68 n CLInICAL TRIALS
usually of such magnitude that the results To date, the majority of clinical trials
of non randomized studies are often ambig- have included a limited segment of the U.S.
C uous and not universally accepted unless the population, that is, mainly middle-class,
therapeutic effect is very large. These same married, White males with little to no inclu-
biases are not present to the same degree in sion of women and minorities. This lack of
randomized trials. Recent development and diversity in trial samples has yielded results
use of mega-trials represents one variation. that are not always generalizable and effec-
The mega-trial is a large, simple, ran- tive. Research also has demonstrated bias
domized trial analyzed on an “intent- to- because of subject factors.
treat” basis. In mega-trials randomization Clinical trials are expensive and resource
serves to achieve identical allocation groups intensive. As a result, subject numbers are
(equal distribution of bias), where there generally limited to the minimum number
is poor experimental control and large needed to demonstrate a significant effect not
between- subject variation. Results of mega- caused by chance. However, small clinical tri-
trials cannot readily be generalized because als may not provide convincing evidence of
their conclusions are observations, not causal intervention effects. Small clinical trials are
hypotheses and therefore not testable. Mega- valuable in (a) challenging conventional but
trials can be repeated but not replicated. untested therapeutic wisdom, (b) providing
Mega-trials dispense with the scientific aim data on number of events rather than num-
of maximum experimental control to remove ber of patients and thus may be sufficient to
or minimize bias and instead use randomi- identify the best therapy, and (c) serving as a
zation to achieve equal distribution of bias basis for overview and meta-analysis.
between groups. To deal with the issue of small sample
In clinical drug trials, following approval sizes, meta-analysis is increasingly being
by the Food and Drug Administration, three used. Meta-analysis (quantitative overview) is
phases of clinical trials begin. Phase 1 stud- a systematic review that uses statistical meth-
ies generally establish whether a treatment ods to combine and summarize the results of
is safe and at what dosages. Phase 2 studies several trials. Well-conducted meta-analy-
assess the efficacy of treatments after their ses are the best method of summarizing all
safety and feasibility has been established in available unbiased evidence on the relative
Phase 1. Phase 3 studies compare effective- effects of treatment. In a meta-analysis, the
ness of Phase 2 treatments against currently individual studies are weighted according
accepted treatments. to the inverse of the variance; that is, more
Some scientists divide clinical trials into weight is given to studies with more events.
three groups: (a) exploratory (initial trials Arrangement of the trials according to event
investigating a novel idea), (b) confirmatory rate in the controls, effect sizes, and quality of
(designed to replicate results of exploratory the trials or according to covariables of inter-
trials), and (c) explanatory (designed to mod- est provides unique information. If carried
ify or better understand an established point). out prospectively, the technique provides
Issues surrounding clinical trials include information on the need for another trial, the
biasing, expense of clinical trials, small sam- number of subjects necessary to determine
ple sizes, and ethical issues. There are many the validity of past trends, and the type of
biases that can compromise a clinical trial, subjects who might be benefited.
such as observer bias, interviewer bias, use Ethical issues in clinical trials include
of nonvalidated instruments, uneven subject issues of informed consent, withholding of
recruitment by physicians, and individual treatment, and careful monitoring of clinical
subject factors. Recent concerns have focused trial results. Additional issues of informed con-
on bias in sample selection. sent include assuring that subjects thoroughly
CoCHRAnE REvIEW n 69
understand potential risks and benefits of par- specialty and subspecialty. In 1974, initial
ticipation and any effects on their care should work toward systematically collating evi-
they decide to withdraw at any point in the dence from controlled trials began in peri- C
study. Issues of withholding treatment include natal medicine, which developed into an
increasing subject risk or subject benefit if international collaboration 10 years later. In
there is reasonable evidence of positive effects 1992, the Cochrane Centre opened in oxford,
of the intervention or treatment. Careful mon- United Kingdom, and two Cochrane Review
itoring of the effects of interventions or treat- Groups were registered: the Pregnancy and
ment is necessary to stop the trial if there is Childbirth Group and the Subfertility Group
associated morbidity or mortality and extend- (The Cochrane Collaboration History, 2010).
ing the intervention or treatment to the con- Twelve months later, the international col-
trol group in the event of significantly positive laboration now known as the Cochrane
treatment effects. Collaboration was launched. The work of
Clinical trials remain the principal way the Cochrane Collaboration in preparing
to collect scientific data on the value of inter- and maintaining reviews centers around
ventions and treatment. However, in design- Cochrane Review Groups of which there are
ing and evaluating clinical trials, rigor of now more than 50 representing a broad range
method, including careful evaluation of of health care specialities (Green et al., 2008).
potential biasing factors, is essential. Meta- Publication of Cochrane reviews on
analysis provides a summary of all available, health care evidence has important societal
unbiased evidence on the relative effects of and economical implications. The philoso-
treatment. However, rigor of methods used phy of the Cochrane Collaboration centers
to conduct the meta-analysis also must be on the need for the best quality evidence
evaluated. being readily available in an easily accessible,
comprehensible format to all stakeholders
Dorothy Brooten including policy makers, health care practi-
tioners, patients, their advocates, and carers.
Therefore, Cochrane reviews target society
at large such that they can be accessed free
CoChrane review of charge by all citizens in countries where
a national license has been purchased by
governments to access the Cochrane Library
Cochrane reviews are systematic reviews (Green & McDonald, 2005). Accessibility
that aim to collate all the available evidence involves more than making reviews avail-
that fits predetermined eligibility criteria to able and easy to find; it includes mak-
assess the effectiveness of health care inter- ing reviews easy to interpret by lay health
ventions. The pioneering work of an epidemi- care consumers (Green & McDonald, 2005).
ologist, Archie Cochrane, has influenced the To this end, a lay summary of evidence is
development of Cochrane reviews. Cochrane included in all Cochrane reviews. “Avoiding
was committed to addressing major deficits duplication by good management and co-
within the British health care services. In a ordination to maximise economy of effort”
seminal textbook, Cochrane (1972) stated is a principle underpinning the work of
that “effectiveness” ought to be one of the the Cochrane Collaboration (Green et al.,
pillars underpinning health care interven- 2008, p. 8). According to Clarke, Alderson,
tions, and he pointed to a collective need to and Chalmers (2002), there is a serious risk
question the effects of health care interven- of wasting billions of dollars spent on con-
tions through the systematic review of evi- trolled trials if systematic reviews of the
dence from controlled trials, organized by findings of individual trials are not collated
70 n CoCHRAnE REvIEW
and made accessible in a standard and struc- of Cochrane reviews on nursing-related
tured way. topics and the use of Cochrane reviews in
C Health care practitioners face daily chal- nursing practice. The CnCF is coordinated
lenges concerning the need for their prac- from Adelaide, Australia, with more than
tice to be evidence based. However, they 35 members.
are confronted with information overload Cochrane reviews with their empha-
because of the increasing number of studies sis on controlled trials reflect a positivist
being published worldwide in thousands of paradigm within scientific inquiry. The
medical, scientific, and health-related jour- Cochrane Collaboration strives for meth-
nals. Cochrane reviews that collate evidence odological excellence in the conduct of
from multiple studies go some way to assist- reviews. The methodology of Cochrane
ing practitioners to make informed clini- review is rigorous and includes the follow-
cal decisions on what interventions work ing: (1) electronic publication, without word
best toward achieving positive outcomes limitations, thus methodological detail can
for patients. Cochrane reviews can inform be included; (2) public availability of a pre-
the development of clinical practice proto- planned methods section termed “protocol”;
cols, guidelines, and pathways as well as (3) application of quality ratings to included
health care policy (Starr, Chalmers, Clarke, & studies that seek to limit bias and random
oxman, 2009; Torloni, 2010). errors; (4) a meta-analysis of homogenous
The vast majority of Cochrane reviews results from studies if feasible; and (5) per-
collate evidence relating to specific diseases iodic updates to include new evidence if
and treatments (e.g., diabetes, cancer). To available. The format of the Cochrane review
date, there are few reviews that specifically is standardized and structured. The official
focus on nursing practice or nursing specific handbook, Cochrane Handbook for Systematic
issues. Davison, Sochan, and Pretorius (2010) Reviews of Interventions published by the
noted that out of 117 protocols and completed Cochrane Collaboration, details the meth-
reviews within the Effective Health Care odological procedure for preparing and
Practice and the organisation of Health Care maintaining Cochrane reviews (Higgins &
Review Group, 27% (n = 32) mentioned nurses Green, 2009).
or nursing practice in the title or protocol. Cochrane reviews use more rigor-
These results would indicate that Cochrane ous methods than non-Cochrane reviews
systematic reviews have some relevance to (Moseley, Elkins, Herbert, Maher, &
nursing. However, a conflict exits between Sherrington, 2009; Tricco, Tetzlaff, Pham,
the dominant focus on controlled trials and Brehaut, & Moher, 2009) and thus are com-
the exclusion of other research methods. monly regarded as being of superior qual-
Many health care research questions are dif- ity to other reviews (Shea, Boers, Grimshaw,
ficult to test using experimental methodolo- Hamel, & Bouter, 2006; Starr et al., 2009). In
gies, thus creating some conflict for nurses 2009, the Cochrane Database of Systemic Reviews
in using Cochrane reviews in clinical prac- received its first official impact factor (5.182)
tice and in their involvement in conducting based on citations in 2008 (Cochrane Reviews,
Cochrane reviews. 2010). The impact factor is a measure of the
Although there is no Cochrane nursing frequency with which the “average article” in
review group, a Cochrane nursing Care Field a journal has been cited in a particular year.
