counseling interventions. over clini. these guidelines serve as the minimum for HPs have leverage. ventive care. HPs covering 4. includ- clinicians. mentation of these guidelines will ensure that orated in this concerted effort with nine HPs all patients receive a consistent level of pre- in NJ.

illustrates their commitment to potential biases are usually of such magnitude sound and safe practice for their members. randomized and nonrandomized trials). Mega-trials clinicians in the delivery of CPS. basis. currently accepted treatments. GRIFFITH equal distribution of bias between groups (Charlton. Clinical tri. lished in Phase I. the medical directors identified development and use of mega-trials repre- methods to screen for complications of this sents one variation. such as pragmatic (practical benefits Randomized clinical trials are comparative to the overall subject population treated) and experiments that investigate two or more explanatory (Viscoli. and treat their safety and feasibility has been estab- health problems to studies of the psychologi. Recent measure. comfort.86 ENCYCLOPEDIA OF NURSING RESEARCH or “B” recommendation as determined by introduces biases from many sources. small sam- sults compared to historical data. Comparing ple sizes. detect. that the results of nonrandomized studies are They also identified diabetes mellitus (DM) as often ambiguous and not universally ac- a growing problem that warrants attention. expense of clinical trials. Nonrandomized clinical trials usu. (b) confirmatory als are often grouped into two major classifi. studies generally establish whether a treat- periment with patients. Some scientists divide clinical trials into The universe of clinical trials is divided three groups: (a) exploratory (initial trials in- differently by different scientists. Issues surrounding clinical trials include mation is collected prospectively and the re. 1995). experiment in which therapies under investi. studies assess the efficacy of treatments after vent. ized trial analyzed on an “intent to treat” bidity and/or mortality in this population. There are many types ment is safe and at what dosages. These same biases are not present to mendation to screen for DM as a preventive the same degree in randomized trials. and ethical issues. Other scientists divide the universe into two gation are allocated by a chance mechanism. disease. They unanimously agreed that clini. Phase III studies compare cal impact of a health problem and ways to effectiveness of Phase II treatments against improve people’s health. following approval Clinical Trials by the Food and Drug Administration (FDA). and quality of life. therapies. ing. control. biasing. There are many prospective data with historical control data biases that can compromise a clinical trial. groups. mental control and large between-subject This project used a systematic approach to variation. not causal hypotheses vides a template for other HPs nationwide to and therefore not testable. It pro. three phases of clinical trials begin. dispense with the scientific aim of maximum experimental control to remove or minimize CYNTHIA GUERRERO AYRES bias and instead use randomization to achieve HURDIS M. (designed to replicate results of exploratory cations. In clinical drug trials. Bruzzi. large. and (c) explanatory (designed to mod- studies. function. vestigating a novel idea). . on which infor. Mega-trials can come to consensus on guidelines that support be repeated but not replicated. ally involve only one therapy. & Glauser. Phase II of clinical trials. sions are observations. In mega-trials randomization serves to Conflicting and confusing guidelines are achieve identical allocation groups (equal dis- detrimental to the delivery of preventive care tribution of bias) where there is poor experi- and create a major barrier to CPS delivery. cepted unless the therapeutic effect is very Although there is no evidence-based recom. The mega-trial is a large. ranging from studies to pre. Phase I A clinical trial is a prospective controlled ex. diagnose. 1995). A randomized trial is defined as an ify or better understand an established point). Results of mega-trials cannot reach consensus among medical directors readily be generalized because their conclu- from competing HPs regarding CPS. simple. random- cians should provide services to prevent mor. These the USPSTF.

use according to event rate in the controls. S. unbiased tify the best therapy. As a result. Issues of withholding treat- approaches to reduce selection bias include ment include increasing subject risk or subject (a) using a broad recruitment base to reduce benefit if there is reasonable evidence of posi- patient and physician biasing factors and (b) tive effects of the intervention or treatment. However. Interventions may . and careful monitoring of clinical also has demonstrated bias due to subject trial results. the meta-analysis also must be evaluated. mainly middle-class. function. If carried out prospectively. For example. interviewer bias. Meta-analysis pro- of patients and thus may be sufficient to iden. However. Additional issues of informed factors. Arrangement of the trials velopmental phenomena. Cognitive Interventions 87 such as observer bias.. subjects were more consent include assuring that subjects thor- likely to participate in clinical trials on multi. and the type of subjects who might be bene- White males with little to no inclusion of fited. that is. such as attention.. To deal with the issue of small sample sizes. meta-analysis is increasingly being DOROTHY BROOTEN used.S. tions or treatment is necessary to stop the Clinical trials are expensive and resource. and (c) serving as a basis evidence on the relative effects of treatment. untested therapeutic wisdom. and individual to covariables of interest supplies unique in- subject factors. Research treatment. married. is essential. popula. Meta-analysis (quantitative overview) is a systematic review that employs statistical methods to combine and summarize the re. concentration. the on bias in sample selection. An inter- weighted according to the inverse of the vari. M. Suggested point in the study. or In a meta-analysis the individual studies are memory (Baltes & Danish. the number of subjects nec- included a limited segment of the U. trial if there is associated morbidity or mor- intensive. vention may be defined as a programmatic ance. Small clinical trials are tions and treatment. essary to determine the validity of past trends tion. rigor of method. & Fox. Well-conducted meta- analyses are the best method of summarizing Cognitive interventions have been defined as all available unbiased evidence on the relative mechanisms designed to change cognitive effects of treatment (Richards. technique provides information on the need To date. Cognitive Interventions sults of several trials. women and minorities. vides a summary of all available. 1993). more weight is given to studies attempt at altering the course of life-span de- with more events. the majority of clinical trials have for another trial. caused by chance. facilitating subject transportation to the Careful monitoring of the effects of interven- study site. for overview and meta-analysis (Sackett & However. oughly understand potential risks and bene- ple sclerosis if they had a higher than median fits of participation and any effects on their income and were disabled from work care should they decide to withdraw at any (Schwartz. in designing valuable in (a) challenging conventional but and evaluating clinical trials. 1980). subject numbers are tality and extending the intervention or treat- generally limited to the minimum number ment to the control group in the event of needed to demonstrate a significant effect not significantly positive treatment effects. uneven subject sizes. C. rigor of methods used to conduct Cook. Recent concerns have focused formation. 1995). withholding of always generalizable and effective. This lack of diversity Ethical issues in clinical trials include is- in trial samples has yielded results that are not sues of informed consent. 1995). effect of nonvalidated instruments. that is. and quality of the trials or according recruitment by physicians. small clinical Clinical trials remain the principal way to trials may not provide convincing evidence collect scientific data on the value of interven- of intervention effects. (b) providing including careful evaluation of potential bias- data on number of events rather than number ing factors. E.

were framed within the paradigm of comple. A number of intervention studies to years of systematic inquiry. and grams of research in which aspects of cogni- fibromyalgia. cognition. such as cancer. and had ment of stress. Since chemotherapy ing such parameters as the goal (enrichment. HIV. those with other chronic conditions. commu. often causes individuals to experience cogni- prevention. pain. Compared comprehensive reviews: (1) dose (number of with the control group. havioral techniques for symptom manage. decrease anxiety and aggressive behav. classroom. pallia. Eller (1999) reviewed the research on arthritis = 16. Three major differ. & Kullberg (2003). the programs of two research- tion). The responses search on music therapy designed to manage of a group of elderly to training varied de- pain. measures at two time points: 2 weeks before ences in the interventions emerged from these surgery and 2 weeks after surgery. do not have cure as their pri. cognitive-be. memory (subjective memory evaluation) Snyder and Chlan (1999) reviewed the re. symptom management. and improve performance and well-be. depression. Individuals were from nurse scientists. or hospital). Over more than 10 illness. tion. Cimprich and Ronis (2003) tested the effi- ing. and met- macological interventions. group showed greater ability to direct atten- get populations. she has demon- ameliorate symptoms from chemotherapy strated that cognitive behavioral health-pro- . and memory. reported difficulty with attention. 20 Ms) with an ples. Timmer- ties to maintain function and live with the man. (2) the tar. mentary and alternative therapies. last over time. heart disease = 32. A total herence. suffer cognitive losses. Nurse scien. health promotion interventions. reported greater memory decline.88 ENCYCLOPEDIA OF NURSING RESEARCH be classified as concrete technologies involv. medication ad. delivered 120 minutes per week of exposure. = 19. The cancer group made effects of chemotherapy. Blozis. M2 = 2. iors. in the home of the individual. tion. visualization. performance.22.50). tested the effectiveness of an efficacy-based scribes the research of nurse scientists in two intervention designed to improve memory areas: (1) the integrative reviews of nonphar. tion.00). which ior (attention. and cancer survivors may multivariate models of affective. the intervention sessions and length of exposure). or health delivery). Therefore. memory self-efficacy. memory- designed to improve cognitive function in efficacy (M1 = 48. the target behav. pending on their health status. tive function have been used as outcomes of mary goal for treatment. and for lower self-reported instrumental activities of reducing blood pressure. or percep. memory. and are not presented as a comprehen. of 78 older adults (58 Fs. and health pro. and the mechanism (train. the setting (family. concentra- ing. Capacity to minated the vast differences between and direct attention was assessed with objective among the interventions. anxiety. Even though the three integrative reviews cacy of a natural environment intervention. These two studies are examples of pro- Chronic illness. A unique program of research is the work motion become important day-to-day activi. This review de. and pain. ers are illustrated. they illu. Becker. treatment are published. McDougall (1999) significant gains in short-term memory of im- reviewed cognitive-behavioral interventions mediate and delayed story recall. tive difficulties and physical fatigue. grouped by chronic condition: cancer = 11. practice. and other guided imagery. These programs are exam. Elderly cancer survivors nity. The cancer group was older. McDougall (2001) and behavioral interventions. and the side daily living scores. and meta- older adults without cognitive impairment.18. M2 = 58.82. average age of 82 years participated in the sive review of cognitive intervention research eight-session program. change (M1 = 2. of Stuifbergen. cognitive. and (2) programs amemory in older adult cancer survivors and of research in chronic illness. and (3) the methodologies. M = 84. or alleviation). Women undergoing treat- tists have broadened the scope of their ment for breast cancer have difficulty with research in health and illness by including attention fatigue.

Topics explored during these coverage as recorded by Medication Event weekly sessions were the role of lifestyle fac- Monitoring System (MEMS) caps. group. livered to 311 patients following gynecologi- creased. remember if the medications were taken as Good. 2002) pro- intentional. Fulmer and her team (1999) tested ple evaluations and treatments referred all two experimental interventions: video tele. pain. the cues used both visual place. combina- ing external memory cues to older adults re. Those individuals who slept well had needs/lifestyle of the individual and embed. but also to being of persons with chronic pain. tion. significantly in. pain intensity lowered by 18% and de- tion compliance than the control group. Two programs of research are described Older adults are particularly vulnerable to here. less pain on the following day. individuals to the research project. whether intentional or un. music. individuals did not receive relief from pain emphasizing technology. the three interventions had the they have taken the medicines as desired. The future holds . ded in the context of their living situation. tors such as diet. pain. are relevant to this and suffering after they had undergone multi- review. while not significantly differ. The intervention ment in salient places surrounding the time groups experienced less pain than the control of day medicines need to be taken and also group only receiving PCA. dition self-efficacy for pain management in- Insel and Cole (2004) also incorporated creased 36%. This intervention demon- the MEMS as a mechanism to enhance the strated that cognitive behavioral treatment availability of environmental cues to not only reduced suffering and improved the well- remember to take medications. Stanton-Hicks. Physicians who determined that these ence behaviors. age. remains a great concern. Anderson. tients. Federman. The cues assist in both remembering practiced the technique for 2 minutes preop- to perform the intended action (prospective eratively and received coaching. When combined provided a way for older people to check if with PCA. activity. intended. tively being investigated. and physical and imental groups. Grass. the and Makii (2002) evaluated the results of percentage of days in which the correct num. showed greater medica. or patient-controlled an- Therefore. cal surgery: jaw relaxation. The primary outcome measure. The intervention focused on provid. the cognitive function of older adults the use of a commercially available technol. Participants in the intervention groups tions. that is a 9% to 29% reduction interventions were tailored to the unique in pain. Wells-Federman and her team (Wells- medication errors. pression scores were reduced by 29%. opioid intake. & Caudill. cognitive vided a cognitive-behavioral treatment pain- function. With older adults. algesia (PCA). Cognitive Interventions 89 motion interventions reduce the burden of Nurse researchers are making progress in illness and improve the health of women with developing cognitive interventions to manage multiple sclerosis (MS). The same effects. The exper. tion of relaxation and music and a control sponsible for self-management of medica. Two programs of research. Arnstein. Research focused ogy produces significant health outcomes to on maintaining cognitive function and pro- assist older adults to maintain their indepen. three nonpharmacological interventions de- ber of doses was taken. The inter- phone and standard telephone against a con. With the greatly increasing older popula- These two studies provide examples in which tion. As a result of the interven- ent from each other. The investi- memory) and remembering if the action was gators evaluated sensation and distress of performed as intended (source monitoring). Compliance gram that met once per week for 10 consecu- was determined as the percent of therapeutic tive weeks. moting improved cognitive function is ac- dence. and sleep. vention was a group pain-management pro- trol group receiving usual care. emotional tension. and presence of depression are management intervention to chronic pain pa- known to influence compliance and adher. In ad- which worsened at 8 weeks.

and testing effects. archi. patterns of change or respondents are partitioned by the extent of growth. different subsamples are drawn from a larger ment of subjects to groups. The panel design. Cohort of cross-sectional and longitudinal data. In a panel study with multiple co- . experimental design lacks random assign. The insti- respondents who follow each other through tutional cycles cohort design is strengthened formal institutions such as universities or hos. examine trends over time. such as control for the effects of age or experience time of diagnosis. There are two major types of cohort de- Cohort Design sign: cohort design with treatment parti- tioning and the institutional cycles design. terns. A cohort is a treatment (amount or length) received. designs were originally used by epidemiolo. tal group. In trend studies. pected to differ only minimally on back. if a nonequivalent nontreatment group is pitals or informal institutions such as a fam. In the group with common characteristics or experi. The purpose in 1976 and have been followed since) al- of a cohort design is to determine whether though some are retrospective. and to experimental designs. There are a number of types of cohort come measure. the Nurses’ Health which some cohorts are exposed to a treat. Study. 2000. Because ferences between cohort groups in variables. test-posttest design or when no pretest mea- A cohort might be graduates of nurse prac. measured at the same time as the experimen- ily. Cohort studies may eventually lead to ences. rates. sures of experimental subjects are available. Trend studies are prospective designs used to ground characteristics. JR. or trends over time. more cohorts are followed over time. titioner programs in the years 1995. Recall that a quasi.000 nurses were enrolled ment or event and others are not.90 ENCYCLOPEDIA OF NURSING RESEARCH great promise for the ability of science to such as biased sample selection. gler. groups. simple comparisons between cohorts may and to identify different patterns between suffer from a number of design problems. hypotheses about causality between variables In the most restrictive sense a cohort de. two or more groups differ on a specific out. In A cohort design is a time-dimensional design a cohort design with treatment partitioning. one or more earlier ences during a given time period. count for many of these threats to the internal validity of a study. time since exposure to a when these might confound results in a pre- treatment. a strong cohort design can ac- GRAHAM J. Populations also can be classified ac. A well-planned cohort design can cording to other time dimensions. MCDOUGALL. 1995). Cohort designs might utilize a combination 2005 or siblings in blended families. Although the cohort at specified time points to look at pat- groups in a cohort design may not be as com. Most cohort de- sign refers to a quasi-experimental design in signs are prospective (e. institutional cycles design. or time since initiating a behavior.g. time. maturation of subjects. or trends over time (Polit & Hun- parable as randomly assigned groups. in which one or drawing causal inferences in quasi-experi. cially useful for describing phenomena. is espe- mental studies because cohort groups are ex. come variable.. Cohort designs are useful for studies. The term cohort studies broadly refers to gists and demographers but are increasingly studies of one or more cohort groups to ex- used in studies conducted by nurses and other amine the temporal sequencing of events over researchers in the behavioral and health sci. Panel designs with multiple co- val records or data on relevant variables can horts are used to study change in the vari- be used to compare cohorts that received a able(s) of interest over time. Cohorts cohorts are compared with the experimental generally refer to age groups or to groups of cohort on the variable(s) of interest. in which 100. to examine sequences. intervening assist older adults in maintaining cognitive historical events that may influence the out- function necessary for quality of life. to examine dif- treatment with those that did not.

Population biased estimates about the phenomena of in. health care. agencies. Collaborative research involves multiple advantages. ect with expertise in the research process or tively or retrospectively from a specific point. Nursing literature also advocates international collaborative ef- CAROL M. innovations in nursing practice an institution or agency. partnerships can be an effective Although benefits exist. the groups can enter the study at differ. MUSIL forts. Multisite partnerships give a the planning. evaluation. groups can contribute the perspective and terest. collabo- ciopolitical accountability. collaborative re- and efficient way to use human. expertise. Most disadvantages are related to interper- riety of individuals. those involved in implementation partici- tion. context. Finally. material resources. supports a context for research that is com- search team whose members bring varying patible with the realities of nursing practice. Investigator bias can be reduced with of individuals. communities. and education to bear can be increased through collaboration. The loss of participate as collaborators. or policy are more likely to be adopted if Two prevailing trends support collabora. rent practitioners. collegiality. Collab- resources for collaborative projects are not oration with clinical agencies can help iden- unique within the research arena. implementation. pated in the inquiry process. Individuals can A major problem with prospective studies contribute the perspective of education. can maximize the potential of all participants ent points in time. bringing specific subjects in a prospective study may lead to human or material resources. A prospective If finite resources are to be allocated. ser- of all types is subject attrition from death. Pooling resources of a va. potential of larger sample size over a shorter and dissemination of research activities. research. Ideal time frame and the benefits of built-in replica- collaboration brings the perspectives of nurs. and needed ings increases with more participants. relevant and timely issues eses about risk factors for disease or other are more likely to emerge as inquiry topics. ships with consumers. Some authors limit the term Potential collaborators fall into several cohort study to designs in which exposed and categories. One potential advantage is a strengthened process and improved outcome Collaborative Research through the contribution from multiple indi- viduals with varying expertise and perspec- Collaborative research involves cooperation tives. perspectives. Resources and potential funding sources ing practice. namely. The on complex issues of health and nursing. tion. in a substantive clinical area. and organizations in multiple inputs. society study is a variation of a panel design in which and specific funding sources ask that the proj- a cohort free of an outcome but with one or ect demonstrate societal relevance and a con- more risk factors is followed longitudinally to nection to public concerns. and the effects of aging and contribute to a greater outcome. and authority within Additionally. Through partner- determine who develops the health outcome. agencies. or cur- The prospective design is used to test hypoth. (Woods & Catanzaro. Individuals can come to the proj- nonexposed subjects are studied prospec. fiscal. or research. constrained resources and so. vice. health outcomes. The possibility of greater dissemination of find- research process. 1988). With diminishing rative interaction can enhance professional resources to fund research and to deliver creativity. and productivity. The unique tify potential student clinical placement and feature involves the configuration of a re. Collaborative Research 91 horts. and search also presents distinct disadvantages. design. or other forms of loss. can be differentiated from the effect of being Related to scarce resources is the call for a member of a particular cohort group increased accountability of research efforts. and disciplines sonal issues and the complexities of pulling . wisdom of a community. Agencies or institutions can refusal.

ers learn from the expertise of each other. Another disadvantage als from multiple health care agencies in a of collaboration is the possibility of multiple geographic region. Collaboration also may add to the time com. of local communities. investigator bias. trust. and listed the requisite personal attributes as practice based on scientific research. research occurs “questions of authorship. priorities. Engebretson and Wardell (1997) there is ownership. tions. Collab. researcher. and in. role conflict. research. In this “trustworthiness. Written ship of an employed nurse researcher. 44) and often synergy and fun. and distinct role delineation. Comfort has been conceptualized as a holistic practice-relevant research. tentative time is the development of practice-relevant re. individual re. tributes as “acceptance. for poor generalizability. The project ideas can be cri. This model provides the review boards and organizational protocols. and legiality. JOANNE W. tives and priorities. RAINS In the unification model. subjects are easily accessible. In this model. Disadvantages involve the potential mitment” (p. competence. development of lay ing in the research process or in a substantive leadership. 150). use of data. research. Five major types of collaborative research Because of the geographic distance between described in the nursing literature are the tra. and scarce research funding. Researchers in this model often re- advantages and disadvantages. 43) and the requisite relationship at- terdisciplinary collaboration is easily ar. the project. This mode of inquiry involves the and expertise means that the research tasks community as an equal partner at every step can be divided. outcome of nursing care and defined as the . recognition of effort” (p. sites. large subject pool. accepted innovation. academic re- searchers from educational institutions and clinicians from health care agencies collabo. model combines community participation. mentum and inspiration of a shared project. and action to solve pressing social The usual equal distribution of experience problems. The participatory action research (PAR) tions work together. consortium model. Teamwork requires clear communica. Disadvantages relate to the com- styles. and subsequent search. present major challenges. Disadvantages involve a long time com- tional model relate to the necessity of de. Detrimental characteristics of the tradi. Thiele (1989) mentioned Examples of the traditional model abound. validation. and the mo- mitment. openness. and resolution of real-life situa- area. The strongest merit of this model decision-making processes. and the professional productivity of the col. Without time and place. Comfort rate as equal partners. plexity of blending two institutions’ perspec- tion. of the process. searchers from the same or different institu. three significant issues that require attention: In the health care model. administrative coordi. and flexibil- model. and com- ranged. decreased data collection time.92 ENCYCLOPEDIA OF NURSING RESEARCH together different perspectives. Benefits include empowerment tiqued by two or more researchers with train. health care setting model. agreement among collaborators should clar- orators include the clinical staff and the nurse ify role responsibilities for each participant. cation of guidelines. ity” (p. contribution and within a clinical institution under the leader. communication and decision making ditional model. benefits of cost sharing. the challenges of meeting nation. Each model has boards. Multiple agencies unification model. mitment and difficulty in obtaining funding. and also introduce multiple protocols or review participatory action research. spin-off projects. creased teaching load for researchers with an Collaborative efforts can be enhanced by educational appointment and the need for the explicit discussion and written communi- resources of funding and research assistance. and enhanced col. Benefits include com- bined resources from education and service. the integrity of the research teaching or work load for the researchers. port an ambiguity regarding their role in In the traditional model. and the need to decrease those features. and because clinicians are involved. schedules. The consortium model involves individu- laborators are at risk.

Because comfort Qualitative studies have been conducted is a basic human need. Journal publications by these authors did not sures can be negative. eralized comfort measures for women during ing to a peaceful death. Patients/families want to its previous baseline. previous experience with health tions were tested: (a) types of immobilization care. Enhanced comfort for persons after coronary angiogram. and religious beliefs. lism. the theory states that inter. Because HSBs are construc- experiencing comfort were derived from the tive. or lead. psychospiritual. (Kolcaba & Kolcaba. ies demonstrated significant differences be- tion and upon which nurses have little influ. In each study. patient/family comfort is the immediate goal ocultural (Kolcaba. first and second stages of labor. ventions that are targeted towards comfort. it guides Kolcaba (1994. The four contexts for engage in HSBs. are subsequent derived from a concept analysis of comfort outcomes. nical and narrow outcomes. patient/family goals (Magvary. Relief. healing). Comfort 93 experience of having needs for relief. diation therapy for early breast cancer. (c) tating health-seeking behaviors (HSBs). conscious and subconscious experiences and transcendence addressed or met in four influence motivation for patients/families to contexts of experience. it guides nurses to test of enhanced comfort is achieved (Dretske. were cific to health-related goals. 2003) provides a theoreti. guides nurses to test relationships between mented to address unmet comfort needs of HSBs and institutional outcomes. Comfort care consists be comforted by nurses in stressful health- of goal-directed. nurses to test relationships between comfort cal framework for practicing comfort care and setting-related HSBs. The process is initiated is elevated in stature among other more tech- by the nurse after an assessment of the com. existing social comfort over time. First. cognitive strategies for persons with urinary Schlotfeldt (1975) discussed HSBs in terms frequency and incontinence. Comfort Theory is focused on enhancing Comfort care is nursing care that is in. such as alcohol or drug define or operationalize the outcome of com- abuse. fectiveness in terms of positive and desirable paring comfort levels before and after inter. a successful process is evaluated by com. fort. Kolcaba. . ease. comfort. nurses have a pragmatic rationale comfort. Consistent with ho. 1991). Briefly. tween treatment and comparison groups on ence. Because the nursing-sensitive outcome that is congruent specified product or goal is enhanced com. and HSBs.These comfort stud- are factors that recipients bring to the situa. Because comfort is related to process of comforting) through which en. the outcome of enhanced comfort outcome) is achieved. ease. thereby facili. 1991). sage for persons near end of life. patients and their families. it ventions should be designed and imple. patients and families to determine the nature of comforting nursing often assist nursing efforts towards enhanced actions and what comfort means to patients. some self-comforting mea. (b) strengthens patients and their families during guided imagery for women going through ra- stressful health care situations. terventions and comfort. (In fact. patient/family comfort for altruistic and tended to enhance a patient’s comfort beyond pragmatic reasons. The Theory of Comfort directs research in The process is incomplete until the product several ways. and (e) gen- external (self-care. they are reciprocally and positively re- literature on holism and were labeled physi. Intervening variables sociates (Kolcaba. Second. lated to comfort. comforting activities (the care situations. and soci.) The effectiveness of comforting inter. with recent mandates to measure nursing ef- fort. relationships between particular holistic in- 1988. Third. three types of comfort. 2003). for enhancing patient comfort. Comfort Theory states that cal. and of comforting interventions. subsequent desirable health and institutional hanced comfort (the desired end product or outcomes. 2003). If the relationship and for generating nursing research about is positive. environmental. functional status). Several empirical tests of Comfort The- ventions is perceived in the context of existing ory have been conducted by Kolcaba and as- intervening variables. spe- transcendence. (d) hand mas- of those that are internal (fertility. 2002). such as financial status. The following interven- support. It is a holistic and fort needs of the patient/family.

nity Health (PATCH). Institutional outcomes could in. sion of innovation. categori- portant mission for nursing. ecological models. and higher sessments. in. and recreation and countability of essential services. or peaceful death (when ap. Most major on goals. faster healing. Epidemiological clude decreased length of stay for hospitalized research includes community needs. biomedical. additional tests cal programs include large-scale interdisci- of Comfort Theory should be conducted. Research is needed to explain under what vices [USDHHS]. Assessment aspects of this process are community devel. Community health research can be classi- To demonstrate that comfort is an im. broad contextual factors. and there were at least two measure. munity coalitions for health throughout the nity problems and assets. nurses are KATHARINE KOLCABA conducting community health research and involving other disciplines and the commu- nity in the process. criti- comfort instruments were adapted from the cal theories. particularly How effective are these programs and policies community health nurses. plinary studies such as the Minnesota Heart cluding attention to increased functional sta. and reach goals. The growth of Community health is influenced by environ. create consensus country requires further study. of success? Nursing interventions. social change theories. Department of Health and Human Ser. nurses. Increasingly. diffu- General Comfort Questionnaire (Kolcaba. and be. Protocol for Excellence in Public Health opment and multisectoral interventions. must collaborate in changing key community health indicators with other disciplines in developing a knowl. The extent leisure activities all promote community to which underserved populations receive health. to capture change community decision making. usually three. Health Program. Planned Approach to Commu- cluding health policy and community partici. Re- definition of health. good jobs. Communities. Community Health Opportunities for nursing research in com- munity health are enormous. Cities and action research. and the Stanford Five-City Project. in comfort over time. nurse-managed clinics or community nursing ries and models that can be applied to the centers. Key health programs—for example. Fi- patient satisfaction. (APEX/PH). com- 2003). search in managed care and its impact on education. faster progress during rehabilitation. community power. and risk factors for disease. Healthy Cities and pation. 2000). munity participation. munity coalitions as part of the community those adapted from Healthy People 2010 health process.S. in. organizational. safe neighborhoods. access to community health is needed to assure ac- health and social services. and HIV/AIDS Community sess and monitor progress in achieving explic. change theories. there are evaluations of community health interventions. For example. Planning—involve the development of com- itly stated community goals. managed care is placing increased demands mental. What are the . such as edge base for community health. nally. need further research. take action. Useful theo. Noncategorical programs include Healthy propriate). Community health is a process of care within cost-containment strategies health promotion and disease prevention in should be studied. The development of com- which community leaders identify commu. conditions coalitions succeed in promoting Because the health of people is affected by community health programs and policies. and ment points.94 ENCYCLOPEDIA OF NURSING RESEARCH interventions were targeted to all attributes study of community health include cultural of comfort relevant to the research settings. on state and local public health systems to havioral factors and encompasses a broad assure the continuation of vital programs. Program. Ongoing community-wide efforts as. for example. (U. For example. assets as- patients. fied in different ways. community development. the Pawtucket Heart Health tus. decreased readmissions.

Ad- successful nurse-managed services that can vances in the use of psychotropic medications be applied elsewhere and in what types of and government policy directives in each communities? country spurred movement of mentally ill pa- Likewise. nursing leaders (Mereness. This was fol- many disciplines in addition to nursing. it was not petitive in the current health care arena. however. social workers were the pri- them from their almost exclusive practices in mary professionals delivering care to men- large state hospitals. tients into the community. The U. (U. taking psychi.K. The challenge is to share develop comprehensive community mental the expertise of each discipline as well as health centers (Miller. extent are these services being integrated into From the early 19th century until the the networks of provider services? Dissemi. Historic influences in psychiatrists could extend their authority be- the United States (U. hospital-based psychiatric nurses who were tributed most to this body of literature. mental hospitals.” con- nation of research findings is also important. which medicine. the community men. health economics. until the publication of the 1975 White Paper. Nursing area of community mental health has steadily was represented by the part-time activity of increased. Most psychiatric nurses in the further build the body of knowledge relevant U. lowed in 1963 by the enactment of the Com- cluding epidemiology. atric nurses into communities and freeing In the U.. & Gebbie.S. and U. the U. in. Action for Mental Health. Nursing research in the tally ill patients in the community. among fellow professionals.K.) and United Kingdom yond the confines of the hospital (Bonner. the United Kingdom having con. Hicks.S. presented to research collaboration. stituted the major treatment resource for the For example.S. that any rates a broad definition of health. 1960s. fol- share the credit and rewards of collaboration. one that real increase in resources were initiated recognizes the multiple community factors (Bonner. dentistry. Better Services for the Mentally Ill. that support and impinge on health. were educated through hospital-based to the theory and practice of community programs. munity Mental Health Centers Act. 1971) show psychiatric nurses functioning in diverse roles.K. The historic re- Nurses can take the lead in interdisciplinary port. health policy. what are the characteristics of mentally ill in both the U.K. England to Parliament. 2000). The concept of community health incorpo. roles. FLYNN descriptive studies (Hess. or “asylums. authorized $150 million in federal funds to and urban planning. Scientific The shift from hospital to community inquiry that includes both qualitative and posed challenges for psychiatric nursing in quantitative research approaches is needed to both countries. lowed suit in 1962 when British politician Although the time is ripe for funding such Enoch Powell presented his Hospital Plan for research efforts. Although the findings of several early BEVERLY C.” resulting from their lack of education tal health movement has had a tremendous in psychiatric theory and unequal status impact on psychiatric nursing. recommended a nity health research require the expertise of shift to community-based care. statistics. seen merely as a technology through which cially in recent years. nursing research in each of these countries managed services at the local level? To what emerged. Congress in 1961. on the demands of an expanded community role. the challenges are enormous. 1969. De- loughery. In both countries. such funding is highly com. 1981). Community Mental Health 95 critical factors that sustain successful nurse. espe. the main role for .) created different climates from which 2000). 1983) during this period Community Mental Health expressed concern that too often nurses in community mental health adopt “residual Over the past 50 years. making them ill equipped to take health. The skills for commu.S.

increased educational opportunities. demonstrates the growing ability of community mental health centers earned a community psychiatric nurses in the U. 1987). In one national nurses grew more sophisticated and diversi.S. counseling. sought pre- largely achieved through their successful in.96 ENCYCLOPEDIA OF NURSING RESEARCH community psychiatric nurses during these as professionals and their relationships with early years was the task of administering de.K. Community By the 1990s. survey of assertive outreach programs. 2000). psychiatric nurses psychiatry and “general nursing. characterized nurses’ commitment to ulation was still quite limited (Beebe.K. & Frank. reflects efforts to understand prescribing ing from mental health teams. develop innovative interventions and expand tation and counseling. was still scarce. Santos. research addressing specific (Slavinsky & Krauss. Over time. families. 2001). & Hore.. funded In the U. and even funded Dehn.S.” Their working in community mental health centers “professionalization” and expansion was and in private practice in the U. investigating the effectiveness of a 1971). 1976) show that. tient compliance in alcohol treatment and re- though half of the nurses employed in four covery. empha- tries. 2001) and identify nurses’ efforts in building new relationships barriers to prescriptive practice (Kaas. 1989) show by role differentiation and expansion for community psychiatric nurses’ self-perceived community psychiatric nurses in both coun. general practitioners grew. Schoenwald. however. this also . 2001. Although nursing re. As their self-image munity mental health care. munity services. In the U. 1982).. of this evolving role (DeYoung & Tower. Hiott. the care of psychiatric patients in the commu. there was recognition of the sizing prevention. most of their time was their practices to include a varied clientele spent performing traditional functions. The find- The 1970s and 1980s were characterized ings of one U.K. The findings of one descriptive study structured home intervention to improve pa- (Davis & Underwood. Government practices of advanced-practice psychiatric initially supported community psychiatric nurses (Talley & Richens.S. their pot injections to patients with severe men. roles becoming more differentiated. to bachelor’s degree and provided some consul.K. The “Decade of the nity and their skill in developing innovative Brain” in the 1990s brought the medicaliza- programs for this population. and a variety need for advanced educational preparation of therapies for certain patient populations. Kelly. and groups and to serve as an integral member of the treatment team as case managers and coordinators of com. less severe problems (Godin. Current nursing research cursion into primary health care and distanc. bursement. Dahl. and active in caring for seriously search related to community mental health mentally ill patients (Iglesias. and nurses in the U. (Deci. 1998. find- fied. In response to the The drive for autonomy for community challenge of integrating biologic knowledge psychiatric nurses in the U. They began to function as therapists for ings show that 88% had a psychiatric nurse individuals. al. caseloads became comprised of patients with tal disorders. scriptive authority. tion of psychiatric practice. study (Barratt. was away from into clinical practice. however. Rabbins et al. were numerically the most also in the range of therapeutic approaches dominant occupational group within com- used in their practices.. White. an early intervention study 2000). With base. funded by the psychiatric nursing interventions for this pop- NIMH. with general practitioners. 2000). & Dias. 1998). eligible for third-party reim- available (Fagin. their training (Godin. 1995). psychiatric munity treatment modalities. Psychiatric home care nurs. psychiatric clinical nurse ing also began to flourish during this period specialists became recognized as independent as reimbursement for these services became practitioners. however. 1996). community psychiatric psychiatric nurses expanded in number. of psychiatric nurses to meet the challenges Another study (Wetherill. psychiatric nurses continued largely by the National Institute of Mental to develop pivotal roles in a variety of com- Health (NIMH) in the 1980s.