(CnCF) has been established and is one of Since the formal establishment of the
16 fields within the Cochrane Collaboration. Cochrane Collaboration, more than 4,000
The aims of the CnCF include becoming a reviews have been published (Cochrane
global alliance of those involved in nursing Reviews, 2010). However, the Collaboration
care who wish to promote the preparation continues to strive to improve review
CoHoRT DESIGn n 71
methodology for example the quality assess- assignment of subjects to groups. Although
ment of included studies. the groups in a cohort design may not be as
In summary, Cochrane reviews pro- comparable as randomly assigned groups, C
vide consumers with readily accessible evi- archival records or data on relevant variables
dence on the effectiveness of health care can be used to compare cohorts that received
interventions. a treatment with those that did not. Because
simple comparisons between cohorts may
Josephine Hegarty suffer from a number of design problems,
Eileen Savage such as biased sample selection, intervening
historical events that may influence the out-
come variable, maturation of subjects, and
testing effects, a strong cohort design can
Cohort design account for many of these threats to the inter-
nal validity of a study.
There are two major types of cohort
A cohort design is a time-dimensional design design: the cohort design with treatment par-
to examine sequences, patterns of change or titioning and the institutional cycles design.
growth, or trends over time. A cohort is a In a cohort design with treatment partition-
group with common characteristics or expe- ing, respondents are partitioned by the extent
riences during a given time period. Cohorts of treatment (amount or length) received. In
generally refer to age groups or to groups of the institutional cycles design, one or more
respondents who follow each other through earlier cohorts are compared with the experi-
formal institutions such as universities or mental cohort on the variable(s) of interest. The
hospitals or informal institutions such as institutional cycles cohort design is strength-
a family. Populations also can be classified ened if a nonequivalent, nontreatment group
according to other time dimensions, such as is measured at the same time as the experi-
time of diagnosis, time since exposure to a mental group. A well-planned cohort design
treatment, or time since initiating a behavior. can control for the effects of age or experience
A cohort might be graduates of nurse practi- when these might confound results in a pre-
tioner programs in the years 1995, 2000, 2005, test–posttest design or when no pretest mea-
and 2010 or siblings in blended families. sures of experimental subjects are available.
Cohort designs were originally used by Cohort designs might use a combination of
epidemiologists and demographers but are cross-sectional and longitudinal data.
increasingly used in studies conducted by The term cohort studies broadly refers
nurses and other researchers in the behav- to studies of one or more cohort groups to
ioral and health sciences. examine the temporal sequencing of events
In the most restrictive sense, a cohort over time. Cohort studies may eventually
design refers to a quasi-experimental design lead to hypotheses about causality between
in which some cohorts are exposed to a variables and to experimental designs.
treatment or event and others are not. The Most cohort designs are prospective (e.g.,
purpose of a cohort design is to determine the nurses’ Health Study, in which 100,000
whether two or more groups differ on a nurses were enrolled in 1976 and have
specific outcome measure. Cohort designs been followed since), although some are
are useful for drawing causal inferences in retrospective.
quasi-experimental studies because cohort There are a number of types of cohort
groups are expected to differ only minimally studies. The panel design, in which one or
on background characteristics. Recall that more cohorts are followed over time, is espe-
a quasi-experimental design lacks random cially useful for describing phenomena.
72 n CoLLABoRATIvE RESEARCH
Trend studies are prospective designs used cost. Further, collaborative research has
to examine trends over time. In trend stud- gained momentum as grant dollars have
C ies, different subsamples are drawn from a dwindled, relevant evidenced-based practice
larger cohort at specified time points to look has become a professional expectation, and
at patterns, rates, or trends over time. Panel health care clients have become consumers.
designs with multiple cohorts are used to In response to these societal and professional
study change in the variable(s) of interest over variables, researchers recognize the need to
time, to examine differences between cohort enlarge their network of potential research
groups in variables, and to identify different partners. Implementation of collaborative
patterns between groups. In a panel study research promotes accountability of research
with multiple cohorts, the groups can enter funds, energizes the exploration of identi-
the study at different points in time, and the fied phenomenon, and provides consumers
effects can be differentiated from the effect of health care the most current knowledge.
of being a member of a particular cohort Through the inclusion of community lead-
group. A prospective study is a variation of ers, faith-based entities, and clients who are
a panel design in which a cohort free of an daily addressing the phenomenon, research
outcome but with one or more risk factors is has become much more relevant and timely.
followed longitudinally to determine who The research questions have increased spec-
develops the health outcome. The prospec- ificity and applicability and offer answers to
tive design is used to test hypotheses about complex health care situations.
risk factors for disease or other health out- Collaborative research encourages the
comes. Some authors limit the term “cohort formation of research networks that include
study” to designs in which exposed and non- all members involved with the phenomenon
exposed subjects are studied prospectively of interest. Each member brings a set of skills
or retrospectively from a specific point. A and ideas that enhance the exploration of
major problem with prospective studies of all the phenomenon. Academicians contribute
types is subject attrition from death, refusal, knowledge and expertise in research meth-
or other forms of loss. The loss of subjects in odology, grant writing, and dissemination
a prospective study may lead to biased esti- through presentations and publications.
mates about the phenomena of interest. Clinicians provide hands on application
of the current health care practice, insight
Carol M. Musil into the clinical environment and aware-
ness of relevant questions (Gitlin, Lynon, &
Kolodner, 1994). Community and faith-based
leaders infuse the research think tank with
Collaborative researCh an understanding of the social and political
factors influencing the phenomenon as well
as awareness of external resources to facili-
The word collaborative is derived from the tate the research process and to address the
Latin word collaborare, which means to labor identified needs (Story, Hinton, & Wyatt,
together (Merriam-Webster, 2010). Therefore, 2010). Finally, the incorporation of the cli-
collaborative research implies that a group ent/participants into the research network
of persons are “laboring together” to exam- brings a depth and an understanding that
ine an idea, a concept, or a phenomenon. all too often has been overlooked in the
Collaborative research has become more research process (Corcega, 1992). Each of
imperative as the world has become more these research team members is essential for
complex through advances in technology, meaningful and relevant research. Aristotle’s
globalization, and escalating health care maxim “the whole is greater than the sum of
CoLLABoRATIvE RESEARCH n 73
its parts” illuminates the synergy that collab- minutes of meetings. All research members
orative research produces. should have administrative support for their
Recently, collaborative research has involvement in the research project. Further, C
gained popularity, and there are many to empower all team members to attend
reports in the nursing literature of successful the meetings, multiple technological means
outcomes (Bossert, Evans, Cleve, & Savedra, should be available (conference calls, online
2002; Chiang-Hanisko, Ross, Ludwick, & and podcasting). The use of technology to
Martsolf, 2006; Paton, Martin, McClunie- promote the collaborative research process
Trust, & Weir, 2004; Story et al., 2010). Some has been documented by Wilson et al. (2007)
of the significant rewards of engaging in col- and described as the development of a vir-
laborative research are as follows: utilization tual research process.
of a broader, more in-depth knowledge base, To address political and power conflicts
joining of financial resources, empower- that might arise, the research team should
ment of all persons who intersect with the establish rules of engagement and deter-
phenomenon of interest, and expeditious mine decision-making processes. If there
dissemination of findings. Additionally, are any concerns of hidden agendas, these
Adam et al. (2009) noted that collaborative issues should be discussed at the outset and
research encourages novice nurse research- expectations of all team members voiced.
ers and practicing nurses to take an active All organizational cultures represented in
role in the research process. Through this the team should be clearly understood by
team approach, novice researchers and prac- all members and the means to work within
titioners develop professional skills not only these cultures determined. To promote a
in research but also in networking with a positive collegial relationship between team
variety of research partners, broadening members, an ongoing process of review and
worldviews and enhancing presentation and evaluation should be in place and apart of
writing abilities. Finally, as stated by Denyes, every team meeting (McCloughen & o’Brien,
o’Connor, oakely, and Ferguson (1989), “the 2006). Adams et al. (2009) suggested that care
advancement of professional nursing requires be taken to insure that all team members are
integration of theory, practice and research clear on the language being used in the team
and one realistic mechanism to achieve this meetings and that all team members are val-
integration is collaborative nursing research” idated regarding the knowledge and skills
(p. 141). they contribute to the research project.
As with any process that involves work- The traditional model of collaborative
ing together, there are challenges that should research involves two or more research-
be addressed to promote successful outcomes ers with similar interest. This group of
for all involved. McCloughen and o’Brien researchers can be from the same organiza-
(2006) provided a thorough exploration of tion or from several different organizations.
challenges that should be addressed when MacDonald, Stodel, and Chambers (2008)
implementing collaborative research, includ- serve as an example of collaborative research
ing “communication, environmental issues, involving variety of health care professionals
politics and power, and organizational cul- and academicians. Avery, Cohen, and Walker
tures” (p. 172). To promote positive and (2008) documented collaborative research
transparent communication and to address involving a university nursing and technol-
environmental issues, research team mem- ogy faculty. The traditional model provides
bers should establish short- and long-term a means for clarification of a phenomenon
goals, schedule routinely meetings with an through pilot or small research studies and
established agenda, rotate meetings between promotes the identification of other poten-
team members work sites, and maintain tial research partners. Communication, work
74 n CoLLABoRATIvE RESEARCH
assignments, and outcomes are enhanced that assist them to become “educated, self-
because of minimal team members, similar reliant citizens capable of making decisions
C educational backgrounds, and complimen- regarding their own future . . .” (p. 186). The
tary skill sets. literature reflects several robust and success-
This traditional model is foundational for ful projects of this nature (Foster & Stanek,
progressing to boarder collaborative research 2007; Minkler, vasquez, Chang, & Miller,
between academics and health care agencies. 2008; Story et al., 2010). Story et al. (2010)
Examples of this type of research model is emphasized the utilization of this model in
well documented in the reports of Allam et al. addressing marginalized and vulnerable
(2004), Gaskill et al. (2003), McCann (2007), populations where lack of trust has often
McCloughen and o’Brien (2006), and Paton prevailed and bridging the gap between the
et al. (2004). Clear and frequent communica- “outsider and the insider” (p. 117). Shoultz
tion, identification of roles and expectations, et al. (2006) provided a comprehensive review
agreement on a decision-making process, of challenges that might be experienced
and support of parent organizations of the when implementing community-based par-
team members are imperative in promoting ticipatory research and provide suggestions
the success (McCloughen & o’Brien, 2006). for proactively addressing these issues.