2003.. parallel trend is the increasing use of CAPPs 1996). for identifying psychiatric ill. In response to the increasing interest of the ferent cultures. referred to also tiveness of their work in primary care.K.S. 1994).001) (Ai & Bolling. & variety of symptoms and conditions (Eisen- Mann. A recent national sam- schizophrenia (Brooker & Butterworth. to meet this conventional or mainstream medical services mandate.. ple study has shown that 30% of people aged 1991). Ni et al. specifically in the vention” to families caring for a relative with aging U. and for using an “insight program” 65 and older used at least one CAPP modality with patients diagnosed with schizophrenia compared with 46% of those younger than (Pelton. it is can public is spending billions of dollars for equally important that research be directed CAPPs. 1992 the Office of Alternative Medicine searchers study the effects of disparity and (OAM) (elevated in 1999 to the National stigma in access to community mental health Center for Complementary and Alternative care across the life span. integrative were of unproven worth with people experi- medicine (NIH. It is also important that nurse re. increasingly used by clinicians and research- One needs only to scan recent reviews of ers. While psychiatric nurses age 65 (p = < . sur- of specific interventions with severely men. that the Ameri- knowledge gained from these studies. population. Criticism was primar. 2002). for providing sex education berg et al. with studies investigating the clinical impact Despite any confusion in use of terms.. the context of specific communities and dif. However. that the CAPPs widely used . The mission of the NCCAM is to assure users. Complementary and Alternative Practices and Products (CAPPS) 97 meant that they were perceived as responsible Complementary and Alternative for many of its failures. Integrative medicine is the newest directed to reappraise the value they placed term added to the range of definitions related upon serving those with severe mental illness. con- as “complementary and alternative medi- tending that counseling-based interventions cine” (CAM). the Federal Government created in nature. these practices and products is not limited to Not only were community psychiatric nurses medicine. among senior citizens. 1998. 1993. reflecting findings in the survey literature nursing research to gain an appreciation of that suggested most people use CAPPs in con- the effort that has and is being put forth by junction with. & of the new millennium) is trying a variety of Sykes. (ranging from 30% to 45% at the beginning tion side effects (Jordan. The term “integrative” is lation. rather than as an alternative to. and that nursing research in American people in the healing potential of this area become more interdisciplinary in CAPPs. and CAM is not a true descriptor in that use of were not cost effective (Hannigan. the term encing minor. and. through rigorous WENDY LEWANDOWSKI research studies. throughout the world can use the wealth of These surveys indicate. psychiatric nurses in the U. veys indicated that a significant percentage tally ill patients. Blanchard. more recently. 2002). The nursing literature is replete (NCCAM. 2001). they were also directed to develop and apply to the concept of “complementary and alter- evidence-based interventions with this popu. native” medicine. 1997). Many also questioned the effec- tices and products (CAPPs). Tunnicliffe. self-limiting problems. 2002). also. Medicine [NCCAM]). Examples include nursing of the adult population in the United States interventions for early detection of medica. most of which is not reimbursed by toward testing nursing interventions within third-party payers. Practices and Products (CAPPS) ily directed toward their decision to shift fo- cus away from the care of patients with severe A large percentage of persons worldwide are mental illnesses in favor of work in primary using complementary and alternative prac- health care. 2002). for delivering a “psychosocial inter. these ancient and modern CAPPs to treat a ness in the elderly (Waterreus. Ni et al. 2003). A to mentally ill patients (Woolf & Jackson.

and the Evalu- turers of these products claim. Menzies.. Conse. Selected complementary and alternative cient. & therapies from emerging. mind-body interventions (e. DeGood. qi gong.. manipulative and body. search in CAPPs. definitive that one practice or procedure is vidual’s physical. one CAPPs is not the adversarial position. mental. selected CAPPs may access a Public Informa- titioners of these modalities and the manufac. emotional. electromagnetic energy fields as in osteopathic. Movement tion of the more than 200 modalities that to offer some content about CAPPs within are reported to have more than 10. homeopathy. chiropractic). ations Section of NCCAM may be accessed at edged today that anecdotes about efficacy the web site http://nccam. medicine. what is defined as such varies based garding indications and contraindications for upon professional or occupational perspec. use of the myriad of procedures and products tive. Rigorous programs of re- ters as well (NCCAM). It is acknowl. The NCCAM fosters re.” but the more schol- since enlarged this number to 13 research arly position of asking whether an interven- centers across the country and has reported tion is effective or not. 1996).g.000 uses.. Still today. massage. 2001). Taylor.98 ENCYCLOPEDIA OF NURSING RESEARCH by the American people do what the prac. However. there are data to support a num- pies was introduced during the decade of the ber of behavioral and relaxation practices 1970s in the United Kingdom and refers to used to treat pain and insomnia.. foods. To promote re. effort of the NCCAM focuses on introduc- and energy therapies (e. tic touch. the curricula of schools of nursing. However. In some cultures the term “al. and pharmacy magnet therapy). many of which are outside dure or product may be more suited than the realm of accepted health-care theory and another for a given person (NIH Technology practices in the United States.g. Among the early initiatives of the that patients are using.g. schools to capture the attention of young search to reduce barriers that keep promising health professionals (Taylor. thereby giving importance to well-de. biologically appears to be less agreement among faculty based therapies (e. one proce- tional health care. and lifestyles. The term complementary medicine/thera. For example. plementary and alternative reflect a broad The challenge today for health care profes- spectrum of modalities and beliefs. including the potential NCCAM was identification of broad catego. sonality traits among individuals. music therapy). provide conclusive evidence of effectiveness. among persons.. there mental imagery.nih. & practices and products categorized as com. those practices and products that link the data currently available are insufficient to be most appropriate therapies to meet the indi. Boyden. tion of CAPPs information into allopathic. and more effective than another for a given condi- spiritual needs. 2001). tion Clearinghouse Database. 1999). Kligler. maceuticals. NCCAM has “CAPPs vs mainstream. sionals is to become and stay informed re- quently. Interested persons search involving any of these practices and seeking state-of-the-science information on products may begin with basic questions: .g. is it safe or not? plans to develop international research cen. A more recent based methods (e. interactions of natural products with phar- ries of CAPPs as a beginning to the classifica. of which is directed by a nurse. 1996. 1998). (Gaydos.g. practices have been studied sufficiently to signed and well-executed research. e. on the practical aspects of its integration herbal products). 2001. nursing. therapeu. ulty responsible for the integration of this naturopathy). tion. Assessment Panel.. dental. content sometimes desire to include it. as well as variations in per- ucts that are provided in place of conven. because of psychosocial differences ternative” refers to those practices and prod. and effectiveness of practices for which there 2003.g. OAM initially established The main issue regarding research in 10 research centers across the (NCCAM. and pharmacy is evident. Taylor. dietary supplements. are not plausible explanations are insuffi. Owens. Yet. (NCCAM. while fac- ternative medical systems (e. These categories fall under the rubrics of al.

ANN GILL TAYLOR tom? From general questions such as these. facilitating the safe integration of se- measurement tool. Instruction may be offered in the use. Findings resulting from research stud. care system as well as prompting the need for with older students exhibiting more anxiety continued rigorous science in this field. clinical situation. 1998). 2000). Focusing on individual may be offered in a classroom setting by an differences among patients when assessing instructor. Re. a large number to students and faculty. and feelings are programs are delivered to learners as replace- an important part of their reality. monly. tive testing which tailors the testing in re- 1999). interactive computer classroom will help fos- Definitions of complementary and alterna. Computer-Aided Instruction 99 What’s going on with a particular therapy in factors foster optimism and increase the po- the investigator’s target population? How do tential for additional evidence-based holistic individual differences. (1998) proposed that use of an or symptom management (Taylor. Problem-solving skill of nurses and other health care professionals development is impacted. This form of instruction outcome measures. ter the development of critical thinking tive procedures and products (CAPPs) and within groups at all levels of education. and effectiveness of CAPPs per. where the pro- mits the investigator to analyze disparate pa. commonly referred to as “technopho- lected CAPPs into the conventional health bia” (Geibart. thoughts. cacy for many symptoms and conditions. thus creat. and not uncom- still lack knowledge about CAPPs. Age is also a factor. therapies to a person for promotion of health Ayoub et al. places students with inadequate ing a barrier to consumers achieving their knowledge and insufficient clinical skills in goal. These than younger ones about computer technol- . Computer-aided instruction is an educational Because nursing takes the position that pa. ment or adjunct to standard classroom or ence the nature of inquiry and the choice of practical experience. increasingly relevant in a basic or advanced entific studies in this area. efficacy. more specific ques- tions about the use of these therapies in pa.. method in which specially designed computer tients’ perceptions. While health con. it may also be used in adap- edge about these therapies (Owens et al. gram reproduces a virtual scenario similar to tient care findings and synthesize these into what the learner would experience in a live. form of clinical simulation. as assessed by a given care. Computer-Aided Instruction tient care evolve to guide the investigator’s re- search. sponse to a learner’s ability. use. questions that will add to the body of knowl. ful to patients (Weis & Guyton-Simmons. early 1990s was anxiety regarding computer sure will continue to drive integration of se. VICTORIA MENZIES coupled with extensive literature reviews and consultation with experts. Rigorous clinical studies continue to be situations which can ultimately prove harm- needed to provide evidence of treatment effi. 1998). or does not happen in the use of a particular therapy for management of a specified symp. these influ. practitioner role with the advent of the in- sumers today are empowered to take control creasingly restricted clinical time allotments of their health care outcomes. Computer-aided ies testing the efficacy of CAPPs may lead instruction may also be offered in an inter- to knowledge that can be useful in making active format for purposes of mastering the- reliable predictions and linking appropriate ory in addition to clinical/psychomotor skills. Utili- estimates of consumer use will continue to zation of this model of education becomes change as researchers complete rigorous sci. Consumer demand and pres. search monies are available for competitive One of the biggest impediments to broader research proposals through the NCCAM and use of the computer as an instructional device other departments within the National Insti. in the period from the late 1980s through the tutes of Health. influence what happens lected CAPPs into health care.

Forker and McDonald (1996) note that ters in order to accommodate clinician intu- with the increased availability of microcom. research ex- students who were asked to design a com. software programs. Distance learn. four nurs. Bachulis. ment might affect the average duration of The technology surrounding computer. such technologies normally seen in a critical care as expert systems. exclusive use of traditional DDS systems vary in terms of complexity paper-and-pencil testing is changing.100 ENCYCLOPEDIA OF NURSING RESEARCH ogy. It can ods to determine complex associations be- also be assumed that with the almost daily tween pieces of data. Simu. Systems ing) utilizing clinical simulation as a part of their instructional program and found that Although there is no clear agreement about only one of the nine. clinicians overcome their cognitive resource ing will continue to become more widely used limitations for processing and storage as well and embraced by educators throughout the as problem solving in an increasingly com- . FILAKOVSKY study. As the use of computers in and out of the and Allen (1999) compared a group of 45 classroom continues to increase. some incorrectly include under the umbrella tients and patients utilizing complex medical of DSS software that are not truly DSSs. patient stay in an institutional setting. terized system used to aid decision making lation lends itself to a number of learning related to semi-structured problems. assignments and testing. mathematical and statistical modeling com- Computer adaptive testing which adapts ponents which act with real data to facilitate to the individual’s ability forms the basis for decision making. models. ition and judgment. aided instruction and testing will continue to The ultimate goal of any DSS is to help expand greatly in the future. ranging from simple provision of to assume that this would be the case with integrated reports to use of inferencing meth- computer simulation activities as well. For example. such a system might be ethics. Students with the computer assign- ments expressed more satisfaction with their assignment. ploring the outcomes of this educational puter program on a relevant clinical topic method will be forthcoming. While differentiation is area. A defining characteristic of many of the specialty practice and achieve. at the core of which are 2000). in general a true DSS is a collection of also lends itself well to simulation (Hart. and compared this group to another group assigned a paper-and-pencil independent JOSEPH M. did not port Systems (DSSs). Initial attempts to integrate the com. The study of pathophysiologic process fuzzy. rapid responses to real situations based on Probably the most familiar form of this type real data. such as epidemiology or bio. and allow Examination (NCLEX) which was started in ad hoc queries and easy changing of parame- 1994. will continue to lend itself to this mode used to predict how a new patient care treat- of education. a DSS can be defined in general as a compu- tion as a part of its academic program. While their goal is to advances in web-based technology. tured. and established guidelines. Clinical simulation in the form of vir- puter into education were limited to using the tual reality will take the learner to new device as an alternative to paper-and-pencil heights in very realistic learning adventures. They provide ment examinations taken by practitioners. Computerized Decision Support ucational programs (five medical. It is safe and scope. at a medical school how to define Computerized Decision Sup- located outside the United States. Gibbons. particularly with complex pa. puters in schools. clinical facilitate effective decision making. they deal education as well as education of a more theo. with problems that are relatively unstruc- retical nature. world. But opportunities. of testing is the National Council Licensing They are designed to be flexible. DSSs is that they are proactive. Ravert (2002) reviewed nine ed. most would agree that score positively as favoring computer simula.

DSSs do this by (McAlister. 1991. ston. research related to the accuracy of ful in limited application (Weiner & Pifer). blocks. 1998. This is a DSS that guides the halter (1990) add the requirement that a med. Hoesing. best prac- the presentation of irrelevant or inappropri. need that demonstrate their benefits in terms First are systems generating differential diag. vocabularies. Petrucci et al. Wyatt and Spiegel. noses. essential data elements. The suggests risk-based care tailored to the spe- use of DSSs in clinical decision support can cific patient risk-factors based on published be divided into two categories: diagnostic guidelines. such systems are often problematic as which has been heavily invested in the basic the potential benefit for the differential diag. 1996). and with a forward chaining inference engine to have again had success in limited application. 1999). taxonomies. 1988. 2000. caregiver through risk assessment and then ical DSS generate case-specific advice. work necessary for the building of DSS sys- nosis-generating DSS to inform caregivers tems. Peters.. of outcome measures (Weiner & Pifer. support systems based on established guide- lines within the hypertensive patient record lines (Bowles.. 1994). and types of ately ranked diagnostic choices (Weiner & information used in nursing research and Pifer. Covvy. Logan. Most thera. & peutic DSSs focus on compliance of caregiv. 1997). However. Werley. Some ers with established quality-of-care guide. research is There are several types of diagnostic DSSs. This basic work includes the develop- about additional relevant diagnoses can be ment and identification of classification sys- outweighed by the “noise” that arises from tems. racy of a DSS system in using assessment data tems help caregivers to interpret results. Lee. 2000). 2000). Their goal is to generate. variability. & Mathieu. 1994). has a history of perhaps 25 years. different clinicians with little interclinician fect of facilitating standardization of care. Such sys. 2001). in improving outcomes is fairly limited (John- aided review of clinical tests such as radio. comes of care (Cuddigan. Ryan. appropriate to the patient (Hendrickson & ing in point of care treatment. While nurse diagnoses based on a given set of objective informaticists have also developed circum- clinical signs and symptoms. Tong. 2003). graphs or pathology specimen evaluation One study was located which tested the accu- (Alberdi et al. such as embedding hypertension guide. Devine. They function scribed DDS systems using these building like a second opinion and have been success. most of ever. helping clinicians to manage information 1986). This has the net ef. 1984). strom. identify nursing diagnoses and interventions Therapeutic DSSs focus on decision mak. tices. Haynes. How. at the point- overload in order to properly assess all of the of-care. Computerized Decision Support Systems 101 plex medical environment. have also moved to development of decision lines. Individualization of patient ther- reducing errors. in therapeutics seems reasonable. Langton. Evans. Others manage ness of specific DSS systems in producing complex processes such as ventilation and nursing decisions that result in better out- oxygenation (East et al. the decisions and the efficacy of these systems A third type of DSS is used for computer. since they are driven by individual patient Healthcare DSS systems use actual patient data (Morris. Zorn. and improving quality of apy is preserved by these explicit protocols care. Some focus on Paganelli. Benner. A good example in nurs- data to provide information that can help ing of such a DSS is the Braden System (Berg- clinicians make decisions. & caregivers to rule in or out a small set of Westra. with the goal of reducing beyond these basic issues to test the effective- errors and complications. A few studies have moved medication dosing. & Wigle.. Another type of DSS is based nursing decision making (McCormick & on a rule in/out model. while the use of DSSs and therapeutic. These are used by Jones. Such systems provide lists of possible Nursing research in the area of informatics diagnoses based on given clinical data. patient-specific evidence-based ther- relevant information and generate systematic apy instructions that can be carried out by and reasonable therapy. 1992). Future research will .

These foci were: (a) us- have only recently been “discovered” by ing data. guage chosen to represent phenomena is nec- and cut health care costs. Similarly. regardless of method. operational definition to be used in the study. The process. A conscious awareness of the lan- ing. precise theoretical and/or and (g) evaluating the effects of nursing infor. 2003). Concept analysis is partic- the country. mation systems. plines. Doing a concept analysis using rigorous methodologies. optimize outcomes of care. the panel identified seven foci for re. (d) investigat- a concept analysis is a set of defining charac- ing new technologies to create tools for pa- tient care. ularly relevant to a young science such as sions are being made in an environment of nursing. the National Institute of Nursing have the purpose of determining the defining Research (NINR) constituted an expert panel attributes or characteristics of the concept on Nursing Informatics. research. then identi. search or for instrument development. (c) acquiring and delivering knowl- conducting research. Some uses of a concept analysis with setting research priorities for nursing are refining and clarifying concepts in theory. the outcomes or the value-laden nature of the Although there are several methods for con- decision (O’Connor et al. and within each focus. However. Because the outcome of edge from and for patient care. concept when it arises in clinical practice or ric populations) assessing the impact of using in qualitative research data. particularly philosophy and linguis- fied and prioritized more specific research tics. handheld DSSs in ambulatory care settings Concept analyses were relatively rare in (Ortiz & Clancy. (c) determine undertake a major research initiative investi. the techniques needs (NINR. As DSS systems requires rigorous thinking about the language are developed to produce specific patient-care used to describe the phenomena of concern protocols that have been validated through to the discipline. in 2001 lawmak. and knowledge to de- nurses interested in semantics and language liver and manage patient care. all of the methods In 1993. these experts cept analysis has been used in other disci- assessed the state of the science. . (b) choose measurement instruments that ac- ers provided the Agency for Health Research curately reflect the defining characteristics of and Quality (AHRQ) with $50 million to the concept to be measured. reduce errors. (e) applying patient-care ergonom. rapidly escalating intensity. 1993). nursing research until the early 1980s but Health care delivery today is so complex have increased dramatically in number over that it is currently straining the resources of the past 2 decades. and multifaceted clinical deci. They were charged under study. and (d) accurately identify the ferent studies (two in adult and two in pediat. CORRITORE discipline. it allows the researcher to (a) (f) integrating systems for better patient care. as the concept. teristics that tell the researcher “what counts” ics to the patient-nurse-machine interaction. Among measure adequately reflects the defining char- funded projects now under way are four dif. improve clinical decision mak. of and sensitive to the use of language in tion in care. and research and arriving at precise Research Agenda. In carrying out this man. information.102 ENCYCLOPEDIA OF NURSING RESEARCH likely focus on how DSSs can help nurses help Concept Analysis patients make decision in scenarios character- ized by the need for careful deliberation about Concept analysis is a strategy used for exam- alternatives due to the risk or uncertainty of ining concepts for their semantic structure. for many years. informatics as part of the National Nursing practice.. 1997). (b) defining development in the discipline. theoretical and operational definitions for re- date. Con- search. ducting concept analysis. essary if nursing scientists are to develop a BARBARA BRADEN comprehensible body of knowledge for the CYNTHIA L. if a new instrument is needed (if no extant gating the problem of medical errors. formulate a clear. these systems causes the researcher to be much more aware have the potential to decrease harmful varia. and describing data and information for pa- Concept analysis is a useful tool for nurses tient care. acteristics).

Stand- that spell out agreed-upon roles and responsi. How nurses think about and de. practice. the choice of topic Being clear about meaning allows better com. tasks. Most often in externally funded stud- insights into the phenomena of concern to ies. usually managed by a steering committee. (c) to shorten the scribe the problems and solutions relevant to time line for conducting the study by simulta- their practice is of paramount importance in neously recruiting subjects at multiple sites. the titioners about the usefulness and appropri. more creative and productive research. recruit- research that can be used to increase the ment. mittees bring proposals for publications and . These other junct to nursing research. and for re- ceiving and centrally analyzing the study data. refine the proposal before it is submitted for munication between researchers and prac. The outcome of a investigators may be involved in helping to concept analysis significantly facilitates com. ten composed of the principal investigator tutions. eral institutions creates synergy that leads to There is considerable discussion in the lit. helping the consumer of nursing care and the (d) to provide mentoring to more junior re- policymakers who influence the practice mi. Consortial Research 103 It is also necessary for thoughtful prac. then confusion and ambiguity will Consortial studies may be conceived by persist. identifying or developing questionnaires or other data collection forms. Regardless of the method used. searchers and staff nurses. It involves coopera. and (f) to increase oppor- core of well-defined concepts to describe their tunities for replication and dissemination. the researcher or leagues or is a way to share resources and practitioner makes it clear what counts as the costs. Scien- quantity and quality of nursing research tific issues for the conduct of the study are within clinical settings. funding. well-defined from each participating site and a few key administrative and working relationships individuals at the coordinating center. (e) to share re- lieu to understand what nursing is and what sources. it is more likely that development of concept so that anyone else reading about it the proposal will be a group endeavor from or discussing it understands what is meant. thus increasing discipline. The oversight role of the coordinating Consortial Research center includes development and implemen- tation of a quality control plan to assure stan- Consortial research is a form of collaborative dardization of sample identification. sites to participate in the study. tial proposal then recruit colleagues at other Concept analysis has become a useful ad. and costs when external fund- nurses do. for data collec- KAY C. (b) to increase the ethnic diversity or other titioners to be aware of the language of the characteristics of a sample. erature about which method of analysis is the To conduct these multisite studies. In the latter case. and data collection procedures. committee. By specifying the defining is more focused on mentoring junior col- characteristics of a concept. who draft the ini- ence will suffer. For example. If nurses do not have a central ing is not available. the coordinating center is responsible for nurses. Whichever approach is taken. one or a few investigators. ing or ad hoc subcommittees of the steering bilities. the subcom- size when studying a low-prevalence disease. and the development of nursing sci. generalizability of results. committee are often formed to propose stan- Consortial studies are done for a number dards and oversee the work on specific as- of reasons: (a) to achieve the required sample pects of the study. AVANT tion and processing procedures. usually serves a coordinating function for the concept analyses can contribute significant study. the start. may be generated by an advisory or steering munication between scientists and prac. When the purpose of the consortium titioners alike. of- tive efforts among researchers at several insti. pool of ideas generated by expertise from sev- ateness of nursing language. The sites have formal. one site most useful.

The investigator then rereads proach. and diaries health prevention research. the commitments for the good of the overall early content analysis focused on linguistic study. Welches. observation. and so Walker. A third model. The investigator tistical power to compare the effects of treat. or may develop schemes to analyze visual rangements have been a preferred structure data from pictures or videotapes. participant safety and end. and (b) providing individual grants to and focuses on structuring particular topics each participating institution with a separate or domains of interest from unstructured grant to the coordinating center. may promote consortial research in nursing In a consortium formed primarily for the is the changing health care system. 1995). or some other cient follow-up time to generate adequate sta. consortial ar. such cases the steering committee often serves the purpose of setting priorities for the activi. notes from an observation. in addition funding is not available. & Field. cost-effective. J. although consortia of schools of the text and numbers and assigns a code to nursing with several practice settings have each segment or group of lines from the tran- . used when external and observational data. tinuum of patient needs. been formed to facilitate the conduct of col- points. integrated care across the con- tee may be composed of representatives ap. 1990). tual arrangements in attempts to provide or disseminating results. Zalar. identifying. BARBARA VALANIS ties of the consortium. field logs. consortial research pointed by each participating institution. and have suffi. M. However. questionnaires. for large randomized trials that must recruit Content analysis begins with reading the substantial populations in a relatively short text or written transcription of an interview. reads the completed text and determines the ment on the study outcomes. This is an advantage for involving a are reflective of the topics (Patton. Content Analysis the two most common types are (a) providing one large grant to a coordinating center. provide intervention. & ment of protocols. time. Another factor that ated. mentoring ju. researchers within the consortium. When external funding is involved. may analyze written text from special docu- In medical treatment research and public ments. As health purpose of sharing resources. care systems increase the number of contrac- nior researchers. It is a time-consuming process that in- approach gives the coordinating center budg. Schut- the steering committee is involved in develop. times also referred to as category labels ond approach requires that each site meet (Morse. The degree to which zuto & Mitchell.104 ENCYCLOPEDIA OF NURSING RESEARCH presentations. experimental research. The new site or increasing the number of subjects topics or domains of interest are descriptive enrolled at existing sites by redistributing names chosen by the researcher and are some- funds from the nonperforming site. as opposed to approving those devel. Nursing has main ideas or topics of the transcription or generally had less experience with this ap. 1988b.. 1989. The sec. Historically. the steering commit. replicating a previous study. varies by will increase as nursing researchers do more study and the reason the consortium was cre. and etary leverage when a site is not performing making categories from patterns of data that up to par. Funding of studies conducted by a consortium may take several forms. Content analysis is a data analysis technique which then subcontracts with each clinical that is commonly used in qualitative research site. The first data. 1985). mode of data collection. shares the cost of to information derived from interviews and the research among participating institutions casual or structured observations. In is likely to become more common. forth. archival records. or clinical aspects before the steering laborative clinical nursing research (Riz- committee for approval. coding. It may be expected that consortial research oped by the coordinating center. zenofer & Potter. 1990. volves organizing. 1988a.

Sometimes this may also be called membering what categories go into each topic labeling. too many topics can cause confusion. more readers. current with each other. ing of particular words. With each subsequent interview or more paragraphs. achieved by determining the extent that the able to assist organization of qualitative data. In the Topics or domains of interest may be cho. part of the study and having the readers look ics that pervade the text soon after the tran. or a pictorial schema and observation. Therefore. topics represent what they are intended to J. rela- tor reflect some commonality. as a consequence of one of the earlier catego- sis or feminist research. framework or focus must be consistent with . or a demonstra. occurs or is antecedent to the topics of “blem- or after the first interview. Some cused study might center on a particular phe. content analysis involve the subjective nature The researcher may also chose to develop of the researcher-determined topics or cate- topics after a first interview or observation. Morse and Field (1995) suggest using represent. M. one or collected. or topics. analysis by counting frequency and sequenc- ment among adolescent girls. What should be included within Sometimes the topics seem to arise naturally each topic should be clearly defined and from the data. tual framework or a particular focus. easiest way to determine reliability in a study oping a topic may be similar to making an that uses content analysis is to have two or index for a book or file labels (Patton. ish care” and “facial scrubbing. having the researcher randomly choosing a searcher usually gets a sense of the main top. The codes developed by the investiga. as with a focused study. thought. Devel. concept. an event. the topics to the topics that were identified by the inves. tionships between the categories and then be- tion or behavior. phrases. described. This is typically carried out by cording to likenesses and similarities. over the text and the topics independent of scribing process is complete and after the first each other. tion of how caring activities are performed. Content Analysis 105 scription. On the other tual framework or focus. and the categories are grouped according study of adolescent face care. be done by hand or by using one of the many Validity in content analysis can be computer software packages that are avail. body adorn. researchers choose to quantify part of the nomenon like leadership style. the topic “facial preparation” sen prior to a study. the topics may be combined or may vary according to the chosen topic or subdivided into multiple categories as the topics. gory labels. Another kind of fo. Often the relation- and so forth. For example. whereas at other times the should be clearly different from the others so researcher must decide on and develop the that the results are mutually exclusive. in a ries. tween topics may be seen. other than the researcher. This organization of the data may indicate the study’s reliability. topics hand. that are developed to reflect a conceptual and the researcher may have difficulty in re. such as metaphorical analy. The topics from the information given. A consensus of the readers would reading. A focused qualita. related and occur at the same time. need arises. “blemish care” and “facial scrubbing” are tigator. The re. As repetitive patterns arise. Segments may consist of a single as the study progresses and more data are word or line. and explained in cialized as only very small amounts of data terms of being representative of that concep- will be able to fit into each. must be justified. Line segments or groups of lines ships may occur at the same time or be con- are separated and are grouped into catego. multiple words or lines. they They caution against making topics too spe. If the topics are based on a concep- between 10 and 15 main topics per study. The major reliability and validity issues of to name a few. 1990). such as an ac. agree The researcher reads through the transcript that the topics are appropriate for a particular of the interview or observation and begins to study and that data can easily be organized sort and organize the interview data ac. ries that was formed (Morse & Field). same study.” whereas the tive study centers on one particular area of topical area “making up the face” may occur interest or intent. under each.

Illi. for older adults in ex. Despite the framework. Crowley.106 ENCYCLOPEDIA OF NURSING RESEARCH the original definitions described by that third of the nations’ CCRCs. nizations have entered into the retirement The initial research in CCRCs focused on business as well. All CCRCs scribed the challenges of adjustment to a have a written contract that residents must CCRC and identified groups of individuals sign. including 1990). approach. Palmer. are well educated. and a monthly service fee. using a qualitative approach. Resnick. Generally older adults who live in CCRCs KATHLEEN HUTTLINGER are those who were never married. The CCRC is usually con. growth of CCRCs. particularly of Petit (1994) implemented the findings of this Type A and Type B CCRCs. housing. especially if they are entrance fee. and have who were particularly at risk for relocation been separated into three categories by the stress: (a) those who had experienced a recent American Association of Homes for the loss. & Spell- continued to grow. proportionally they ac- sis is often used in exploratory and descriptive count for a smaller percentage of senior hous- research. (Adams. Generally these throughout the United States although five are descriptive surveys in which residents are states (Pennsylvania. getting vaccinations. and (3) Type C did not begin to grieve over their losses until CCRCs are based on a typical fee-for-service they fully completed the work of the move. Aged: (1) Type A homes are “all inclusive” and (c) the young-old (60 to 70 years) age as they offer guaranteed nursing care in the group. Anticipating problems and letting resi- nursing facility at no increase in the residents’ dents know that they might have certain feel- monthly fee. requires a good deal of planning and adjust- change for a one-time capital investment or ment for older adults. To- Continuing Care Retirement karz. (b) those with a decline in mental status. apartments and maintaining the residents’ The majority of the nursing research done optimal health and function so as to need in CCRCs has been on the health practices fewer health care services. (2) Type B CCRCs do not guar. but for-profit orga. 1996. 2003). Resnick individual remains within this community for (1989). and other services. depends on high work as she developed the role of the wellness occupancy rates in the independent living nurse in a CCRC. Jenkins. monitoring cholesterol . ment. The decision to move into a CCRC nursing home care. The terms of the contract vary. however CCRCs are becom- A continuing care retirement community ing more affordable and attracting those with (CCRC) is a type of facility that provides more moderate incomes (Kitchen & Rouche. Most relocating to another city or state. This is due to the dra- be used. and the pact this had on the older adult. Resnick. asked about specific health behaviors such as nois. & Bogutz. and Ohio) are home to more than one. 2000. Petit. a conceptual orientation may not ing than previously. 1998a). The study also identified the need for a contractual agreement to provide a specific frequent follow-up in the first 6 months to a number of days per year or lifetime of the year following the move-in as many residents resident in the nursing facility. Resnick. Resnick. Initially CCRCs were for afflu- ent older adults. and/or CCRCs are sponsored by religious or other moving from a large home to a smaller apart- nonprofit organizations. CCRCs are located bring. Florida. 1994. meals. and health conscious (Krauskopf. 1993. because content analy. However. and health promotion of these individuals The number of CCRCs has increased dra. 1996. de- the remainder of his or her life. matic increase in assisted living facilities. the adjustment to the community and the im- structed as a village or community. ings helped residents in the adjustment pro- antee unlimited nursing home care but have cess. California. or married without children. Financial stability. matically (50%) during the 1980s and has 1998a. Brown. Communities 1989.

Smith et al. goals. Resnick (1999) explored the 61% had an up-to-date tetanus booster. The care-seeking pro- in fewer health-promoting or preventive be. Vaitkevicius et al.. The findings. age was the only variable a qualitative study using ethnographic field that was significantly related to health behav. yearly. tional performance in these individuals. participant observation. 1999) also used a a small percent use nicotine (11%). approxi. alco. Based on munity (Blustein & Weiss. or prostate ex.. make end-of-life treatment preferences. ventions in these settings (Resnick. Resnick (2003) health. and there is better participation in health promot. cess was described as sequential phases and haviors. and fo- With increased age the residents participated cus group interviews. and mately 60% have stools checked for blood ambulating. exercise directly and/or indirectly influenced and Resnick and Andrews (2002) tested an exercise behavior in the residents (Resnick. and stage of change related to proach to health promotion in these sites. 31% to 37% get Pap tests. dressing. About 50% of those only variable associated with having an inju- living in CCRCs drink alcohol regularly. interviews.e. exercise activity. however. creased residents’ willingness to participate grams. which focused on what helped older adults in CCRCs continue to be a viable living envi- a CCRC adhere to a regular walking program ronment for older adults. A total tests. Resnick & Nigg. The influence of these variables on work has also been done to test exercise inter- exercise behavior was supported in a qualita. determination). and approximately ing a fracture.. and under combined qualitative and quantitative ap- 50% exercise regularly. and a little over 50% monitor their beliefs in their ability. and aminations. were identi- ing activities of older adults living in CCRCs fied as common themes that influenced per- when compared to older adults in the com. In order for these and what decreased their willingness to ad. (1996) considered the care-seeking behavior tionships between health behaviors among of older adults living in a CCRC. fears. The majority of residents in the case reports identified positive outcomes such CCRCs studied did get yearly flu vaccines as weight loss and improved recovery follow- and a pneumonia vaccine. Russell In a series of analyses examining the rela. formance of functional activities. only rious fall. 65% to in and actual performance of activities of 80% get prostate examinations. such as the fear of falling. Age. Resnick (1998b. even in this population continued education and the personality component of motiva- is needed to encourage personal decision tion) as well as physical condition (standing making related to health promotion activi. gender. daily of living. stools for occult blood. self-efficacy expectations. Pap which encouraged regular exercise. though not extensively studied. outcome expectations. Crowley (1996) also considered the crative it is imperative that there be a focus on . outcome tested the impact of an individualized ap- expectations. Al- haviors. The findings can also be used to develop were the most important predictors of func- interventions to improve specific health be. research that incorporated semi-structured iors and accounted for 7% of the variance. motivation (self-effi- 1999). Personality (i. such as bathing.. of 21% of the 225 residents exercised. physical and mental stages that evolved over time. 2000. Continuing Care Retirement Communities 107 and dietary fat intake. 2003. Some 2003). balance and lower extremity contractures) ties. the unpleasant sensa- skin for abnormal growths regularly. Overall tions associated with the activity. This was residents of CCRCs. facilities to keep costs down and remain lu- here. quantitative findings. 2002). 2000) House. and participation in and the outcomes of a wellness program health screenings including mamograms. suggest that cacy expectations. health behaviors of older adults in a CCRC hol and nicotine use. A incidences and predictors of falls in a CCRC smaller percentage (approximately 30%) and found that the number of falls was the monitored their diets. Resnick et al. 1998. educational intervention to help older adults 1998a. Approximately 40% proach to explore what increased or de- to 50% of the residents get yearly mamo. Wagner & tive study (Resnick & Spellbring.

141). psychological. psychological. coping. 142). such as finances and educa- theory of psychologists Lazarus and Folkman tion. and moderating mands that are appraised as taxing or ex. diagnosis. (buffering) mechanisms” (Underwood. 19). 150). of social support and other resources become tive or negative evaluation. situa- tion. & Orth. “internal or external event. child/ado. Oberst. the problem” (p. mediating. health-care utilization patterns and in nursing research can be categorized as an the impact this has on nursing care services. and outcomes. and other. or spiritual reac- Coping tions. Prominent are stud. ment that is appraised by the person as taxing grams need to be considered both from a or exceeding his or her resources and endan- health perspective as well as a fiscal perspec. and Other coping theories tested in nursing re- sequelae such as distress. Stressors vention. caregiving. the situation (secondary appraisal). Frost. These processes are active and dynamic. Stress involves ap- CCRCs that nursing should consider include praisal of the stressor for well-being (primary care processes around relocation to different appraisal) and what can be done to manage levels of care. free of posi. Continued “what the person actually thinks or does” research needs to build on the preliminary (p. and treatment stress. coping in nursing be categorized as social. end-of-life issues. disease. Nursing re- changing cognitive and behavioral efforts to search has shown that social support “works manage specific external and/or internal de. 372). and there is evidence that specific functions ing is a process requiring effort. This definition accentuates the fact that cop. p. search with individuals include Scott. Other important areas of research within Folkman. many Stress in this perspective is defined as a “rela- CCRCs have “wellness programs” which are tionship between the person and the environ- nursing driven. family re. For example.108 ENCYCLOPEDIA OF NURSING RESEARCH maintaining health and function. spiri- research is defined using the definition and tual. and hospitalization stressors. Coping is one of the most prolific topics in Lazarus and Folkman (1984) also distin- all of nursing research. The theory most often employed in nurs- and cardiac disease or events. Model of Family Stress. and/or cue” (Werner. and Ad- search since coping has important observable aptation (McCubbin & McCubbin. The most frequent disease/illness situ. Coping resources examined in nursing can With few exceptions. acute gies are “directed at managing or altering conditions. findings from exploratory studies and begin Nursing research portrays coping as part to develop and test interventions that will of a dynamic process consisting of a stressor. Emotion-focused coping is “coping that is lescent illness and hospitalization. specific ill. sponses related to illness/disease. p. mainly with chronic illness. and measurable effects on health outcomes. focusing on important in certain situations and specific . Thousands of studies guish between problem-focused and emo- have been conducted by nurse researchers on tion-focused coping. Adjustment. help older adults in CCRCs maintain their appraisal. They define coping as “constantly cial support (Underwood. ies of individuals and families facing chronic and Dropkin’s Stress-Coping Model incorpo- illness. 1984. injury pre. medical treatment. rating anxiety in the stress and coping pro- ations in nursing coping research are cancer cess. the problem causing the distress” (p. social. through main. 2000). Coping is an ing research on family coping is the Resiliency exceedingly important area of nursing re. They can be either normative or cata- strophic. p. Problem-focused strate- coping. ceeding the resources of the person” (p. health and function. The social resource most studied is so- (1984). resources. gering his or her well-being” (Lazarus & tive. The outcomes of these pro. BARBARA RESNICK 2000. 1996). directed at regulating emotional response to ness. 150). 10) that has the potential to bring about or actually activates significant physi- cal. condition.