Additionally, Gaskill et al. (2003) suggested A final model involves broadening of
that the partnership between the academic any of the previously discussed models to
and the practice sites be entered into with the include international partners. Melkers and
understanding that longevity will be needed Kiopa (2010) documented the professional
to build a milieu of trust, collegiality, and growth of all members involved in interna-
sustainability for this research relationship. tional collaborative research project. Jones,
Finally, Allam et al. (2004) documented the Wilson, Carter, and Jester (2009) provided a
inclusion of clients into this model and the thorough discussion of the benefits and chal-
strength this addition brings to the research lenges to consider in developing a successful
design, implementation, and outcomes. international research team.
Hospital-based research led by nurse The attributes offered through successful
executives and involving all levels of nurs- collaborative research become more appar-
ing service began to be noted in the liter- ent as expectations call for research that is
ature as magnet status for hospitals was of the highest quality, financially savvy, and
established during the mid to late 1980s capable of producing credible and applicable
(Kramer & Shcmalenberg, 2005). The empha- outcomes. To maximize the potential of col-
sis of achieving magnet status has led to laborative research, research partners should
increased specificity of research skills by all establish clear communication guidelines,
nurses affiliated with hospital organizations team goals, outcomes, role expectations, and
that have or are seeking to gain magnet sta- methods to work with the organizational
tus. Further, this change in hospital culture powers and cultures. To ensure maximum
has led to increased collaborative research effectiveness, collaborative teams should
within hospital organizations, streamlining routinely evaluate the research process
of research dollars, and increased dissemi- (McCann, 2007; McCoughen & o’Brien, 2006).
nation of research findings. Happell (2010) highlights methods to ensure
The most inclusive collaborative research that each team member maintains ownership
model is that of community-based partici- of their contributions to the research project
patory research, which involves academics, and encourages a written document that
practice, and community members. Corcega verifies the following key elements: member
(1992) stated that the strength of this model names with indentified expertise and orga-
is the empowerment of community members nizational affiliation, roles, determination
CoMFoRT THEoRY n 75
of authorship, solutions for potential change provides precision for assessment, interven-
in dynamics of team membership (illness/ tion, and evaluation of interventions that go
move), and methods for conflict resolution. beyond technical nursing skills and physi- C
cian orders. The importance and effective-
Kaye Wilson-Anderson ness of comforting interventions, such as
Joanne Warner coaching, encouragement, guided imagery,
environmental manipulation, back massage,
therapeutic presence and listening, and so
forth, may be quantifiable and visible within
CoMFort theory the patient record. From analysis of these
data, evidence for best practices and policies
may be derived.
Providing comfort to patients has a long his- Kolcaba (2003) provides a theoretical
tory within the mission of nursing. Comfort framework for practicing comforting care
has been conceptualized as a holistic outcome and for generating nursing research about
of nursing care. It has been defined as “the comfort. The theory states that interventions
experience of being strengthened by hav- should be designed and implemented to
ing needs for relief, ease, and transcendence address unmet comfort needs of patients and
addressed or met in four contexts of experi- their families. An assumption is that comfort
ence: physical, psychospiritual, environmen- is a basic human need; therefore, patients and
tal, and sociocultural.” These four contexts families often assist efforts toward enhanc-
for experiencing comfort are derived from ing comfort.
the literature on holism (Kolcaba, 2003). The The effectiveness of comforting inter-
rationale for providing comfort to patients ventions is dependent on the context of
and their families comes from (a) the histor- existing intervening variables. Intervening
ical mission of nursing to provide comfort, variables are factors that recipients bring to
(b) the satisfaction that this kind of care gives the situation and upon which team members
recipients and the deliverers of care, (c) the have little influence, such as financial status,
efficiency of using a consistent pattern for existing social support, prognosis, and reli-
care planning, and (d) the strengthening gious beliefs. Enhanced comfort strengthens
component of comfort which is derived from patients and their families during stressful
its original meaning (Kolcaba, 2003). health care situations, thereby facilitating
Comforting care consists of goal- health-seeking behaviors (HSBs).
directed activities (the process of comfort- Institutional integrity was defined by
ing) through which enhanced patient and/ Kolcaba (2003) as the quality or state of
or family comfort (the desired end product health care organizations being complete,
or outcome) is achieved. The process is ini- whole, sound, upright, professional, and eth-
tiated by the nurse and/or other team mem- ical providers of health care. When patients/
bers after an assessment of the comfort needs families engaged in HSBs, they heal faster,
of the patient/family. Because the specified learn more, and increase their functional
product or goal is enhanced comfort, the status. Thus, comfort theory (CT) states
process is evaluated by comparing comfort that institutions such as hospitals, agencies,
levels before and after interventions that and private practices would demonstrate
are targeted toward comfort. The process is improvements in institutional outcomes,
incomplete until the product of enhanced such as fewer readmissions or recurrences
comfort is achieved (Kolcaba, 2003). of health problems, higher patient satisfac-
Within the structure of nursing knowl- tion, and desirable cost–benefit ratios. Also,
edge, the technical definition of comfort institutions that provided sufficient support
76 n CoMFoRT THEoRY
for nurses to practice comforting care would (d) hand massage for persons near end of
demonstrate increased nurse loyalty and life, and (e) generalized comfort measures for
C productivity and less absenteeism because women during first and second stages of labor.
this kind of nursing care is less stressful In each study, interventions were targeted to
and more satisfying, not only for patients/ all attributes of comfort relevant to the research
families but also for nurses. settings. Comfort instruments were adapted
CT focuses on enhancing patient/family from the General Comfort Questionnaire
comfort for altruistic and pragmatic reasons. (Kolcaba, 2003) using the taxonomic structure
Patients/families want to be comforted by of comfort as a guide, and there were at least
nurses in stressful health care situations, and two measurement points, usually three, to
CT reminds nurses about the strengthen- capture changes in comfort over time.
ing aspect of comfort interventions. Because CT guides researchers to test relation-
comfort theoretically is related to subsequent ships between comfort and HSBs. These
desirable health and institutional outcomes, relationships have been consistently pos-
the outcome of enhanced comfort is elevated itive, and comfort has found to be a good
in stature among other more technical and indicator for those who do well in therapy
narrow outcomes. It is a desired, holistic, or new regimens. Therefore, nurses have
value-added, and (often) nursing- sensitive a pragmatic rationale for enhancing their
outcome that is congruent with recent man- patients’ comfort. Third, it guides nurses to
dates to measure nursing effectiveness test relationships between HSBs and insti-
in terms of positive patient/family goals tutional outcomes (such patient satisfaction,
(Magvary, 2002). CT also is nurse-friendly the national and publicized benchmark for
because it places responsibility and incen- “best hospitals”).
tives on health care institutions to provide To demonstrate that providing comfort
working conditions conducive to comfort- is an still an important mission for nursing,
ing care. Improving working conditions is more tests of CT must be conducted. Choices
the underlying rationale for the inception of for desirable HSBs could include increased
the Magnet Status award by the American functional status, increased T-cell count,
nurses Association (Kolcaba, Drouin, & faster progress during rehabilitation, faster
Kolcaba, 2006). Suggestions and rationale for healing, or peaceful death (when appro-
teaching comforting care and using CT as a priate). In addition to meeting benchmarks
framework for ethical decision making are such as higher patient satisfaction scores or
in Kolcaba’s (2003) book and on her Web site decreased nurse turnover, institutional out-
(www.TheComfortLine.com). comes could include decreased length of stay
CT guides nurse researchers to test rela- for hospitalized patients, decreased readmis-
tionships between particular holistic inter- sions for the same or related medical problem,
ventions and comfort. Several empirical tests and general cost–benefit analyses for specific
of the first part of comfort theory (CT) have evidence-based protocols. Improved institu-
been conducted by Kolcaba (2003). These tional outcomes are of interest to administra-
comfort studies demonstrate significant dif- tors, funding agencies, third-party payers,
ferences between treatment and usual care and policy makers.
groups on comfort over time. The following A large number of comfort management
interventions were tested: (a) types of immo- strategies and guidelines have been created
bilization for persons after coronary angio- by Kolcaba, and each component is available
gram, (b) guided imagery for women going on her Web site. These strategies include but
through radiation therapy for early breast are not limited to comfort contracts, comfort
cancer, (c) cognitive strategies for persons rounds, comfort assessments, comfort check-
with urinary frequency and incontinence, lists, comfort instruments for small children
CoMMUnITY MEnTAL HEALTH n 77
and patients who are nonverbal or uncon- increase in resources was initiated (Bonner,
scious, comfort management competency 2000; Wright, Bartlett, & Callaghan, 2008).
tests, instruments for research, and so forth. The shift from hospital to community C
posed challenges for psychiatric nursing
Katharine Kolcaba in both countries. Most psychiatric nurses
in the United States were educated through
hospital-based programs, making them
ill equipped to take on the demands of an
CoMMunity Mental expanded community role. Although the
findings of several early descriptive studies
health (Hess, 1969; Hicks, Deloughery, & Gebbie,
1971) show psychiatric nurses functioning in
diverse roles, nursing leaders (Mereness, 1983)
over the past 50 years, the community mental during this period expressed concern that
health movement has had a tremendous too often nurses in community mental health
impact on psychiatric nursing, taking psy- adopt “residual roles,” resulting from their
chiatric nurses into communities and freeing lack of education in psychiatric theory and
them from their almost exclusive practices in unequal status among fellow professionals.
large state hospitals. nursing research in the In the United Kingdom, social workers
area of community mental health has steadily were the primary professionals delivering
increased, the United Kingdom having con- care to mentally ill patients in the commu-
tributed most to this body of literature, espe- nity. nursing was represented by the part-
cially in recent years. Historic influences in time activity of hospital-based psychiatric
the United States and United Kingdom cre- nurses who were seen merely as a mech-
ated different climates from which nursing anism through which psychiatrists could
research in each of these countries emerged. extend their authority beyond the confines
From the early nineteenth century until of the hospital (Bonner, 2000; Wright et al.,
the 1960s, mental hospitals, or “asylums,” 2008). In both countries, the main role for
constituted the major treatment resource community psychiatric nurses during these
for the mentally ill in both the United States early years was the task of administering
and United Kingdom. Advances in the use of depot injections to patients with severe men-
psychotropic medications and government tal disorders.
policy directives in each country spurred The 1970s and 1980s were character-
movement of mentally ill patients into the ized by role differentiation and expansion
community. The historic report, Action for for community psychiatric nurses in both
Mental Health, presented to the U.S. Congress countries. In the United States, there was
in 1961, recommended a shift to community- recognition of the need for advanced edu-
based care. This was followed in 1963 by the cational preparation of psychiatric nurses
enactment of the Community Mental Health to meet the challenges of this evolving role
Centers Act, which authorized $150 million (DeYoung & Tower, 1971). The findings of
in federal funds to develop comprehensive one descriptive study (Davis & Underwood,
community mental health centers (Miller, 1976) show that although half of the nurses
1981). The United Kingdom followed suit in employed in four community mental health
1962 when British politician Enoch Powell centers earned a bachelor’s degree and pro-
presented his Hospital Plan for England to vided some consultation and counseling,
Parliament; however, it was not until the most of their time was spent performing
publication of the 1975 White Paper, Better traditional functions. With increased edu-
Services for the Mentally Ill, that any real cational opportunities, funded largely by
78 n CoMMUnITY MEnTAL HEALTH
the national Institute of Mental Health in and expand their practices to include a var-
the 1980s, psychiatric nurses grew more ied clientele base.