Choice of strate- ceived. Index. and Fink’s Family Social Support In. com. facilitating constructive action. Coping can be differentiated as coping Generalizations indicate that context deter. Family instruments include the Ways of Coping Questionnaire. Coping 109 phases of illness. challenge. coping is consistently related to positive Other coping resources gaining nursing re. or treatment. and the McCubbin and colleagues’ Social Support Family APGAR. has been shown to be related to posi- tion. Op- search attention include hope. & McCubbin. social support style suggests typical responses across situa- can come from a variety of sources such as tions. manageable. perceived support ally do in the face of stress. markable growth in the nursing research on McCubbin. coping in several areas. specific stressors. challenge. families is related to positive health out- Family sense of coherence is conceptualized comes. Problem-focused individuals and families. phase. tive social support for adults. where Lazarus and Folkman’s theory is most often (Ford-Gilboe & Cohen. 427). control. It includes control. Instruments most frequently cused strategies. children. there has been re- dex (DeMarco. most often to assess coping strategies in nurs- larly when families are faced with caregiving ing research are the Jaloweic Coping Scale. and self-efficacy. Ford-Gilboe. health crisis. sense timism is an important strategy for individu- of coherence. cused strategies are specifically tailored to the dividuals are Norbeck’s Social Support Ques. confidant. Evidence is grow. receipt of may contribute to health” (Antonovsky. and may function through obtaining as an “explanation of how these resources assistance. 2000). p. and mitment. and meaningful. rus & Folkman. many also focus on behaviors based on tive health outcomes for adults. problem-fo- utilized for measuring social support with in. coping (Baldacchino & Draper. Nurse researchers availability is often more strongly related to examine coping strategies much more fre- coping effectiveness than actual support re. traumatic situations. advice or information. Another newer area is spiritual is support that hardiness mediates “the rela. ciation between social support and deleteri. 2000). and/or presence of a 1998. Many tionships between stressful life events and researchers have found that spiritual coping family adaptation” (Ford-Gilboe & Cohen. and retaining control. 1984). p. Instruments used port is an important family resource. 8). While most inves- health-related hardiness conceptualized by tigations tap stressors specific to the situa- Pollock. Most of these studies concentrate personality phenomenon encompassing com- on serious illness. Coping mines social support needs. quently than coping styles. Posi- orientation rendering events and stimuli com. and prehensible. 2001). and confidence. strategies enhance positive health outcomes. Friedemann. Coping strategies are what people actu- confidant or network. stress/burden. while more global emotion-focused tionnaire and Weinert’s Personal Resource strategies are used across situations (Laza- Questionnaire. several generalizations ing that hardiness enhances coping for both stem from the research. 2003). Use of spiritual resources or cop- . Antonovsky als. gations are numerous. especially developmental transitions. a applied. Over the last decade. style or coping strategies (behaviors). and control. Hardiness. Theoretically. Emerging as Ryan-Wenger’s taxonomy of children’s cop- important in family nursing research. Specific findings of nursing coping investi- mitment. situation. particu. health outcomes and general well-being. One of these areas Hardiness is the psychological resource is family coping. there ing strategies. Evidence is growing that sup. and/or resources. choice defined sense of coherence as an enduring among options. supporting self-esteem. Another area is coping in most studied in nursing coping research children/adolescents (Stewart. social support has both positive and gies has been found to differ based on illness negative aspects. People in many health/illness situations use a ous outcomes such as depression and anxiety mix of problem-focused and emotion-fo- (Underwood). and there is a negative asso.

most examined the impact of depression on ings of anxiety and depression pre. (CVD). Nurse researchers investigating terventions aimed at ameliorating the effects coping are too numerous to mention. Nail. is related to positive health out. of depression and anxiety on CABG surgery report instruments. (CABG) Surgery 1998. 23%. or a combination of same points in time. leading Hoskins. such as prayer or religious at. Frasure- ing strategies change over the course of illness Smith. Exemplary programs of research Demand for CABG surgery exceeds re- include those of Grey. Parahoo. M. 1998). 2003. Prevalence rates with positive outcomes.. Exerting control is also associated viously healthy individuals. Relationships between et al. tion. Demaria. a significant number of patients report feel. at the of depression. surgery has been studied from quantitative as well as qualitative perspectives. provides significant improvement in nurse-led shared care intervention (McHugh symptoms in 76%–90% of the patients (Rah. & Perrault. providing education about the effects ing more prevalent. 2003). & Erdman. An estimated 800. Lesperance. Levels of anxiety and depression in patients Coronary artery bypass graft surgery. Taams. Teo et al. Most studies employ self. Northouse. coming of these risk factors on postoperative morbid- from all nursing specialty areas and many ity and mortality. . but interviews are gaining outcomes. independent of classic risk factors. 2002) with 519. to waiting lists. stages. Cop. Emotion-focused for patients with CVD range from 16%– strategies. Although some studies included the succeeds in treating physiological problems. & Stringer. in tendance. and developing and evaluating in- in popularity. strategies to identify patients at risk for ad- Research designs most frequently used are verse events. Passchier. and Ryan-Wenger. patients with established CAD and in pre- comes. 2000. anxiety. 1982). 2001). sources in many developed countries. Hagedoorn. Patients on JOAN STEHLE WERNER waiting lists experienced anxiety. Nurses can play pivotal roles in descriptive/correlational and qualitative or identifying patients who need further evalua- interpretive. and negative impacts on quality of life (Screeche-Powell & Owens. imtola. prognostic importance in determining CABG coping strategies perceived by participants as surgery outcomes supports the development most effective are often not those they engage of pre. Hinds. Although CABG surgery tients. especially in 60% for depressive symptoms (Pignay-De- situations where there are few options.000 surger. Less desirable coping strategies are Evidence that depression and anxiety have associated with negative outcomes. measurement of both anxiety and depression.). for clinical depression.. J. The experience of waiting for bin. Researchers have found that anxi- postoperatively and depression has been ety levels significantly decreased over time linked to morbidity and mortality (Borowicz and remained linear. can be beneficial. Johnson. a com.. maria. McCub. countries. anxiety and depression over time were rela- Research findings support the relationship tively weak while those relationships. Fitzsim- Coronary Artery Bypass Graft mons. depression. Jonsdottir & Baldursdottir. Longitudinal research is becom. awaiting CABG surgery were significantly re- mon treatment for coronary artery disease duced in a randomized controlled trial of a (CAD).000 performed surgery demonstrate that recovery is neither in the United States in 2000 (American Heart simple nor experienced consistently in all pa- Association. Finally. were relatively strong the two with risk for cardiovascular disease (Duits. Boeke. et al.5% and tive outcomes.and/or recovery. often associated with more nega. Jaloweic. Longitudinal studies of the impact of psy- ies are performed worldwide each year (Boro. chological variables on outcomes of CABG wicz et al. 2001). and 31.110 ENCYCLOPEDIA OF NURSING RESEARCH ing strategies.and postoperative nursing assessment in frequently.

. and Charl. Depression has consistently been associ. Schrader.and postopera. 1996). and Spertus (2003) Several studies have addressed gender dif- found depression 1 month after surgery to be ferences in recovery from CABG surgery. 1999). lower physical son (1999) identified other predictors of post. Bagiella. and a lower quality of pression on mortality. has been associated with higher levels of post. and use An issue in evaluating patients for depres. and moderate to se.. unexplained by illness severity. and early extubation has been associ. Veledar. energy deficits. high rates of 100% Caucasian. Almost all studies used self-report to severe depression at baseline and mild or questionnaires for measuring depression. Postoperative neuropsychological deficits Scheier et al. men only. function. pressive symptomatology and functional im- ated with fewer patients with depressive pairment (Con. men. Goldsborough. Haddock. Younger women least one stressful life event in the last year. characteristics. mortality rates for patients with moderate tively. 80% rience a cardiac-related event than were those scored in the moderate range of anxiety pre. 2001) have are a common complication of cardiac sur- found depressive symptoms. McLaughlin. & Knight. Investigators (Perski et al. zewski. represented a 3:1 male. myocardial in. ical performance (Andrew. Williams-Russo. multiple investiga- . and more depressive symptoms in operative depression: poor social support. 2000). & Ignas- symptoms on day three postoperatively (Sil. Knee- Shapiro. Pirraglia. Khann. These patients exhibited significantly dent of classic cardiovascular risk factors. racial homogeneity. In a study investigating the impact of de- tiredness. depression was a predictor indepen- tively. with incidence ranging from 25%–80% eratively to predict postoperative cardiac (Borowicz. with preoperative symptoms of depression. high attrition. Postoperative anxi. were at a higher risk of in-hospital death than low level of education. Limitations of from 54 to 65 years. Gorkin. and Sloan bone. (2003) found that women than the preoperative score. charge were significantly more likely to expe- tive day two. Pe. 2002). Conard. Baker. Linden. Duits et al. congestive heart failure.. Although investigators have farction (MI). Baker. these reviewed studies include low enrollment to-female ratio. of self-report measures to evaluate anxiety sion is the timing of the evaluation. In a study of 38 males. Postoperatively. Connerney. a better predictor of depression at 6 months Vaccarino et al. gery. Saur et al. Coronary Artery Bypass Graft (CABG) Surgery 111 1997. more. for women but not operative emotional distress (Khatri et al. tively report prevalence ranging from 16– Blumenthal et al. immobility. more sleep disturbances. life (Edell-Gustafsson & Hetta. Thompson. and depression. Andrew. those with depressive symptoms). or other patient ated with adverse outcomes after CABG sur. presurgery health status. & Weintraub. pre. 1998.. repeat CABG. cult recovery. and Knight (2001) found mortality Recently-reported longitudinal studies rates to be six times higher among the patients evaluating depression pre. or angioplasty) found that changes in anxiety and depression and were positively correlated with the rate of did not influence changes in neuropsycholog- readmission for cardiac events. Poston. who failed to meet the criteria (including operatively with anxiety-prone reactivity per. 2001). 1999). & Mc- events (unstable angina. Selnes. and ranged from 85%– of women. Abramson. (2003) also identified higher 50% preoperatively and 19–61% postopera. were older and more often had unstable an- terson.or postop. gina. a difference decreasing with age (Vac- vere dyspnea. at the month before surgery. Jones.. refusal to participate. pain was correlated with de- 2001). 1999. 1999) and women had a more diffi- bert et al..9% of the patients postopera. moderate to severe depression that persisted Subjects’ (n = 50 to 336) mean ages ranged from baseline to 6 months. (2001) determined that patients meeting cri- ety was directly related to perception of pain teria for major depressive disorder at dis- with the strongest relationship on postopera. Further- sisting in 38. Hypothermia during CABG carino. gery.

1995. To date. since depression has clearly been linked to anxiety may be associated with cardiac events increased morbidity and mortality. more studies now relate to other settings. 2001). no one mechanism has of settings. at 3 months no studies investigating the effect of antide- postsurgery. whereas 1999.. and relating erative intervention should be offered to pa. 2001. A stress-management program. and. Karlsson. Andrews. and mortality through multiple pathophysio- logical pathways. De La Mare. To date. 1997. De Soete. Asbury. Factors predictive of itors on the treatment of depression (specifi- post-CABG cognitive deficits were preex. nursing services for the purpose of measuring operatively may decrease postoperative anxi. 2002). productivity. & Larsson. alteration in platelet recep. cally sertraline and fluoxetine) in patients isting cognitive deficits. All cost analysis is chological states and cardiac events. and post. gery to determine their efficacy. Cost Analysis of Nursing Care itary-adrenal and/or sympathomedullary axes. low activity lev- els. premorbid intelligence. employing a variety of practice been identified as the causal link between psy.. most nota- tients experiencing depression and/or anxi. and monitoring and control- . tients awaiting CABG surgery (McHugh et Much of the research on cost analysis of al. and several social design efforts. nursing costs to other cost models. daily activities. clinical experience suggests that nursing care has focused on “costing out” routine screening and effective treatment pre. 2002). to some extent. These include exerting a SUSAN H. and the inflammatory to individual clients or aggregates in a variety processes. patients for true nursing costs. Schlesinger. based on assumptions that must be examined Although the benefits of short-term preop. 1982. greater age. surgical morbidity (Mumford. charging individual There is general agreement that early postop. as algesic use. The need and motivation for these cost- chological intervention may be associated ing efforts have evolved with the economic with reduction in length of hospital stay.. an.. less subjective tension. efficacy of selective serotonin reuptake inhib- Khatri et al. especially symptoms of depression and. ran- pass (Millar. Kenzie. myo. cost analysis of nursing care fo- relaxation techniques. ries. diminished heart rate variability. there is a need for large. and made explicit when reporting findings erative interventions have been examined in (Friedman. Clearly. Van domized trials of both antidepressants and Dijk et al. effects on of hyperactivation of the hypothalamic-pitu. & For example. 2000). lower with cardiovascular disease (CVD). Data is also accumulating about the (Vingerhoets.. offered 3 months after cuses on justifying the cost effectiveness of the MI or CABG surgery improved emotional professional practice models. have the methodologies and setting focuses. patients who received their first pressants after CABG surgery have been pub- CABG surgery without cardiopulmonary by. Some studies have shown that early psy.112 ENCYCLOPEDIA OF NURSING RESEARCH tors have found that anxiety and depression parameters (Trzcieniecka-Green & Steptoe. poor adherence to treatment). impact perception of cognitive functioning 1996). Perski et al. Cost analysis of nursing care reflects a body cardial and ventricular instability in reaction of administrative studies that focus on quan- to mental stress. underpinnings of the health care system. bly Diagnostic Related Group (DRG) catego- ety. nursing delivery models. evaluating re- well-being. lished. & Jannes. Ashton et al. models and analysis tools. psychosocial interventions post CABG sur- Based upon several reviews of recent data. MCCRONE direct influence on health-related lifestyle be- haviors (smoking. poor diet. performed in acute-care hospitals. most studies in the 1980s were Glass. based upon Today. & Murray. comparing costs of various ety and depression and facilitate recovery. 1999). tifying nursing costs needed to deliver care tors and/or reactivity. Berglin. & Mc- only one randomized controlled study of pa.

Capasso . Pallas. 1992) compared GRASP Cost analysis studies always have been rel. severity of illness. cost per case. acuity systems.0001). search. Shared variabil- the entire profession for the future. Cost Analysis of Nursing Care 113 ling nursing costs within an ever-tightening. nursing tions in these circumstances. or treatments continue to be studied. Length of stay was found to corre. use in the same way. Not all DRG categories Within the context of rising capitation pene. distinguish between true differences in case late highly to nursing work performed. but the shared variability was only studies may become central to the survival of 44% and 49% respectively. This work was confirmed by variables. Bolley. cost analysis is essential to accurate validity or reliability reported on the instru- capitation bidding and financial viability of ments used to measure related variables. Variances in esti- the early 1980s through 1990. ing in nonacute settings that are the emerging cost-conscious health care environment. come analysis to secure a larger picture of 1992). appreciated. task aspects of professional practice are mea- ing models. sured by these systems but that interpersonal The most notable characteristic of cost and observational aspects may not be fully analysis studies is the variety of definitions. or poten- determined solely on a cost per hour of ser. length of stay (LOS) was a consistent and varied by up to 30%. Intensity for Nursing Index (PINI). have been studied. task/procedure complexity. and measurement tools used in the Cockerill. and justifying budgets. vices are included in indirect care calculation? Cost analysis research is a type of nursing What role should overhead and depreciation administrative research that evaluates aspects costs of nursing-related resources play? of the delivery of nursing care. patient charges. These studies focused on in-patient settings. cross-institutional data will be meaningful. and mo- New studies are needed that will combine bility” were significant predictors of both traditional cost analysis with differential out. As cross. and there has been little tration. but such . More study is care hours. Because of the impact of surement tools were statistically significant DRGs. of care. which nursing petitive bidding. ity between GRASP and Medicus was only trained. Medicus and GRASP scores (Phillips et al. Another major area of dispute for costing this type of research has been performed in studies is the lack of a standard acuity mea- a multidisciplinary fashion under the broader sure because of the proprietary nature of most rubric of health services administration re. or cost per DRG basis. treatment nificantly correlated with both systems (p < protocols. It is impossible to variable. focusing on mated hours of care across workload mea- costing-out nursing. One study (Phillips. whose study compared case costs for patients hensive review of 73 studies published from across six acuity systems. Prescott. and Pink (1993) studies. Eckhart (1993) performed a compre. PINI sig- trators in selecting delivery models. For example. nurse administrators ity systems do not measure nursing resource must struggle to support the cost-effective. or needed to normalize acuity systems before percent of nursing costs to hospital costs. focus of health care. costs and measurement error across institu- whether measured by acuity indexes. & Soeken.” Such PINI items as “hours vice. and it was concluded that the two acu- (UAPs) proliferate. As “best practices” nitions critical to this area of study must be benchmarking pushes the envelope of com. Neither system was pre- ness of professional nursing practice. Castorr. More recently. demonstrating cost-effective staff or other care providers are included in nursing practice becomes essential to securing direct care calculations? What support ser- managed care contracts. Larger dictive of PINI items “knowledge deficit. Defi- the parent organization. Cost and efficiency of nursing procedures so little is known about cost analysis of nurs. These findings seem to indicate that the “true cost-benefit ratio” for specific nurs. nursing costs. questions of appropriate skill mix cannot be emotional status.. tial for injury. unlicensed assistive personnel 34%. standardized. and Medicus acuity systems to the Patient evant to decision making by nursing adminis.

What are the most efficient and effec. In the history of nursing the development of tomer satisfaction. emerge for this type of analysis. More complex issues the specialty of critical care is fairly recent. other disciplines? Additionally. 1970s. are difficult to duplicate in other settings. 2002. to a least costly delivery mode saves money. one was signif.) The first specialty organization was These calculations may be critical for institu. As critical pathways (benchmark effectiveness gained from segregating any pa- performance tools) evolve as care guides. Determining a routine tool in the care of many patients what activities can be safely eliminated from and critical care broadened to include the a pathway without negatively impacting care care of patients other than postanesthesia and outcomes will have cost and resource savings those with cardiac disease. Russo and Landcaster (1995) evaluated unlicensed as. Although fit analysis model that incorporates the out- both were comparable for wound closure rate comes of practice. cially elusive. . MARY L. visits. Cho et al. paralleling the growth and development of intensive care units (ICUs) in the 1960s and ductivity across discipline levels. we must move toward a cost-bene- treatments (saline vs. the polio epidemics of the 1950s. Variables are identified in these studies that do impact nursing costs. and case costs must be cal. such as nursing turn. and nursing satisfaction. hydrogel). The first ICUs were areas in the hospi- training. The devel- propriate for patients at each step of the path. ences in managing groups of critically ill pa- culated.” sociation of Critical-Care Nurses (AACN). opment of the mechanical ventilator and ad- way? For example. With multiple required a higher number of home nursing nursing providers impacting a patient’s care. such analyses demonstrate the multi. given the “generic” and group icantly more expensive. and impact on quality must be tal designated for the care of patients recov- added to the equation. The saline treatment nature of nursing practice. 2003). quality patient outcomes. when is it safe to transfer vances in coronary care led to recognition of a fresh open heart patient from critical care the need for specialized skills and knowledge to a stepdown environment? (Earliest transfer bases among nurses caring for these patients.. the American As- as we move to “best demonstrated practices. tients. such as those injured in the Boston tive pathways toward resolution of a given Coconut Grove fire of 1942 and victims of health problem? What practice setting is ap. we need to Another fertile area for cost analysis is to quantify the costs of increased patient mortal- evaluate cost differences among professional ity and failure to rescue associated with practice models. accounting for the difference in cost. ering from anesthesia who required close Given the growth of capitation.. and cus. Critical Care Nursing sistive personnel models relative to cost-effec- tiveness. Relative pro. most of these changes in nurse/patient ratios based on re- studies use proprietary practice models that cent landmark studies (Aiken et al. a short period of time was spurred by experi- patient outcomes. Recognition of the efficiency and directions. ratio of productive to nonproductive hours. This aspect has been espe- and cost of treatment supplies. of each person or each subspecialty of nursing factorial nature of costing research and the practice that a patient may experience in the need to look beyond the obvious in doing course of their care from contributions of such analyses. However.114 ENCYCLOPEDIA OF NURSING RESEARCH and Munro (2003) compared two wound Finally. tions to secure managed-care contracts in a As electrocardiographic monitoring became cost-competitive environment. recruitment. formed by nurses working in coronary care. cost analy- monitoring during a period of physiological sis of nursing services will need to take new instability. how do we separate the relative contributions Clearly. FISHER over. the tients who required intensive nursing care for costs of pathway changes on nursing delivery.

A search of grants funded Characteristics of the ICU environment in 2003 by the National Institute of Nursing that have been consistently implicated in Research (NINR) yielded 24 federally funded studies and have been the target of changes in studies of pediatric and adult patients with environment and care routines include sleep cardiac problems. (d) interventions. and an ethnographic 1969 (Lynbaugh & Fairman. Critical Care Nurse. and the impact of gender on diotomy delirium in open heart surgery pa- the mechanism. and a Phenomena of interest can be described as certification program. one of the most the pace of critical care research and practice. recent history acute-care nurse practitioners in improving of alcohol abuse. high-risk ne. described as a distur- diopulmonary system undoubtedly contrib. such research focusing on complex subjects such as lighting and noise (Noble. 2003).000 nurses in the monitoring techniques. epidemics. and productive. coupled with a ditory hallucinations. and sophisticated in environmental factors. De- At the same time. 1992). characterized by in- uted to the early commitment to research. Interest in studying the critical care envi- onates. bance of consciousness. critical care sources of unusual sensory stimulation. (e) outcomes of critical care. ronment began with observation of postcar- ural disasters. the aging population. has been Critical care researchers are venturing into found to be an independent risk factor for multiple areas. (b) critical care nurses. both in medicine ium and disorientation. prolonged ICU and hospital stay.S. was formed in chanical ventilation. and management tients in the 1960s. phenomenon and identify causative factors From the outset. there is an increasingly vast lirium may be associated with visual and au- amount of published research. social isolation. Yet critical care noid ideation. psychological. and U. mortality rates 6 months after discharge. and transfer from a nursing . and 45 other countries. critical care has been a soon broadened to include all forms of delir- research intensive discipline. gene hospital admission may trigger delirium’s on- expression in cerebral ischemia. prone positioning in posing risk factors that are present prior to pediatric patients with acute lung injury. Journal articles Heitkemper and Bond (2003) reviewed published since 2003 in American Journal of major advances in nursing research in critical Critical Care. their investigations. (c) world. four genetically-based deprivation. and multiple studies. Efforts to describe this of disease. infection and emerging infectious terns of inquiry. 1982). including age over 70 years. Critical Care Nursing 115 originally named the American Association outcome in patients receiving long-term me- of Cardiovascular Nurses. creative. This step study of dying patients in surgical intensive was rapidly followed by the development of care unit. Delirium. formal rec. Heart and care.” This syndrome is maintaining physiological stability of the car. content in undergraduate programs. and more specifically. Today. attention and a change in cognition or percep- based practice. now called delirium. AACN is the falling into five broad areas: (a) the critical largest specialty nursing organization in the care environment. and higher mics and molecular biology on disease states. examining family interactions with continuing education programs. Domains of nursing science predicted to Lung. detection. man-made and nat. Nursing Research. with more than 65. Predis- as heart-rate variability. including the impact of geno. and Biological Re- emerge as important contenders for research search for Nursing were reviewed for evi- priorities include genetic therapeutics and dence of significant trends and changing pat- counseling. clinicians as the goal of care shifts from cure ommendations for critical care curricular to comfort. and sometimes para- trend toward specialization. common complications in the ICU. grouped under the and in nursing. The initial narrow focus on heading “ICU psychosis. health disparities. It is thought to be related to nurse scientists have been extraordinarily a variety of physiological. the use of set. Dracup and Bryan-Brown tual disturbance that develop rapidly (Tru- (2003) observed an unprecedented change in man & Ely.

although environmental growing nursing shortage due to dissatisfac- factors are known to play a role in its develop. given the recent turmoil and changing nature Until the recent emphasis on reducing the of world events. The emergency depart. research projects were have been so prevalent. ICU environment to appear less threatening where Cullen and colleagues (as cited in to patient family members and to meet family Dracup & Bryan-Brown. and where the risk of an adverse event ment as an environment of care has also been rises by 6% for each day of ICU stay. Tittle. cal floor. posed solutions evident in the literature in- as the issue of family presence during patient clude nursing interventions using a teamwork resuscitation has received considerable atten. comparing cade 1979 to 1988 (VanCott. such as electrocardiography or intracranial velopment. such as rapid turnover. them with non-ICU nurses. the frequency of patient deaths in- a subject that has received increasing atten. staffing in order to ensure patient safety. In addition to Moody. 1991). prove patient outcomes. such as burnout and stimuli initiated in the ICU setting. the focus of research on critical ates. and address the nism for delirium. then. Pro- showcased as an important context of care. hallmark of critical care since its inception. creased by 7% for each additional patient tion from nurse scientists and greater funding assignment added to the nurse’s workload. not available on the general hospital ward. there was considerable interest in pressure monitoring. During the first decade of critical care de. partic. the performance of invasive procedures. disasters. and health disparities as envi.000 surgical patients. opi. tion with working conditions. In a landmark ment and symptomatic escalation. In response to these changes. The boundaries between the sheltered see continuity of patient care. Aiken and col- is the potentially deleterious effects of light leagues (2002) reported that when the safe and noise in the neonatal intensive care unit patient-staff ratio exceeded 4 to 1 on a surgi- on the growth and development of neonates. cost of expensive services. inter- imbalance. that studies of monitoring techniques cialty. In general. & Wilson. 2003). or for monitoring of some physiological pa- ease. model to improve patient outcomes and the tion by nurse researchers over the past several use of acute care nurse practitioners to over- years. Precipitating was particular interest in the effects of work- risk factors occurring following patient ad. there content areas were the effect of patient posi- . frequent when compared with the incidence ularly as it affects attitudes of family members of medication-related errors outside of the and staff nurses alike. ICU.000 nurses and Another growing environmental concern 230. Currently. the subject of ICU visitation has preventable adverse drug events are twice as been examined by many investigators. Physiological monitoring has been the however. A third recurring theme This problem is particularly salient in the in the scientific literature is the need for the highly complex critical care environment. studying the practitioners of this new spe. ing in the ICU environment on stress levels mission have been found to be any noxious and the effects of stress. It is understandable. Severe metabolic changes causing disciplinary care and appropriate levels of imbalances in neurotransmitter concentra. im- tions are thought to act as the basic mecha. Thus. study of more than 10. the most common looking for demographic differences. In a review of critical aimed at describing characteristics of nurses care practice research conducted in the de- who chose this area of practice. quent and close physical assessment by nurses ment to capture the threats of infectious dis. 2003) found that needs.116 ENCYCLOPEDIA OF NURSING RESEARCH home (Truman & Ely. have become more permeable. ICU environment and the rest of the world. the most common Heitkemper and Bond (2003) recommend reason for ICU admission was either for fre- that nursing broaden its definition of environ. care nursing has shifted to a broader recogni- and the emergence of electrolyte and fluid tion of the importance of collaborative. the administration of benzodiazepines. for nursing research. rameter that required specialized technology ronmental factors in need of further research.

work of the effectiveness of heparinized versus non- breathing. der Project II were to describe and compare ducting basic laboratory and animal investi. determination of proper feeding tube particularly on use of quality management placement and detection of aspiration. found to vary depending on the specific pro- port. and adolescents tion. while eral. outcomes research in critical care focused tioning. or family sup. rejection of organ transplanta. 1992). patients’ perceptions of pain and their re- gations. 20% of total hospital costs (Berenson. adults and chil- as suctioning or chest tube drainage proce. including such topics as diaphrag. however. In her year-end review for the procedure was found to be a key fac- of nursing intervention research. Naylor tor. femoral line removal. search program of large. such as measuring has been a recent trend toward emphasizing changes in cerebral blow flow during suc. The sample Interventional studies have become more size consisted of 91 children (ages 4 to 12). inflammation. the tools such as critical pathways. This study. wound drain removal. tightly controlled studies of nursing tinuing interest in the accuracy of measure. as well heparinized flush solutions for maintaining as the determination of novel biomarkers of patency of arterial catheters. intensity and its associated distress were communication techniques. oxygen consumption. which supported the practice of heparinizing tion. earlier studies have typically used inves. there the critically ill patient. Critical Care Nursing 117 tion on hemodynamic parameters (11%). It has been esti- following acute myocardial infarction. ulation studies (5%). such as case management. Like much of nursing research in gen. and more than 63% of such as APACHE or TISS. Thunder Project I was a comparison of temperature. such as teaching. frequent in the recent past. The majority of 151 adolescents (ages 13 to 17). and tive environments of care.024 sub- care nurse researchers are receiving genetic jects (AACN. and nonburn wound ischemia following brain injury. ects. In the past decade. had a sample of 5. How patients were prepared come more common. large. tion. dren (ages 4 to 7) reported turning to be the dures. lem of small sample sizes is the AACN re. and genetic susceptibility to cerebral central line insertion. termed “Thunder Proj- usefulness of physiologic monitoring contin. distressing. coordinated by an AACN research team.” have enabled researchers to conduct ues to receive attention. painful procedure. the not receive medication prior to and during a use of standardized acuity rating systems. ple. many ICU intervention studies have children (8 to 12 years old) rated tracheal been limited by small sample sizes. sponses to turning. adults (over 18 years of age). 1993). cedural events. 1984. the These investigations. or on specific nursing procedures. making com. matic fatigue. 2003). NINR: several of these projects focused on As is occurring in other disciplines. Rudy & Grenvik. Greater numbers of critical flush solutions. dressing change (Puntillo. especially in the con. Overall. systems of provision of ventilator care in patients with care. The objectives of Thun- training as well as federal funding for con. tracheal suctioning. found wound care to be the most painful and tigator-designed instruments. For exam- ment of cardiac output with position change. to describe study adults did not receive any medication for pro- populations and control for acuity have be. multi-site studies cardiac output measurement (6%). and sepsis. In addi. such cedure performed. Procedural pain chosocial interventions. More than 75% of children did parisons across studies difficult. most painful and distressing procedure. analgesic administration and information there were 78 nurse-led studies funded by the about expected sensations that might occur.959 these studies have focused either on psy. and alterna- Acute Respiratory Distress Syndrome. such as special care meeting the psychosocial needs of the patient units and observation units. suctioning as the worst. mated that critical care accounts for 15% to One very promising approach to the prob. and 5. The high cost of . neuromuscular blockade. cytokine response to inflamma. problems specific to critical care. anticipatory preparation should include (2003) noted that between 1999 and 2002. and coag.

It is in this area of nurses research that one can find numerous nursing 4. and For nurse scientists to succeed in the imple- functional and cognitive status after cardiac mentation of programs of research and dis- surgery and cardiac rehabilitation. delay and collaboration of scientists working in the in seeking treatment for chest pain.. 6/24/02) include the following: meaning for its existence. sizes. Cultural/transcultural focus is the study of Current research priorities (www. ronment The emphasis for research efforts has also 3. Naylor (2003) pointed out that ety following cardiac surgery. that are sensitive to ologies have flourished. management. nurse decision mak. UPDATED BY CAROL DIANE EPSTEIN search priorities for the 1990s included venti- lator weaning procedures. multiple disciplines. Creation of a healing. they will need to uti- tional nurse-led interventions have targeted lize interdisciplinary collaboration and. tinue to concentrate in the areas of monitor- ing techniques. Cultural/Transcultural Focus sue oxygenation. that can measure outcomes. there continues to be a need for the tients. many of patients living with heart failure. populations. DALY tions. find ways to effectively transcend tra- heart failure using telephone counseling and ditional disciplinary boundaries for the sake a web-based approach. In addition. as well as supporting of addressing fundamental health issues and patients undergoing cardiac rehabilitation. hemodynamic monitoring techniques. and nutritional support mo- dalities (Lindquist et al. and society. Effective and appropriate use of tech. communities. other than physi- Qualitative approaches in research method. requiring the expertise brillation following open-heart surgery. optimal contribution of critical care tices for nursing care. the beneficial effects studies in order to generate adequate sample of tight glycemic control of preoperative pa. and outcomes research. the science underlying these inter- focused on long-term disability posthead in. improving the health of individuals. patient anxi. transient myocardial ischemia. heart transplantation. ventions often spans knowledge derived from jury. basic. Critical care research is expected to con. ulti- compliance as a primary goal in patients with mately. Effective approaches to symptom studies in the scientific literature. ure readmission. and/or out- mitment to reducing health care spending will comes continue to make testing of more cost-effec. 2. atrial fi. Educa. and behavioral sciences. clinical. social. endotracheal suc- tioning with saline lavage. humane envi- tive approaches to care a research priority. Nursing management bedside practices of interest have included 5. Nurse investigators pursue this focus to understand the associa- 1. BARBARA J. care for intubated patients. sessment. Prevention and management of com- testing different methods for providing oral plications. 1993). and end-of-life given the complex nature of effective inter- care. the environment shared by a group seeking org/research. Processes and systems that foster the been directed toward establishing best prac. heart fail.118 ENCYCLOPEDIA OF NURSING RESEARCH critical care in the context of a national com. and the success of a weaning protocol development of valid and reliable instruments for patients receiving mechanical ventilation. ally competent care. tion of culture to health and to provide cultur- nology to achieve optimal patient as. should be replicated and tested with varying ing about hemodynamic status. AACN’s re. Although this focus is .aacn. skin breakdown In addition to the need for more multi-site in open-heart patients. ological parameters. prolonged the previously reported intervention studies mechanical ventilation. semination of findings. measurement of tis. specific procedural interven. families. Predictive studies of risk factors have ventions. such as focusing on nursing interventions.

its impact on pa. (d) the name of the highest stage tor’s awareness of or openness to the com- of cultural knowledge changes over time. worldwide area of criticized for inadequately recognizing real study and practice about culture and caring (rather than perceived) barriers to care. tuality. and findings do not ad. discussion only cursory emphasis in most curricula or may not relate findings to that group. ers. and transitions. cology research (Phillips & Weekes. Afro-American. plexity and pervasiveness of culture in the with cultural competence or cultural profi. Searchers are cautioned that (a) the names of including physiological measurements are racial or ethnic groups are often used only used in C/TCR. self-care. tradition regard transcultural nursing as the For example health belief models have been proper term for a formal. Negro. However. interviews. Qualitative approaches have long and are often used interchangeably. which parallels an intake may be found in the Cochrane database for history and involves all aspects of the disease evidence-based practice using a keyword course and clinical encounter. health dis. 2001). of illness are increasing. & Phillips. descriptive. 2002). Black. Some C/TCR studies (particularly inter. Frequently used frameworks include Leining- Americans and others. women. United States by 2030 and the persistence of Most quantitative C/TCR is theory-based. and applica. Taylor. Researchers in the Leininger existing frameworks for particular groups. Studies of model development to pro- dahl. 2001).. and few nurses are cultural (g) findings ascribed to culture are often not experts. history. nurs* and care. (e) data. a welcome trend ventions and randomized controlled trials) since this approach. cul. istent or inadequate. major health disparities between Euro. (b) race. Although most data collection strategies. Culture receives specify a focus on a cultural group. g. par- vance true cultural knowledge. health-seek- ing research on culture is needed. such as published in Nursing Research over five de. the terms are essentially synony. ninger-based Model of Culturally Competent tion of the Oncology Nursing Society’s cul. the realization (e. administrative journals. are increasingly represented in tural competence guidelines to published on. and ethnicity lack consensual definitions naires. the Diversity Competency Model and the Lei- cades (Flaskerud et al. small scale. or political structures. In light of projections that racial and distinguished from the effects of socioeco- ethnic minorities will be the majority in the nomic status. Reports are now ap- mous and questions of disciplinary origin are pearing on the cultural appropriateness of unimportant. health belief models. spiri- within nursing. Cultural/Transcultural Focus 119 growing within research. To some. (f) although reports tient care has been limited. seems relevant search based on such terms as the disease and practical to clinicians as well as research- name. nurs* and interven. mote culturally competent organizations and parities among vulnerable populations as build culturally diverse workforces. and practice settings. . African of their potential depends on the investiga- American). Studies seeking explanatory models nals. The cultural/transcultural research (C/TCR) ex. more and better nurs. becoming popular. ticipant observation. and written question- ture. been intracultural. the most frequently used are descriptive labels. research encounter (Morse.. focus groups. and the interconnectedness (rather Cultural/transcultural research is found in than the individuality) of African-American a great variety of research and clinical jour. (c) ac. and names of racial or cultural groups. Leadership. er’s culture care theory. 2002). transtheoretical model of behavior change is ist. self-efficacy. The overwhelming majority of C/TCR has bases on special populations are often nonex. been recognized as well-suited to C/TCR and ceptable names for groups change over time are frequently used. ethnographies. ciency being currently preferred. stress and Different perspectives on the meaning of coping. ton and Flaskerud’s (2000) model for HIV Recent reviews of C/TCR include race and prevention among Latinos are under develop- ethnicity as nursing research variables (Drev. ing behavior. Culture-specific models such as McQuis- tion. ment.

and health. JACOBSON Cultural Awareness Scale are being devel- oped to measure the outcomes of programs to promote multicultural awareness. Recent estimates of the pro. More investi. The sheer volume of very similar studies of health beliefs and practices. 2000). studies with tain groups suggests a sufficient base for in- large sample sizes. ing. alternative healing practices and their pos- ing steadily. plication of these guidelines should mesh diovascular health for African-American nicely with the third great need of C/TCR. ally competent research (Meleis. sex roles. are needed of Native-American (McQuiston & Flaskerud. & Bradley. Villaruel. 1996). 1996). 2002. and Korean women (Meleis. Cultur- management in ethnically diverse families ally competent research is broader than ef- (Chesla et al. McMurray. an interview or survey on health knowledge. school children (Harrell. 2000. and ever briefer inpatient stays. 2004). The of cultural perspectives on ethics. or spirituality within cer- cross-national nursing studies. Middle East. was no index to the few nursing journals pub- gators must move from descriptive studies to lished at the time. tervention studies. Instrument reading level is receiving of the economic case for culturally competent considerable attention in recognition of the care are needed to insure that culture is con- prevalence of low literacy and low English sidered in this era of managed care. 2004). However. and program. Folk and quality of measurement in C/TCR is improv. sensitive study. need systematic. cultural fit of items and the psychometric Studies of cultural adaptations of care in properties of an instrument for the target homes. persons are rare but urgently needed. Bandiwula. Allied Health Literature First is the need for more intervention studies (Douglas. tures (groups not defined by race or ethnicity) ies of recruiting and retaining subjects and are needed. A second great need is for plinary or international teams. lips & Weekes. and development studied. is growing rapidly. self-efficacy within one designated group and the importance of family decision mak- conducted by a single investigator. and sexual subcul- Methodological research. sible combinations with biomedical ap- lation are widely recognized. particularly programmatic mott. Porter & Villaruel. More studies. Phil- Active C/TCR programs and their princi. Cumulative Index to Nursing and There are three major needs in C/TCR. and both the proaches. agement. & Herman. given ern. folk remedies. Individual librarians took . HIV risk reduction in. HIV prevention among Latinos studies.. use in African-American adolescents (Jem. or a concept like the health beliefs. which is for research to be planned and con- sky. ies of rural. forts to select culturally appropriate instru- terventions for impoverished Latina and ments or to recruit appropriate subjects. Gan. 2000). 2003). pal investigators include diabetes education 1993. 2000).. occupational.6% to 14%. Studies of multiracial or multiethnic health needs of South American. 1999). diabetes planned to be culturally competent. Research needs to be for Mexican-Americans (Brown). The standards for rigorous trans. In the late 1940s. as are comparative explorations instrumentation.120 ENCYCLOPEDIA OF NURSING RESEARCH and nonprogrammatic. Stud- Native-American health is noteworthy. the development of brief rapid strate- group are increasingly being reported and gies for cultural assessment. there ture range from 3. existed for the biomedical literature. The the growing numbers of people who identify dearth of programmatic nursing research on themselves as having multiple heritages. condom ducted with greater community involvement. studies done by interdisci. Instruments such as the Cultural Self-Efficacy Scale and the SHAROL F. including stud. Boyd. case man- proficiency in many populations (Weinrich. 1996. application of existing guidelines for cultur- matic research are becoming more frequent. et al. Ap- Asian women (Flaskerud. car. although Index Medicus portion of interventions in the C/TCR litera. family values. The typical study is interventions to randomized controlled trials.