C sophisticated and diversified. They began to In the United States, psychiatric nurses
function as psychotherapists for individu- continued to develop pivotal roles in a vari-
als, families, and groups and to serve as ety of community treatment modalities. In
case managers and coordinators of commu- one national survey of assertive outreach
nity services. Psychiatric home care nursing programs, findings show that 88% had a
also began to flourish during this period as psychiatric nurse as an integral member
reimbursement for these services became of the treatment team (Deci, Santos, Hiott,
available (Fagin, 2001). Although nurs- Schoenwald, & Dias, 1995). over time, psy-
ing research related to community mental chiatric clinical nurse specialists became
health was still scarce, an early intervention recognized as independent practitioners,
study (Slavinsky & Krauss, 1982), funded eligible for third-party reimbursement, and
by the national Institute of Mental Health, active in caring for seriously mentally ill
characterized nurses’ commitment to the patients (Iglesias, 1998; White, 2000); how-
care of psychiatric patients in the commu- ever, research addressing specific psychiat-
nity and their skill in developing innovative ric nursing interventions for this population
programs for this population. was still quite limited (Beebe, 2001; Rabbins
The drive for autonomy for community et al., 2000). The “Decade of the Brain” in the
psychiatric nurses in the United Kingdom 1990s brought the medicalization of psychi-
was away from psychiatry and “general nurs- atric practice. In response to the challenge
ing.” Their “professionalization” and expan- of integrating biologic knowledge into clin-
sion was largely achieved through their ical practice, psychiatric nurses working in
successful incursion into primary health care community mental health centers and in pri-
and distancing from mental health teams. vate practice in the United States sought pre-
Government initially supported community scriptive authority. Current nursing research
psychiatric nurses’ efforts in building new reflects efforts to understand prescribing
relationships with general practitioners and practices of advanced practice psychiatric
even funded their training (Godin, 2000). nurses (Talley & Richens, 2001) and identify
Community psychiatric nurses expanded in barriers to prescriptive practice (Kaas, Dahl,
number and also in the range of therapeutic Dehn, & Frank, 1998).
approaches used in their practices. As their By the 1990s, community psychiatric
self-image as professionals and their rela- nurses in the United Kingdom were numeri-
tionships with general practitioners grew, cally the most dominant occupational group
however, their caseloads became composed within community mental health care; how-
of patients with less severe problems (Godin, ever, this also meant that they were per-
1996). The findings of one U.K. study (Barratt, ceived as responsible for many of its failures.
1989) show community psychiatric nurses’ Criticism was primarily directed toward
self-perceived roles becoming more differen- their decision to shift focus away from the
tiated, emphasizing prevention, counseling, care of patients with severe mental illnesses
and a variety of therapies for certain patient in favor of work in primary health care. Many
populations. Another study (Wetherill, Kelly, also questioned the effectiveness of their
& Hore, 1987), investigating the effectiveness work in primary care, contending that coun-
of a structured home intervention to improve seling-based interventions were of unproven
patient compliance in alcohol treatment and worth with people experiencing minor, self-
recovery, demonstrates the growing ability of limiting problems, and were not cost effective
community psychiatric nurses in the United (Hannigan, 1997). not only were community
Kingdom to develop innovative interventions psychiatric nurses directed to reappraise the
CoMPARATIvE EFFECTIvEnESS RESEARCH n 79
value they placed upon serving those with expand, it will be difficult for nurses to plan
severe mental illness, they were also directed and test community interventions to decrease
to develop and apply evidence-based inter- stigma and/or disparity and to understand C
ventions with this population. how such interventions work. Research pri-
one needs only to scan recent reviews of orities related to stigma and disparity are
nursing research to gain an appreciation of nonetheless fertile grounds for future nurs-
the effort that has and is being put forth by ing research in community mental health.
psychiatric nurses in the United Kingdom to
meet this mandate. The nursing literature is Wendy Lewandowski
replete with studies investigating the clinical
impact of specific interventions with severely
mentally ill patients. Examples include nurs-
ing interventions for early detection of med- CoMparative eFFeCtiveness
ication side effects (Jordan, Tunnicliffe, &
Sykes, 2002), for identifying psychiatric ill- researCh
ness in the elderly (Waterreus, Blanchard, &
Mann, 1994), for providing sex education to
mentally ill patients (Woolf & Jackson, 1996), Comparative effectiveness research in nurs-
for using an “insight program” with patients ing is the generation and synthesis of evi-
diagnosed with schizophrenia (Pelton, 2001), dence generated through prospective and
and for implementing a self-management retrospective nursing studies with either pri-
model of relapse prevention for psychosis mary or secondary data sources by
(Stevens & Sin, 2005). Findings from a sys-
tematic review of 52 randomized controlled • comparing the benefits and harms of
trials of mental health interventions deliv- alternative nursing methods to prevent,
ered by the U.K. mental health nurses (Curran diagnose, treat, and monitor a clinical con-
& Brooker, 2007), such as family work with dition or to improve the delivery of care;
families of patients with schizophrenia (Leff, • comparing the same nursing method(s)
Sharley, Chisholm, Bell, & Gamble, 2001) and between different patient groups;
transitional discharge planning (Reynolds • comparing the same nursing method(s)
et al., 2004), show that psychiatric mental between different clinical environments; or
health nurses are involved in the delivery of • comparing one or more nursing methods
a wide range of evidenced-based interven- across combinations of treatments, patient
tions in the community. groups, and/or environments.
Today in the United States, the call by
the U.S. Surgeon General (U.S. Department At the clinical level, comparative effec-
of Health and Human Services, 1999) and tiveness research investigates nursing
the Presidents’s new Freedom Commission methods (preferably already shown to be effi-
on Mental Health (2007) to reduce stigma cacious in randomized controlled trials) in
and disparity related to accessing commu- real-world settings; that is, under ordinary
nity mental health care services has spurred and variable conditions, when prescribed
nurses’ interest in stigma research (Halter, by licensed nurses with varying degrees of
2004a, 2004b; Raingruber, 2002); however, expertise and practicing across the spectrum
movement toward understanding and reduc- of health care settings, to treat a heteroge-
ing stigma and disparity is still at its infancy, neity of patients. Comparative effectiveness
and nursing research in these areas has been research in nursing aims to discover the
qualitative and nonexperimental (Pinto-Foltz best nursing methods for personalizing care
& Logsdon, 2009). Until these research areas to individual patients by broadening the
80 n CoMPLEMEnTARY AnD ALTERnATIvE PRACTICES AnD PRoDUCTS
evidence base and by providing more, bet- use of CAPPs among senior citizens, specif-
ter, and detailed information with which to ically in the aging U.S. population. In recent
C craft a nursing management strategy for each national and regional sample studies, 62% to
individual patient. The ultimate purpose of 88% of people 65 years and older used at least
comparative effectiveness research is to assist one CAPP modality compared with 46% of
consumers, clinicians, purchasers, and policy those younger than 65 years (p < .001; Ai &
makers to make informed decisions that will Bolling, 2002; Cheung, Wyman, & Halcon,
improve health care at both the individual 2007; ness, Cirillo, Weir, nisly, & Wallace,
and population levels. 2005). The 2007 national Health Interview
Survey data also provide the first definitive
Ivo Abraham report for out-of-pocket costs for complemen-
Sally Reel tary and alternative therapies among adults
in the United States. The total, $33.9 billion,
equals 1.5% of total 2007 U.S. health care
expenditures (nahin, Barnes, Stussman, &
CoMpleMentary and Bloom, 2009).
alternative praCtiCes In response to the increasing interest of
the American people in the healing potential of
and produCts CAPPs, the federal government created in 1992
the office of Alternative Medicine, elevated
in 1998 to the nCCAM because the Congress
A large percentage of persons worldwide are believed that the widespread public use of
using complementary and alternative prac- CAPPs in the absence of scientific evidence
tices and products (CAPPs), referred to also warranted a more focused research effort at
as “complementary and alternative medi- nIH (nIH/nCCAM, 2010c). The mission of
cine” (CAM) and, more recently, as “inte- nCCAM is to define, through rigorous scien-
grative medicine” (national Institutes of tific investigation, the usefulness and safety
Health, national Center for Complementary of CAPPs and the role they play in improv-
and Alternative Medicine [nIH/nCCAM], ing health and health care. The anecdotes
2010d). The term “integrative health care” is about efficacy and effectiveness of practices
increasingly used by clinicians and research- for which there are not plausible explanations
ers, reflecting findings in the survey liter- are insufficient today, thereby giving impor-
ature that suggest most people use CAPPs tance to well-designed and well-executed
in conjunction with rather than as an alter- research. Beginning with the appointment
native to conventional or mainstream health of the first director of nCCAM in May 1999
care services (nIH/nCCAM, 2007b). and the publication of its first strategic plan
Despite any confusion in use of terms, in September 2000, nCCAM has funded both
recent surveys (Barnes, Bloom, & nahin, 2008; extramural and intramural research focused
nIH/nCCAM, 2007a) indicated that a signifi- on CAPPs-related clinical, translational, and
cant percentage of the adult population in the basic research on the efficacy, safety, and
United States (38.3% or approximately 4 in mechanisms of action of diverse CAM modal-
10 adults) and a small percentage of children ities (nIH/nCCAM, 2010b). Celebrating its
(12% or approximately 1 in 9 children) have 10th anniversary in February 2009, nCCAM
used or are using a variety of these ancient boasts a Web site (http://nccam.nih.gov/) that
and modern CAPPs to treat symptoms and provides educational materials in written and
conditions, ranging from back and other audiovisual form.