Recognizing that the boundaries of received for their own population. analysis. clinical innovations. These materials may be present in phasis on nursing research. Content other titioners. both access to materials describing or studying that as a practice and as a science. used disciplines. The basic premise under- lying the existence of the Index is that effec- the thesaurus demonstrate the development tive and knowledgeable practice depends on and growth of the nursing profession. Current Procedural Terminology-Coded Services 121 it upon themselves at particular hospitals or Other changes have taken place over these schools of nursing to index the journals they years. organizations. Current Procedural Terminology- rials are just a few of the other types of materi. standards of practice. occupational therapy. and communicative ing Literature in 1961. available as well.000 titles. and data collection ical pathways. and classifica. As would Throughout the nearly 40 years of its exis- be expected. as have the names of nurs. many indexing terms are similar tence. Coded Services als indexed. ing place in the profession itself. reflecting the changes tak. the current journal list in- ogy. There are 17 such disci- dex. including physical therapy. Recent years have seen the development The “red books. continues to be its primary function. published as The Cumulative Index to Nurs. family nurse prac- cludes more than 1.000 services . dissertations. Individual access via the Internet is Nursing and Nursing Research to the Ameri. health—professionals with materials written portant differences. Searching this material on a regu- ing specialties. lines. practice acts. Books DIANE SHEA PRAVIKOFF and book chapters. descriptions. and managed care has re- sources. audiovisuals. database became part of several online ser- Seventeen journals were included in this pub. This in. which began as an internal project. accredita- miliar part of nursing education throughout tion materials. and nursing than that listed above includes practice guide- intensity. vices (CPT) include more than 8. 1964) and became a fa. specialty and ad- a variety of formats and from a variety of vanced practice. resulting in The Cumula- on the staff of White Memorial Hospital and tive Index to Nursing and Allied Health Liter- later. and even full text of some jour- have been added. and many terms added to about and for them. pamphlets and pamphlet chapters. Increased em- practice.” as this publication became of CINAHL-created documents as part of the known. One such nursing intersect with many other health care librarian in Los Angeles. Los Angeles County Hospital. Research terms describing design. the primary goal of the organization or identical to those used in the indexing of has been to connect nursing—and later allied biomedical journals. nal articles. and consumer health and patient education mate. crit- methodology. disorders. survival analysis. although that grew and changed. indexed are different from those in indexes of the biomedical and other literature. These include research instrument community (Raisig. There are some im. ature (CINAHL®). case management. Whereas indexing began with fewer sulted in indexing terms such as phenomenol- than 10 journals. Because of the difficulty in ob- taining these materials they are often defined Current procedural terminology-coded ser- as elusive or fugitive literature. lar basis should be a professional obligation tion systems. Ella Crandall. a cumulation of in. In 1983 the CINAHL® electronic dexing covering the period 1956 to 1960. vices and was released as a CD-ROM in lication—from the American Journal of 1989. “Allied Health” was added to the 3 × 5 index cards to meet the needs of nurses Index title in 1977. were well received in the nursing database. the United States. the materials the duration of their careers. of members of all health care disciplines for Aside from the terms used. can Association of Industrial Nurses Journal. and legal case descriptions. was plines covered. The database can no longer be viewed as only Over the next several decades the Index a bibliographical database.

rehabili- tation nurses. Robinson & Griffith. at the time of the survey. orthopaedic nurses. p. The number of CPT codes performed by spe- is done by a nurse. oncology nurses. services. 1997). ges). PhD. deliberations on reforming the payment this number appears to be small. Survey results revealed that associate B). This exploratory study suggested physicians’ resource costs: work as well as that nurses often perform CPT-coded services practice and malpractice expense. The more in the process of revising the payment system. Supervision by physi- fore provide the needed data. individual respondents per- codes might explain nursing work and there. 1991). It is used by policy makers in their of currently published codes in the manual. nine for the same service (Mittelstadt. After realizing that the generalist AJN stating that nurses should be paid the same study was clearly supported by nurses. Charges to Medicare in 1988 for the activities were performed by nurses (Griffith. The average diagnostic services and thereby serves as a number of coded services performed by the method for payment by public (Medicare and respondents was 27. Given the large number payers. & Griffith. to the PPRC. She stated: critical care nurses. however. the purpose procedures by registered nurses. with little or no supervision by physicians. or how many services cialty nurses ranged from 233 for family are delivered by the nurse and billed under nurse practitioners to 58 for school nurses. now billed by a physician. The Ameri. Griffith & Rob. the PPRC stated years) reported performing significantly that nonphysician providers should be paid fewer coded services and. Carol was determined that 493 of over 7. system. expressed con. codes were performed by school nurses. 1993.427. The nurse specialist groups were surveyed and it first nurse to serve on the Commission. experienced nurses (practicing more than 10 In its report to Congress. family nurse practitioners. . 1997). only 107 codes In 1986 Congress created the Physician comprised 56. (Health Care Financing Administration and vise it on reforms of the methods used to pay Bureau of Data Management and Strategy.000 CPT Lockhart. nurses at a percentage of physician payment levels working in hospital settings performed more reflecting differences in physicians’ and non. 1991.122 ENCYCLOPEDIA OF NURSING RESEARCH listed in the Physicians’ Current Procedural The American Journal of Nursing (AJN) Terminology manual published annually by (Griffith & Fonteyn.869 RNs of the CPT system is to provide a uniform returned the questionnaire and 150 made language that describes medical. surgical. the physician’s name. nephrol- Nursing’s role in the delivery of Medicare ogy nurses. studies were cians for these groups of nurses was infre- conducted to look at how many billable CPT quent. $22. 1989) published a ques- the American Medical Association (AMA).. FAAN. RN. little or no data showing how much of a particular service. Nursing groups such as the American and baccalaureate degree nurses performed Nurses Association lobbied PPRC to consider significantly more coded services than nurses the contributions of nurses as they engaged with diplomas and masters degrees. can Nurses Association (ANA) disagreed. en- cern about the lack of nursing data available terostomal nurses. 1993. physicians under the Medicare program (Part 1990). 4. coded services included in the survey were Thomas. The mean number of coded services per- 1989. 1051) formed by individual respondents ranged from 79 for family nurse practitioners to 18 In an attempt to identify whether CPT for school nurses.9% of all Medicare procedures Payment Review Commission (PPRC) to ad. Robinson & Griffith. formed 0 to 162 codes.793. (Griffith & Fonteyn. and telephone calls or wrote letters. and mid-wives (Griffith & Rob- Part B services is undocumented. with a range of 0 to 60 Medicaid) and private (commercial insurers) (Griffith et al. as expected. tionnaire on the performance of CPT-coded Developed by the AMA in 1966.34 (aggregate allowable char- inson. We have inson. 1991).

policy makers. KAREN R. the AMA. activity terms were categorized into 80 NIC ANA. the public-consumers of care that ings supported the importance of nursing. Randell. HURDIS M. the CPT-5. One of the workgroups. could be categorized using Nursing Interven. findings re. and health care interventions in an effort to dem. another nurses want to proceed in this direction. ROBINSON . It is anticipated that the CPT- for pneumocystis carinii pneumonia.ama-assn. satisfaction. Recognizing that the CPT system does thereby providing meaningful data to con- have deficiencies. GRIFFITH sory Group (PAG). vention categories while only 6% of the terms As we progress further through the 21st were classifiable by CPT codes. 2001).html). Efforts are being made tions Classification (NIC) and Current Proce. fectiveness through workload analysis. Current Procedural Terminology-Coded Services 123 A criticism of the CPT codes is their limita. and payers (Robinson the task of developing the next generation. began sumers. These find. they should be cost outcomes (Henry. Griffith. Nursing 5 Project will be completed in the near future. to patient and program productivity and ef- Marx & Mullinix. organizations to determine where and how vealed evidence that NIC is superior to CPT the CPT system lacks adequate codes for the for categorizing these activities in a study appropriate description of services of differ- population of 201 AIDS patients hospitalized ent providers. Because nurses have the abilities to onstrate nursing’s contribution to quality and deliver in all of these areas. nurses deliver will become even more inter- specific classifications for categorization of ested in cost. Marx. & Miller. their challenge must be to accurately docu- ing services into CPT if they are not otherwise ment their contribution of nursing practice described in another CPT code (Sullivan. to gather information from other provider dural Terminology (CPT) codes. All terms in the data set were tatives serving on AMA work groups of the classifiable using the NIC system and 60% project (Robinson. The CPT-5 Project includes six workgroups and an Executive Project Advi. quality. 1997). directly reimbursed for their services. & Sullivan- of the terms were classified into 14 NIC inter. Holzemer. et al. category/3883. However. has represen- CPT codes. accessibility. 1999).” is reviewing tion to describe only physician services and and evaluating weaknesses of the current not the full range of health services provided system for coding the provisions of health by the entire team. in 1998. 2001). In a study comparing the services by nonphysician health care profes- frequency with which nursing activity terms sionals (http://www.. then way to address the issue is to introduce nurs. “Nonphysician Practitioners. If Hsieh. active in dialogues with AMA on inclu- interventions across 22 classes and into 15 sion of nursing work in CPT-5.

however. 1970. mathematical assumptions about the data. Conse- 124 . there is a hidden danger in the quire careful execution and are intended to ease with which one may execute such pro- give meaning to data by organizing disparate grams. psy- tests are appropriate for (and assume) nomi. propriately. tions about the data. is restricted to those for which testing (see Labovitz. t. analysis is one of modus tollens. bility theory and involves using a number of The logic of null hypothesis statistical data specific statistical tests. Rozeboom. How- ent values of the statistic under different as. φ. Walker. Because the investigator must un- application of logic and reasoning. Although each test has its own set of ining data gathered for any research investi. the investiga- pieces of information into understandable tor must fully understand the underlying sta- and useful aggregates. etc. however. statements.g. others assume ordinal data. ing probabilistic for null hypothesis statistical Specific tests are selected because they pro. D Data Analysis nal data. For example. 1960. A. Each antecedent by denying the consequent. tistical procedures and the implied assump- eses. the test (or null) hypothe.. These programs. sumptions of the tests. 1986. SPSS. testing. 1993. so the null hypothesis must be false. chology. late these test statistics and their sampling soning through the use of statistics. an ap. tions of these tests in order to apply them ap- Statistical data analysis is based in proba. the calculation of probability levels for differ. ever. for decades scientists from differ- the data in response to the research questions ent disciplines have questioned the usefulness or hypotheses posed. Quantitative data anal. Loftus. the available data meet certain required as.. denying the ation between two or more variables. distributions. plied branch of mathematics. 1993. or measures of associ. vincingly argued that. The selection of specific and triviality of null hypothesis statistical tests.g. J. That of these tests or statistics (e. for examples from sociology. if the null hypothesis is correct. SAS. the original syllogism is invalidated. EQS) can aid the data analysis is more often associated with investigator with the tedious and complex quantitative research. a branch derstand the computer programs to use them of philosophy. or degrees of freedom. to nonnumeric data. to numeric serve only to expedite calculations and ensure data. mathematical operations necessary to calcu- ysis involves the application of logic and rea. Cohen (1994) and others have con- sumptions—that is. F. Although applicable to Several statistical computer programs both qualitative and quantitative research (e. all gation to support conclusions or interpreta. or hypoth. Qualitative data analysis involves the accuracy. by making this reason- sis and the sample size. public health. ment. is..) has a known distribution that allows ings cannot occur but our findings did occur. For valid data analysis. vide the most meaningful representation of Moreover. and still others assume an interval level of measure- Data analysis is a systematic method of exam. LeFort. appropriately. statistical tests assume random sampling. some M. and nursing). β. LISREL. χ2. our find- γ. Both re.

g. viewers ask study participants a series of tistical probabilistic statements to support the questions—in writing by having participants investigator’s interpretations and conclu. nurse researchers part of the actual data analyses. Until the 1980s. or events into co. prespecified way. characteristics. and responses to multiple questions and is de- these methods vary on a number of important signed to assign a numeric score to respon- . tend to have a more flexible. NUDIST) have been de. Another important dimension concerns ous effort. relying been done manually. categories. Although of coding words.g. and biophysiological measures. increased attention to the factors dimensions. investigator’s arguments.. AARONSON ing. sample sizes. complete a paper-and-pencil task or. there are no statistical probabilistic tests form). unstructured Historically. both Structured. Researchers collecting qualitative data to apply to their coding. fatigue) or a psychological attribute Nurse researchers use a wide variety of meth.g. Interviews can be conducted either in person or over the telephone. Interviews and questionnaires often incorporate one or more Data Collection Methods formal scales to measure certain clinical data (e. The most programs for quantitative analyses. the data being collected are quantitative or icance is warranted and power.. However. observa- the tedious and error-prone tasks of analysis. The and accurately execute the analytic method instrument is called an interview schedule selected. on ongoing insights during data collection to puter programs (e. quantitative data collection remains the most herent or meaningful categories or themes as frequently used approach. effect sizes qualitative. (e. guide the course of further data gathering. Also. tions. The collection of quantitative in- In contrast to quantitative data analysis. writ- strength of the original study design and the ten document or instrument that specifies ex- ability of the investigator to appropriately actly what questions are to be asked. by having participants engage in exclusively on the strength and logic of the some other activity. qualitative data coding has approach to collecting information. those for frequently used modes of data collection by qualitative data analysis are merely aids for nurse researchers are self-reports. objects. nurse researchers (for substantive significance). techniques. Qualitative data analysis depends more quently. such as sorting cards. One dimension involves whether that contribute to findings of statistical signif. Nonetheless. quantitative self-report data are types of data analysis ultimately rest on the usually collected by means of a formal. as with the computer the basic mode of data collection. attitudes toward nursing homes). when the data are collected orally and a ques- tionnaire when the data are collected in writ- LAUREN S. because have shown increasing interest in collecting qualitative data analysis involves nonnumeric qualitative data (information in narrative data. A ods for collecting data (the pieces of informa. and experiences. quantitative data (information in numeric creased attention in quantitative data anal. ions. but more recently com. ports can be gathered orally by having inter- Quantitative data analysis allows for sta. predominantly used methods of collecting and confidence intervals are receiving in. form) that could be analyzed by statistical ysis.. Self-re- and themes. less fre- sions. veloped to aid the investigator in this labori. formation tends to involve highly structured which requires that the investigator assign a methods in which exactly the same informa- numeric code to all data prior to beginning tion is gathered from study participants in a the analyses. qualitative data analysis consists comparable. Data Collection Methods 125 quently. scale typically yields a composite measure of tion used to address a research problem). Self-re- Using them still requires that the investigator ports involve the collection of data through make the relevant and substantive decisions direct questioning of people about their opin- and interpretations about codes.

have the advantage of being objective. Observational meth. or characteristics. or duration of preselected behav- completely unstructured interviews (conver. some research involves the analy- communications. the re. cial settings.g. instruments and equipment. cal data—for example. pallor—are gathered not through technical but the data can sometimes be quantified. mentation. observations in narrative form. but judgmental errors and other bi- pect of the respondent’s life experiences). instruments but rather through observations Self-report methods are indispensable as a or self-reports. the observer may use a rating scale to measure views (conversations guided by a broad topic dimensions such as the intensity of observed guide). with a minimum of researcher-imposed struc- ferred to as a Q-sort. a researcher can can be classified as either in vivo measure- also ask respondents to maintain a written ments (those performed within or on living diary of their thoughts on a given topic. Observational techniques are an with small groups). or biophysiological instru- the direct observation of people’s behavior.126 ENCYCLOPEDIA OF NURSING RESEARCH dents to place them on a continuum with or with the aid of observational equipment respect to the attribute being measured (e. a Rorschach test). organisms) or in vitro measurements (those jective techniques.g. niques. although not always con. which reports are gathered orally. most like me–least like me). engaging in naturalistic behav- uum (e. Although most unstructured self. characteristics.. A special type searchers who are primarily interested in of unstructured observation is referred to as qualitative data. and activi. order or worded in a given way. rate. and ases can pose a threat to the validity and critical incidents (discussions about an event accuracy of observational data. Projective tech. important alternative to self-report tech- chronological self-disclosures about an as. collecting qualitative self-report data include frequency. conversational fashion.g. sational discussions on a topic). the collection of new data through self-re- ods are techniques for collecting data through port. Pro. life histories (narrative. encompass a as blood tests). Biophysiological measures are variety of data collection methods that rely on quantitative indicators of clinically relevant the participant’s projection of psychological attributes they require specialized technical traits in response to vaguely structured stim. the Structured observational methods dictate researcher starts with some general questions what the observer should observe and how and allows respondents to tell their stories in to record it. When self-report data are participant observation: the researcher gains gathered in an unstructured way. such sidered a form of self-report. Researchers who depression). observation. Clinical records. such as videotape cameras.. such as are available ties. or behavior that is critical to some outcome Data for nursing studies may also be de- of interest). Instead. Alternatively. Methods of often use checklists to record the appearance. accu- but they are susceptible to errors of reporting. In this approach the observers a natural. performed outside the organism’s body. which involves having ture and interference with those being ob- the participant sort cards with words or served. A less frequently used method collect qualitative observational data do so of collecting structured self-report data is re. iors. The second major mode of data collection Although most nursing research involves is through observation. events. descriptions of skin niques almost always solicit qualitative data. typically in so- phrases on them according to some contin. entry into the social group of interest and searcher typically does not have a specific set participates to varying degrees in its function- of questions that must be asked in a specific ing while gathering the observational data. Qualitative clini- uli (e. . People are observed. either directly through the human senses through written documents. to many biases. Biophysiological measures means of collecting data on human beings. focused inter. The researcher makes notes of his or her Self-report methods are also used by re. sis of preexisting data.. and precise and are typically not subject including a variety of response biases. focus group interviews (discussions behavior. ior. rived from biophysiological measures.

and out-of-range values. replaced with correct values or assigned to Nursing data issues revolve around several the missing values category. and Once each variable has been inspected and so forth. it formed or statistics produced. Frequency dis. from being tion. If violated.. This might include the devel- of documents (e. outliers. When one be assessed before any manipulations are per. those conducting variables also must be checked for outliers. tributions and descriptive statistics are gener. alternative approaches must be quately match the research question with the sought. there is no consensus regarding what but only three have adequate numbers of sub. the assump- search process. is usually information. opment of total scores for a group of items. the validity of the data and the appropriate- ness of the analyses. If a categorical the universe of relevant nursing data. information is de- solutely essential for good science. nursing charts. DENISE F. interventions. nursing knowledge and science are devel- propriate.. new variables pensive data sources. one must decide about eliminating the data set nor what data elements are required fourth category or combining it with one of to capture nursing diagnoses. corrected where necessary. Systems to label or name these data transformations may be attempted or elements also are inconsistently defined. POLIT BARBARA MUNRO Data Management Data Stewardship Data management is generally defined as the procedures taken to ensure the accuracy of Data and information are the symbolic repre- data. Then each variable is inspected. the complex nature of nursing phenom- . and data.. The first relates to identification of investigated and dealt with. cles) can be used as data sources for both subscores. for out-of-range values. Each of these new qualitative researchers (e. newspaper arti. Prior to each statistical test. nonparametric statistics employed. Data Stewardship 127 such as hospital records. oped. It is also a challenging task tions underlying the test must be checked. Incorrect values must be ing data. Next. and outcomes. skewness. constitute rich and relatively inex. administer. From this perspective. Data stewardship refers to the responsi- equality of groups. entities that are objective. the ability to ade. If continuous variable are skewed. data management is ab. Cur- variable is supposed to have four categories rently. researchers doing a quantified content ation of some new variables may involve the analysis). attend to. Careful attention to data manage- appropriate approach. Data are defined as discrete consuming process. and missing bility to manage. Information that has been synthesized scanned in to being entered manually. Although this nized and that have meaning or interpreta- may occur in a variety of ways. ing is concerned. historical research) and quantitative ones skewness. data elements make up a minimum nursing jects. Although often a tedious and time. use of sophisticated techniques such as factor The collection of data is often the most and reliability analyses. as ap. It ensures work within budgetary constraints. the others. from data entry through data transfor. The cre- (e. letters. and the ability to ment must underlie data analysis.g.g. fined as data that are structured and orga- The first step is data entry. A variety of other types may be created. Outliers must be factors. sentation of the phenomena with which nurs- mations. the so as to identify and formalize interrelation- crucial point is that the accuracy of the data ships is referred to as knowledge.g. and so forth. data are viewed as the raw material on which ated. that requires creativity. time-consuming and costly activity in the re. term represents all three types of content. Decisions must be made about dealing take charge of the universe of relevant nurs- with each of these.

and coordination and synthesis of Processing data implies the transfer of data current efforts are needed. and consistency. Reliability refers to random measurement Death and Dying errors such as ambiguities in data interpreta- tion. 1993). control. lected. tent and design decisions concern format. relevance. Content analysis of sponsibilities for nurses in building knowl- nursing data and their usefulness have to be edge bases. and record it. Unlike other biological sciences. Data stewardship use of data and knowledge to deliver and suggests that attention be paid to these char- manage patient care. signing objects to categories that represent and cost need careful consideration. definition and description of the data and information required for patent care. propriate access. & character possessed by those objects. then one lected and recorded. and (c) how one ac- acteristics. standardized languages. interpreted infor. clarity and comprehensiveness of data col- cant variables should be measured. There is a cost associated ness of the meaning contained in the context with the use and development of automated of the data. point of care delivery. is critical. utility. data ing phenomena can be measured by using entry and retrieval messages. Measuring quirements for legitimate access to data must nursing phenomena also requires the ac. with maximum settings. cludes qualitative means (assigning objects With the advent of automated data pro- to categories that are mutually exclusive and cessing and computerized information sys- exhaustive) and quantitative measures (as. tems. and when data are retrieved or ab- objects to represent the kind or amount of a stracted for studies (Hays. Measure. Androwich. the time of documenta- ment is the process of assigning numbers to tion. If nurses are to in raw form to a structured. Martin. Re- surement is to be meaningful. These measurement errors that affect Death is the cessation of life. collect. benefits and boundaries for representing Data stewardship poses challenges and re- nursing phenomena. The definition clinically generated data can occur at the of death has changed over time as advances . level of detail. The con- the amount of a characteristic possessed). of complex variables that occur in diverse Minimum time investment. be managed to facilitate the flow of clinical knowledgment of the “fuzzy” and complex data while simultaneously restricting inap- nature of nursing phenomena and the rich. Quality of data and information is related to the ability and willingness of clients CAROL A. be stewards of their data. For example. Norris. decisions about data content. must be studied to understand their not be sacrificed because of cost. such as whole comprehensiveness of information should text data. 1994). accuracy is of con- quires and delivers knowledge from and for cern at the level of judgment in collecting patient care (National Center for Nursing Re- data as well as at the level of the data col- search. cern of clinicians is the amount of time in- cur because nursing consists of a multiplicity vested in harvesting data and recording it. and security. timeliness. confidentiality. is needed. A primary con- or monitoring. Information has characteristics should focus on the following areas: (a) the of accuracy. few nurs. Decisions related to con- those variables to measure them.128 ENCYCLOPEDIA OF NURSING RESEARCH ena poses measurement difficulties. If one is able to identify what signifi. accuracy. cially when data are in electronic form. It in. Finally. the value and use of data databases. and interfaces physical instruments with signal processing with nonclinical data systems. privacy. reliability. and that are not coded or numeric. (b) the quality. espe- velop concrete behavioral indicators if mea. however. then further study mation form. Ambiguities tent of data demand stewardship to ensure and abstract notions must be reduced to de. Measurement difficulties oc. ROMANO to disclose information as well as to the nurse’s ability to observe. Redundancy is challenged with the difficulty of isolating must be eliminated. Standardization of terms of data further explored.

dying have identified problems with the care Both quantitative and qualitative methods of dying persons and their families (SUP. and psychological. or the irreversible sensation of all brain ward death and dying and family responses. The family is the unit of care and a multidisci. Benoliel (1983). 1981). central paradigm. and spiritual problems is paramount” care. ing strategies of families in hospice home social. retrospective medical record analysis. 152). including the brain stem (Presi. (p. for which there is no treatment that can sub. The educational needs of caregivers for process and bereavement. little was known about determining when dying begins with the the nature of support that is helpful to pa- statement: “people are to be considered to be tients and families and the influence of other dying when they have a progressive illness variables. persons with a diagnosis of cancer were the A number of recent studies of death and focus of seven studies (Thiemann. Inc. Death and Dying 129 in medicine and technology made it possible research are described in the following sec- to prolong cardiac and respiratory functions tions. control symptoms such as pain were lacking. Studies of hospice care are palliative care and hospice. Nursing’s contribu. Dying is one of of nursing research on death and dying from the many the transitions we experience in life. in a comprehensive review dent’s Commission. 1989) Corless (1994) reviewed hospice studies from defined palliative care as “the active total care 1983 to 1992 and noted that researchers ex- of patients whose disease is not responsive to amined the impact of hospice as an innova- curative treatment when the control of pain tion. World Health Organization (WHO. She concluded that al- viduals. 1997. have the opportunity to caregiving techniques. cop- and other symptoms and of psychological.. The approaches used in these studies were plinary approach is used to address physical. and satisfaction with hospice home care. Field & Cassel. hospitals and focused on nurses’ attitudes to- tions. to the growing dissatisfaction with medical Other terms associated with end-of-life care of the terminally ill. The began to appear in the literature in the 1980s. 1995. and information on change the experience of dying and promote community resources. primarily case studies. and by care settings such as hos. were descriptive in approach and lacked a it occurs at different rates and ways in indi. The focus of care Research on hospice family caregivers has is enhancing the quality of remaining life and focused on persons with a diagnosis of can- providing support to the family in the dying cer. family perceptions of hospice care. such as age and culture. Caring for a dying family member is an tions to end-of-life care and areas for further emotionally intense experience. The American Geriatrics Society though the stressful nature of death and dying (AGS) offered clinicians some guidance for was well documented. quality end-of-life care. Q-sort techniques. functions. and spiritual needs of the dy. as the largest group of tion on the patient’s illness. basis of a diagnosis of a terminal illness or Florence Wald. 2004). noted most nursing studies It is difficult to determine when dying begins. Connecticut. ing person and their family. versity Nursing. Nurses. by “artificial” means. Hospice refers to a concept of care Studies of the effectiveness of interventions to that can be provided in a variety of settings. The hospice movement began in the stantially alter the outcome” (AGS. and a group of volunteers prognostic assessments of patients or family were instrumental in starting the first hospice. in New Haven. Teno et frequent educational needs were for informa- al. 1969 to 1984. Hospice experienced rapid growth due in part pice. Dean of Nursing at Yale Uni- one without a cure. instructions on health care providers. were used with similar findings. Hospice fam- . 1997). United States in 1974 with the opening of Dying has been defined by researchers on the Hospice. Early studies of death and dying by nurses cepted definition of death is the irreversible in the 1960s and early 1970s took place in cessation of circulatory and respiratory func. physician prognosis. members. 2000). Today the widely ac. The most PORT.

munity-based sample. Dying trajectories differ at the end of life nosis. ety of settings with diverse population groups nomic. of consciousness and cognition (American ment. four types of illness trajectories: sudden As people are living longer with chronic ill. with various patterns of functional decline. fluctuating disturbance Preferences for Outcomes and Risk of Treat. however there are few studies of functional ited and has occurred in acute care hospitals decline in large populations. end-of-life decision making. and physicians. Several large-scale national studies in the the Project Death in America. It fre- a large-scale controlled clinical research study quently accompanies acute physical illness of more than 9. 80% for all hospitalized patients. death. The second phase was Previously. of aggressive treatment. The Study to Understand Prognoses and Delirium is an acute. Studies of fam. Lunney. Estimates of hospitals. end-of-life care and support research. The majority of studies are found that functional decline differs among with persons who have a diagnosis of cancer. there is a need for studies to examine the and frailty. in a com- tors concluded that physician-patient com.190 participants in the Established Popu- life at the end of life (Mezey. 2000. and indicate that delirium is associated with cog- . The setting of care for older Foley. and current knowledge is inadequate to support evidence-based medicine at the end of life Delirium (Field & Cassel. time for rest and part of the intervention and worked with pa- sleep. tion remained flawed. & Gates. the education the quality of end-of-life care. 2000). delirium was found to munication was often unreliable and physi. information on how to tients. be superimposed on dementia in 13% of cians showed little interest in the patient’s the cases. & lations for Epidemiological Studies (EPES) Brody. families. legal. and how to maintain nately the intervention failed. Lackey. spiritual needs. death from organ failure. delirium was thought to be an intervention designed to improve commu. and patients suffered ily needs and coping are descriptive with undue pain at the end of life. SUPPORT investiga. Lipson. Each of the four groups had dif- experience of dying from chronic illnesses. and organizational obstacles obstruct in order to influence practice and improve excellent care at the end of life. and the Depart- 1990s described problems and deficiencies in ment of Health and Human Services have end-of-life care. Mitty. Harring. known by the acronym SUPPORT. of physicians and other health providers fails to provide them with the knowledge and SARAH A. self-limiting and benign.000 patients in five teaching and is found in all care settings. 2002). The Robert Wood Johnson Foundation. example heart failure and dementia. More recently. Nurses were an important cancer need time for self. Communica- independence (Thielemann. term care settings. small samples and lack diversity of age. cancer death. Dubler. and 14% to 39% for residents in long- and patient outcomes. Lynn. and Guaralnik’s study (2003) adults has a direct impact on the quality of of 4. WILSON skills required to care for dying patients. 1996). and ethnic groups. eco. Recent discoveries nication. was Psychiatric Association [APA]. Nurse lowing major deficiencies in care: too many researchers need to conduct research in a vari- people suffer at the end of life. diag. The study was designed to examine the incidence of delirium range from 7% to end-of-life decision making and test an inter. 1997). or hospices. preferences for care. there was an overuse ton. for ferent trajectories of dependency and needs. Research on the experience of dying is lim. The first older patients receiving home health care ser- phase of the study examined decision making vices. Unfortu- deal with the patient. 46% for vention to improve end-of-life care.130 ENCYCLOPEDIA OF NURSING RESEARCH ily caregivers for persons with a diagnosis of pain management. The Institute of Medicine made funding available to educate nurses in studied end-of-life care and identified the fol. ness.

delirium remains un. and interven- State Examination (MMSE). or inappropriate behavior or speech. The prevailing ing the recognition of delirium. cognitive status and diagnosing delirium. principles guiding prevention and treatment knowledge and skill alone are insufficient. A few strategies to prevent and/or treat Improving the recognition of delirium re. Mion. bedside screening measures as timely. rence of delirium. mum daily. Ver. which also accomplished through risk reduction. 2000). ium Assessment Scale (MDAS). health care and clinical practice is Inouye’s CAM. greater costs of care. To better understand why these interven- CHAM). standardized and misdiagnosed (although there is disagree. interventions have had no effect tom Interview (DSI). and depression. 2004. Others recommend brief screen- hypoalert variant of delirium. of which instrument to use depends in part and greater chances for dementia and death. families. modest benefits (Cole. dementia. However. tions with surgical versus medical patients sion Assessment Method (CAM). or duration of delirium. incidence. instruments are reviewed in greater detail derstudied. (a) identify patients at risk. consist of multifactorial interventions that: given the profound impediment to the recog. Form A (CAC-A). However. O’Keefe’s Delirium Assessment tions have not been more successful. effec- ment as to whether more patients are misclas. These providers. Expert opinion recom- Delirium is frequently underrecognized mends the routine use of brief. on admission to the hospital and at a mini- lying dementia or those with the hypoactive. Current standards for surveillance of delir- 2001). most have resulted in only tion are necessary starting points for improv. Trzepacz’s Delirium on the recurrence of delirium or on outcomes Rating Scale (DRS). Rapp et al. identify. Albert’s Delirium Symp. Foreman. some . of delirium is summarized here. Inouye’s Confu. Explanations ing every 8 hours as an element of the stan- for the underrecognition and misdiagnosis of dard nursing assessment. delirium in hospitalized patients have been quires a complex and dynamic solution. pagne’s NEECHAM Confusion Scale (NEE. it is recommended that the assessment be re- and the failure of providers to use standard. and (c) highlights the powerful influence of the prac. adult patients. peated. tested with various groups of hospitalized Knowledge of delirium and skill in its detec. the variable presentation of delirium. ized methods of detection. (b) target strate- nition of delirium posed by negative ageist gies to minimize or eliminate the occurrence stereotypes. or no- the similarity among and frequent cooccur. ticeable changes in the way the patient thinks. tive. Moreover. delirium por. and inexpensive methods for assessing sified as false positive or false negative) (In. and Breitbart’s Memorial Delir- for 12 months or more after the index inci. Each has its dent of delirium. The Despite these profound negative conse. advantages and disadvantages. Neelon and Cham. Such in. supportive care. 6 months after discharge from the hospital. & Cooney. Recognition of delirium is especially ium are to screen for the presence of delirium problematic in elderly patients with an under. on the purpose and patient population. Katz. Several instruments have been developed Multicomponent interventions targeting to screen for or diagnose delirium. rather than targeting a struments include: Folstein’s Mini-Mental single risk factor for delirium. The current state of knowledge elsewhere (Foreman & Vermeersch. when delirium include the fluctuating nature of de. severity. several risk factors. These conclusions are supported of precipitating factors as primary prevention by the work of McCarthy (2003). 1999). most frequently used instrument in research quences for patients. Additionally. the selection tends poorer outcomes.. unusual lirium. ouye. and society. have proved more successful in reducing the meersch’s Clinical Assessment of Confusion. there is evidence of new inattention. Delirium 131 nitive and functional impairments persisting Scale (DAS). correct or eliminate the underlying tice environment on how providers think cause(s) while providing symptomatic and about and respond to delirium.