musculoskeletal pain to anxiety and/or sleep In addition, nIH has collaborated with
disorders. A parallel trend is the increasing the U.S. national Library of Medicine to
CoMPLEMEnTARY AnD ALTERnATIvE PRACTICES AnD PRoDUCTS n 81
create a Web site in a “town hall” platform. mandates. nCCAM now has developed five
Its goal is to create an across-the-lifespan primary research training centers to support
“informed consumer” by providing the national and international research projects, C
best evidence possible and the most reliable all of which are focused on elucidating mech-
resources available that are relevant to the anisms of action of CAPPs as defined within
health of the U.S. population. Providing such each of the major modality categories (nIH/
a platform provides the U.S. populace with nCCAM, 2010b). For example, recent stud-
opportunities and access to primary, second- ies include, but are not limited to, exploring
ary, and tertiary health prevention and main- the mechanisms and effects of metabolic and
tenance measures (nIH/national Library of immunologic effects of meditation, effects
Medicine, 2010). of various CAPPs research on autoimmune
The term complementary medicine/ and inflammatory diseases, and chiroprac-
therapies was introduced during the decade tic manipulation (nIH/nCCAM, 2010b).
of the 1970s in the United Kingdom and refers State-of-the-science information on selected
to those practices and products that link CAPPs and searches of federal databases
the most appropriate therapies to meet the of scientific and medical literature may be
individual’s physical, mental, emotional, and found on nCCAM’s Clearinghouse Web site
spiritual needs. In some cultures, the term (http://nccam.nih.gov/).
“alternative” refers to those practices and Selected CAPPs have been studied suf-
products that are provided in place of con- ficiently to provide conclusive evidence of
ventional or allopathic health care, many of effectiveness. For example, there are data to
which are outside the realm of accepted health support a number of behavioral and relaxa-
care theory and practices in the United States. tion practices used to treat pain and insom-
Today CAPPs re grouped into the broad cat- nia. However, data currently available are
egories of natural products, mind–body prac- insufficient to be definitive that one practice
tices, manipulation and body-based practices, or procedure is more effective than another
and other CAM practices, which include for a given condition. Yet, because of psycho-
movement therapies (e.g., Trager psychophys- social differences among persons, cultural
ical integration, Feldenkrais method), energy diversity, and variations in personality char-
therapies (e.g., therapeutic touch, qi gong, acteristics among individuals, one procedure
electromagnetic energy fields as in magnet or product may be more suited than another
therapy), traditional healers as found in the for a given person (Cuellar, Aycock, Cahill, &
native American medicine man, and whole Ford, 2003; Mackenzie, Taylor, Bloom,
medical systems such as traditional Chinese Hufford, & Johnson, 2003; nIH Technology
medicine (nIH/nCCAM, 2010d). Assessment Panel, 1996; owens, Taylor, &
To promote research in CAPPs, the office DeGood, 1999).
of Alternative Medicine initially established A challenge for health care profession-
10 research centers across the country, one of als today is to become and remain informed
which was directed by a nurse. The Center for regarding indications and contraindications
the Study of Complementary and Alternative for use of the myriad of procedures and
Therapies at the University of virginia was products that patients are using, including
thus established in 1993 as one of the original the potential interactions of natural products
nIH-funded centers to stimulate research in with pharmaceuticals, foods, and lifestyles.
this emerging field. The movement to offer content about CAPPs
Building upon this successful initia- within the curricula of schools of nursing,
tive, nCCAM has continued to increase the medicine, and pharmacy continues to be evi-
number of research centers, aligning the dent (Stratton, Benn, Lie, Zeller, & nedrow,
focus of these with its mission and legislative 2007). Among faculty responsible for the
82 n CoMPLEMEnTARY AnD ALTERnATIvE PRACTICES AnD PRoDUCTS
content, there appears to be not so much a and effectiveness of CAPPs permits the inves-
lack of agreement about integrating prac- tigator to analyze disparate patient care find-
C tice aspects of evidence-based CAPPs into ings and synthesize these into questions that
the curricula (Gaydos, 2001; Kligler, 1996) as will add to the body of evidence about these
there is acknowledgment of the challenges. therapies (owens et al., 1999). Findings result-
Such challenges include the need for quali- ing from research studies testing the efficacy
fied faculty, the crowded curricula content, of CAPPs will continue to lead to knowledge
a lack of defined best practices in CAPPs, that can be useful in making reliable predic-
and the postgrant sustainability of programs tions and linking appropriate therapies to
funded to integrate CAPPs into the curric- patients for promotion of health or symptom
ula (Lee et al., 2007). Addressing these chal- management (Lin & Taylor, 1998).
lenges remains core to efforts expended by The definition of what constitutes CAPPs
nIH/nCCAM to support integration of evi- will continue to evolve as researchers com-
dence-based information about CAPPs into plete rigorous scientific studies in this area. In
professional schools’ curricula (Pearson & an effort to empower consumers and encour-
Chesney, 2007; Rakel, Guerrera, Bayles, Desai, age health care professionals to stay current
& Ferrara, 2008; Yildirim et al., 2010). Such with advances in CAPPs research and clin-
curricula will need to support the education ical application, nCCAM launched a Web
of health care professionals about the science portal dedicated to a “Time to Talk” cam-
behind CAPPs, the evidence for effectiveness paign (nIH/nCCAM, 2008). Currently, this
and safety, the interactions among CAPPs site provides tips for consumers to discuss
and with other health care modalities, and use of CAPPs with their health care provid-
the pharmacology of biological agents ers and suggestions for health care providers
(nottingham, 2006). to elicit CAPPs usage information from their
The basis for research into CAPPs patients. The goal is informed health care
should not be adversarial, that is, “CAPPs that promotes safety and best care practices
versus mainstream health care modalities,” in health care settings.
but rather the scholarly inquiry into whether In addition to the need for rigorous
or not an intervention is effective, safe, and research on CAPPs, inclusion of education
contributes to the overall well-being of the about these modalities in the curricula for
consumer (nIH/nCCAM, 2010b). Rigorous health care providers and development of
research involving any of these practices and resources for consumers need to exist for
products can be across the spectrum of basic the development of competency standards
research, translational research, efficacy and measures involved in credentialing
studies, and effectiveness research. Research health care providers in CAPPs practice. of
often begins with basic questions: How does course the issues of liability will need to be
it work? How do individual differences, as addressed.
assessed by a given measurement tool, influ- Although consumers today are empow-
ence what happens or does not happen in ered to play a larger role in their health care
the use of a particular therapy for manage- outcomes, a large number of nurses and other
ment of a specified symptom? From general health care professionals still lack knowl-
questions such as these, coupled with exten- edge about CAPPs, thus creating a barrier
sive literature reviews and consultation with to integrative health care. Rigorous clinical
experts, more specific questions about the studies are needed to provide evidence of
use of these therapies in patient care evolve CAPPs treatment efficacy for many symp-
to guide investigators’ research. toms and conditions. Research monies are
Focusing on individual differences available for competitive research propos-
among patients when assessing use, efficacy, als through the nCCAM and other agencies
ConCEPT AnALYSIS n 83
within the nIH. Consumer demand contin- adequately reflects the defining characteris-
ues to drive integration of selected CAPPs tics); and (d) to accurately identify the con-
into the conventional health care system as cept when it arises in clinical practice or in C
well as to prompt the need for continued rig- qualitative research data.
orous science in this field. These factors fos- Concept analyses were relatively rare
ter optimism and increase the potential for in nursing research until the early 1980s
additional evidence-based holistic and sup- but have increased dramatically in number
portive care, facilitating the safe integration over the past two decades. Concept analysis
of selected CAPPs into an integrative health is particularly relevant to a young science
care environment. such as nursing. The process, regardless of
method, requires rigorous thinking about
Ann Gill Taylor the language used to describe the phenom-
Victoria Menzies ena of concern to the discipline. Doing a
concept analysis causes the researcher to be
much more aware of and sensitive to the use
of language in research. A conscious aware-
ConCept analysis ness of the language chosen to represent
phenomena is necessary if nursing scientists
are to develop a comprehensible body of
Concept analysis is a strategy used for exam- knowledge for the discipline.
ining concepts for their semantic structure. It is also necessary for thoughtful prac-
Although there are several methods for con- titioners to be aware of the language of the
ducting concept analysis, all of the methods discipline. How nurses think about and
have the purpose of determining the defin- describe the problems and solutions relevant
ing attributes or characteristics of the con- to their practice is of paramount importance
cept under study. Some uses of a concept in helping the consumer of nursing care and
analysis are refining and clarifying concepts the policymakers who influence the practice
in theory, practice, and research and arriving milieu to understand what nursing is and
at precise theoretical and operational defini- what nurses do. If nurses do not have a cen-
tions for research or for instrument devel- tral core of well-defined concepts to describe
opment. Concept analysis has been used in their practice, then confusion and ambiguity
other disciplines, particularly philosophy will persist, and the development of nursing
and linguistics, for many years. However, the science will suffer.
techniques have only recently been “discov- Concept analysis has become a useful
ered” by nurses interested in semantics and adjunct to nursing research. The outcome of a
language development in the discipline. concept analysis significantly facilitates com-
Concept analysis is a useful tool for munication between researchers and prac-
nurses conducting research. Because the out- titioners alike. By specifying the defining
come of a concept analysis is a set of defin- characteristics of a concept, the researcher or
ing characteristics that tell the researcher practitioner makes it clear what counts as the
“what counts” as the concept, it allows the concept so that anyone else reading about it
researcher (a) to formulate a clear, precise or discussing it understands what is meant.
theoretical and/or operational definition Being clear about meaning allows better
to be used in the study; (b) to choose mea- communication between scientists and prac-
surement instruments that accurately reflect titioners about the usefulness and appropri-
the defining characteristics of the concept ateness of nursing language.
to be measured; (c) to determine if a new There is considerable discussion in the
instrument is needed (if no extant measure literature about which method of analysis is
84 n ConCEPTUAL MoDEL (FRAMEWoRK)
the most useful. Regardless of the method sample size when studying a low-prevalence
used, concept analyses can contribute signif- disease; (b) to increase the ethnic diversity
C icant insights into the phenomena of concern or other characteristics of a sample, thus
to nurses. increasing generalizability of results; (c) to
shorten the time line for conducting the
Kay C. Avant study by simultaneously recruiting subjects
at multiple sites; (d) to provide mentoring
to more junior researchers and staff nurses;
(e) to share resources, tasks, and costs when
ConCeptual Model external funding is not available; and (f) to
(FraMework) increase opportunities for replication and
dissemination.
Consortial studies may be conceived by
Conceptual models (sometimes referred to one or a few investigators, who draft the ini-
as conceptual frameworks or grand theories) tial proposal then recruit colleagues at other
are abstract representations of phenomena of sites to participate in the study. These other
interest to the discipline. Specific theories can investigators may be involved in helping to
be derived from these conceptual models. The refine the proposal before it is submitted for
conceptual models themselves are not test- funding. When the purpose of the consor-
able, but the theories derived from the models tium is more focused on mentoring junior
may be tested. These grand theories provide colleagues or is a way to share resources and
global perspectives of the discipline and offer costs, it is more likely that development of
ways of viewing nursing phenomena on the the proposal will be a group endeavor from
basis of these perspectives. Examples of con- the start. In the latter case, the choice of topic
ceptual models in nursing are those of Martha may be generated by an advisory or steering
Rogers, Imogene King, Hildegarde Peplau, committee. Whichever approach is taken, the
Jean Watson, and Florence nightingale. pool of ideas generated by expertise from sev-
Descriptions of several of these models are eral institutions creates synergy that leads to
contained elsewhere in this text. more creative and productive research.
To conduct these multisite studies, one
Joyce J. Fitzpatrick site usually serves a coordinating function
for the study. Most often in externally funded
studies, the coordinating center is responsible
for identifying or developing questionnaires
Consortial researCh or other data collection forms, for data collec-
tion and processing procedures, and for receiv-
ing and centrally analyzing the study data.
Consortial research is a form of collabora- The oversight role of the coordinating center
tive research that can be used to increase includes development and implementation
the quantity and quality of nursing research of a quality control plan to assure standard-
within clinical settings. It involves cooper- ization of sample identification, recruitment,
ative efforts among researchers at several and data collection procedures. Scientific
institutions. The sites have formal, well- issues for the conduct of the study are usu-
defined administrative and working rela- ally managed by a steering committee, often
tionships that spell out agreed-upon roles composed of the principal investigator from
and responsibilities. each participating site and a few key individu-
Consortial studies are done for a num- als at the coordinating center. Standing or ad
ber of reasons: (a) to achieve the required hoc subcommittees of the steering committee
ConTEnT AnALYSIS n 85
are often formed to propose standards and adequate statistical power to compare the
to oversee the work on specific aspects of effects of treatment on the study outcomes.
the study. For example, the subcommittees It may be expected that consortial C
bring proposals for publications and presen- research will increase as nursing researchers
tations, participant safety and end points, or do more experimental research. Another fac-
clinical aspects before the steering committee tor that may promote consortial research in
for approval. The degree to which the steer- nursing is the changing health care system.
ing committee is involved in development As health care systems increase the number
of protocols, questionnaires, and so forth, as of contractual arrangements in attempts to
opposed to approving those developed by the provide cost-effective, integrated care across
coordinating center, varies by study and the the continuum of patient needs, consortial
reason the consortium was created. research is likely to become more common.
In a consortium formed primarily for
the purpose of sharing resources, mentor- Barbara Valanis
ing junior researchers, replicating a previous
study, or disseminating results, the steering
committee may be composed of representa-
tives appointed by each participating insti- Content analysis
tution. In such cases, the steering committee
often serves the purpose of setting priorities
for the activities of the consortium. Funding Content analysis is a data analysis tech-
of studies conducted by a consortium may nique that is commonly used in qualitative
take several forms. When external funding is research, which focuses on structuring par-
involved, the two most common types are (a) ticular topics or domains of interest from
providing one large grant to a coordinating unstructured data. It is a time-consuming
center, which then subcontracts with each process that involves organizing, identifying,
clinical site, and (b) providing individual coding, and making categories from patterns
grants to each participating institution with of data that are reflective of the topics. The
a separate grant to the coordinating center. topics or domains of interest are generated
The first approach gives the coordinating by the researcher on the basis of data derived
center budgetary leverage when a site is not from collection source and are also often
performing up to par. This is an advantage referred to as category labels. Historically,
for involving a new site or increasing the early content analysis focused on linguistic
number of subjects enrolled at existing sites and observational data. The earlier or clas-
by redistributing funds from the nonper- sic content analysis included techniques for
forming site. The second approach requires reducing texts to a unit-by-variable matrix
that each site meet the commitments for the and then analyzing the matrix quantitatively
good of the overall study. A third model, to test hypotheses (Denzin & Lincoln, 2000).
used when external funding is not available, In addition to information derived from
shares the cost of the research among partici- interviews and casual or structured observa-
pating institutions within the consortium. tions, researchers may analyze written text
In medical treatment research and pub- from special documents, archival records,
lic health prevention research, consortial field logs, and diaries or may develop
arrangements have been a preferred struc- schemes to analyze visual data from pictures
ture for large randomized trials that must or videotapes.
recruit substantial populations in a rela- Content analysis begins with reading
tively short time, provide intervention, and the text or written transcription of an inter-
have sufficient follow-up time to generate view, notes from an observation, or some
86 n ConTEnT AnALYSIS
other mode of data collection. The investiga- that are available to assist organization of
tor reads the completed text and determines qualitative data.
C the main ideas or topics of the transcription Most qualitative research suggests using
or observation. The investigator then rereads between 10 and 15 main topics per study
the text and numbers and assigns a code to (Denzin & Lincoln, 2000; Patton, 2002). They
each segment or group of lines from the tran- caution against making topics too special-
scription. Sometimes this may also be called ized as only very small amounts of data will
labeling. Segments may consist of a single be able to fit into each. on the other hand,
word or line, multiple words or lines, one or too many topics can cause confusion, and
more paragraphs, or a pictorial schema and the researcher may have difficulty in remem-
may vary according to the chosen topic or bering what categories go into each topic as
topics. The codes developed by the investi- the study progresses and more data are col-
gator reflect some commonality, such as an lected. With each subsequent interview or
action or behavior, an event, a thought, a con- observation, the topics may be combined or
cept, and so forth. Line segments or groups subdivided into multiple categories as the
of lines are separated and are grouped into need arises. As repetitive patterns arise,
categories, and the categories are grouped relationships between the categories and
according to the topics that were identified then between topics may be seen. often, the
by the investigator. relationships may occur at the same time or
Topics or domains of interest may be cho- be concurrent with each other. For example,
sen before a study, as with a focused study, in a study of adolescent face care, the topics
or generated after the first interview and “blemish care” and “facial scrubbing” are
based on the inquiry or subjective findings. related and occur at the same time. In the
A focused qualitative study centers on one same study, the topic “facial preparation”
particular area of interest or intent, such as occurs or is antecedent to the topics of “blem-
metaphorical analysis or feminist research, ish care” and “facial scrubbing,” whereas the
or it may focus on a particular phenomenon topical area “making up the face” may occur
like leadership style, body piercings among as a consequence of one of the earlier cate-
adolescent girls, or a demonstration of how gories that were formed. Some researchers
caring activities are performed. choose to quantify part of the analysis by
The researcher may also choose to counting frequency and sequencing of par-
develop topics after a first interview or obser- ticular words, phrases, or topics.
vation. Sometimes the topics seem to arise The major reliability and validity issues
naturally from the data, whereas at other of content analysis involve the subjective
times the researcher must decide on and nature of the researcher-determined topics
develop the topics from the information or category labels. What should be included
given. Developing a topic may be similar within each topic should be clearly defined
to making an index for a book or file labels and should be clearly different from the oth-
(Patton, 2002). The researcher reads through ers so that the results are mutually exclu-
the transcript of the interview or observation sive. The easiest way to determine reliability
and begins to sort and organize the inter- in a study that uses content analysis is to
view data according to likenesses and simi- have two or more readers, other than the
larities. The researcher usually gets a sense researcher, agree that the topics are appropri-
of the main topics that pervade the text soon ate for a particular study and that data can
after the transcribing process is complete easily be organized under each. This is typ-
and after the first reading. This organization ically carried out by having the researcher
of the data may be done by hand or by using randomly choosing a part of the study and
one of the many computer software packages having the readers look over the text and the
ConTInUInG CARE RETIREMEnT CoMMUnITIES n 87
topics independent of each other. A consen- residents’ monthly fee; (2) Type B CCRCs do
sus of the readers would indicate the study’s not guarantee unlimited nursing home care
reliability. but have a contractual agreement to provide C
validity in content analysis can be a specific number of days per year or lifetime
achieved by determining the extent that the of the resident in the nursing facility; and
topics represent what they are intended to (3) Type C CCRCs are based on a typical
represent. If the topics are based on a concep- fee-for-service approach. Financial stability,
tual framework or a particular focus, they particularly of Type A and Type B CCRCs,
must be justified, described, and explained depends on high occupancy rates in the inde-
in terms of being representative of that con- pendent living apartments and maintaining
ceptual framework or focus. Therefore, top- residents’ in optimal health and function so
ics that are developed to reflect a conceptual as to need fewer health care services.
framework or focus must be consistent with The number of CCRCs continues to grow,
the original definitions described by that and there are more than 725,000 older adults
framework. However, because content analy- living in more than 2,240 CCRCs. The major-
sis is often used in exploratory and descrip- ity of CCRCs are located in 12 states. Because
tive research, a conceptual orientation may of the dramatic increase in assisted living
not be appropriate. facilities, CCRCs proportionally account for
a smaller percentage of senior housing than
Kathleen Huttlinger previously. Given the anticipated increase in
number of older adults, it is expected that the
number and occupancy of these settings will
likewise increase.