On return risk for or experiencing delirium. Ad- . members communicate indirectly with each sity of Iowa Gerontological Nursing Inter. used to develop a more structured question- sive and are generally based on expert clinical naire. these studies have not face participation. to im. 1999). more rigorous development and testing of the tions were less successful with patients who efficacy and effectiveness of interventions to are at greatest risk for delirium: those who are prevent and treat delirium. to provide a ratio- failed to improve the process and outcomes of nale for their judgments. to add items that care in delirium. and primary pre. Also. demented. to each of the questionnaires. the need for further mean degree of agreement and the ranking of study of delirium in all care settings is clearly each item are computed. and frailer. goal-directed manner. ventions Research Center (Rapp and the Iowa The first questionnaire that is mailed asks Veterans Affairs Nursing Research Consor. Thus. ses to identify characteristics of patients for Greater insight into the underlying pathoge- whom these interventions have failed. uals. few aspects of these guidelines are on the previous one. persistence.e. and recurrence of delirium tionale if they disagree with the ranking. the APA (1999). Each successive questionnaire is built opinion. indicating that much work are missing. H. and the of knowledge of delirium. and Univer.132 ENCYCLOPEDIA OF NURSING RESEARCH investigators have conducted post-hoc analy. naire requests participants to review the items Young and George (2003)—the individuals identified in the first questionnaire and to responsible for compiling the British guide. FOREMAN improve these interventions because these PATRICIA E. These netic mechanism(s) of delirium would enable analyses have indicated that these interven. to set priorities. se. It provides the opportu- been designed or powered in such a way as nity for broad participation and prevents any to determine which of the multicomponents one member of the group from unduly influ- actually contributed to the positive outcomes. it is difficult to determine how to MARQUIS D. including the epidemiol. The Delphi technique is a research method vention has been confused with secondary used to identify key issues. and to better target and time interventions. prevention. is given to panel members on the responses and treatment of delirium. the meta. and again to indicate their degree of prove our understanding of the duration. changing provider behavior has been con. agreement or disagreement and give their ra- verity. prevention. Moreover. The responses to this questionnaire are then lines. VERMEERSCH studies have been conceptually confused: effi- cacy has been confused with effectiveness. other in a limited. Moreover. panel British Geriatrics Society (1999).. of the second questionnaire the responses are On the basis of this summary of the state reviewed. participants to respond to a broad question. The technique consists of using a series bolic and physiologic deviations that disrupt of mailed questionnaires to develop consen- neurotransmitter synthesis and functioning) sus among the participants without face-to- (Trzepacz. mean ranking from the second questionnaire ogy and natural history of delirium. functionally impaired. Delphi Technique fused with preventing or treating underlying causal agents for delirium. Feedback To improve the recognition. In the third ques- documented. gregating the judgments of a group of individ- ing pathogenetic mechanisms (i. However. Such study should focus on all tionnaire. items are clarified or added. tium. The second question- based on empirical evidence. These guidelines tend to be comprehen. 1998) have developed practice guide. interventions have and to improve decision making through ag- targeted risk factors rather than the underly. indicate their degree of agreement or dis- lines—found that the existence of guidelines agreement with the items. participants are asked to review the aspects of delirium. and to rank-order the items ac- remains to improve the care of individuals at cording to their perceived priority. encing other members’ responses.

first few weeks of recovery. It has since been applied in diverse tients. The Through this defense mechanism. sciousness the reality of the situation at hand. DEMI to seven. and the experiences to share. such as industry. 1994). occurred can be adaptive behavior during the search priorities for the 1980s. and of coping because once the pain has been nursing because of its usefulness and accuracy alleviated and the person is resting comfort- in predicting and in prioritizing. The to achieve consensus on the parameters of problem then becomes one of understanding . (c) place a high priority on complet. First. the individ- technique was later used to solicit opinions ual attempts to minimize or ignore the signifi- of experts on atomic warfare as a means of cance of the symptoms. changes use various resources such as denial Several disadvantages of the Delphi tech. this denial can be maladaptive if it andowski and Kositsky (1983) and Lindquist interferes with one’s ability to deal with the and colleagues (1993) used it to identify re. However. Denial in Coronary Heart Disease 133 ditional questionnaires are sent until the normal grief by enlisting a panel of experts group reaches consensus. associated with it. The American Nurses Asso. Lindemann (1981) surveyed members of the 1971.. Rob- cipants must have a high level of ability in inson. Denial can be either healthy or unhealthy. there must be by the various types of threatened or real adequate time for mailing the questionnaires. For coronary pa- defense. the number of questionnaires used ranging from three ALICE S. this procedure have been used. enabling the per- dith. ciation Center for Nursing Research (1980) Denial of the fact that a coronary event has used the technique to identify national re. Those who experience these de Ven. Robinson. (b) have relevant information Coronary heart disease. As a re- The Delphi technique has been used in sult. To be eligible to participate as a panelist in a Delphi study the respondent should (a) Denial in Coronary Heart Disease be personally concerned about the problem being studied. fail to take prescribed medications. social services. deny that anything significant has happened. lifestyle changes needed to recover from the search priorities for critical care nursing. and acute phase of the illness (Cassem & Hackett. in an attempt to cope with the anxiety caused nique limit its application. son to cope with the shock and confusion. And third. Second. Hackett. ably. pro- American Academy of Nursing to identify longed denial or disbelief might cause the in- and prioritize issues important to nursing in dividual to ignore necessary activity restric- the next decade. 1993. orities for urological nursing research. The Delphi technique was first developed It is one of the first adaptive behaviors or by the Rand Corporation as a forecasting tool mechanisms that an individual uses during in the 1960s. tice and research. That is. Demi. 1993. 1998. it is easy for the patient to rationalize or nursing studies to identify priorities for prac. precipitate many sudden ing the Delphi questionnaire on schedule. 1971. 1988. and changes that severely disrupt the balance of (d) believe that the information compiled will psychosocial and environmental factors in an be of value to self and others (Delbecq. it is not difficult to use denial as a form fields. Van individual’s life. Many variations of in the field of grief and mourning. and Gray (1996) used it to identify pri. there are no other symptoms. and their analysis. Ketterer et al. 1975). when investigators found that the stress-producing event of an acute episode results of a Delphi survey produced better of chest pain (Hackett & Cassem. 2003). 1982). 1994. parti. Denial is the ability of an individual to pants must be highly motivated to complete mentally ignore or push from one’s con- all the questionnaires. & Gustafsen. Mere. predictions than round-table discussions. Lew. or the method Demi and Miles (1987) attempted realize the significance of the illness. In a creative application of tions. losses associated with the disease (Cassem & their return. partici. written communication.

it disease. Denial can be adaptive. However. and aid in its further is beneficial for the health care professional study (Robinson. 1994). however. final determination. by the 4th day as the patient’s con- on one’s ability to work through the losses dition stabilizes. analysis indicated that the 20-item RSAI- onary problems. Earlier studies led In summary. little attention has been given to measur. denial makes it possible for to revisions and reconceptualizations (Rob. whether real. the front the patient’s denial. Even though the Hackett-Cassem Denial to deal with reality in smaller. of trying to push the patient out of denial tients’ personality traits and behaviors were before they are ready. Each type of denial has tify denial in persons with coronary heart its own purpose for the person. 1988. and should not directly confront the teristics of the participant. Rather than measuring traits. Four aspects of denial The use of denial by coronary clients is were extracted to include denial of secondary described extensively in the literature. if the denial is mal- and-pencil self-report (Hackett & Cassem. denial decreases. approximately 10 years. These findings were consis- through the grief process. Hackett (1971). Form D probably is a multidimensional mea- sent a single. ment. 2003). Since denial does not repre. quantify it. but rather focus RSAI directly focuses on the patients’ present on establishing a trust relationship with the . ing it. provide the scale required the interviewer to make infer. patient with opportunities to express any ences when rating denial behavioral charac. thus. denial of anxiety. day of potential or actual myocardial in- gel. grief process might have a long-range effect however. ever. may use another type. the nurse should not directly con- 1974). adaptive. found a significant decrease in mean denial produces a grief response (with denial. consequences. fears. Some individuals Self-Appraisal Inventory (RSAI). or perceived. use counseling strategies. merous real and threatened losses. cardiac patients to block out information inson. clues that coronary clients providing supportive evidence to the health are using denial may not be recognized care professional that using single specific or through personal interviews or traditional as. whereas others assessment instrument. self-administered instru- Given that coronary events result in nu. this pro. and all Using the RSAI-Form D. more manage- Scale was available for measuring denial. since move. mine the type of denial that is being utilized The RSAI has been under development for (Robinson. The nurse can determine general use of denial as a defensive trait. it becomes necessary to work farction patients. Therefore. Therefore.134 ENCYCLOPEDIA OF NURSING RESEARCH when denial is helpful to the coronary patient reactions to illness and it is designed as a and when it is harmful. patient’s denial. the able pieces. which have resulted in Form with which they cannot cope. global criteria does not provide sufficient sessment methods. 1988). listen closely to the that the nature of several questions in the patient. paper-and-pencil. It could to observe and listen closely to patients to also assist health care professionals to plan understand their perspective as well as deter- interventions to manage denial. 1994. threatened. shock. tent with those reported by Cassem and cess should not be prolonged. Factor and changes in lifestyle caused by having cor. a larger sample is needed with it is often difficult to determine if denial is the addition of items to the scale to make the adaptive or maladaptive. one can assist them in not related to coronary heart disease and the adjusting to the loss. How. denial of illness and treatment. was designed to iden. a self-report may use one type of denial. scores from the 2nd to the 4th hospitalized and disbelief being the initial response) (En. it was not a paper. sure. easily understood phenomenon. so instead number of items on the scale regarding pa. An the patient’s degree of denial and its effective- additional weakness of this measurement was ness as a coping strategy. It allows them D. the Robinson data for assessing denial. 1962). who stated that feelings of ment from denial to the next phase of the denial are generally mobilized on the 2nd day. In addition. and denial of impact. However. Robinson (1994) loss.

Depression and Cardiovascular Diseases 135

patient, use reality-focusing techniques, uti- tion, RR = 1.30 for angina pectoris, and RR
lize teaching strategies, and provide a psycho- = 1.15 for myocardial infarction). Further,
logical professional to meet and discuss the Cox proportional hazards regression model
diagnosis with the patient (Robinson, 1993). demonstrated that depressive symptoms were
an independent predictor of mortality. In an-
KAREN R. ROBINSON other study of the relationships among de-
pression, coronary heart disease (CHD) inci-
dence, and mortality, Ferketich, Schwartz-
Depression and Cardiovascular baum, Frid, and Moeschberger (2000) found
Diseases that depressed men and women were at in-
creased risk for incident CHD events, com-
Over the past 10 years, there has been grow- pared with nondepressed counterparts (RR
ing interest in the relationship between de- = 1.73 (1.11–2.68), RR = 1.71 (1.14–2.56),
pression and cardiovascular diseases. These correspondingly). Moreover, unlike de-
are two of the most widespread public health pressed women, depressed men had an in-
problems in the United States, and are among creased risk of cardiac mortality with ad-
the leading sources of functional impairment justed RR = 2.34 (1.54–3.56).
and disability. Recent research findings link- Prospective population-based studies of
ing depression and cardiac disease will there- depression also found an increased risk for
fore be discussed, along with implications for CHD due to depression. Mendes de Leon and
future research. others (1998) conducted a cohort study and
In response to the growing awareness of found a slight increase in risk for CHD events,
the magnitude of the interaction between de- RR = 1.03 (1.01–1.05), in fairly healthy older
pression and adverse cardiac outcomes, sev- women. However, de Leon failed to find sup-
eral large-scale community-based studies port for depression as an independent risk
have been conducted. Penninx and others
factor for CHD events in elderly men and
(2001) followed a cohort of 2,847 men and
women in the aggregate. Another prospective
women aged 55 to 85 years for 4 years. These
study used data from the Yale Health and
investigators examined the effect of minor
Aging Project (Williams, S. A., et al., 2002).
depression (i.e., Center for Epidemiologic
The sample consisted of 2,501 men and
Studies—Depression scale [CES-D] score of
women, with a mean age of 74 years who
≥ 16) and major depression (i.e., using DSM-
were disease-free elders and were followed
III criteria) on heart disease mortality. They
found that patients with major depression for up to 14 years. In comparison with nonde-
had significantly higher risk for cardiac mor- pressed individuals, depressed individuals
tality compared with those who had minor demonstrated 69% increase in the risk for
depression. These findings suggest that the incident heart failure. In addition, depressed
severity of depression is related to higher car- participants were more likely to be women;
diac mortality. In another study, Schulz and consequently, depression was a significant
others (2000) studied a total of 5,201 men risk factor of heart failure among women but
and women aged 65 years and older enrolled not among men.
in the Cardiovascular Health Study. Control- Using a randomized clinical trial, Berkman
ling for sociodemographic variables and com- and others (2003) assessed the preventive ef-
mon comorbid conditions, individuals with fect of cognitive behavioral therapy (CBT)
higher scores of depressive symptoms were on depression in 2,481 myocardial infarction
more likely to die than those who had lower (MI) men and women. Although CBT re-
scores. Depressed participants with heart fail- duced depression and decreased social isola-
ure at baseline had the highest mortality risk tion, it failed to reduce mortality or recurrent
(adjusted RR = 2.44, RR = 1.62 for stroke infarction events after a 6-month interven-
patients, RR = 1.60 for intermittent claudica- tion period.


In short, research findings from commu- ines, such as IL-6 and TNF-α, depression,
nity-based studies suggest that depression is and incidents of negative cardiac outcomes.
a risk factor for cardiac morbidity and mor- Briefly, any single mechanism will fall short
tality. However, interventions that may re- of capturing the underlying pathogenesic pro-
duce depression have failed to reduce depres- cesses of depression and cardiac disease.
sion-related cardiac outcomes (e.g., see Berk- Therefore, several mechanisms are needed to
man et al., 2003). It is essential to note that account for the development and progression
many of these studies have controlled for de- of the two.
mographic variables and medical comorbid- This overview from a biopsychosocial per-
ity that might otherwise explain the find- spective reveals that there is sufficient evi-
ings reported. dence to support an important association
Recognition of the overlap between de- between depression and cardiac disease. It
pression and cardiovascular disease has led also suggests a number of significant direc-
to increased interest in finding plausible bio- tions for future research. Large, randomized
behavioral mechanisms which link them to- clinical trials are needed to determine
gether. In fact, there is evidence to indicate whether early detection of depression cou-
that depression may contribute to increased pled with early intervention can prevent the
incidence of cardiovascular events. This effect development of cardiac disease or reduce the
may be mediated by other behavioral and risk for incidents of negative cardiac events.
biological factors that play major roles in the Another research priority is to elucidate the
development of negative cardiac outcomes. potential mediating factors related to depres-
There are several known behavioral risk fac- sion, such as failure to comply with medical
tors (e.g., sedentary lifestyle, smoking, high- care, sedentary lifestyle, eating habits, and
fat dietary intake) among depressed individu- smoking. Also, biological studies are needed
als that may contribute to the development of to quantify the latent effect of the alterations
cardiac disease. In addition, recent research in the level of risk biomarkers (e.g., homocys-
findings suggest that several biomarkers are teine, IL-6, TNF-α, IL-2, serotonin, dopa-
implicated in both depression and cardiac dis- mine, cortisol, heart rate variability, and
ease pathogenesis. First, research showed that platelet activation), which could have a nega-
the hypothalamic-pituitary-adrenocortical tive effect on cardiac function. Moreover, de-
(HPA) axis is activated during depression, pression seems to be more of a problem for
which increases sympathoadrenal activity. women with cardiac disease than for men.
Consequently, some risk markers such as cat- Therefore, future studies are needed that fo-
echolamines, cortisol, and serotonin are ele- cus on whether there is a disproportionate
vated in both depression and some cardiac weight of comorbid depression and cardiac
diseases. Second, depressed patients are at outcomes among women.
increased risk for rhythm disorders. Recent Designing large-scale clinical trials that
evidence indicates that cardiac patients who test biobehavioral research models, along
are depressed exhibit reduced heart rate vari- with considering both physiologic and behav-
ability, a known risk factor for sudden death ioral outcomes, are essential to better un-
in patients with CVD (Carney et al., 1995). derstating of the depression-cardiac disease
Third, depressed patients are more likely have communication. In addition, studies designed
platelet dysfunction that may have a negative to develop a more clear account of psychoso-
impact on the development and prognosis of cial risk factors to cardiac disease are urgently
cardiovascular disease such as atherosclero- needed. Finally, in an era of genetic research,
sis, acute coronary syndromes, and thrombo- identifying genes or gene expression mecha-
sis. Finally, the research demonstrated a close nisms that may link depression and cardiac
relationship among proinflammatory cytok- disease may pave the path for ultimate under-

Depression in Families 137

standing of the link between depression and toms are present for a minimum of 2 weeks
cardiovascular diseases. most of the day, nearly every day: (a) de-
pressed mood, (b) loss of interest or pleasure
ALI SALMAN in all activities, (c) decrease or increase in
appetite or significant weight change, (d) in-
somnia or hypersomnia, (e) psychomotor re-
Depression in Families tardation or agitation, (f) fatigue or loss of
energy, (g) feelings of worthlessness or exces-
Depression is a major mental health problem sive guilt, (h) difficulty concentrating or inde-
affecting 25 million Americans and their fam- cisiveness, and (i) recurrent thoughts of
ilies. By 2020, depression will be the third death, recurrent suicide ideation or attempt
leading cause of disability worldwide. Most (American Psychiatric Association (APA),
people suffering from depression live with 1994). One of the five symptoms must be
their families, usually their spouses and chil- depressed mood or loss of interest or plea-
dren, and the negative impact of depression sure. Together, these symptoms cause signifi-
on families has been well-documented cant functional impairment. In addition to
(Coyne et al., 1987; Keitner, Archambault, MDD, depression is further classified in the
Ryan, & Miller, 2003; Lee, 2003; Miller et Diagnostic and Statistical Manual of Mental
al., 1992). Nursing has long viewed families Disorders (DSM-IV) (APA, 1994) into other
as a context for caring for the individual with diagnostic subtypes such as minor depression
depression, but only recently has focused on or dysthymia by signs and symptoms, onset,
the whole family. course, duration, and outcomes.
Depression is a rather vague descriptive Family refers to any group that functions
term with a broad and varied meaning rang- together to perform tasks related to survival,
ing from normal sadness and disappointment growth, safety, socialization, or health of the
to a severe incapacitating psychiatric illness. family. Family members can be related by
William Styron (1990) describes in Darkness marriage, birth, adoption, or can self-identify
Visible the unsatisfactory descriptive nature themselves as family. This definition is suffi-
of the term depression: “a noun with bland ciently broad to be inclusive of all types of
tonality and lacking any magisterial presence, families; however it is recommended that re-
used indifferently to describe the economic searchers provide specific definitions of fam-
decline or rut in the ground, a true wimp of ily appropriate to their research.
a word for such a major illness” (p. 37). Genetic-biological research of depression
Depression is a universal mood state with in families includes genetic and biological
all people experiencing a lowered mood or marker studies (Flaskerud, 2000; Viguera &
transient feelings of sadness related to nega- Rothschild, 1996). The four research ap-
tive life events such as loss. For most, the proaches to the genetics of mood are: (a) fa-
feelings of sadness or disappointment resolve milial loading studies (e.g., comparing fami-
with time and normal functioning resumes. lies with depression to families without the
In contrast, the symptoms associated with the disease), (b) studies evaluating the inheritabil-
psychiatric illness of depression can disrupt ity of mood disorders (e.g., twin studies), (c)
normal functioning, influence mortality and studies of incidence of the risk for, but not
morbidity, and can cause a myriad of prob- yet ill from, mood disorders to determine bio-
lems within the family (Badger, 1996a; logical or psychological antecedents, and (d)
Bluementhal et al., 2003; Cuijpers & Smit, in theory, studies using genetic probes to de-
2002; Katon, 2003). The psychiatric illness termine which relatives and which pheno-
of major depressive disorder (MDD) is diag- types are associated with the genetic contri-
nosed if five out of the following nine symp- butants to mood disorders (Suppes & Rush,


1996). The results of the familial loading adults being sufficiently distressed themselves
studies are clear whether the approach used to require therapeutic intervention (Coyne et
is the “top-down” (i.e., studies of children al., 1987). The majority of recent studies of
with depressed parents) or the “bottom-up” families with members with depression have
approach (i.e., studies of relatives of de- used primarily inpatient samples, have fo-
pressed children) (Birmaher, Ryan, & Wil- cused on women as the identified patient,
liamson, 1996; Jacobs & Johnson, 2001). have often excluded parents with depression,
Children with depressed parents have a sig- and have been quantitative in nature
nificantly greater risk of developing de- (Schwab, Stephenson, & Ice, 1993). Few
pressive disorders and other psychiatric dis- studies have used qualitative approaches to
orders than do children with parents without understand family members’ perspectives and
depression (Buckwalter, Kerfooot, & Stolley, treatment needs. Badger (1996a) used a
1988; Peterson et al., 2003; Nomura, Wick- grounded theory method to describe the so-
ramaratne, Warner, Mufson, & Meissman, cial psychological process of families living
2002). Biological marker studies have fo- with members with depression. The process,
cused on growth hormone, serotonergic and family transformations, refers to the cogni-
other neurotransmitter receptors, sleep, and tive and behavioral changes that occur within
hypothalamic-pituitary axis (Keltner, 2000; the family from the time the member initially
Viguera & Rothschild, 1996). Despite evi- exhibits symptoms through recovery and at
dence from genetic studies about the strong remission. As family members moved
support for the genetic inheritance of depres- through the three stages (acknowledging the
sion, and the fact that abnormalities in bio- strangers within, fighting the battle, gaining
logical markers persist throughout the life a new perspective), all members are trans-
span, the relationship between genetic-bio- formed and family functioning forever al-
logical predisposition and environment re- tered. These results support findings from
mains unclear. previous studies and provide perspectives of
Psychosocial research of depression in family members not normally included in de-
families has focused on communication, mar- pression research.
ital problems and dissatisfaction, expressed Despite identifying the multiple problems
emotion, problem-solving, coping, and fam- in these families, the role of the family in the
ily functioning (Beach, Sandeen, & O’Leary, treatment process has received less attention.
1990; Biglan et al., 1985; Keitner, Miller, Systematic family interventions have only be-
Epstein, Bishop, & Fruzzetti, 1987). The evi- gun to be developed and modeled after pro-
dence strongly supports that families who grams used with people with other psychiat-
contain members with depression have ric disorders and their families (Holder &
greater impairment in all areas than matched Anderson, 1990; Kietner et al., 2003). For
control families, and than families whose example, Lee (2003) found that in mothers
members are diagnosed with alcohol depen- who participated in a program to improve
dence, adjustment disorders, schizophrenia, maternal coping skills, these coping skills
or bipolar disorders (Coyne et al., 1987; moderated between depression and negative
Keitner, Miller, & Ryan, 1993). It is not sur- life events, reducing the negative effects on
prising that depression has its most negative children. To date, few clinical trials have vali-
impact on families during acute depressive dated the effectiveness of these interventions.
episodes (Miller et al., 1992), yet families Families have identified the need for informa-
with depressed members consistently experi- tion about how to facilitate communication,
ence more difficulties than matched control decrease negative interactions, handle stigma,
families even 1 year after initial treatment gain a new perspective, care for self and rede-
(Billings & Moos, 1985). Family members sign their relationships (Badger, 1996b). In
living with members with depression report theory, education, support and partnering
greater health problems, with about 40% of could move family members more quickly

Depression in Older Adults 139

through the stages to prevent depression from symptoms (Futterman, Thompson, Gal-
becoming a recurrent and chronic illness for lagher-Thompson, & Ferris, 1995). Clinical
the entire family. Future research should de- depression is usually qualified by an adjective
velop and test psychoeducational and sup- to specify a particular type or form, including
port interventions with families. Although a reactive, agitated, and psychotic. In addition,
common concern with research with families based on etiology, depression is classified as
remains the unit of analysis (individual, dyad, endogenous (due to internal processes) or ex-
or family as a whole), research representing ogenous (due to external factors). Depression
all perspectives is needed for nursing to more is termed primary when it is not preceded
fully understand and treat depression in fami- by any physical or psychiatric condition and
lies. secondary when preceded by another physi-
cal or psychiatric disorder. Finally, depres-
TERRY A. BADGER sion is classified as acute (less than 2 years
duration) or chronic (more than 2 years).
Clinical depression consists of characteristic
Depression in Older Adults signs and symptoms, as well as type of onset,
course, duration, and outcome. The Diagnos-
Depression is the most common mental disor- tic and Statistical Manual of Mental Disor-
der among older adults in the United States ders (DSM IV) (American Psychiatric Associ-
and one of the most disabling conditions ation, 1994) classifies clinical depression into
among elderly persons worldwide (Sable, major, minor, and dysthymic subtypes. Ma-
Dunn, & Zisook, 2002). More than 6 million jor depression refers to a depression that
Americans age 65 and older representing ap- meets specific diagnostic criteria for duration,
proximately 15% of U.S. older adults suffer impairment of functioning, and the presence
from depression (Sable et al., 2002). The of a cluster of physiological and psychologi-
prevalence of clinical depression ranges from cal symptoms (American Psychiatric Associa-
about 5% in community samples to 20% in tion). Minor depression includes fewer de-
nursing home residents and nearly 30% of pressive symptoms than major depression.
older adults seen in primary care settings Dysthymia consists of fewer symptoms than
(Alexopoulos, 2001). About 50% of older are expressed in major depression but more
adults who are hospitalized for medical ill- than in minor depression, and it is more
nesses or receiving long-term care experience chronic (American Psychiatric Association).
clinically significant depression (Alexo- Diagnosing depression in older adults is
poulos). Older adults are vulnerable to de- fraught with challenges. Depressed mood is
pression for a number of reasons. Approxi- one of the depressive symptoms that older
mately 80% have at least one chronic medical adults may experience, but others may also
condition that can trigger depression (Sable et experience a range of affective responses (Fut-
al.). In addition, about 6 million older adults terman et al., 1995). Indeed, many studies
need assistance with their daily activities (Sa- have reported that in older adults, a predomi-
ble et al.), and inability to meet one’s own nant depressed mood may not be as promi-
personal needs has been associated with in- nent as symptoms of irritability, anxiety, or
creased vulnerability to late-life depression. physical or somatic symptoms and changes
While depression is often viewed as a clini- in functioning (Alexopoulos, 2001; Futter-
cal syndrome with specific diagnostic criteria, man et al.; Sable et al., 2002). In addition,
depression has also been conceptualized as a symptoms of cognitive impairment that may
mood state or as a collection of symptoms occur in elders with depression may be mis-
(Beck, 1997). Because older adults may not taken for dementia (Sable et al.). It is esti-
meet the diagnostic criteria for the clinical mated that about 15% of older adults have
syndrome, studies of older adults commonly depressive symptoms that do not meet diag-
use the term depression to mean depressive nostic criteria specified by the Diagnostic and


Statistical Manual of Mental Disorders (DSM (Blazer, 2003). Depression is thought to af-
IV) (American Psychiatric Association, 1994) flict older adults of all racial and ethnic back-
for diagnosis of major depression (Alexo- grounds similarly (Alexopoulos, 2001; Bruce,
poulos). Nevertheless, these older adults can 2002); however, its symptoms may not be
experience functional deficits in activities of consistent across racial/ethnic groups, mak-
daily living (ADL) and instrumental activities ing early diagnosis and treatment chal-
of daily living (IADL) that compromise their lenging.
independence and quality of life. Indeed, the Research on depression among older
symptoms of depression can lead to total in- adults was ignored in the past and is still a
ability of the older individual to care for self neglected area. Clearly, much more nursing
and to relate to others. There is also a poten- research is needed. It is critical that nurses
tial for persons with depression to negatively assume leadership in disseminating informa-
affect family members and others around tion about the outcomes of a variety of treat-
them. ments that can be used for depression in later
Not surprisingly, few elders in the commu- life. There is a particular need to examine
nity seek mental health services. Most de- suicide in late life and to develop better assess-
pressed elders are seen by general prac- ment instruments for detecting suicidal ide-
titioners for psychosomatic complaints. Part ation in elders.
of the symptomatology of depression is a fo-
cus on physical problems, and this requires JACLENE A. ZAUSZNIEWSKI
practitioners to carefully assess for depressive MAY L. WYKLE
symptoms. Suicide is a risk factor for de-
pressed older adults. The suicide rate for indi-
viduals aged 80 and over is twice that of the Depression in Women
general population and is particularly high in
older White males. Interestingly, most sui- Women seeking help in the general health
cidal elders recently visited a general prac- care sector often are depressed. Studies indi-
titioner prior to their suicidal act. cated that between 20% to 45% of women
Studies of risk factors for late-life depres- using primary care have major depressive dis-
sion have examined the effects of gender, age, order (MDD) (Bixo, Sundstro¨m-Poromaa,
and race/ethnicity. Like earlier depression, Bjo¨rn, & A˚stro¨m, 2001; Hauenstein, 2003;
late-life depression more commonly strikes Kirmayer & Robbins, 1996; Miranda, Azo-
women than men, at approximately a 2:1 car, Komaromy & Golding, 1998). In these
ratio (Kockler & Heun, 2002). Recent popu- settings, patients are more likely to report
lation-based studies have estimated the prev- their depressive symptoms as physical prob-
alence of geriatric depression at 4.4% for lems (Barsky, Peekna, & Borus, 2001; Katon,
women and 2.7% for men, while the esti- Sullivan, & Walker, 2001) and physicians
mated lifetime prevalence for clinical depres- less likely to identify and treat the disorder
sion is about 20% in women and 10% in (Freiman & Zuvekas, 2000; Katz et al., 1997;
men (Kockler & Heun; Sable et al., 2002). Sundstro¨m, Bixo, Bjo¨rn, & A˚stro¨m, 2001).
Although female gender is a risk factor for Nurses are positioned to detect and manage
depression throughout the life span, gender this major public health problem because of
differences decrease with increasing age (Sa- their prominence in the general health sector
ble et al.), and white men ages 80 to 84 years and their often greater proximity to patients.
are at greatest risk for suicide (Kockler & MDD remains a significant source of mor-
Heun). bidity and disability in women under 65. The
Cohort studies have shown that the oldest- physical symptoms of lethargy and sleep and
old, those over age 85 years, are more likely appetite disturbance combine with the cogni-
than the younger-old, those between 65 and tive symptoms of disinterest, helplessness,
74, to experience depressive symptoms hopelessness, and worthlessness to exact both

Depression in Women 141

significant mood disturbances and functional ability in women (NIMH Research on Wom-
impairments. Unfortunately, MDD is com- en’s Mental Health—Highlights FY2001–
mon among women. The population preva- 2002).
lence of MDD in women is 6% to 17% (Kes- Maternal depression also has significant
sler et al., 2003). Combined with dysthymia, effects on children. Research has shown cog-
a milder but more chronic and equally disa- nitive and social deficits in children of de-
bling mood disorder, the population preva- pressed mothers that appear early in infancy
lence ranges from 12 to 25%, a rate twice (Essex, Klein, Cho, & Kalin, 2002; Field,
that of men (Kessler, 2003). Women’s key 1998; Kaplan, Bachorowski, & Zarlengo-
risk factors for MDD include a family history Strouse, 1999). These deficits persist into
of the disorder, single parenting, a history childhood and adolescence and have chronic
of child abuse, impoverishment, and poorer effects on personal, school, and social func-
educational achievement (Brown & Moran, tioning (Essex, Klein, Miech, & Smider,
1997; Hanson et al., 2001; Kessler et al., 2001; Gotlib et al., 1998; Murray, Sinclair,
1994; Kessler et al., 2003; Weiss, Long- Cooper, Ducournau, & Turner, 1999; Oyser-
hurst, & Mazure, 1999). Social discrimina- man, Bybee, & Mowbray, 2002).
tion and sexual harassment also contribute A complex interaction of biological, psy-
to the preponderance of MDD in women. chological, and social factors contribute to
Marginalized women have the highest rates MDD in women. Gender disparities in the
of MDD (Brown, Schulberg, Madonia, occurrence of MDD and its coincidence with
Shear, & Houck, 1996; Hauenstein & Ped- women’s hormonal changes point to estrogen
dada, in revision; Miranda et al., 1998). as a physiological mechanism in women’s de-
While MDD is present in elderly women, pression (Shors & Leuner, 2003; Steiner,
the highest incidence of the disorder occurs Dunn, & Born, 2003). Gonadal hormones
in women 25 to 34, a time when women are thought to alter neurotransmitter func-
are developing both their work and family tioning and learning resulting in more af-
careers. Depressed women have higher rates fective symptoms and nonresponsiveness in
of unemployment or partial employment, ab- stressful circumstances. There is mounting
senteeism, poor work productivity, and fail evidence that childhood trauma such as sex-
to progress in their work careers. This trans- ual abuse can alter hypothalamic-pituitary-
lates to an estimated annual cost per em- adrenal axis (HPA) functioning and increase
ployer of almost $10,000 for every depressed vulnerability to future depression (Putnam,
woman working in the firm (Birnbaum, 2003).
Leong, & Greenberg, 2003). Mood disorder Hormonal factors alone do not precipitate
also impairs women’s family careers (Gotlib, MDD in women (Kessler, 2003). The unsta-
Lewinsohn, & Steely, 1998; Wade & Cair- ble HPA system is affected by women’s psy-
ney, 2000). Depressed women are more likely chological and social environment, which
to divorce than are unaffected women, and may serve to precipitate physiological events.
divorced women tend to be economically dis- For example, animal models show that fe-
advantaged. Divorced women often are re- male rats when exposed to uncontrollable
sponsible for young children, and raising stress will fail to respond in subsequent con-
these children alone is difficult. These work trollable stress situations, a response style not
and family patterns associated with MDD shared by males (Shors & Leuner, 2003). In-
contribute to a cycle of hopelessness, worth- terpersonal distress is one example of uncon-
lessness, and poverty that promotes a chronic trollable stress. Research has shown that
and recurrent course of MDD that is refrac- women locked in dysfunctional relationships
tory to treatment. This is a global phenome- for economic or other reasons are more likely
non; the World Health Organization Global to have recurrent depressive episodes (Ham-
Burden of Disease study showed that MDD men, 2003). Pessimistic thinking arising from
was the leading cause of disease related dis- low self-esteem also has been associated with


depressive symptoms in women (Peden, Hall, The multifactorial nature of depression in
Rayens, & Beebe, 2000). Not surprisingly, women, however, may require different or
MDD is more common among women who more complex psychological and social inter-
exhibit dependent personality traits (Widi- ventions than those that meet the minimum
ger & Anderson, 2003). Despite progress in standards for depression treatment. Many of
reducing gender discrimination, many wom- the psychotherapies are considered gender
en’s social environment contributes to MDD neutral but few studies address gender differ-
by stripping them of personal power. Early ences in outcome. One example where gender
victimization contributes to victimization as differences in outcome were examined is that
adults. Low self-esteem increases the likeli- by Pyne and his group who used a simple,
hood of an early and often unstable marriage nurse-managed intervention, which included
that leads to divorce. Divorce is associated tailoring known efficacious treatment to the
with economic hardship and single parenting. preferences of the patients and regular tele-
Victimization, marital instability, single par- phone follow-up. The treatment was cost-
enting, and economic hardship have all been effective in women, but not in men, when
associated with often intractable depression quality of life was evaluated as the outcome.
(Bauer, Rodrı´guez, & Pe´rez-Stable, 2000; Gender-specific treatments might target psy-
Brown & Moran, 1997; Earle, Smith, Har- chological and social factors known to exac-
ris, & Longino, 1998; Gotlib et al., 1998; erbate depression in women. For example,
Kessler, Walters, & Forthofer, 1998; because of the reciprocal effect of marital in-
McCauley, Kern, Kolodner, Derogatis, & stability and MDD, interventions that focus
Bass, 1998; Petterson & Albers, 2002; on reducing interpersonal distress and spou-
Scholle, Rost, & Golding, 1998; Wade & sal conflict may be especially promising for
Cairney, 2000). While the evidence for these women (Hammen, 2003; Wade & Kendler,
associations is convincing, the reciprocal rela- 2000; Worell, 2001). Interventions that stim-
tionship between MDD and the social condi- ulate positive life change also may work pref-
tion of women is far less understood and is erentially in women (Albertine, Oldehinkel,
an area of needed research. Ormel, & Neeleman, 2000). Treatment for
Evidence-based treatments for MDD in- MDD driven by gender-specific theories
clude pharmacotherapy and psychotherapy. based on women’s own voices and experi-
Minimum treatment includes 2 months of an ences, and the diversities and complexities of
antidepressant at a dose known to be effica- women’s experience may promote recovery
cious in treating MDD or at least eight visits instead of simply remission (Eun-Ok & Afaf-
to a specialty mental health provider that last Ibrahim, 2001; Worell, 2001).
a minimum of 30 minutes each (Kessler et Recommendations for needed research on
al., 2003; Young, Klap, Sherbourne, & Wells, MDD in women have been enumerated by
2001). The data show that minimum treat- the American Psychological Association and
ment can effect remission in the short-term the Office of Women’s Health at the National
but the extent to which there are long-term Institutes of Health (Mazure, Keita, &
benefits is yet to be determined. There is sig- Blehar, 2002; U.S. Department of Health and
nificant evidence, however, that few receive Human Services, 1999b). Recommendations
even this minimum level of care (Kessler et for research range from bench research to
al.; Wang, Berglund, & Kessler, 2000). While public education. Research focused on treat-
there are few large trials focusing specifically ment approaches is especially relevant to
on women, three studies using evidence- nursing. First, gender-specific treatments for
based treatments have demonstrated modest MDD need to be developed and tested. Treat-
treatment effects with both urban and rural ments must be based on the unique biological,
women attending primary care (Hauenstein, psychological, and social conditions of
2003; Miranda, Nakamura, & Bernal, 2003; women generally, and tailored to the needs
Pyne et al., 2003). of ethnically diverse women and those in dire

Descriptive Research 143

social circumstances. The design of treatment The progress in descriptive research activ-
programs should target recovery, not simply ity in nursing has been influenced by several
symptom remission. Second, research on events and movements over the past several
treatment outcome requires evaluation of decades: advanced degree education in nurs-
multiple areas of functioning including mari- ing, philosophical debate about the role of
tal stability, parenting, and work productiv- nursing and nursing research in the scientific
ity. From a policy perspective, MDD in community, establishment of centers for
women will not become a priority until the nursing research, and the formation of an
impact of MDD at the family and community agenda for knowledge development in
level is realized and the effects of adequate nursing.
treatment are determined. Third, attention With the help of federal traineeship
must be paid to the provision of treatment money, the earliest doctorally prepared
that is accessible. Health services research in nurses obtained degrees in basic science pro-
this area should consider novel venues and grams. The adoption and rejection of the logi-
providers. For example, treatment services cal positivist view of science helped clarify
for women could be moved to the community linkages between philosophy, theory, and
in places where women commonly gather, method. At one extreme, nurse scientists and
such as churches, schools, and community theorists argued that the future of nursing
centers. Because mental health care is a dwin- knowledge development lay in empirical
dling commodity it is important to consider studies that allowed for repeated observa-
nonspecialty professional and lay providers. tional statements under a variety of condi-
Nurses can be pivotal here, both in providing tions. It was believed that one ultimate truth
direct service and in organizing and supervis- could be found after repeated objective obser-
ing lay providers. Research paradigms that vations, which would eventually lead to dis-
develop and test alternative health delivery covery of universal laws.
methods will go far in closing the gap between Critics of the logical empiricist approach
need and treatment. argued that truth is influenced by history,
context, and a chosen methodology and is
EMILY J. HAUENSTEIN constantly in a state of flux. What is humanly
unobservable one day may be observable
with the help of technological innovation an-
other day. Although logical positivism is no
Descriptive Research longer espoused in nursing theory and sci-
ence, its role was crucial in initiating dialogue
Descriptive research encompasses a broad about what nursing knowledge is and how
range of research activity in nursing and has research in nursing should be advanced.
comprised the majority of nursing studies. These dialogues have helped swing the pen-
Early research efforts were focused on de- dulum from valuing experimental research as
scriptive epidemiological studies. Nightin- the gold standard in nursing to recognizing
gale’s pioneering work is a well-known exam- the important role of descriptive and explor-
ple of this type of research. Well schooled in atory research.
mathematics and statistics, Nightingale cre- Over the years, nursing leaders have strug-
ated elaborate charts demonstrating morbid- gled to establish which approach to knowl-
ity and mortality trends of soldiers during and edge development is appropriate and neces-
after the Crimean War. Her detailed record sary for nursing. Dickoff, James, and Wieden-
keeping and graphic representation of these bach’s (1968) four levels of theory for nursing
data convinced officials of the need to im- included the most basic type, factor-isolating
prove sanitary conditions for soldiers, which theory, as the product of descriptive studies,
drastically reduced mortality rates (Cohen, with higher level theories built on the neces-
L. B.,1984). sary base of this first level of theory. Steven-


son (1990) depicted a stepwise conceptualiza- vational studies, case studies, life histories,
tion of research in nursing, with exploratory grounded theory studies, concept analyses,
research at the bottom and utilization in prac- ethnographic studies, and phenomenological
tice at the top. Descriptive research was studies. Many qualitative methodologies em-
thought to build on exploratory research ploy exploratory as well as descriptive tech-
findings and to provide a foundation of sup- niques.
port for intervention studies, with the ulti- A large portion of descriptive research in-
mate goal of utilizing research findings in volves the use of surveys or measurement
practice. N. R. Reynolds, Timmerman, An- tools, physiological measurements, and inter-
derson, and Stevenson (1992) encouraged views. Other naturalistic or qualitative meth-
nurse researchers to employ meta-analysis odologies (e.g., ethnography, grounded the-
techniques to descriptive research. Meta- ory, phenomenology) have become more
analysis is a useful statistical tool that synthe- available to nurse researchers in the recent
sizes extant nursing research, but it has past and continue to add to the descriptive
largely been applied only to experimental research knowledge base in nursing.
studies. Application of this technique to de- Many nursing organizations and associa-
scriptive studies can help determine when a tions have delineated priorities for a nursing
phenomenon is ready for testing with inter- research agenda that include clarifying philo-
vention studies. sophical underpinnings of holism, research
Descriptive studies often are used when on care and caring, health promotion, disease
little research has been done in an area, to prevention and wellness, development of
clarify and define new concepts or phenom- knowledge about the family and social sup-
ena, to increase understanding of a phenome- port networks, and research on minority
non from another experiential perspective, groups and culturally different views of
or to obtain a fresh perspective on a well- health and illness. Adding to nursing’s
researched topic. Also, the formulation and knowledge base in these areas will require
testing of measurement tools (e.g., to measure using descriptive research along with other
depression, anxiety, or quality of life) employ research methodologies and incorporating
descriptive research techniques. The develop- the results of these studies into nursing prac-
ment and refinement of these tools will con- tice and research endeavors.
tinue, with increasing emphasis on outcomes
research as nurses are required to demon- ANITA J. TARZIAN
strate how their interventions make a differ- MARLENE ZICHI COHEN
ence for their patients.
Public and private funding of nursing re-
search has allowed for an expansion of nurs- Diabetes
ing knowledge based in research. Of the many
studies funded by National Institute of Nurs- According to the Diabetes Research Working
ing Research, Sigma Theta Tau, and private Group’s recent report Conquering Diabetes:
foundations, descriptive research continues A Strategic Plan for the 21st Century, diabe-
to command a large portion of research dol- tes is the 6th leading cause of death in the
lars. Descriptive research can employ quanti- U.S., primarily resulting from cardiovascular
tative or qualitative (including naturalistic) disease. Diabetes is a disease that affects peo-
methodologies. Quantitative descriptive ple of all ages and from every racial back-
methodologies include surveys, measurement ground. African, Hispanic, Native, and Asian
tools, chart or record reviews, physiological Americans, the fastest growing segments of
measurements, meta-analyses, and secondary the U.S. population, are particularly vulnera-
data analyses. Qualitative descriptive meth- ble to diabetes and its most severe complica-
odologies include interviews, focus groups, tions (National Institute of Diabetes and Di-
content analyses, reviews of literature, obser- gestive and Kidney Diseases, 2003). For ex-

Diabetes 145

ample, heart disease, stroke, kidney disease, sensitive approaches include Sharon Brown
blindness, and death due to diabetes are more at the University of Texas at Austin; Felicia
common in African-American versus Cauca- Hodge at the University of California, San
sian adults. Francisco; Gail Melkus at Yale University;
The simplified criteria for diagnosis of dia- and Anne Skelly at the University of North
betes using fasting plasma glucose ≥ 126 mg/ Carolina, Chapel Hill. Although each of the
dl or casual plasma glucose ≥ 200 mg/dl with principal investigators has developed specific
classic symptoms confirmed on a subsequent aims for their individual programs of research
day may be impacting the numbers of persons using quasi-experimental designs, there are
identified as having diabetes (American Dia- some common areas of study. Examples of
betes Association, 2003). The total preva- the diabetes-related outcomes that these in-
lence of diabetes in the United States is esti- vestigations are addressing are diabetes
mated to be 18.2 million: 13 million diag- knowledge, health beliefs and behaviors, met-
nosed and 5.2 million undiagnosed (Centers abolic control of glucose, body mass index,
for Disease Control, 2003). Along with the lipid levels, blood pressure, self-efficacy, and
tendency for obesity, inactivity, and an ever- QoL. Focus groups with diverse populations
aging population, the incidence of diabetes is are commonly used to gain a more compre-
expected to grow. In pediatric populations, hensive understanding of the sociocultural
an emerging epidemic of type 2 diabetes is concerns of the study participants regarding
occurring due to higher rates of overweight diabetes management, to assist with tailoring
and sedentary behavior in youth as young as culturally sensitive and feasible interventions,
10 years of age, seen predominantly in ethnic and to allow for detecting differences in more
minorities (Fagot-Campagna, 2000). successful versus less successful results. Most
Given these sobering statistics, there is of the studies included longitudinal evalua-
strong evidence that the United States will tions of the interventions, which address dia-
face ongoing public health challenges to ad- betes education in nutrition, exercise, home
dress the potential burgeoning onslaught of glucose monitoring, and coping skills
individuals who face declining health status, training.
quality of life (QoL), and lost productivity Limited research with adults who have
related to an earlier onset of diabetes. Tighter type 2 diabetes was available on the physio-
glycemic control is shown to decrease the pro- logical benefits of interventions. Laurie
gression of diabetes complications in persons Quinn at the University of Illinois at Chicago
with type 1 and type 2 diabetes (Diabetes has collaborated with James Rimmer, an ex-
Control and Complications Trial Research ercise physiologist, to identify the feasibility
[DCCT], 1993; United Kingdom Prospective of a health promotion intervention with pre-
Diabetes Group Study [UKPDS], 1998). The dominantly low-income, low-education,
conundrum facing nurse researchers is how American women with multiple chronic con-
best to develop interventions that promote ditions (e.g., obesity, hypertension, joint
effective, individualized self-management in pain, and depression) in addition to diabetes.
persons diagnosed with diabetes and to im- The 12-week intervention consisted of health
plement screening procedures for early detec- behavior training with peer support, nutri-
tion and prevention in those most at risk for tion education, and prescribed exercise based
developing diabetes. upon personal aerobic capacity (peak V02).
The majority of nursing studies focus on Using a 3 day per week format with transpor-
adults with diabetes, particularly in African- tation provided, subjects had significant im-
American women and Mexican and Native provements in total and LDL cholesterol, car-
Americans with type 2 diabetes. The nurse diovascular fitness, muscular strength, and
researchers investigating symptom manage- nutrition knowledge. Thus, there is compel-
ment, self-management or self-care, and com- ling need to devise interventions that target
munity-based interventions using culturally approaches for individuals with complex so-


ciocultural, economic, and educational back- This research is partly based upon earlier
grounds (Rimmer, Silverman, Braunschweig, work that found decreased heart rate vari-
Quinn, & Liu, 2002). ability, a marker for early cardiovascular au-
Studies of youths with diabetes are ad- tonomic disease, associated with having type
dressing the needs of adolescents and their 1 diabetes and poorer metabolic control
families. The nurse researchers examining is- (Faulkner, Hathaway, Milstead, & Burgh-
sues in this population are Margaret Grey at en, 2001).
Yale University, Carol Dashiff at the Univer- Improvements in glycemic control through
sity of Alabama at Birmingham, and Melissa individualized interventions developed and
Faulkner at the University of Illinois at Chi- tested through scientific inquiry will increase
cago. Family and developmental perspectives the odds for minimizing complications of dia-
are incorporated into the designs of studies betes, which affect personal QoL and produc-
of youths. Key variables are self-care or self- tivity and contribute to the economic burden
management, self-efficacy, QoL, coping, associated with diabetes care. Future research
family adaptation, and autonomy as related must embrace not only better outcomes, in-
to improvement in metabolic control. Grey cluding decreasing health disparities in mi-
is conducting a longitudinal study using QoL norities, but also the enormous need for pre-
and metabolic control to evaluate the effects vention in those predisposed to the disease.
of coping skills training (CST) in youths re- Newer technologies for insulin delivery, con-
ceiving intensive diabetes management. This tinuous glucose sensing, and genetic engi-
investigation is the longest ongoing clinical neering for individual therapies are on the
trial specifically testing the efficacy of an in- horizon. Through their leadership in interdis-
tervention with youths who have type 1 dia- ciplinary science, nurse researchers will re-
betes. Adolescents who received CST and in- main integral to the advancement of evi-
tensive diabetes management had signifi- dence-based diabetes care.
cantly better metabolic control and less im-
pact of diabetes on their QoL than youths MELISSA SPEZIA FAULKNER
receiving intensive diabetes management
alone after 1 year. Such evidence lends sup-
port for devising interventions to optimize Disaster Nursing
both glycemic control and perceptions of
QoL in youths with diabetes. Dashiff is devel- Norris et al. (2002) defined a disaster as a
oping a model of influences on the develop- sudden event that has the potential to terrify,
ment of adolescent autonomy and family pro- horrify, or engender substantial losses for
cesses for self-care and diabetes control in many people simultaneously. Disasters are
early and middle adolescence. Her data will classified by the nature of the event, i.e., natu-
reflect the evolutionary development of the ral, technological, and deliberate acts of mass
parent-adolescent subsystem prospectively violence (terrorism), and/or by the impact of
over a 2-year period with the goal of identi- exposure, i.e. “dose response.” Natural disas-
fying factors that improve diabetes control ters are geophysical forces (e.g., earthquakes)
when providing family-based interventions. or weather forces (e.g., hurricanes, torna-
Consistent with the overall aim of pre- does). Technological disasters are frequently
venting long-term diabetes-related complica- attributed to human negligence and error and
tions as teens make the transition to adult- include collapse of structures, environmental
hood, Faulkner is investigating cardiovascu- catastrophes, and failures of public transpor-
lar risks in adolescents with type 1 and type tation equipment. Traumatic events are rele-
2 diabetes. The intent is to describe potential vant to nursing science and practice for sev-
sociodemographic, behavioral, or physiologi- eral reasons. First, these events are more com-
cal factors that predispose youths with either mon and have more pervasive impacts than
type of diabetes to subsequent heart disease. previously thought. Norris (1992) in a survey

Disaster Nursing 147

of residents in four Southeastern cities All three types of disaster, natural, technolog-
showed a lifetime exposure rate of 69%. ical, and mass violence events, were examined
Those surveyed had experienced at least one and analyzed for effect size. The magnitude
traumatic event. Tragic death, robbery, and of severity of negative consequences for the
serious motor vehicle injuries were the three individual level response samples reviewed by
most frequently reported. The impacts of di- Norris et al. was rated by level of impairment:
sasters on individuals and communities are minimal—11%, moderate—51%, severe—
multidimensional and immense, and adapta- 21%, and very severe—18%. When the data
tion to loss is of long rather than short dura- were assessed by type of event, victims of
tion (Murphy, 2001; Norris et al.). terrorist attacks (as opposed to natural and
Research findings (Hall, Norwood, Ur- technological events) suffered the most severe
sano, Fallerton, & Levinson, 2002; Murphy, consequences. Norris et al. reported that
2001; Norris et al., 2002) resulting from all women and youths were more severely af-
types of traumatic events suggests five major fected than men and older adults. Rescue and
domains of human responses following expo- recovery workers were reportedly the most
sure to one of these events: (a) Specific psy- resilient. Examples of U.S. disasters rated as
chological problems include shock, terror, “high impact” by Norris et al. were the Buf-
guilt, horror, irritability, anxiety, hostility, falo Creek dam collapse (1972), the Exxon
post traumatic stress disorder (PTSD), and Valdez oil spill (1989), Hurricane Andrew
depression; (b) Cognitive responses include (1992), and the Oklahoma City bombing
inability to concentrate, confusion, self- (1995). Findings emerging from World Trade
blame, intrusive thoughts (flashbacks) about Center study samples, i.e., Manhattan and
the experience, decreased sense of self-effi- nearby areas, showed incidence of symptoms
cacy, fear of losing additional control over of stress ranging from 20% to 40%, sug-
life events, and fear of reoccurrence of the gesting a high disaster impact (Galea et al.,
event; (c) Biological responses include sleep 2002; Schuster et al., 2001).
disturbance (insomnia, nightmares), exagger- Disasters and their outcomes are difficult
ated startle response, and indicators of stress to study. There are several reasons for this
and immune disorders. Behavioral responses and some cannot be overcome. First, “pre-
include avoidance, social withdrawal, inter- event” data are rarely available. It may be
personal stress (decreased intimacy and low- that mental disorders are overestimated in
ered trust in others) and substance abuse; (d) some postdisaster samples. Second, study re-
Resource losses include losses of income, so- ports vary widely in their methods. Norris et
cial support, time for noneffect activities, so- al. (2002) noted that 68% of the samples in
cial embeddedness, optimism, self-efficacy, their data set provided single, one-time data
and perceived control; and (e) Collective re- frequently by telephone. Initial, postevent
sponses. Neighborhood and community re- data collections ranged from immediately
sponse studies are rare with assessments gen- after an event up to 7 years later, making the
erally taking three approaches: Participants determination of immediate impact difficult
have been asked to report community condi- to estimate. Most longitudinal studies have
tions, individual level responses have been not collected follow-up data for more than a
aggregated, and archival data have been used year, leaving long-term outcomes unknown.
to illustrate loss and responses to loss, for Thus, study design variability poses a threat
example, changes in liquor sales in a given to generalizability of findings.
neighborhood or community (Bromet, Par- Four suggestions for the study of disasters
kinson, Schulberg, & Gondek, 1982; Gleser, are to: increase the number of community and
Green, & Winget, 1981; Norris et al.). family studies, examine the roles of protective
Norris et al. (2002) summarized both the factors and lost resources, develop and test
individual and collective outcomes obtained evidence-based interventions, and increase
from 160 disaster samples from 29 countries. nurse researcher involvement. Research is


needed in regard to factors that prevent or per accounts, that are not directed to specific
impede negative consequences, e.g., the roles individuals as their audiences. Discourse as
of social networks and the efficiency of relief the object of analysis is usually obtained from
agencies. Collective responses interact with natural occurrences rather than from con-
individual responses, making outcome mea- structions designed solely for the purpose of
surement a challenge. The measurement and analysis as either exemplary or ideal cases.
documentation of posttrauma responses has The term discourse in discourse analysis
improved over time, but there is a lack of is commonly accepted as a mass noun with
understanding in regard to how to reduce the above definition. However, the use of “a
high levels of PTSD. Beaton and Murphy discourse” or “discourses” can be often
(2002) have made some initial recommenda- found in discourse analysis with the post-
tions in regard to the timing of psychosocial structural, critical perspective. But the cur-
interventions following terrorist events. Fi- rent literature abounds with both usages of
nally, nurses provide postdisaster emergency the term (i.e., “discourse” and “a discourse”),
services and follow-up treatment, and some not necessarily used consistently within one
have assisted in study data collection, but specific perspective.
only a few have been study investigators. Discourse analysis has its historic origin in
the ancient Greek differentiation of grammar
SHIRLEY A. MURPHY and rhetoric in language use (van Dijk, T. A.,
1985). Although the study of rhetoric was
differentiated from the study of grammar in
Discourse Analysis linguistics throughout the centuries, it was
not until the middle of the 20th century that
Discourse analysis is a method that has multi- a more formal approach to discourse analysis
ple meanings referring to a wide range of gained its appeal in linguistics. Hence, “prag-
analytical procedures. Such methodological matics” in linguistics emphasizing discourse
diversity has resulted not only from various analysis has been separately developed, in
philosophical traditions that treat discourse contrast to the study of language proper that
differently but also from conceptualization focuses on formal grammatical, syntactical,
of discourse analysis by diverse disciplines and morphological structures. Following this
that emphasize different aspects or meanings modern revisit in linguistics, many other dis-
of discourse. Discourse is viewed as an appro- ciplines have begun to take discourse as the
priate subject matter for research by various proper subject of their scientific study. Al-
disciplines, including linguistics, philosophy, though there are cross-disciplinary discus-
anthropology, sociology, psychology, infor- sions of the methodology and application of
mation science, literary criticism, journalism, various approaches of discourse analysis,
and practice disciplines such as nursing and there is no unified, integrated approach to
medicine. discourse analysis. The literature across the
Although the term discourse in relation to disciplines suggests that there are at least
discourse analysis is defined and used differ- three general perspectives within discourse
ently in linguistics and in other disciplines, analysis: (a) the linguistic perspective, (b) the
discourse refers to language-in-use as con- conversation perspective, and (c) the ideol-
nected speech or written texts produced in ogy/critical perspective.
social contexts, rather than in terms of single The linguistic perspective takes discourse
sentences considered in terms of grammar as text produced by language use in either
and syntax. Discourse analysis deals with speech or writing. Thus, discourse text for
texts of conversations and written texts pro- this perspective can be from interpersonal
duced among individuals, as well as those conversations, written texts, or speech expo-
produced within larger social, historical envi- sitions such as testimonies. This perspective
ronments such as journal articles or newspa- encompasses the formal pragmatics in lin-

Discourse Analysis 149

guistics, sociolinguistics in sociology, and phasis is on the linguistic forms as used in
ethnography of communication and ethno- social life.
poetics in anthropology. Hence, within this The conversation perspective takes dis-
perspective there are several different meth- course as conversational texts; it has been
odological approaches to discourse analysis. developed from the ethnomethodological tra-
Even within each orientation there are varia- dition of Garfinkel in sociology. In this tradi-
tions in the ways discourse texts are analyzed, tion, Sacks (1967) and others pioneered con-
depending on the frame within which various versation analysis as a form of discourse anal-
contextual features are brought into the ana- ysis. Conversation analysis views discourse as
lytic schema. a stream of sequentially organized discursive
The formal pragmatics that had its begin- components that are designed jointly by par-
ning with Z. S. Harris (1952) has been recast ticipants of conversation applying a set of
by speech act theory in the philosophical tra- social and conversational rules. Conversation
dition of Searle (Searle, Kiefer, & Bierwisch, analysis studies rules that participants in con-
1980) and J. L. Austin (1975) and also by versation use to carry on and accomplish in-
poetics of the literary study. Discourse analy- teraction, such as topic organization, turn
sis from the formal pragmatics orientation taking, and use of response tokens. In recent
addresses such aspects as speech competence years, however, conversation analysis has ex-
with respect to discursive rules, text gram- tended to include behavioral aspects of inter-
mar, discourse comprehension, or discourse action (e.g., gesture, gaze, and laughter) as its
organization. analytical components. The use of transcripts
Sociolinguistics as a branch of sociology is and transcription symbols has been exten-
a study of language use within the functional sively developed in this perspective.
paradigm of sociology, which views social Discourse analysis in the ideological/criti-
life in relation to larger social structures such cal perspective differs from that in the other
as gender, status, social class, role, and eth- two perspectives in its emphasis on the nature
nicity. Sociolinguists are concerned with of discourse as historically constructed and
ways in which people use different linguistic constrained idea and knowledge. Discourse
forms according to macrostructural and con- in this perspective is not considered in terms
textual differences. of linguistic form or interactive patterning.
Anthropological approaches in the linguis- Rather, discourse is not only what is said or
tic perspective are ethnopoetics and ethnog- written but also the discursive conditions that
raphy of communication. Ethnopoetics is the produce imagined forms of life in given local,
study of oral discourse as speech art in the historical, and sociocultural junctures and
tradition of literary analysis and is concerned thus is embedded in and with power and ide-
with the structures of verbal aesthetics. The ology.
focus is on the poetic patterning of discourse This perspective was represented by post-
within different cultures. On the other hand, structuralists such as Foucault (1972) and Ly-
ethnography of communication, advanced by otard (1984), who viewed discourse analysis
Hymes (1964), is concerned with general lan- not simply as an analytical process but as a
guage use as practiced in specific sociocultu- critique and intervention against marginali-
ral context. Ethnography of communication, zation and repression of other forms of
done either from the cross-cultural, compara- knowledge and discursive possibilities. Fou-
tive orientation or from the single-culture ori- cault treats discourses in relation to rules tied
entation, is based on the assumption that dis- to specific historical conditions of usage and
course should be studied, positing it within as power relations. Hence, discourse analysis
the dynamics and patterns of discourse events in this perspective is oriented to revealing soc-
in a given cultural context. In all these iohistorical functions and power relations
branches of the linguistic perspective, the em- embedded in statements of talks and texts as


well as what Foucault called “systemic ar- attributes found in nursing research, educa-
chives,” of which statements form a part. tion, and practice, nurses are prepared to ad-
The foregoing discussion indicates that dress the issues of disparities in minority men-
discourse analysis is not a unified approach tal health. Nurses have ethical responsibilities
to studying language use. Although three per- that include doing no harm through the pro-
spectives are identified for this method, there vision of safe patient care (Gastmans, 1998).
is a blurring of differences among the perspec- Practicing within an ethically challenging en-
tives. The method, however, remains multi- vironment calls for nurses to be aware of and
discipline-oriented. In nursing, discourse to address the issues of health disparities for
analysis is being applied with all three per- racial/ethnic minorities. It is imperative that
spectives. Discourse analysis with the linguis- nurses become culturally competent in the
tic perspective has been applied to study dis- care that they give to all people including
course comprehension in client-nurse interac- racial/ethnic minorities. The Institute of Med-
tions or discourse organization of nurses’ icine Committee on understanding and elimi-
notes and to analyze various discourses on nating racial and ethnic disparities in health
such topics as abortion, individualized care, care (I.O.M.) defines “disparities in health-
and professionalism in the nursing literature care as racial or ethnic differences in the qual-
related to macrostructural or contextual fac- ity of health care that are not due to access-
tors. related factors or clinical needs, preferences,
On the other hand, discourse analysis with and appropriateness of intervention” (pp. 3–
the conversation perspective has been applied 4). Racial/ethnic minorities are less likely to
to the study of turn taking and topic organiza- receive needed mental health care and when
tion in client-nurse interactions and to exam- they do it is of poorer quality than whites.
ine the dynamics of home visiting. Within The four major minority groups are both
the ideological/critical perspective, discourse racial—Black, Native Indian/Alaskan Native,
analysis has been applied to examine nursing and Asian/Pacific Islanders, and ethnic—
documentation as a form of power relations, Hispanic (any race). Miranda, Nakamura,
to analyze discourse of nursing diagnosis in and Bernal (2003) stated that although race
the nursing literature, and to explicate the is based on an outdated impression of biolog-
language of sexuality, menopause, and abor- ical origin, race does designate strong social
tion as power relations and ideology. Written meanings, whereas ethnicity refers to affinity
texts produced by clients and nurses and cli- with a group that is believed to share a com-
ent-nurse conversations, as well as texts in mon lineage. According to the U.S. Census
the public domain, are the rich sources for Bureau (2001), from 1900 to 1965, racial/
applying discourse analysis to study the lan- ethnic minorities made up 10% of the U.S.
guage-in-use from these perspectives. population. By 2000, they were almost 30%
of the U.S. population, and by the mid-21st
HESOOK SUZIE KIM century racial/ethnic minorities will be ap-
proximately 40% of the U.S. population. The
U.S. Census Bureau reported that of the 281.4
Disparities in Minority Mental million people that live in the United States,
Health 12.3% are Black, 0.9% are Native Indians/
Alaskan Natives, 3.7% are Asian/Pacific Is-
Disparities in mental health services for ra- landers and 12.5% are Hispanic.
cial/ethnic minorities are continuous, ongo- Today, racial/ethnic minorities still are af-
ing, and persistent (Miranda, Lawson, & Es- fected by long-term legalized racism/discrimi-
cobar, 2002; Institute of Medicine [I.O.M.], nation. For Blacks, it was slavery; Native
2003; U.S. Department of Health and Human Americans and Japanese—forced relocations;
Services [U.S.D.H.H.S.], 2003; Sue, 2003). Hispanics—conquest; and Chinese—invol-
Because of the holistic and preventive care untary noncitizenship. This led to institution-

.H.. tion of mental illness leads to the avoidance tal health field. a lack of cul- misdiagnosis. Racial/ethnic minorit- norities with mental illness from seeking help. Stigma prevents many mi..O.. minority populations are sustained by barri.S. treatment. varying presentations of mental health symp- eas. U. the treatment of of mental health treatment. communication. Most dynamics and the impact on persons who research has been done with the black popu. and (d) underrep. 2002.S. I. Disparities in Minority Mental Health 151 alized racism.H. 2003). Tardive dyskinesia within subgroups (Miranda et al.S. Misdiagnosis leads to mistreatment in the tively similar across racial/ethnic popula. and cul.. 2003).. Other studies indicate that minorities are tal health care.S. Stigmatiza- cians. Misdiagnosis occurs in all groups in.. improper medication. 2003). and educators in the men. tive treatment is unlikely to occur (I.H.O. 2002. with a continued distrust by cluding whites but it occurs to a more signifi- minorities of organized systems. portunity of entry to and ease of use of mental Stigma of people with mental illness has health services.D.H..H. and as needed only half the care of whites..H. 2003).S. Almost 30% of His. mental illness has always been separated from resentation of racial/ethnic minority clini. ism/discrimination.S.D.M.D. form of no treatment.S. or undertreatment. I. hood of minority persons receiving more in- ture.M.D. a change in public than are white patients and therefore. likely to seek care. ies were less likely to receive appropriate care According to the Surgeon General.M.S. has contributed to a lack of use of mental I..S. racial/ethnic minorities experience (a) less op. excessive dosing. Prevalence of mental disorders are rela. stigma.M.D. ..O.. of and the treatment of persons with mental There are major gaps in empirical data illness.. treatment. U. including the cant degree in minorities (Miranda et al. although there are clear variances ment. (b) less potential for receipt existed throughout history (I..H. locations are less likely to be insured or more which may not be culturally competent. the treatment of physical illness.H. I.M.S.O. 2003. effec- likely to be underinsured. need and deserve mental health services lation. People who do not have a primary source toms among racial/ethnic minorities and pa- of health care or who live in remote and rural tient’s acceptance of the interview process. Race and Ethnicity (2003) reasoned that appropriate care than whites (I.O.. Unless mary source of health care and many racial/ a proper diagnosis is made. plays a stronger role in not seeking treatment Black patients with affective disorders are with racial/ethnic minorities than with more likely to be diagnosed as schizophrenic whites. likely to have untoward effects from treat- Mental health disparities for racial/ethnic ment because of sensitivity to medication.). 2003). U.H.H. inappropriate treatment (I. 2003. (c) poorer quality Over this period of time.D.H.S.M. inappropriate treat- tions.S. panics and 20% of Blacks do not have a pri. and lack of research tural competence among service providers (U. in the white population (Miranda et al.. stigma for depression or anxiety than were whites. less attitude should occur and people will be more like to receive lithium (Miranda et al.H.H.O.M. Further..M. Being insured in.. and intermittent or ers to cultural competence that include rac.S. (U. services that it is imperative to determine its tural competence have been studied. 2003).O. 2003).). 2002). As stigma lessens. Stigma is so widespread and such a for mental health services for racial/ethnic formidable barrier to seeking mental health minorities. (a major side effect of major antipsychotic Blacks in need of mental health care receive medication).D. The Surgeon General in the health services that contributes to the likeli- landmark supplement.S. Misdiagnosis. creases the likelihood for accessibility to men. health-care system. U.H. Mental Health: Cul. mindful of the ethnic minorities live in remote and rural ar. 2002. Miranda et al. 2003).O. 2003. of mental health services. researchers. and the rate of medications are complications more likely to uninsured minorities to whites is 2:1 occur in racial/ethnic minority groups than (U.