Continuing Care Generally, older adults who live in
CCRCs are those who were never married, or
retireMent CoMMunities married without children, are well educated,
and health conscious (American Association
of Homes and Services for the Aged, 2006;
A continuing care retirement community Lewis et al., 2006; Zalewski, Smith, Malzahn,
(CCRC) is a type of facility that provides vanHart, & o’Connell, 2009). Initially
housing, meals, and other services, includ- CCRCs were for affluent older adults; how-
ing nursing home care, for older adults in ever, CCRCs are becoming more affordable
exchange for a one-time capital investment or and attracting those with more moderate
entrance fee and a monthly service fee. Most incomes (Anderson, Michelman, Johnson, &
CCRCs are sponsored by religious or other Quick, 2008). The decision to move into a
nonprofit organizations, but for-profit orga- CCRC requires a good deal of planning and
nizations have entered into the retirement adjustment for older adults, especially if they
business as well. The CCRC is usually con- are relocating to another city or state and/
structed as a village or community, and the or moving from a large home to a smaller
individual remains within this community apartment.
for the remainder of his or her life. All CCRCs Residents in CCRCs overall use of
have a written contract that residents must Medicare-covered medical services is no
sign. The terms of the contract vary and have different from older adults who live in tra-
been separated into three categories by the ditional community settings, with the excep-
American Association of Homes and Services tion of lower expenditures for hospital care
for the Aged: (1) Type A homes are “all inclu- (Ruchlin, Morris, & Morris, 1993). The types
sive” as they offer guaranteed nursing care of health care services provided vary on the
in the nursing facility at no increase in the basis of the facility. Most facilities have a
88 n ConTInUInG CARE RETIREMEnT CoMMUnITIES
nurse responsible for those in independent throughout the aging process (Adams, 1996;
living to help with routine care activities such Lewis et al., 2006; Petit, 1994; Resnick, 1998,
C as dressing changes, administration of inject- 2003; Resnick & Spellbring, 2000; Resnick,
able medications, and health screenings. It is Wagner, & House, 2003). Studies have
these nurses who are the first response to included descriptive surveys where residents
emergencies and often the first to identify are asked about specific health behaviors such
changes in the older resident. Depending as getting vaccinations, monitoring choles-
on the CCRC, there may also be a geriat- terol and dietary fat intake, exercise activity,
ric nurse practitioner available for daytime alcohol and nicotine use, and participation in
management of acute and chronic problems health screenings including mammograms,
and a cadre of primary and specialty physi- Pap tests, stools for occult blood or prostate
cians. The availability of health care is seen examinations, or osteoporosis management.
as a major advantage to living in a CCRC, Findings have indicated that the majority of
and the focus on health promotion and dis- residents in CCRCs get yearly flu vaccines,
ease prevention is of importance to residents. have had at least one pneumonia vaccine, and
The focus on health and the maintenance approximately 61% had an up to date tetanus
of health, which is held by the residents in booster. A smaller percentage (approximately
CCRCs and supported by managers within 30%) monitored their diets. Approximately
these systems, make the CCRC a perfect envi- 50% of those living in CCRCs drink alcohol
ronment for geriatric nursing research. regularly, only a small percent use nicotine
The initial research in CCRCs focused (11%), and less than 50% exercise regularly.
on the assessment of residents before move With regard to cancer screening, approx-
in (Resnick, Russell, & Ruane, 2003) and their imately 40% to 50% of the residents get yearly
adjustment to the community once the move mammograms, 31% to 37% get Pap tests, 65% to
occurred (Petit, 1994; Resnick, 1989). With the 80% get Prostate examinations, approximately
aging of the communities and the residents, 60% have stools checked for blood yearly, and
the focus of this work has moved toward a little more than 50% monitor their skin for
learning about transitions of care within these abnormal growths regularly. overall, there is
settings (e.g., moves from independent living better participation in health promoting activ-
to assisted living or nursing home; Ashcraft, ities of older adults living in CCRCs when
owen, & Feng, 2006; Shippee, 2009; Young, compared with older adults in the community
2009). Specifically, transitions have been con- (Lewis et al., 2006; Resnick, 2003). Residents of
sidered with regard to the meaning of those CCRCs tend to continue to engage in screen-
transitions for older adults as well as the risk ing activities even when these are not recom-
factors for transitions. Transitions within the mended (Lewis et al., 2006).
CCRC setting are described by residents as In addition to a description of the health
disempowering and final and noted to cause promotion behaviors of these individuals,
a loss of social networks. Factors associated consideration has been given to factors that
with increased risk of transitions include influence the residents’ willingness to engage
depression, urinary and bowel incontinence, in screening activities. Combined qualita-
cognitive impairment, and functional disabil- tive and quantitative approaches were used
ity. The findings from these studies provide to explore this question (Resnick, 1998, 2003;
recommendations for how to help prepare Rosenberg et al., 2009). Common themes
residents in CCRCs for transitions from one were identified by open-ended interviews
level of care to another. and indicated that the common reasons for
The majority of research done in CCRCs, not engaging in specific health activities
however, is focused on health promotion were as follows: (1) never being told to by a
ConTInUInG CARE RETIREMEnT CoMMUnITIES n 89
primary health care provider, (2) not wanting having an injurious fall. Individuals who had
to do anything even if the tests were abnor- atrial fibrillation or neurological problems,
mal, (3) feeling they were too old, and (4) a were not married, and did not adhere to a C
desire to contract the known problem so as to regular exercise program were more likely
facilitate death. to have multiple falls. In addition, it was
The impact of the CCRC environment noted that the falls were less likely to occur in
(i.e., access to services and physical environ- residents who exercised regularly (Crowley,
ment) on healthy behaviors has also been 1996). A CCRC setting was also used to test a
considered. Increased access to services in Post-Fall Index with the goal of using this tool
“all-inclusive” settings (Young, Inamdar, & for secondary prevention of falls in future
Hannan, 2010) increases the opportunities research (Gray-Miceli, Strumpf, Johnson,
for health promotion. In addition, the phys- Draganescu, & Ratcliffe, 2006).
ical environment, particularly the many CCRCs continue to be a viable liv-
opportunities for walking and other types ing environment for older adults. In order
of physical activity (Resnick & D’Adamo, for these facilities to keep costs down and
2011; Zalewski et al., 2009), is associated remain lucrative, it is imperative that there
with increased function and physical activ- be a focus on maintaining health and func-
ity regardless of the residents’ underlying tion and in helping individuals remain in the
capability. Conversely, with regard to life least invasive level of care (i.e., independent
prolonging interventions such as availabil- living). Continued research needs to build on
ity of automated external defibrillators, as the preliminary findings from exploratory
per the wishes of residents, these devices studies and begin to develop and test inter-
are not easily available for use in the facil- ventions that will help older adults in CCRCs
ity (Woodley, Medvene, Kellerman, Base, & maintain their health and function, prevent
Mosack, 2006). There is also no overwhelm- injuries, address end-of-life care preferences,
ing support of smart home technologies and optimize use of health care resources.
among CCRC residents because of concerns Examples of this include consideration of the
about privacy (Courtney, Demiris, Rantz, & increasing number of CCRCs with wellness
Skubic, 2008). There tends to be a philosophy programs and the outcomes of these pro-
among residents of optimizing health but grams from a health and fiscal perspective.
avoiding aggressive interventions that will other important areas of research within
sustain life in the face of illness (nahm & CCRCs need to address smart home tech-
Resnick, 2001). nologies and use of technology in general to
Falls, which are a common problem for promote health and safety, for example, use
older adults in any setting, is another area of smart phones to detect a fall among older
that has been studied in CCRCs. For exam- individuals or medication management tech-
ple, predictors of falls in a CCRC was stud- nology. Testing of the impact of electronic
ied (Resnick, 1999), and findings supported medical records to optimize transitions
the need to evaluate predictors of falls within within settings and between CCRC settings
each specific community as environmental and acute care facilities should also be the
risks and activity patterns may be very differ- focus of future research. CCRCs have been
ent. In the community studied, falls generally and will continue to be a wonderful housing
occurred between noon and midnight, within alternative for older adults, and consideration
the residents’ apartments, and when walking needs to be given to how to make these sites
(63%) or transferring (19%). only 16 (10%) of affordable for all.
the falls resulted in a fracture. The number
of falls was the only variable associated with Barbara Resnick
90 n CoRonARY ARTERY BYPASS GRAFT SURGERY
to improve quality of life (QoL; Dunckley,
C Coronary artery bypass Ellard, Quin, & Barlow, 2008; Hawkes,
nowak, Bidstrup, & Speare, 2006). Although
graFt surgery CABG surgery succeeds in increasing sur-
vival and decreasing angina in most patients,
it is now recognized that adjustment to
Coronary artery bypass graft (CABG) sur- CABG surgery is a multidimensional process
gery is a commonly used revascularization that is not completely explained by medical
procedure for coronary heart disease. An factors (Hawkes et al., 2006). Investigators
estimated 800,000 surgeries are performed have found that a substantial proportion of
worldwide each year (Borowicz et al., 2002), patients do not experience an improvement
with 448,000 performed in the United States in their QoL, with some patients actually
in 2006 (American Heart Association, 2009). experiencing decrease in QoL after sur-
In the United States, CABG surgery uses gery (Hawkes & Mortensen, 2006). In sev-
more healthcare resources than any other sin- eral global studies, researchers examined the
gle procedure and accounted for more than course of changes in QoL as well as longi-
209.3 billion dollars in health care costs in tudinal predictors of QoL. Patients under-
2003 (www.rxpgnews.com). In many devel- going percutaneous coronary interventions
oped countries, demand for CABG surgery experienced a relatively rapid increase in
exceeds resources leading to waiting lists. health-related QoL (HRQL) in the first month
Patients on waiting lists experienced anxiety, with little change by 3 months after surgery.