However.D.M.S..M. U. appropriate clinical formulation when vary- ing presentations of mental health symptoms MARGARET A.. crease in quality of life (Aggarwal et al. ameliorate racism/discrimination. Tinetti and colleagues (2000) suggested at ethnic match of provider and client. This designation would cultural match. Because dizziness results ethnic minorities (Baker & Bell.H.S. where the client regards the lead to a multifactorial approach to evalua- provider as culturally-sensitive. Academic and minorities are influenced by the cultural in.S. 2002). needed to correct the provider’s knowledge nostic criteria for quantifying mental health and decrease prejudice. entific studies with racial/ethnic minority verse ethnic minority populations to deter.. and a de- estimate the prevalence of clinically-signifi. tence. treatment continu- regarding minority mental health. mine their cultural relevance and sensitivity Knowledge development regarding the (Baker & Bell. and function (Maramba & Hall.M..O. health professionals and treatment may be Cultural influences of both provider and delayed. related disparities in mental health care are 2003. from impairments or diseases in multiple sys- I. where the best approach to dizziness is to consider it both are of a common ethnic background. cant mental health symptoms among racial/ Yardley.O. and the academic and clinical commu- ities. 2003. falling. a geriatric syndrome. the data ethical influences.D. 1999).D. Cultural competence needs to be viders. dizziness can often . Baker & Bell. 2003). and tion and treatment that has been successful willing to regard the individual’s unique with other geriatric syndromes such as falls needs. functional decline.S. 2003). These have not been included in the text as an integrated part of multiaxial assessment Dizziness is a common and perplexing com- due to incomplete empirical data to guide plaint for older adults and their health pro- practice. I. Diag. Mental health ments. and have recommended that theoretically-based treatment in minority mental health (I. and culturally-competent mental screening instruments need to demonstrate health treatment options comprise future sci- satisfactory reliability and validity across di. ity.H.. stigma. 2003) communication problems. 1999.. Dizziness in the Elderly view.S. Future re. including historical and among mental health care of blacks. search is needed to increase knowledge and Also. 1999. tom and multiple etiologies make diagnosis cally-measured for its impact on outcomes and treatment difficult. WHEATLEY in minority ethnic populations exist. misdiagnosis. Sue. 2000. 2003). studies (Miranda. The many presentations of the symp- well-defined. U.H. evidence-based. the symptom may be discounted by (Sue. U. flexible.H. After many years of looking tems.H. nity’s lack of consensus guiding inquiry into The treatment outcomes for racial/ethnic minority mental health care.O. though their use may para. and empiri. fear of that direct the uninformed provider to under. inquiry. An ap. 2003). EVANNE JURATOVAC pendix to the DSM-IV TR (2000) features guidelines for the cultural formulation to be putatively incorporated into the clinical inter.152 ENCYCLOPEDIA OF NURSING RESEARCH Significant gaps in nursing literature exist positive health outcomes. 2003. This is a step toward symptoms exist. is identified as a better predictor of and delirium.. Although Baker and needs of racial/ethnic minorities is influenced Bell addressed instrument appropriateness by several factors. 2003.O.H.M. empirical study of minority mental health and competence and bias of providers (I. This elusive symptom effecting bal- patient potentiate communication difficulties ance has been associated with falls. provider cultural incompe- are generalizable to other racial/ethnic minor. Since it cannot be associated with mental health therapies seen. 2000). populations. anxiety. bringing the best evidence into day-to-day doxically limit the provider from making an practice. culturally-appropriate measure- 2003.S..

anxiety.). Postural hypotension may involve to our position in space. ing diagnosis and treatment difficult. & Drone. causing feelings of While they note that the elderly may have insecurity and anxiety (Mendel. Vestibular reha- Sloane. and one study has shown that is the feeling that the surroundings or person older adults do just as well as younger adults is moving or spinning. caused by displaced otoconal crystals in the phy. Dizziness in the Elderly 153 be linked to distinct underlying causes that as to the underlying cause of the dizziness can be treated (Drachman. understanding of situations that exacerbate mine a cause. Patients can tient to can be challenging. Balance or the ability to plored. disorders. and is often associated with lightheadedness ness was not associated with race. 1998). Aging can cause ongoing safety measures to avoid dizziness. Murphy. their symptoms and their responses. or falls. garwal et al. maintain an upright position results from vi. many must learn even deciding which specialist to refer a pa- to live with ongoing symptoms. Mor.. and Despite medical strides. and appropriate treatment. learn to manage their symptoms through an acteristics usually help the practitioner deter. fainting or falling. to develop guidelines for medical practice. 2000). in responding to a rehab program (Whitney. disequi. and vasovagal syncope once per month (Aggerwal et al. Symptoms arising from cardiovascular disor- sponse are needed. Nanda. 2001). Medication treatment can decrease the result in a feeling of dizziness are many. or syncope more than vertigo.6% when defining dizziness rhythmia. Benign paroxysmal decreased efficiency or function in any or all positional vertigo often responds to move- of these balance mechanisms. & Drone. and Dallara (2001) bilitation using physical therapy can amelio- proposed four subtypes of dizziness: vertigo rate symptoms. Disequilibrium Descriptions of dizziness can range from can also be due to vestibular causes or balance a sensation of spinning or motion to light. interrupt blood flow to the vestibular system. ar- prevalence of 9. Sloane. But clinical char. Sloane. these subtypes can give clues Tinetti (2001) found dizziness associated . through a 360° rotation of the age. proprioceptive. Beck. and a Dizziness has a negative impact on quality final category includes other sensations. the brain. lightheadedness. Dizziness increases disease are also common peripheral vestibu- with age and is more common in women lar causes. Williams. transient ischemic attacks. and many neurological conditions should also be ex- variations of these. presyncope is the sen. mak- symptoms of Meniere’s disease. Beech. Kao. sation of feeling faint or lightheaded. Acute labyrinthitis and Meniere’s Williams. Central integration and motor re. & Weinman. Wrisley. inner ear. The multiple disease processes which can head. Bergenius. of life for older adults. and vestibular input to are based on the etiology of the symptom. carotid as a regular symptom that occurred at least sinus hypersensitivity. & Furman. 2002). 1991. & Gill. Tinetti. Dizziness results when ders are often resolved through medical man- there is a mismatch between the messages as agement. Yardley Recent efforts have focused on defining tested a nursing educational program includ- the symptom of dizziness and its subtypes so ing exercises that ameliorated anxiety and that it can be studied empirically in order physical symptoms (Yardley. Treatments for dizziness in elderly clients sual. 1991. and dizzi. 2000). 2000). One population-based Presyncope is often related to cardiovascular study in a biracial community found a lower causes including orthostatic hypotension. The prevalence of dizziness has been re. and these categories. which may ex- ment therapy designed to move the displaced plain the increased incidence of dizziness with otoconia. Zander. Vertigo is often caused by benign paroxys- ported to range from 24% to 34% of older mal positional vertigo (BPPV) and may be adults living in the community (Boult. librium is the sense of unsteadiness. Mur. Coeytaux. Marchetti. Vertebrobasolar insufficiency may (Boult. Medication effects. Evans. Ag. & difficulty placing their dizziness into one of Langius. and headedness.

the- the symptoms. veloped by Tesio. and in other studies. and Luxon (1992) and Doctoral education in nursing includes two used to examine the relationship of anxiety general types of programs offering distinctly and vertigo.. 1996) measures symp. grams leading to research-focused doctorates Further research is needed to explore the ef. anx. DSN. and activity levels. Cesarani. and Per. Over three fourths of existing programs ucca (1999) using item-response methodol. one practice-focused pro- grouped into three categories: functional. measures have been developed to help under. The basic differen- naires were completed by 127 patients from tiation is between research-focused and prac- a specialty clinic. of Philosophy—PhD) or the professional ment was an adaptation of a pain inventory. and support further investigation of designed to prepare the nurse for leadership the instrument. HELEN LACH cline (Aggarwal et al. over 88 emotional. Factor analysis was offers the EdD. and somatization. and physical. doctoral programs comprise the majority of iety. responses of significant others to the offer either the academic doctorate (Doctor dizzy person. Six programs are offered jointly or col- structs. 2000). Doctor of Nursing Science—DNS.154 ENCYCLOPEDIA OF NURSING RESEARCH with depression. anxiety. methodology. search. A vertigo symptoms Doctoral Education scale was developed by Yardley. Research-focused doctoral programs toms. programs.. fear sequences will be needed. & Waranch. into the best ways to educate and deliver in- tions. another study demonstrated good laboratively between two or more institu- test-retest reliability. of falling. programs. 1990) was developed that are currently offered by practice-focused to explore the impact of dizziness on everyday programs include the Doctor of Nursing life and includes 25 three-level items. 1999). and functional de. Question. and the Doctor of Nursing Practice been used in several studies. Curricula for pro- stand the problem of dizziness and its impact. The scale was tested institutions offer doctoral programs in nurs- in 63 patients who complained of dizziness ing and several (7 currently) offer both a re- and findings indicated good test-retest relia. They are designed to prepare the The Inventory for Dizziness (Hazlett. gram. gait and balance available for treatment. Effects were (DNP or DrNP). search-focused and a practice-focused pro- bility as well as homogeneity of the con. and has (ND). medical conditions. Research-focused items for exploring symptoms of vertigo. additional research disorders. in practice and for specialized advanced prac- The Dizziness Handicap Inventory (DHI5) tice and administrative roles. Some accepted and enjoys considerable prestige. because the PhD is universally recognized and aging this uncomfortable symptom. one research-focused program specialty dizziness clinic. Haacke. which are fewer in number. 2000). which can lead to avoidance of activity (Yardley. Currently. A short version was de. or administered to 184 patients presenting to a DNSc) degree. different types of degrees. formation to older adults who suffer its con- ciated with falls (Lawson et al. and various as- . Masson. Dizziness is common trend in research-oriented programs to offer and the difficulties of diagnosis and treatment the PhD rather than the professional degree. gram awards the DNS. typically contain a core of required courses fects of dizziness and interventions to manage addressing nursing theory. Alpini. Others have also found dizziness asso. graduate for a lifetime of scholarship and re- Tusa. The instru. and medica. Practice-focused doctoral used for item selection and factor develop. are ment. offer the academic doctorate. reflecting the ogy for item reduction. Factor analysis identified tice-focused programs. As new interventions are ory development strategies. Measures to explore the effects of dizziness have been developed. The degree titles (Jacobson & Newman. only increase the patient’s challenges in man. Verschuur. particularly in academia. tions.

ter’s level and others permit post-baccalaure- velop a high level of research expertise in ate entry. and nursing service grams are most likely to assume faculty posi. sity. Graduates of practice-fo- tions upon graduation. Theoretically programs offering the nurse specialist). toral programs include: the scientific under- Additionally. and at New York University in the practice-focused doctoral programs have re. Some practice- complete the dissertation. ecutive practice. programs provide the ba- credits focus on research methodology and sis for advanced specialized expertise in at actual conduct of research. while others also include DNS are more likely to emphasize research specialty preparation in administration or ex- that is applied and relates directly to clinical. 1920s. with the major differences rapid increase in programs and enrollments being that they typically have fewer credits came concern about maintaining high qual- addressing research and do not require a dis. The American Association of Colleges of sertation. programs. tice. curricula for such programs often in. of the 1970s. After a 30-year hiatus during which ceived renewed interest as a viable alternative no new programs were opened. programs more than doubled. arena as advanced practice nurses. Doctoral Education 155 pects of research methodology and statistics. students usually are required to pinnings for practice. began at Teachers College. becoming involved in related to the evaluation of practice and the hands-on research-related experiences such accrual and application of evidence for prac- as research residencies or practica and re. research-focused pro. In all cases. program ture. a total of 18 programs had been tise in clinical practice. quality improvement. and conducting a major velopment. graduates are expected a specialized area of nursing practice. nursing. On the average. Graduates of research-focused pro. clinical grams. Although they are not new to nursing.e. de- search assistantships. Although the de.. some require students to enter tion. however. administrators. nurse practitioner. In addition. least one area of nursing practice. DNSc. nurse midwife. There are several different administrative. cialty areas to those concerned with the direct grams leading to the professional doctorate care of patients as implemented in advanced (DNS. nurse anesthetist. with some specialty preparation at the mas- clude practicum experiences designed to de. focused doctoral programs limit their spe- gree title is different. doctoral nursing education increase in practice-focused doctoral pro. analytic methodologies plines (cognates). indicators of quality regarding student and . half or more of the ration. managers and evaluators. The curricula differ initiated. most study in 4 years: 2 years to complete the programs include a practice-related project course work and an additional 2 years to and a residency experience. An important trend in nursing is the rapid Historically. but increasingly are cused doctoral programs frequently assume being employed as researchers in clinical envi. by the end who wish to attain the highest level of exper. advanced practice in a develop substantive expertise in a specialized given specialty area of nursing. use of technology and information. change strategies and selecting courses in nursing and related disci. and interdisciplinary collabo- dissertation. interest in to the academic doctorate for individuals doctoral education was rekindled. Columbia Univer- grams. Areas of content that are common Nursing took a leadership role in developing to virtually all of the practice-focused doc. and with the cused programs. positions as clinical educators in schools of ronments. Typically. quite similar to the academic doctoral pro. The to provide visionary leadership in the practice required dissertation is often applied in na. During the 1980s the number of considerably from those of the research-fo. or policy-related practice and points of entry into practice-focused doctoral leadership. A disserta- full-time students complete their doctoral tion is generally not required. DSN) have curricula that are practice nursing roles (i. In addition to research prepara. application and evaluation of independent research protect and writing the health policy. ity. organization area of nursing knowledge and research by and system leadership.

Kennedy.277 drunken Adolescents driving fatalities. dition. diction and Substance Abuse at Columbia In addition to the growing interest in prac. drinking/driving behavior after the program. Penn. Isaacs. The vir. and adolescents who expanded from the tools of scholarship to have been drinking are involved in fatal increasingly addressing the growing body of crashes at twice the rate of adult drivers (Na- substantive nursing knowledge. and investigating intervening as a tus as a true academic discipline. The need for doctoral gradu. University. During the 1990s. tually universal acceptance of the doctorate However. and support re. 40% of the students in- to maintain quality in the face of rapid change dicated they would change their behavior. Grap. As a program showing pictures of automobile ac- result the profile of the “typical” doctoral cidents to determine if there was a change in student is changing. yet the challenge lowing the program. The average age of doc. Thirty percent of youth aged 15 greater emphasis on the content that consti. tional Highway Traffic Safety Administra- portionate focus on process changed to tion. 2002). tween degree levels and eliminating work ex. arena of excitement and innovation in nurs. a growing faculty shortage and the need to Only two of the six focused on drinking/driv- produce more doctoral graduates. curriculum content. Emphasis cents drink and drive. and for institutions it is driving and there are no studies focusing on the pinnacle of academic attainment. passenger in drinking/driving situations may offer approaches to change behavior that may ELIZABETH R. intervening in drinking/driving situations. had been drinking (National Center on Ad- tific process. the can be concluded that little has been pub- doctorate is the pinnacle of attainment in lished in the nursing literature on drinking/ nursing education. ideas about the zines. parties. maga- sources. Kuthy and colleagues evaluated a 20-minute perience as prerequisite to admission. One month after the program a telephone and students often enter doctoral study from interview indicated that the 274 high school clinical as well as academic backgrounds. half of the fa- culture. Fueled in part by ered on drinking/driving for 2002 and 2003. and Gra- ham (1995) found that in 5% to 10% of these Drinking and driving is rooted in the central cases there were sober passengers who could role that alcohol plays in American life and have intervened. driver’s education students showed a signifi- Doctoral education continues to be an cant change in drinking/driving behavior. Fol- ates continues to escalate. In ad- administrative patterns. talities in persons 16 to 19 years of age had . toral nursing students is gradually decreasing. Shreve. tice-focused doctoral programs. Given this were refined as the emphasis on establishing situation and despite drinking laws. prevention program with 39 students. LENZ prevent the injurious consequences associ- ated with drinking/driving among adoles- cents. Alcohol is commonly found at cele. to 20 who were killed in automobile accidents tutes the input to and products of the scien.156 ENCYCLOPEDIA OF NURSING RESEARCH faculty qualifications. The dispro. Furthermore. and leisure activities. health promotion is a major goal as the terminal degree signifies nursing’s sta. & Henderson. an important Six articles on drinking/driving were pub- trend is that increasingly students are being lished in the nursing literature from 1995 to encouraged to progress as quickly as possible 2001. 1995. It is of paramount concern. are increasingly streamlining progression be. programs ing among adolescents (Kuthy. Shreve evaluated a student drinking/driving ing education. 2002). adoles- and maintaining quality continued. brations. Drinking and Driving Among In a national study of 10. and billboards present messages that nature of scholarship and doctoral education shine a positive light on drinking. For individuals. advertisements on television. of nursing. 1998). No nursing publications were uncov- toward the terminal degree.

S. hypnotics. and caffeine. and the rest intervening as a passenger in drinking/driving for all other illegal drugs or misuse of legal queried 52 youths about drinking/driving sit.. and con. was estimated at $97. treatment facilities. 13% had driven a car or other vehicle after sedatives. It can be concluded apy). inhalants. drugs (White House Office of National Drug uations and interventions. Drug Abuse 157 at least one sober passenger in the car who orders (American Psychiatric Association could have cessful than less assertive interventions. The a car with a drinking driver. These are more effective than metabolism and activity such that physical The most common drugs of cents in grades 9–12 conducted in 199 abuse in the U. short- the link between drinking and driving there term and residential in-patient treatment. or family ther- ahead. and thera- talities. and anxiolytics (anti- drinking alcohol (Grunbaum et al. Findings of the Control Policy [ONDCP]. normal brain functioning. phencyclidine (PCP).3%).S. include behavioral therapies (counseling. and lost work. is potential for reducing drinking/driving fa. compared to men.html). and stranded largest percentage of admissions was for co- because they did not get in the car with a caine (38. opioids. 1996).nida.7 bil- drinker from driving (Shore & Compton. cannabis (marijuana). relaps. Treatment methods a ride.. and treatable disease subcategory of psy. Having some familiarity Money spent on illicit drug purchases was with the intoxicated individual seems to be found to be $57. or suggestions. ing women report histories of physical and chiatric illnesses called substance-abuse dis.1%). drug addiction treat- people tend to intervene more with friends ment. Up to 70% of drug-abus- ing. 1994). are cocaine (crack). Smart and Stoduto (1997) found that crime. clear demands. anxiety agents). psy- pants were: to persuade.5%) drinking driver and had no one to turn to for and marijuana (19. usually creating cessful interventions in drinking/driving as powerful feelings of pleasure or euphoria. medical care. Drug abuse interferes with Shore and Compton (2000) describe suc. social welfare programs. of which $38 bil- more conducive to intervening. nico- schools in 34 states.3 billion. other than alcohol. were 874. $7 billion for marijuana.nih. however. to plan chotherapy. In a study of adoles. and to threaten. In general longer and more comprehensive treatment programs MARY JANE SMITH have better results compared to short-term or minimalist treatment programs (http:// nida. Smith and lion was paid for cocaine. more addiction and craving for more of the drug assertive interventions tend to be more suc. $9. stand. [APA]. to interfere. study included the following drinking/driving Most drug abusers are men. Drug Abuse Drug abuse among women often presents different health and treatment challenges Drug abuse or addiction is a chronic. pleas. treatment medications (methadone that if youth passengers intervene and break maintenance for heroin addiction). occurs (http://www. forceful statements. than with strangers. hallucino- driver who had been drinking alcohol and gens. In 1995 there situations where the participants were: entan. 2002). These costs included 1998). 30% reported that in tine. sexual abuse and drug and alcohol abuse in . endangered while riding in 70% and women 30% of admissions. Threatening the drinking driver’s competence The societal economic impact of drug is less likely to be effective in stopping the abuse in the U. lion per year in 1992. Thus.6 billion for colleagues (2004) in a qualitative study on heroin.000 admissions to publicly funded gled with a drinking driver who was deter. there are long-term effects on brain crete actions. drug-free outpatient treatment. peutic communities. support groups. with men accounting for mined to drive. Interventions described by the partici.html). am- the previous 30 days they had ridden with a phetamines. followed by heroin (25.

stroke. Use of PCP and club drugs (MDMA/ eating. GHB/date rape drugs. this area so as to be on the cutting edge of Thus. developed and tested. While a daunting experience. the peer group. the realm of tissue diseases. Persons with severe cognitive Areas for future research include preven- impairments may simply forget how to eat tion research on the special issues facing men or may have accompanying neurological versus women and specific to each age group compromise affecting the swallow. there is currently no evi- to develop ones that are designed to best dence to substantiate this claim among match the needs of a specific subpopula. treatment failures. or the community masticated and moved back to the pharynx. and sense of powerlessness. Dysphagia ing into poverty. tion opiates (oxycodone. homelessness. hydrocodone). Case finding and treat. Finally. mated in adults over 50 from 16% to 22%. such as impairment of the neuro- approaches to case finding and referral for muscular pathways. 2003). the oral stage. Dysphagia is a symptom exhibited by either Furthermore. adult women. from Alzheimer’s disease to psychogenic dys- souts. tasteless and often is put into drinks without 1991). 2001.158 ENCYCLOPEDIA OF NURSING RESEARCH one or both parents. Swallowing has both voluntary and invol- The major foci of prevention research—the untary phases. inability to move food back in the mouth to making the decision to seek drug treatment a total inability to take nourishment. is all require additional research and theory de. structural or connective treatment are needed. ment are exceptionally difficult because drug. is under involuntary control. sometimes an indicator of swallowing Ecstasy. abusing women are often in relationships with drug-abusing partners and they have JOANNE SABOL STEVENSON well-founded fears of losing the relationship and its economic protection if they seek treat- ment. and Ketamine/ problems. under conscious control. Generally. matically moved through coordinated reflex- entists would do well to become trained in ive actions. (Lind. adolescents. and malignancy of the head and neck risk for this scenario. the prevalence of dysphagia in the general Among both men and women there have population is unknown. Genetic research is and esophageal stages. from school-aged youth through the elderly. dysphagia may occur anywhere along ative new treatment modalities need to be the route food and fluid take to the stomach. that is experienced on a continuum from the self-confidence. The GHB pending on the state (Centers for Medicare trend is of particular concern as the drug is and Medicaid. persons most likely to be at high risk for dysphagia include persons the victim being aware of ingesting the drug. healthy older adults and the reasons it is seen . risk has been esti- been recent increases in illicit use of prescrip. The number of nursing home residents re- while cocaine/crack use has decreased quiring extensive to total assistance with slightly. phagia. Parkinson’s dis- Women on college campuses are especially at ease. ranges between 17% to 43% de- Special K/Vitamin K) has increased. where food is auto- adding new insights every day and young sci. Rather than one-size. or elderly men or women. where food is individual. Lindgren & Janzon. Better problem. or mental disorders ranging drug-abuse treatment is fraught with drop. Cre. with head injuries. drug-abusing women were difficulty swallowing or pain on swallowing found to have exceptionally low self-esteem. adult men. depending on an individual’s health drug-abuse knowledge development. While aging has been suggested as a risk fac- fits-all treatment modalities. perhaps it is time tor for dysphagia. and the pharyngeal velopment and testing. Treatment for women often means fall. and losing custody of their children. tion—youth. power- lessness. and relapses.

Thus. veloped a position statement on the use of phagia experience recurrent pneumonias. Dysphagia 159 are more likely related to other factors such proved survival. Accompanying symp. McGill Ingestive Skills Assessment (MISA) nitive impairment with an ineffective swallow (Lambert. change in dietary habits. two instru- the issue may initially present as a safety ments were developed in the past 5 years. By using a Identification of persons with dysphagia national nursing home database. the HPNA disease. for example in the acute stroke vic. tency. Several national orga- cludes a change in voice. wide regional variation in use of tube feeding lems and start effective treatment for a poten. Gisel. Park. tional and safe swallowing for as long as pos- and caregivers concerning the benefits and sible. or re- tim. feed- Travis (1999) demonstrated that much of the ing skills. liquid and solid ingestion. Kabu- ing. cause of dysphagia or other problems. the individual’s capacity medical futility of tube feeding in persons for rehabilitation. recommended counseling patients. 2002) associated with all select organizational characteristics. & Mor. and has justification for use of tubes was not sup. Mul- tially occult disease. As pro- ing end-of-life care. 2002). researchers found needs to make early to prevent further prob. the problem: should someone with a severe cog. burdens of this intervention as well as advo- Ethical issues in dysphagia dramatically cating for advance care planning concerning increased within the past 5 years as results this issue. while oral and pharyngeal dysphagia in. change in pressure ulcer sta- as poor oral health or adverse effects of medi. criticized for having too broad inclusion crite- . improvement cations. of tube feeding (Mitchell. larger. Groher. Christmas. in this impaired population (Aronheim. Sieger. 2001) and that toms (Palmer. However. im.g. 2003) and the Massey Bedside Swal- of the literature concerning the use of enteral lowing Screen (MBSS) (Massey & Jedlicka. tus. de- with swallow. Roy. Persons with esophageal dys. for persons with progressive sist foods. influenced the rate throat. nurses need to be familiar with when they consider this issue in persons with these findings. of functional status and comfort. However. and ria—positioning. chometrically sound instruments. of “sanctity of life” versus “quality of life” Assessment of dysphagia can be accom- are often at the core of debates regarding use plished by the nurse through the use of psy- of tube feeding for persons with dementia. 2003). including the Hospice and Pallia- initiating a swallow. dysphagia may be tempo. families. the Mini- can be a critical assessment that the nurse mum Data Set (MDS). for-profit homes in urban areas lack- dration. prior declarations regard- with severe cognitive impairments. difficulty nizations. the testing of the MBSS was tion of the consequences of malnutrition. & Wood-Dau- who is losing weight be tube fed? A review phinee. and drool. For artificial nutrition and hydration in which some individuals. While not advocating for either diseases such as dementia and Parkinson’s using or not using tube feedings. they addressed the point at the end of life rary and with aggressive rehabilitation may when persons are unable to take foods be- reverse. complaints of food “sticking” in the ing a nurse practitioner.. nurses need to consider from large studies began to demonstrate the causes of dysphagia. Teno. vihill. dehy. decline in risk of infection. coughing. While the ethical arguments severe cognitive impairments (Amella. good interrater reliability and internal consis- ported by well designed studies: the preven. and put possible treat- viders of information and counseling to fami- lies and caregivers regarding end-of-life deci. & Fries. e. moto. stages of dysphagia include weight loss. texture management. The MISA addresses a range of crite- pairments by Finucane. ments into an evidence-based perspective sion making. the goal of care is to maintain func. feeding in persons with severe cognitive im. 2003). and coughing or choking tive Nurses Association (HPNA) (2003).

2003). of aspiration pneumonia. tube feeding. their problem when directly asked (Parker. bedfast.118). 2004). and questionable eating patterns.. 1998) that examined predictors of aspi. Kimberly. ing MDS data from three states (n = 102. congestive heart failure to eat and swallow and development of fur- (CHF). 2002) showed that et al. Skarupski. while interest. In this descriptive berg (2001) found that among patients who study. Us. 18 factors predicted aspiration using individualized nursing interventions. Ohlsson. dysphagia can be both painful as well dictor of aspiration in both studies. the researchers found that of the 3% were admitted to a facility after stroke with of the residents who had pneumonia (n = swallowing difficulties (n = 24) and received 3. small sample size. and lowing problems also was a predictor at 3 Fries (2002) sought to determine predictors months for persons with more complications. had experienced a stroke were aware of their swallowing problems and would alter their ELAINE J. Re. among persons with stroke and progressive ration: tube feeding was found to be a pre.842). & Strang.. It is critical for nurses to examine quality- phagia/swallowing problems. Case mix index. to eating—the pleasure of a good meal and searchers sought to determine if persons who good company—is not lost. of-life issues for all persons with impairment ingly. dante. ther complications. cerebrovascular accident (CVA) was in eating and swallowing problems. the level a logistic regression model: the highest were of alertness and the energy level of the pa- suctioning. & Fulfaro. Nursing interventions should facili- study while feeding dependence was the tate the social as well as nutritional aspects strongest predictor in the earlier study but of meals so that the one of the critical factors was only mildly predictive in the larger. Poor awareness of swal- Langmore. 2000. Casuccio. and dys. indicators of delirium. cancer..160 ENCYCLOPEDIA OF NURSING RESEARCH ria. Merca- large study support and refute an earlier 5. year study led by the same author (Langmore Holmberg. but once this is speech pathologist. who will develop complications. chronic obstructive pulmonary tients was most predictive of increased ability disease (COPD). AMELLA . Results of this studies (Perry & McLaren. weight loss. and Rahm Hall- consequences of dysphagia. dysphagia as a barrier to the enjoyment of previous ac- was not found to be a predictor in the earlier tivities.83). et al. thus decreasing complica- screening criteria (Sasaki & Leder. only 3 had awareness of known. In a descriptive study of 27 persons Nurses should not only be assessing who who were determined to be dysphagic by a is at risk for dysphagia. C. Park. 2003. tions. Sjostrom. one of the assumed Westergren. Several actually protective (OR = .

E Elder Mistreatment health. EM is a serious concern because older adults glect and concluded that EM is an intentional may have disease symptoms or age-related action that causes harm or creates a serious changes that imitate or conceal mistreatment risk of harm (whether or not harm is in. gests that only 1 in 14 EM cases is reported ally in this country (Pillemer & Finkelhor. 1997. is related to stressed caregiver research.2 million cases annu. punching. other physical contact. or failure to fulfill any part of a caregiver’s Theories for EM causality have been pos- obligations or duties to an older adult. EM assessment and intervention. which ther knowingly or unknowingly. Dyer. Guadagno. Mosqueda. Neglect is the refusal Kerzner. 2002). 2002. & Murphy. and religious equally deleterious to the older person groups. Capezuti. Exploitation is fraudulent activity in connection with an older adult’s property or Elder mistreatment (EM) is a complex syn. and an investigation of caregiver behaviors that abandonment of the elderly. Abuse is generally understood as EM (Bergeron & Gray. physical assault inflicted on an older adult Brush. to some public agency. Ne. cultural. & Lawson. and abandonment is defined as the drome that can lead to morbid or even fatal deliberate and abrupt withdrawal of services outcomes for those afflicted. exploitation. amount of care an elder person requires and Self-neglect occurs when an older adult. Mistreatment is in caring for an older adult. along with any signs or (2003) convened an expert panel to review symptoms of the same. Evidence sug- between 700. Few clinicians have been trained in other person who stands in a trusting rela.. ethnic. ited. 1993). 1996).000 new cases of EM by doing a careful history and physical annually (Tatara. symptoms. and nolly. Harrell et al. Underreporting of prevalence and risk for elder abuse and ne.. making the assessment process tended) to an at-risk elder by a caregiver or complex. neglect. 2003. Bitondo Dyer. or is the failure by a also led to underreporting. With an unprece- caregiver to satisfy the elder’s basic needs or dented number of individuals living beyond to protect the elder from harm. Nurses can do much 1988). assessment with attention to the subjective The National Research Council (NRC) complaint of EM. Abusive behavior Fulmer.000 and 1. The dependency theory refers to the glect may be intentional or unintentional. and it affects all have fewer social sanctions but may be socioeconomic. Restriction as a the term used to describe outcomes from such form of EM has recently been examined in actions as abuse. 2004. Heath. kicking. 2003. There are the age of 65 and even beyond the age of 85. assets. Fulmer et al. resulting in harmful effects. several types of EM described in the NRC nurses must be sensitive to the possibility of report. The National Elder Abuse Incidence to help in the screening and detection process Study documented over 500. & Con- may include hitting. which has tionship to the elder. ei. lives in such describes overwhelmed caregivers who lose a manner that is deleterious to his or her their control or stop providing reasonable 161 . The prevalence of EM is estimated (Fulmer & Gurland.

and computers. O’Brien. A. poor hydration. along they grow older. 1993). wire. reports of hitting or any one person talking with another.. care planning. and the nursing laws or requirements that professionals home setting. tor for EM and should automatically trigger or mentally retarded caregivers. Hyex. For example. 2003). It of people. money.. & Horwitz. unexplained loss of money transceivers. mation exchange. Signs and symptoms of EM might in. Reichman. provides excellent mal and then become violent and abusive as guidelines for the assessment of EM. psychiatrically impaired individuals. mum of two connected points. erzealous protection of a competent elder is search Council. An electronic network is consid- is especially difficult to evaluate the demented ered to be the connection or linking of two older adult for EM. Conversely. switches. Transgenerational violence theory refers ciation.). The psychopathology must be given to an older adult who has di- of the abuser theory refers to any nonnormal minished or absent decision-making capacity. of mentally retarded elders over 65 years of Hurst. caregiver. works connect at least two people using ized older adults. a form of ageism that infantilizes the older Early studies looked at the prevalence of individual and takes away their autonomy. et al. or the subjective report of abuse. burns. 1997. should be familiar with. Electronic computer net- . evidence of fearfulness around a Television networks connect large numbers caregiver. The number EM assessment (Lachs. although some in cases. Cognitive status cade.. TERRY FULMER There is no Denver Developmental screen for older adults that enables the clinician to understand what an 80-year-old looks like Electronic Network and what conditions are likely to represent EM. EM from a variety of perspectives: acute care. can constitute a network. Interdisciplinary care nitions. who can contribute to this area of inquiry is great. Ov- ers for very elderly parents (National Re. The need for researchers signs or symptoms of EM. methodological approaches. Each team member is able it difficult to understand the conditions under to use their own expertise to the benefit of which EM is likely to occur. other violent behavior against the older adult. age has grown substantially over the past de. or goods. face-to-face. Telephone net- sexually transmitted disease in institutional. 2003). testing and use of validated instruments. & Berbig. G. al- to children who learn violent behavior as nor. A summary of EM instruments for have looked at it as a retribution act: an adult screening and assessment is available (Ful- child may strike back at a parent or caregiver mer. Coyne. A key prac- education and training has improved. Although EM older adults (Fulmer et al. which puts the elder at Abuse and Neglect (American Medical Asso- risk. fractures. creating situations where mentally re. 1993). Differences in operational defi. Aravanis et al. Each state has elder mistreatment reporting community nursing care.. etc. can only be determined by rigorous clinical tarded or disabled offspring become caregiv. This might be viewed from with flowcharts for assessing and intervening a learning theory perspective. a careful and thorough or more computers to allow data and infor- interdisciplinary team approach is required. Special attention who was once abusive. such as substance abusers (alcohol. and follow-up with attention to and documentation of any with the older adult. there are data that reflect The American Medical Association’s Diag- the caregiver’s dependency on the elder (for nostic and Treatment Guidelines on Elder shelter. 2004). In general. Williams. there is tice implication for EM is the inclusion of still a great need for more systematic nursing family violence questions in every history assessment. and the teams are especially important in the EM as- lack of national prevalence studies have made sessment process. though over 10 years old.162 ENCYCLOPEDIA OF NURSING RESEARCH care. 1992. a network is composed of a mini- clude unexplained bruises. Dementia has been documented as a risk fac- drugs).

and nursing knowledge acquisi. should be examined as an independent vari- search. that is. are usually bidirectional. Moore. Local electronic World Wide Web (WWW). electronic network managed by a nurse. larger networks zolo’s (1994) in the American Journal of called wide area networks (WAN). tion and information exchange. faceted. which Library. and Brennan (1992) investigated the use of electronic net. borns to the “old-old” and the nursing and ies to support nurses’ use of electronic net. Net promoted the exchange of information change and may or may not be bidirectional. are be. and Person-to-person conversations. Television and some Barnsteiner’s (1993) and Graves’s (1993) computer network applications may be unidi. the nurse-patient relation. Emergency patients range from new- There are anecdotal reports and case stud. respectively) and DuBois and Riz- may serve a department. They con- cluded that a computer network is an excel- lent tool to facilitate support and information Emergency Nursing exchange among caregivers and between nurses and caregivers for patients with AIDS Emergency nursing is by its very nature multi- and Alzheimer’s disease. Elec. This research will promote the advancement Although the essence of nursing has been of health and patient care by providing the a network.T. however. Moore. (1991) and Ripich.Net). nursing research. such as clinical information sys- a means of communicating but also facilitate tems. as large as the Internet. work with nursing resource availability (On- rectional. medical diagnoses for which they seek treat- works. in. is needed. promote education re. nurse educators. Brennan. even if using nursing students. tional Technology Network (E. The goal of networks is information ex. there is limited nursing research on elec. scientific foundation for the appropriate ap- ship. bidirectional computer line Journal of Nursing Knowledge Synthesis networks are the most common. that nurses will have the best information gardless of geographic limitations. ples of nursing use of electronic networks. not only provide networks. Intranets. coming more and more common. As information technology increases in use Electronic networks are exciting tools for and health care requires increased efficiency. SCOTT ERDLEY works to facilitate nursing support of home SUSAN M. tion technology as one tool for providing the tronic networks. ing education for nurses are additional exam- ployment of Internet technologies. It was the first international some sort of intermediary like the telephone. Sparks (1993) has been instrumental ment include common illnesses such as flu in her advocacy and promotion of electronic symptoms to life-threatening injuries or . as well as on patients and their electronic health record. Electronic networking creased interdisciplinary collaborative re. which are the internal de. plication of electronic networking techno- tronic networks. and Smyth logies. SPARKS care clients and their caregivers. and the Nursing’s AJN Network to promote continu- Internet. Research access and acquisition of needed resources. Emergency Nursing 163 works may be as small as two computers or networks and resource availability for nurses. concerning the effects of electronic net- Electronic networks will continue to affect working on nurses and other health care pro- areas integral to nursing. E. education without walls for patients able through the inclusion of electronic net- and nurses. will include other larger networks so collaborative research. families. works in all stages of the research process.T. and allow resources to assist nursing care. such as the Internet and the best possible patient care. considered to be a In the early 1990s she championed the Educa- network of networks. and ideas for nurses. nursing and will be increasingly important in nurses will rely more and more on informa- information acquisition and dispersion. W. such as a lifetime fessionals. Examples and the Virginia Henderson STTI Electronic include local area networks (LAN).

the Emergency Nurses Associa. (f) ways to enhance health promo- cialty. efficient. Emergency nursing research. and pediatric issues.” care. and emergency nursing research. (d) in- presents challenges that are unique to the fluence of health care technologies. emergency nurse burnout. the number of emergency presentations were topics focusing on blood- nursing research articles increased from 49 drawing techniques. for Disease Control and Prevention [CDC]). Ameri. Of note to be too broad to foster the concerted effort is that while usage of the emergency depart. It becomes clear established a list of “research initiatives” that that although the research culture in emer- would receive preference in funding deci. tion. has decreased by tice.S. tion and injury prevention. trauma was “scattered across many topics. services. The current research initiatives are: (a) excellent studies are being conducted. Several multisite studies been extended to use in other areas of were developed and conducted by a team of nursing. In addition. MacLean. but emergency nursing affecting emergency nursing practice. and equipment on emergency nursing prac- While the exact number is unknown. and (h) mechanisms to as- Ambulatory Medical Care Survey: 2002 sure quality and cost-effective educational Emergency Department Summary. using practicing emergency nurses as data collectors. and market forces to emergency emergency nursing to be their clinical spe.164 ENCYCLOPEDIA OF NURSING RESEARCH events. pects of pain management. a doctorally prepared present at stressful times has received a good nurse researcher was hired to be the Director deal of attention. pain management proto- gency nursing research. and many foci. facilities. the direct result of funding provided by the tion (ENA) Foundation was established as a ENA Foundation. and as- representing a fivefold increase. As the major source of funding for emer. pro- estimated that about 80. 2004). NOC.000 RNs consider ductivity. but this knowledge base has ation’s headquarters. emergency or urgent care setting. use studies in the years between 1982–1991 to of the emergency department for nonurgent 262 published studies between 1992–2002. While these initiatives gave a sense of di- This represents a 23% increase in emergency rection. then. needed to build an emergency nursing knowl- ment has increased. One such study involved means to provide funding (and encourage- the issue of family presence during resuscita- ment) for peer reviewed research. (c) factors nursing specialties.2 million visits to hospital handling complex ethical issues related to emergency departments (National Hospital emergency care. Excellent studies that have had im- approximately 15% (National Center for portant consequences for the care of emer- Health Statistics. effective and efficient outcomes of emergency dence-based knowledge from other clinical nursing services and procedures. The convergence of A review of research presentations and these factors served to aid in the creation of posters displayed at the most recent annual a “research culture” as a visible component meeting of the Emergency Nurses Association of emergency nursing. injury prevention. The breadth of emergency nursing quality emergency nursing care delivery. Centers programs for emergency nurses. the ENA Foundation cols. What is known is that in 2003. not only by and for emer- of Research at the Emergency Nurses Associ- gency nurses. that emergency nursing research poster presentations included: triage. Desy. can give an overview of topics of interest in As noted by Bayley. the is- . (g) methods for cans made 110. March. standardized language usage (NIC. gency nursing has consistently increased and sions. illnesses. has mechanisms to assure effective. researchers. They found. in many ways they were considered department usage in the past decade. NANDA). The concept of family members being shortly thereafter. it is tice. the number of emergency edge base necessary for evidence-based prac- departments in the U. gency patients and their families have been In 1991. Some examples of however. Included in oral McMahon (2004). (b) care enables emergency nurses to apply evi. (e) factors affecting health care cost.

Empathy ics. to accurately interpret the client’s Results demonstrated that the answer to thoughts and feelings as if they were their the first question about value of the research own. When tients in the emergency department for long empathy is appropriately expressed it is in periods of time. to be one with the other person’s frame of sons with emergency health problems. The results (HRSA/MCHB) focused on the provision of of the study can organize and focus future family-centered care in the emergency depart. ANNE MANTON ers. genuine positive regard. The second ques.” Participants in the study were highly experienced in emergency nursing and most had advanced degrees. ing priorities for the ENA Foundation and In 2002. The information derived activities from a number of different perspec. After the round I re- sponses were collapsed into 154 research top. and it is often this question for practicing emergency nurses. evidence- tion’s Maternal and Child Health Bureau based practice to their patients. shown to improve physiological and psycho- issues of pain management were of most con. seek to provide the most relevant. Desy. and the provi. holding pa. Empathy 165 sue of the research being scattered rather than The authors noted the consistency of the focused remains a concern. and the ongoing educational the form of sincerity. having to do with the importance of vate world. all of the highly ranked research topics had This is in keeping with a commitment of the safety and quality of care as the central or- Association to engage in injury prevention ganizing principle. needs of emergency nurses. undertook a Delphi study able to develop the knowledge base essential to identify and prioritize “research questions for effective emergency nursing practice. and others. participants in round II were asked to evaluate each of the topics using two ques. In addition. reference. emergency nursing researchers will be ENA Foundation. Coast Guard have a right to quality emergency care deliv- in research funded by the Coast Guard to ered with compassion. touted as the essence and art of nursing. Empathic nursing care has been the research to consumers of emergency care. that interpretation back to the client in form- cerned issues related to staffing. research endeavors as well as establish fund- ment. needs for emergency nurses included methods Carl Rogers (1961) believed that empathy of effective patient education. of greatest value to emergency nurses and of highest importance for health care consum. is the ability to perceive the internal frame of sion of sufficient numbers of adequately pre. ing a positive nurse-client relationship. the Emergency Nurses Association and the Now. logical outcomes for clients (Hope-Stone & cern. es- The Emergency Nurses Association also pecially the value statement “All individuals has worked closely with the U. with funding and support from search is brighter because of the Delphi study. and to verbally and nonverbally convey question to practicing emergency nurses con. reference of another with such exactness as pared professional nurses for the care of per.S. and sensitive understanding of the client’s pri- tion. Other areas of highly ranked research Mills. findings with ENA’s mission and values. MacLean. The future for emergency nursing re- McMahon.” They postulated that examine factors related to boating injuries. Bayley. Em- and (2) what is the importance of research pathy in nursing is the ability of nurses to on this question for consumers of emergency penetrate the covert thoughts and feelings of nursing services?” the client. from this important study will be of immense tives. Empathy is a dimension of nursing that is tions: “(1) what is the value of research on central to caring competence. 2001). Carper (1978) correlated empathy . the Association has also help to future emergency nurse researchers conducted extensive research funded by the as well as practicing emergency nurses who Health Resources and Services Administra.

and the Empathic later studies have shown that by including Tendency Scale to measure empathic commu- strategies such as art. The intervention perspectives. the child will try to sooth another line empathy as a way of monitoring changes child that is crying. Alligood. (b) empathy as a profes. which may have implications for about empathic communication. Scale of Empathic Skills. Results in- nurses. 1998). searchers to call into question attempts by gression of empathy from infancy onward.166 ENCYCLOPEDIA OF NURSING RESEARCH with aesthetic knowing in her description of outcomes indicating advancement of the sci- fundamental patterns of knowing in nursing. Wikstrom (2001) investigated the effect of sional state. (c) empathy as communication an intervention program on student nurses’ process. However. The most advanced level in basic empathy after exposure to various of empathy emerges in late childhood when empathy learning modalities. creased empathy as a result of knowledge and vene (Goldman. The level of empathy education. measurements. Wilt. Evans and children begin to feel empathy for the plight colleagues (1998) suggested new approaches to facilitate students’ discovery of their basic of an entire group. causing the re- Developmentally. empathic un- can be identified. Being able to (1998) addressed empathy as a multidimen- empathize with potential victims encourages sional phenomenon and stressed the impor- people to act and help others. reinforced. engagement in learning about empathy. was not sustained over time. and O’Neil morality are found in empathy. tance of understanding two types of empathy: derlies many facets of moral judgment and basic and trained. nurse educators can nication skills and empathic tendency levels. Their intervention consisted of education dents. G. there is a natural pro. dicated that nurses gained empathic commu- Kunyk and Olson (2001) described the nication skills as a result of empathy training. and group received empathy exercises involving . this training did not significantly ature between 1992 and 2000. An instance when empathy leads to thy to natural. They found change the nurses’ basic empathic tendency five conceptualizations of empathy: (a) empa. Empathy un. the more to cry when recognizing distress in another empathy a bystander feels for the victim the human. They used the Layton Empathy felt toward another will shape one’s moral Test and the Hogan Empathy Scale to mea- judgments and empathic attitudes. tal investigation of empathy with 260 nurses Early nursing research on empathy indi- who were randomly assigned to intervention cated that empathy development programs and control groups. children feel distress and will start dents. From a historical perspective. the roots of G. ing students and found that trained empathy low certain moral principles. such as the poor or the empathy and emphasized that basic empathy oppressed. However. The thy as a special relationship. Putting sure trained and basic empathy in 106 nurs- oneself in another’s place leads people to fol. such as the innate tendency of a child to intervene on behalf of a victim. They likened trained empathy to in- more likely it is that the bystander will inter. Nurse authors investigator assigned participants to interven- are approaching empathy from a variety of tion and control groups. They utilized Dokmen’s had little to no effect on empathy. They likened basic empa- action. or ordinary feelings for moral action is when a bystander is moved others. During adolescence. to alleviate misfortune and injustice (Gold- Oz (2001) conducted a quasi-experimen- man. nursing faculties to teach empathy to stu- At 1 year. 1998). time frames. They emphasized the importance of to cry when they see another child cry. ence regarding empathy in nursing. raw. and refined in derstanding can reinforce moral convictions order to develop expertise in the expression developed earlier in life that center on a desire of empathy. After obtaining a measurement of students’ base- 1 year. (d) empathy as caring. Evans. levels. concept of empathy found in the nursing liter. thy as a human trait. and (e) empa. enhance basic empathy among nursing stu.

There how empathy may or may not be teachable is scant research on how nurses assess a pa- using various educational and experiential tient’s decisional capacity to make choices strategies. is presented here. informal or formal caregiver. sues (e. and is widely published in peer-review jour- work provides new understandings of basic nals. and organizational charac- personal. agree that the decision to choose/appoint an- thy and emphasizes the importance that other to make decisions for one in the event nurses have to develop and understand their of loss of decision-making capacity (i. however.. “The Sick Girl. life-sustaining treat- empathy has been viewed from a behavioral ment decisions. Viewing empathy ethicomoral perspectives on choices at the as a state rather than a trait of individuals end of life. Kunyk and Olson (2001) found evidence DIANNA HUTTO DOUGLAS that the concept of empathy is being ad- vanced conceptually and empirically with more depth and breadth in the nursing litera.. ethics and morality. and literature. sites of care.e. Nursing as a profession cussion and account-making regarding inter. empathy. vider. and social systems. End-of-Life Planning and Choices ture. film. surrogate decision maker. End-of-Life Planning and Choices 167 the use of a reproduction of Edvard Munch’s for developing strategies to enhance empathic painting. or Alligood (2001) and the Empathy Re. from myriad perspectives: patient. empathy education combined with experien- pathy as compared to the matched control tial exercises in empathic understanding such group. They. represents a perspectival shift and opens ave. basic empathy skills and to discern the differ- ing. Living Will). change of condition). interpersonal. pain. sumer and professional education needs. and legal scholars nues for research in nursing related to empa. The research findings supported the as art. the art of nursing can be enhanced. Research findings suggest that about life-sustaining treatments. research. late nurses’ basic empathy. and mental (trait) perspective. insisted that a more ma- ture concept of empathy must emerge before End-of-life (EOL) planning and decision- empathy can be fully useful in nursing prac. needs more replication of studies to identify pretations of empathy depicted in the paint.g. con- concept of empathy operates within the con. empathy has been requires less cognitive capacity than the cre- conceptually and empirically advanced in the ation of a list of treatments desired and not nursing literature. nursing homes). responding to clients. With continued use of art as a complementary strategy to research and growth in the understanding of theoretical knowledge on empathy to stimu. There was a significant improvement in ential impact of empathy education versus the intervention group members’ levels of em. barriers and facilitators.” to stimulate dis. Research represents virtually all A middle range theory of empathy conceptu. and education.g. Studies have raised critical desired at some point in the future regarding questions about the nature of empathy and unknown conditions (i. sion-making capacity. developed an implicit middle system costs.. law and range theory of empathy to explain how the regulation.. making (i. choices) have been explored tice. Health Care Proxy [HCP]) is less risky and In the past 20 years. professional pro- search Team at the University of Tennessee. Molloy et al. health care clinical and management domains alized within this established nursing frame.e. According to Alligood. teristics. clinical is- view of empathy emanates from a develop. The nursing research surrounding deci- empathy for nursing. cul- text of King’s general systems framework of ture. Clinicians. age and site-specific issues (state) approach. the more current (e.. however. retirement homes. Du- own empathy as a basis for clinical practice rable Power of Attorney for Health Care/ (Alligood). family. health Knoxville. baseline measurements of empathy in nurses (1996) assessed individuals living in nursing and nursing students can be a starting point homes. ethicists. and homes for the .e. pediatrics.

Data analysis Hospice care can be provided in ALRs in indicated that many cognitively impaired res. lated validity and reliability. that is. Cartwright (2002) concluded that choose a surrogate health care decision staff and family differ about the kind and maker. and confidence from practice patients with terminal cancer to die at home rather than from theory and class discussion. and resources were key factors in use King’s “interacting systems” or transac. family participa- determined that it was possible to differenti. being present the Standardized Mini-Mental Status Exami. to age in place and die there.g. The authors suggest that the nurse- sions about EOL care are easier when staff patient relationship in a home care setting is listen to family’s fears and concerns. education among NP students. that is. the “hospicelike” care or have a contract with a investigators recommended that formal di. 1999). tion in decision making prior to death. Lehna (2001) de. Orem’s self-care deficit model was used to cated that students were gaining knowledge. Qualitative analysis of specially trained nurse and by a geriatrician the investigator-designed interview revealed independent of each other. Self-care deficit of patient and Goodwin. Pasquarelle. The tool demonstrated criterion-re. residents and could be used for that circum. home. and goal achievement theory. engage different. In a review of the instrument (“Guidelines”) for determining if research literature about the EOL care pro- a nursing home (NH) resident had the capac. to (ALRs). and Peterson (2002) suggest caregiver. and Bobrowitz (2000) developed an making difficult choices. including assessment by a S. ate between those who could learn about and knowledge of what the dying process looked create an AD from those who could not.. cit and symptom relief. thors suggest that it would be good only for and Smith (2000) used case-based analysis to RNs and NPs who wanted to actively address describe and discuss ethical and legal issues EOL issues using a nursing model. to was instrumental in identifying and facilitat- facilitate advance care planning. that arise in nursing care of patients dying at For family members of NH residents. Some NHs and cluded in NP education.. Findings indi. and receiving spiritual nation (SMMSE). maintaining patient autonomy. but the availability of idents had this capacity. directive (AD). an predictive than the MMSE in identifying such older person choosing to remain in an ALR. richer. staff and residents about ADs. Mezey. A. pacity were used. 1999). Ladd. Most NHs provide as part of their practice. & Daley. Five different measures of ca. Ramsey. using like and how long it might take. most ALR—for a variety of reasons—transfer vised and tested a needs assessment for EOL dying residents to the hospital. Kiehl. hospice provider and all NHs must educate dactic curricula and role modeling be in. Dying at home means . availability of nurses and other that primary care nurse practitioners should supports. (Grov. skilled nursing care and oversight is ex- leagues suggest that the Guidelines are more tremely variable (Mitty. vided in NHs and assisted living residences ity sufficient to create a HCP. Few study of nurse practitioners (NP) (n = 145) states require that ALR residents or staff be reported that most (but not all) NPs were educated about ADs but many ALRs want knowledgeable about the legal guidelines for residents to have made a decision about CPR EOL decision making but few included ACP at the time of admission. The investigators that staff caring behaviors. support were important for family members Mitty. and more nuanced than in them in ACP well before a crisis or terminal the hospital setting. This ap. To address this. elicit factors associated with the option for competency. Mezey and col.168 ENCYCLOPEDIA OF NURSING RESEARCH aged for their capacity to create an advance event. Thus. Teresi. have to use additional private funds to access Schlegel and Shannon’s (2000) descriptive the kind of care needed at the end of life. may scribed purpose. virtually all states. ing patient’s choices regarding self-care defi- proach has not been tested although the au. 2003). The nurse tion model. at the time of death. quality of EOL care in these settings. deci. and provide relevant information (e. what antibiotics can and cannot do) (Wilson.

information needs. LSTs and were more certain and comfortable taining treatment (LST). and the patient’s known sessing patient and family understanding and preferences. sented with two conditions—critical illness ment with the patient’s AD wishes. clarifying goals hold a LST but were resistant to withdrawal. for communication. In the face of irreversible there is no difference. They suggest as- to scare resources. eral studies discussed in this chapter suggest terrater agreement is reported with regard to future research that would vary with regard the assigned role. and leading and unrepresentative findings. Kluger. A. and burdens of treatments. almost equal numbers of with the patient to define the role of each spouses would consent to or forgo CPR and family member in decision making—with and a breathing machine. ity and relationship with significant others. more tions to be addressed. 5 chose Many legal scholars and ethicists hold that to forgo all LSTs. Barck. ples. tive models have support value in commu- ways carry it out. also suggests that situational factors and or. and using words Factors associated with advocacy included such as “death” and “dying” in discussions poor prognosis. Nor- who carried out the action but claimed no ton and Talerico’s (2000) strategies to facili- responsibility for its consequences. S. far fewer (n = 5) would for the patient. if any. Factors associated with neutral. neu. ques- sionals were advocates than resistors. patient discomfort. Many of the studies we reviewed basic decision-making roles were identified: were based on small and uncontrolled sam- advocate (to withhold/withdraw LST). (2003) delineate several recommendations to Mezey. and Gwyther nurses’ passive role-taking. Pre- nurse has to try to anticipate their disagree. Reckling (1997) directly ob. Few spouses appeared to be acting served and interviewed family members (n = under the substituted judgment standard of 16) and professional staff (n = 29) of 10 ICU decision making. culture studies advise ity or resistance were constraints on practice. Reckling one proceed? Which nursing model. Among 50 spouses. and distrust. In the face of They also recommend that the nurse work critical illness. attention with patients and families. high burden were more likely to consent to holding LSTs. caution in using the “d” words: How should fear of legal liability. In. with their decision. To study the deci. propose a holistic assessment that includes to rate their agreement with. Ladd et and irreversible coma—spouses were asked al. this often fell to nurses nity-based care delivery to elders. treatment. Lindeman. Three choices. Some re. feeding tube. ganizational culture may have influenced Lowry. Among Reckling’s patients. tate EOL decision making include guidelines spondents felt that it was permissible to with. ethically or legally. and Mittelman promote a positive death experience that in- (1996) described the decisions made by clude professional as well as patient and fam- spouses (n = 50) of patients with Alzheimer’s ily education about the physiological dying . Maislin. End-of-Life Planning and Choices 169 that the family has to be prepared and the disease to consent to or to forgo LSTs. Nurses were the only professionals who collaboration among health care providers. can best guide the nursing strategy? Bosek. and families could be an effective findings was the feeling that those who made approach to ACP. More healthcare profes. Sev- resistor (to withdraw/withhold LSTs). tested. design and methods. there are many limitations to Survey were used to measure attitude toward the research regarding EOL planning and withdrawing and withholding LSTs. certainty of. spouses were more likely to forgo all tween withholding or withdrawing a life-sus. Design weakness can generate mis- tral party (will go with any position). ventilator. comfort with four LSTs: CPR. subject. assumed a neutral role. be. or interventions to be family members were resistors than advo. Yet. coma. and assessment of the patient’s decisional author. to site. given that such collabora- the decision to withdraw a LST did not al. and antibiotics. such as. Baggs and Mick (2000) suggest that cates. Spouses experiencing sion makers involved in withdrawing or with. patients. forgo antibiotics. Some items from the Social Context In general.

clinicians report the follow. duration has shown that patients who receive no form of negative pressure application. troversy continues regarding the most effica- Given the cultural diversity of caregivers and cious endotracheal suctioning procedure. & Preusser. breath sounds. or following (post-hyperoxygenation) suc- tion. rhythmias. suction catheter size. closed vent hypoxemia. to require thoughtful and sensitive research the utilization of research findings has been design. The to the catheter stimulating the bronchial ETS procedure has a number of components smooth muscle and inner lining of the trachea including: hyperoxygenation (increased in. and content of EOL care continues tioning procedure have been well researched. con- of ADs for decision making at the end of life. choconstriction and tracheal trauma are due and blood oxygen levels to indicate need. Associated variables include: FiO2. 2000). open vs. which is the lowering of blood oxy- gen levels. A critical evaluation of the . Hyperoxygenation is the ad- ETS through an inline suction catheter to ministration of a fraction of inspired oxygen maintain mechanical ventilation. alveoli with the application of vacuum. Bron- volume loops on the mechanical ventilator. Endotracheal suctioning cheal trauma. saw-toothed flow. either prior to (pre-hyperoxygenation) saline instillation for the purpose of irriga. 1991. coughing. (e) cardiac ar- rial oxygenation. mented other side effects which include: (a) uum during catheter withdrawal to aspirate atelectasis. creased intracranial pressure. understanding the nature. While components of the endotracheal suc- context. search data to identify the most significant Atelectasis is due to the insertion of a suction clinical indicators to determine the need for catheter with an outer diameter that is too ETS.170 ENCYCLOPEDIA OF NURSING RESEARCH process. care recipients. (f) cardiac arrest. (d) in- needed to maintain airway patency and arte. hyperinflation (volume of inspired air component of the ETS procedure used to pre- above baseline tidal volume). variable in the clinical setting. Research ther continuously or intermittently. respi. causing catheter impaction and ratory rate and pattern. However. MITTY dure have been developed to prevent the com- MIA KOBAYASHI plications associated with the procedure. (b) bronchoconstriction and tra- tracheal secretions. Hy- Endotracheal Suctioning poxemia. and (g) death. (c) alterations in arterial pres- is usually performed every 1–2 hours or as sure (hypotension and hypertension). comfort interventions. Researchers have docu- endotracheal tube and the application of vac. blood oxygen. The majority of research has been con- ducted to develop techniques to minimize the most common complication: hypoxemia. (FiO2) greater than the patient’s baseline oxygenation. the patient’s baseline tidal volume. depth of suction catheter ery of a breath of inspired air greater than insertion. presence the removal of respiratory gases from distal of secretions in the tubing. There is insufficient re. application of negative pressure ei. via the ventilator or manual resuscitation Hyperoxygenation/hyperinflation is a bag. Hyperinflation is defined as the deliv- suction pressure. The compo- nents of the endotracheal suctioning proce- ETHEL L. Stone. and post. (Czarnik. large for the inner diameter of the endotra- ing clinical cues: color. and the utility Despite almost 80 years of research. may result from the disconnection Endotracheal suctioning (ETS) is a common of the patient from the ventilator during the nursing intervention to remove mucus and procedure and/or due to the removal of oxy- debris from the tracheobronchial tree by the gen from the respiratory tract during the ap- insertion of a suction catheter through the plication of vacuum. and number of hyperoxygenation/hyperinflation with of hyperoxygenation/hyperinflation suction ETS show a significant decline in arterial sequences. Everhart. cheal tube. spired oxygen) which can be delivered either Turner & Loan. level of negative tioning.

few centimeters prior to the application of portant intervening variables. K. influences the degree of tracheal trauma. 1991). Endotracheal Suctioning 171 research examining the effect of hyperoxy. oxy. and increased intracranial pres- at a flow rate of 15 L/min or flush and ade. Since the level of negative arterial pressure and may be due to the num. and Hyperoxygenation/hyperinflation breaths hypoxemia. Rudy Closed ETS using an inline suction cathe. The patient should be assessed for blood oxygen levels decline more with open changes in blood pressure. despite the ETS is common clinical practice. Bell. during ETS.). 1991. 1991. Hence. The num- produces a greater increase in airway pres. tion. Investi. Corley. and increased intracranial pres- . research data indicate that there is a cumula- eroxygenation/hyperinflation breaths (Stone. neg- tion sequences. Rudy. limited to no more than two per episode. E. have con. vacuum to prevent catheter wedging. 1995). ative airway pressure. 5–10 minutes should elapse to allow for the genation. sure (Rudy. & Brucia. If additional suction passes are needed. Without hyperoxygenation. Glass. Researchers have documented ID ratio of 1:2. Recent studies comparing the ventilator 1993). 8. pressure of 100–120 mm Hg. quate time is allowed for refill from the reser. catheter in a rotating motion (Czarnik et al. A recent survey indicated that the (ID) of the endotracheal tube can be a signifi- majority of critical care nurses use hyperoxy. and positive end expiratory pres. cant factor in the development of atelectasis genation alone (n = 55/60) (Paul-Allen & Os.. the vac- cluded that hyperoxygenation/hyperinflation uum can be applied either continuously or breaths delivered via the ventilator have re. pressure or suction applied to the catheter ber of hyperoxygenation/hyperinflation suc. catheter and an endotracheal tube of cause both a decrease or increase in mean 7. The duration of suction application gators have also determined that the MRB should be no more than 10 seconds. ar- ETS than with closed. patient’s hemodynamic variables to return to sure during ETS.. baseline. This can be achieved with a that hyperinflation followed by ETS may 14 Fr. tracheal tube without the application of vac- ity of different MRBs to deliver 100% oxy. & Stone.. voir. venting suction-induced hypoxemia. and heart rate when tion sequences or catheter passes should be compared to the ventilator. However. Research has shown that consistency is mechanical stimulation of the tracheal tissue improved when the MRB has a reservoir of that may cause bradycardia.000–2. ber of hyperoxygenation/hyperinflation suc- sure. catheter should be advanced down the endo- tors have reported inconsistently on the abil. heart rate. With hyperoxygena. uum until gentle resistance is met to reduce gen. tive increase in arterial pressure. (Stone. secretion recovery.While saline instillation prior to niques and the results. closed ETS. & Preusser. Grap. rhythmias. premature atrial 1. via the ventilator or MRB. which have controlled im. and intracranial pressure with each pass 1996). Investiga.000 cc attached to an oxygen source contractions. Turner. the decline genation/hyperinflation on suction-induced in blood oxygen levels is equal or less with hypoxemia shows variability in the tech. et al. researchers recommend a suction can be delivered using either a manual resus. as lator is the preferred mode for delivering hyp. 1989). investigators have docu. The catheter should be withdrawn a and the MRB. intermittently with no significant difference sulted in elevated blood oxygen levels which in tracheal trauma while withdrawing the are superior or equivalent to the MRB in pre. ter permits uninterrupted ventilation. 2000). Kerr. Researchers recommend an OD/ trow. Stone. 1990. or 9 mm. of the suction catheter and inner diameter ner. M. arterial pressure. K. the venti. conclusive research to support any physiolog- mented that three to four hyperoxygenation ical benefit and it may actually cause a decline breaths at 100% oxygen and 135–150% of in blood oxygen levels (Raymond. heart rate. The tidal volume has been effective in preventing relationship between the outer diameter (OD) suction-induced hypoxemia (Stone & Tur.. S. & Parks. there is in- conflicting findings. The suction citation bag (MRB) or a ventilator. S. Brucia. Baun.

When closed ETS lative over the duration of ET insertion re. and comforting measures. leading to publications with catheter through the ET tube. perforation of the The summary reviews from Wrightson trachea and hypopharynx. cerebral blood flows. pneumothorax. Segar. 1993. 1992). ulceration. 2000). tube is inserted. sedations. have investigated ETS pro- way.172 ENCYCLOPEDIA OF NURSING RESEARCH sure and the patient’s ability to tolerate the gardless of modes of MV support. a better monitoring approach is crucial lifesaving to provide adequate oxygen and during MV support in neonates (Shiao. namic monitoring.. the nature of catheters and ETS. the airway secretions and debris when the ET Skov et al. system (insufflation of suction catheter using . and these traumas can- ance and the character of secretions (amount. bradycardia. Interven- ing the ET catheter to clear out the secretions tions minimizing the detrimental effects of and debris (Turner & Loan. procedures in NICU care. Loan). cated providing 1 minute 100% oxygen be- Ryding. nurse researchers includ- stops the mucociliary transport system and ing Turner and the ETS critical care nursing inhibits the infant’s capacity to cough and study groups. causing tracheo. frequency ventilators. and increased conclusive study on preoxygenation indi- intracranial pressure (Shiao. ET suctioning (ETS) proce. quencies and duration of ETS procedure. as well as researchers from clear out the secretions and debris in the air. ETS is the only method that can sessment (Bernert et al. 1990). ETS include preoxygenation. au- tain patent airways to ensure adequate gas tonomic neural responses. The lungs conventional MV and all new forms of high- should be auscultated to assess airway clear. MV is Thus. including procedure should be documented. Significant changes have been demon- period(s) of MV. shallow suc- ETS could be one of the most detrimental tioning. not be recovered until 28 days after removing color.. Skov. tracheal lesions. Yatsiv. as the ET tube essentially Since the 1970s. particularly preterms. who need MV are very sensitive to environmental stim- Endotracheal Suctioning in uli and easily develop episodes of desatura- Newborns: NICU Preterm Infant tion. Merrill. & Greisen. stopping no very clear understanding of pathophysiology more than 1 cm past the end of the ET tube. 2002. Pryds. 2002. & Goitein. 2000). and viscosity) should be recorded fol. must follow a fine line are the major population in need of a modern between oxygen toxicity and hypoxemia. medical sciences. neonatal intensive care unit (NICU). 2000). 1992). 2002) KATHLEEN STONE and in causing hypoxia lasting 4 minutes or longer (Wrightson. be used to maintain the airway by clearing Chapleau. strated for ETS procedures with hemody- dure has to be performed by nurses to main. gas exchange in these neonates. ETS tops all NICU procedures in caus- ing worst desaturation events (Shiao. the ET tube and discontinuing MV (Turner & lowing ETS. neonates (Turner & Loan. The trauma fore ETS using a manual Ambu bag (Kerem. tion (preoxygenation) for different durations Other complications of ETS include hypoxia before the ETS procedure. During the 2002). (1999) supported the use of hyperoxygena- and bacteremia (Turner & Loan. 1997. and behavioral as- exchange. Neonates. In addition to RDS. & Robillard. ETS involves steps of inserting a sterile cedures closely. Shiao. to the tracheobronchial tissues can be cumu. Ventilatory weaning. and the fre- bronchial trauma including mucosal necrosis. intubation and mechanical ventilation (MV) though aggressive. the presence of pa- Care tent ductus arteriosus and the increased oxy- gen-hemoglobin affinity of fetal hemoglobin Neonates with respiratory distress syndrome are cardiopulmonary causes of hypoxemia in (RDS) who require endotracheal (ET) tube preterm neonates. for the airway system and ETS trauma in and using negative pressure while withdraw. though the most and desaturation. 1999).

should only be performed on an as-needed ation can be supplied using MV (Turner & basis by observing and assessing (including Loan. & Stonestreet. without the benefits of removing air. ent. including more advanced monitor- Turning the infant’s head sideways for ETS ing of tissue oxygenation to prevent hypoxia to reach the left lung was not supported either associated with ETS. As the length of the trachea method. Chen. tion catheter only 1 cm beyond the ET tube) caused less aggravations and negative affer- instead of deep ETS method (stopping suction ent vagal stimulation. SHIAO when the infant’s head is turned sideways or extended. or nerves to produce aggravating bradycardia feeding. and the individual effect has not from ETS procedure before next ETS. way and in the ET tube. Wang. been documented. Hyperventilation is commonly used in ing oxygen saturation should be examined to combination with hyperoxygenation in neo. The less desaturation (Chou. thus. Oh. turning the head sideways will only increase the risk of ET tube removal Enteral Tube Placement and lead to airway trauma from the deep suction method. neonates. medication instillation. (Turner & Loan. Because safety issues related to en- and hypoxia in infants without obvious bene. involving the com- use of shallow ETS method (to insert the suc. 2000). Enteral Tube Placement 173 a special adapter to allow MV to continue Three additional matters for ETS are sug- while suctioning occurs) is used to cause less gested from Wrightson’s reviews (1999). An enteral tube is defined as any small-bore moving the airway secretions (Turner & tube passed through the nose or mouth into Loan. without any benefits of re. the airway tissue such as the shallow ETS way secretions. 1999). thus the trauma to 2003) and not beyond the ET tube to prevent the trachea in neonates is less than using ear- lier catheters with fewer or a single side hole trauma to the tracheal tissue. since this caused less damage Brubakk. only the issues surrounding nasogastric/ . ETS catheters are now designed with gests advancing the suction catheter to the multiple side holes to prevent abruptly in- same length as the ET tube (Ahn & Hwang. with to cause pneumothorax from excessive pres. Brann. 2000). 3 cm of the tube can be moved in and out of the trachea SHYANG-YUN PAMELA K. newest shallow ETS method. Unlike adults. and ways to eliminate ETS trauma to airway. Chest physical therapy was not the stomach or small intestine for the purpose supported as it only stimulates afferent vagal of decompression. forting management of infants with ETS. teral tubes that can be passed directly through fits in removing airway secretions (Turner & the wall of the stomach or jejunum are differ- Loan. 2001) and caused to the tracheal tissue (Wrightson. hyperinflation auscultation) the signs of secretion in the air- using peak inspiration pressure is not recom. comforting interven- as it only increases the chances of traumatiz- tions in addition to preoxygenation with ETS ing the airway with the increased risk of dislo- to prevent detrimental hypoxia and cerebral cating and removing the ET tube from the effects. ETS interruption of oxygen supply. hyperoxygen. however. Wrightson). Future research Saline installation before ETS was not sup- could be designed for the following areas in ported by the reviews (Wrightson. the monitor readings includ- ance. changes in the infants (Burgess. Other recent studies indicated that seda- Also supported from the reviews was the tions and music therapy. each time. prevent hypoxia and to ensure the recovery nates. rina or tissue). 1999). 2003). and attenuated auto- catheter when it meets resistance. ETS procedures mended in neonates because of the potential should not last longer than 1 minute. creased suction pressure. 2000). is only about 4 cm in neonates. & Pai. indicating nomic neural responses for hemodynamic that the catheter is touching the tracheal ca. Also. no more than two consecutive ETS passes sure due to the infant’s poor alveolar compli. sug.

one adult study (Hanson. termining tube position. length. tine. Adamson. enhances gut (NEX) distance to determine the insertion healing.174 ENCYCLOPEDIA OF NURSING RESEARCH orogastric (NG/OG) tubes and nasointestinal occur. Al.6% of NG/OG tubes in 30 premature in- no doubt that they are common. feeding through the tube will agus. a telephone sur- OG tube erroneously passes into the duode.3% of NG/OG tubes were tubes. bley. 1988). diar. was not accurate. the standard measurement used in and also is less costly and is associated with practice. such as aspiration pneumonia or parenchy- monary complications. Clinkscales. Feeding through a mal perforation with resulting pneumotho- tube ending in the esophagus increases the rax). which in his sample was 91. will be reviewed. The state of the sci- eny. and Carroll (1978) found at autopsy in in- Previous studies found NG/OG/NI tube fants that an NG tube inserted using the NEX placement errors to be common. Ellett. 1996). & Eisenberg. can All of these errors involved high placements lead to serious complications. result in pulmonary aspiration or other pul. Surprisingly. 1998). with preva. which include initial erroneous place. however. Niv & Abu. ments as well as displacements over time. incorrectly placed using the NEMU distance. R. small cm) adapted from his regression equation on amounts of nutrients are fed into the lumen NEX. At present no methods have trointestinal (GI) system is functional and the been shown empirically to be adequate for need for assisted feeding is expected to be predicting correct tube insertion length. L. Even in clients maintained mended a formula ([NEX − 50 cm]/2 + 50 primarily by total parenteral nutrition. Maas. ment in the stomach.4% accu- of the gut through enteral tubes to maintain rate for estimating the distance for placing the structure and function of the small intes. Bramson (1987) found on radiograph that though estimates of error rates vary. 1988. feeding by NG/OG/ Only a few studies have addressed inser- NI tubes remains an essential lifesaving pro. least two areas—predicting the insertion dis- lion enteral tubes are placed in adults and tance for correct tube placement and de- children in the United States annually (Meth. fants were incorrectly placed using the NEX Errors in placement of NG/OG feeding distance and 39. tion-length estimators in children. 1979) con- achieves a positive nitrogen balance sooner cluded that use of the direct nose-ear-xiphoid than total parenteral nutrition. Studies in children show that length from the tip of the nose to the lobe of between 20. They proposed that a Curry.3% to 89. Ziemer cedure. vey of 113 Level II and III nurseries in five num and the client is fed formula requiring midwestern states found that 98% of nurses both gastric and pancreatic enzymes for com. often result in serious complications. and 1999. and possibly dumping syndrome may gated the methods recommended in the nurs- . Feeding by ence regarding each of these knowledge needs NG/OG/NI tubes is preferred when the gas. in spite of the risk of pulmonary aspiration. Increasing the safety of NG/OG feed- (NI) tubes will be discussed. When an NG/ evidence from these studies. malabsorption that results in tion distance (Shiao & DiFiore. If a tube ends (which. if in the respiratory tract or the esoph- in the airway..5% of enteral tubes the ear to a point midway between the xiph- are placed incorrectly when placement error oid process and the umbilicus (NEMU).9% and 43. & Forsee. ing requires knowledge development in at It is estimated that approximately one mil. continued to use NEX to calculate tube inser- plete digestion.5% depending on how narrow advanced a few centimeters for correct place- or broad the definition of error was (McWey. 1986). Wei- is broadly defined (Ellett & Beckstrand. & Reines. there is 55. more accurate method would be using the Avid. distance almost always reached just past the lence rates of errors in adults ranging from lower esophageal sphincter and needed to be 1. and reduces bacterial translocation. The short-term. Enteral feeding is physiologic. Curran. Schabel. the NG tube tip correctly in the stomach. For many clients. Beckstrand and colleagues (1990) investi- rhea. inadequate weight gain (or weight loss). Spies. Hanson recom- low rates of sepsis.

Metheny and coresearch- ing the length from the nose/mouth to the ers (1999) found that gastric aspirates had proximal end of the tube. quadrant of the abdomen. testing is the administration of gastric acid- . and (f) measuring significantly lower pH values (mean 3. rates. ment-locating methods imperative.4% of GI placements in adults. it has yet to be used verify the position of flexible small-bore NG/ clinically to detect respiratory placements OG tubes. About 15% tube. In addition. and trypsin correctly classi. ommended by many to determine tube place. Indeed. M. & Falcone. and regression on height. Berglund. It may be impossible to obtain end of the tube under water and observing any fluid if one or more of the orifices are for bubbles in synchrony with expirations in. and coresearchers (1999) suggested Several methods of detection have been that these expected differences might be use- investigated in adults. Placing the proximal of a problem. pepsin. pepsin. (d) examining the In a study of 800 aspirates collected from visual characteristics of aspirates. there- cally ventilated. radiographs have been rec. the absence of fluid is not necessarily reliable method to assess tube position be. was supported by Hanson’s tion of respiratory placements.. This proved nurses’ predictions of stomach and method. 1990). Finally. (e) measur. W. height. McSweeney. Another cause injection of air into the tracheobron. evidence of improper placement. flexible volves risk that clients will aspirate water on small-bore tubes tend to collapse when nega- inspiration. Metheny. Wehrle. and other factors affecting pH read- sound over the epigastrium or left upper ings. Stewart. bilirubin. they found regres.5) than CO2 level at the proximal end of the NG/OG intestinal aspirates (mean 7. especially those being mechani. ments. there (1979) study in adults. have different mean pH values. pH testing alone is an inadequate locator in ing the proximal end of the tube under water both adults and children because of overlap and observing for bubbles in synchrony with in pH between sites. & Truitt. Simple auscultation is not a fore. & Wiersema. Although in the research setting inves- no bedside tests are currently available for tigators were very successful in obtaining as- measuring pepsin and trypsin. (c) auscultating for a gurgling aspirate. however. Smith. and Wehrle sion on height in three age groups to be the (1994) showed that visual characteristics im- superior predictor of esophageal length. 605 fasting adults. difficulty in obtaining expirations. Carpenter. including: (a) aspirat. 1998). radiographs as well as their expense makes Fluids aspirated from different organs the development of adequate bedside place. B. thus limiting pirate. is evidence that CO2 monitoring has the po- Currently an abdominal radiograph is the tential to differentiate respiratory from GI only consistently valid and reliable way to placement. however. ful for testing for feeding tube placement er- ing gastric contents and measuring the pH. In eny. To sum- ment in