depression, and negative impacts on quality However, patients undergoing CABG sur-
of life (Fitzsimons, Parahoo, & Stringer, 2000; gery experienced an initial deterioration in
Screeche-Powell & owens, 2003). HRQL and then improved significantly. The
Several randomized controlled trials change in the scores on anxiety and depres-
examined the effectiveness of nurse-led sion accounted for most of the change in
programs for patients awaiting CABG sur- HRQL (Hofer, Doering, Rumpold, oldridge,
gery. Patients awaiting surgery with at least & Benzer, 2006). In a study evaluating the
one poorly controlled risk factor (e.g., high influence of preoperative physical and psy-
blood pressure, high cholesterol, smoking, chosocial functioning on QoL after CABG
etc.) were randomized to standard care or surgery (Panagopoulou, Montgomery, &
a nursing intervention. outcome measures Benos, 2006), researchers identified that pre-
included anxiety, depression, blood pres- operative psychological distress was the
sure, cholesterol level, length of stay, body only predictor of QoL at one month and six
mass index, and costs of hospital expendi- months after surgery.
tures. There were no significant differences Longitudinal studies investigating the
between the groups except for total costs impact of psychological variables on out-
of hospital expenditure, with the interven- comes of CABG surgery demonstrate that
tion group having fewer admissions, and recovery is neither simple nor experienced
therefore lower costs. Depression and anxi- consistently in all patients.
ety scores did decrease for the intervention Although some studies included the
group, but the difference between the groups measurement of only anxiety or depression,
was not statistically significant (Goodman most examined the impact of both anxiety
et al., 2008). and depression on recovery. In a systematic
For patients undergoing CABG surgery, review of preoperative predictors of postop-
there are four goals: to increase survival, erative depression and anxiety, McKenzie,
to relieve symptoms of angina, to reduce Simpson, and Stewart (2010) found that the
the likelihood of future heart attacks, and majority of studies reported an improvement
CoRonARY ARTERY BYPASS GRAFT SURGERY n 91
in patient’s depression and/or anxiety posto- to 100% Caucasian. Most investigators found
peratively. that anxiety levels significantly decreased
The most common predictor of postop- over time and remained linear. Postoperative C
erative anxiety was preoperative anxiety. anxiety was directly related to perception of
The impact of gender and age was equivocal pain with the strongest relationship on post-
with some studies identifying age as predic- operative Day 2. neither gender nor age was
tive and an equal number finding it not pre- significantly associated with level of pain
dictive. one study identified a relationship (nelson, Zimmerman, Barnason, nieveen, &
between age and anxiety (Krannich et al., Schmaderer, 1998). In a large study with 1,317
2007). Although younger patients were more patients, there was a dose–response relation-
anxious before surgery and showed a decline ship between state anxiety and risk of death
in symptoms after surgery, anxiety symp- or myocardial infarction but no association
toms in older patients showed little change between self-reported anxiety and athero-
(Krannich et al., 2007). sclerotic progression of grafts (Wellenius,
As with the findings related to anxiety, Mukamal, Kulshreshtha, Asonganyi, &
the most frequently identified predictor of Mittleman, 2008). In one study, patients with
postoperative depression was preoperative chronic postoperative pain had significantly
depression. In studies with women, female higher levels of anxiety and depression
gender was a frequently reported predictor than those without chronic pain (Taillefer
of postoperative depression, but the impact et al., 2006). The mechanism by which anx-
of age was equivocal. A conclusion from the iety increases mortality and morbidity is
systematic review was that the most com- not yet understood (Rosenbloom, Wellenius,
mon predictors of postoperative anxiety and Mukamal, & Mittleman, 2009).
depression were preoperative levels. one Longitudinal studies evaluating depres-
consistent recommendation was that clini- sion reported prevalence rates ranging from
cians needed to routinely assess patients’ 16% to 50% preoperatively and from 17% to
depression and anxiety before surgery to 61% postoperatively. Almost all studies used
identify those patients at greater risk for post- self-report questionnaires. Subjects’ (n = 50 to
operative difficulties. In keeping with these 759) mean ages ranged from 54 to 70 years,
recommendations, screening for depression most represented a 3:1 male-to-female ratio,
in patients with coronary heart disease has and ranged from 82% to 100% Caucasian.
recently been recommended by the American In addition to preoperative depression lev-
Heart Association (Lichtman et al., 2008). In els, investigators have identified predictors
addition, with more women and older adults of postoperative depression as poor social
undergoing CABG surgery, the impact of age support, at least one stressful life event in the
and gender on postoperative recovery needs last year, low level of education, and mod-
to be further explored. erate to severe dyspnea (Pirraglia, Peterson,
A number of studies have examined the Williams-Russo, Gorkin, & Charlson, 1999).
course and outcomes of anxiety for patients one study found that 6 weeks after surgery,
undergoing CABG surgery. Longitudinal fatigued older patients (>65 years) had sig-
studies evaluating anxiety reported prev- nificantly higher anxiety and depressive
alence rates ranging from 4% to 50% symptoms with residual aspects of hav-
preoperatively and from 25% to 61% post- ing higher anxiety (experiencing panic and
operatively. Almost all studies used self- worry) remaining high at 3 months (Barnason
report questionnaires for measuring anxiety. et al., 2008). Depression has consistently been
Subjects’ (n = 35 to 1,317) mean ages ranged associated with adverse cardiac outcomes
from 54 to 70 years, most represented a 3:1 after CABG surgery. Investigators have found
male-to-female ratio, and ranged from 82% depressive symptoms, pre- or postoperatively
92 n CoRonARY ARTERY BYPASS GRAFT SURGERY
predict postoperative cardiac events (unsta- were no significant differences (vaccarino,
ble angina, myocardial infarction, repeat 2003). vaccarino, Abramson, veledar, and
C CABG, or angioplasty), and are positively Weintraub (2002) found that women under-
correlated with the rate of readmission for going CABG surgery were older, less edu-
cardiac events (Perski et al., 1998; Saur et al., cated, had more severe and unstable angina,
2001; Scheier et al., 1999). Connerney, Shapiro, had congestive heart failure, had lower func-
McLaughlin, Bagiella, and Sloan (2001) deter- tional status, and had more depressive symp-
mined that patients meeting criteria for toms in the month before surgery. Younger
major depressive disorder at discharge were women were at a higher risk of in-hospital
significantly more likely to experience a death than men, a difference decreasing with
cardiac-related event. Furthermore, depres- age. In a Canadian study, investigators found
sion was a predictor independent of classic that after adjusting for age and comorbid
cardiovascular risk factors. Both increased conditions, female gender was associated
preoperative depression and postoperative with a 10% increase in length of stay, a 97%
anxiety were identified as risk factors for increase in mortality, and a 7% increase in
cardiac-related hospital admissions within overall cost (Bestawros, Filion, Haider, Pilote,
6 months of surgery (oxlad, Stubberfield, & Eisenberg, 2005). In contrast to the earlier
Stuklis, Edwards, & Wade, 2006). In addition, findings, a recent study in Japan found that
postoperative depression was associated the clinical outcomes for females after CABG
with infections, impaired wound healing, surgery were comparable with those of males
poor emotional and physical recovery, and (Fukui & Takanashi, 2010).
a higher risk of atherosclerotic progression Postoperative neuropsychological defi-
among patients with saphenous vein grafts cits can be complications of cardiac surgery.
(Doering, Moser, Lemankiewicz, Luper, & A group of investigators in China found
Khan, 2005; Wellenius et al., 2008). that patients undergoing surgery with
Blumenthal et al. (2003) identified higher bypass exhibited more neuropsychologi-
mortality rates for patients with moderate cal deficits and anxiety than those patients
to severe depression at baseline and mild or whose surgeries were completed off pump.
moderate to severe depression that persisted Investigators found that depression and
from baseline to 6 months. In contrast to the anxiety were correlated with some factors
finding of the earlier studies, a more recent of cognitive dysfunction (Yin, Luo, Guo, Li,
study suggested that preoperative depres- & Huang, 2007). In contrast to these results,
sion was not associated with a significantly Stroobant and vingerhoets (2008) found that
higher risk for mortality, but after adjust- off-pump patients showed higher cognitive–
ment for known mortality risk factors, preop- affective depression scores than on-pump
erative anxiety symptoms were significantly patients. on-pump patients generally
associated with increased all-cause mortality showed no depression, whereas off-pump
risk. Investigators identified that there was patients had a mild depression that contin-
a trend toward significance of depressive ued for 3 to 5 years after surgery. In another
symptoms and mortality risk, but the signif- study, no differences were found between
icance may have been attenuated by the use patients undergoing surgery on and off
of psychotropic medications (Tully, Baker, & pump. Although significant improvement
Knight, 2008). was identified in state anxiety and depres-
Several studies have addressed gender sive symptoms, the number of patients with
differences in recovery from CABG surgery. depressive symptoms remained constant.
In some studies, women had more symp- Unlike other studies, patients in this sam-
toms and poorer functioning after CABG ple reported significant subjective improve-
than men, whereas in other studies, there ment in concentration and memory (Sandau,
CoRonARY ARTERY BYPASS GRAFT SURGERY n 93
Lindquist, Treat-Jacobson, & Savik, 2008). A education intervention after CABG surgery
study examining perceived cognitive func- (Fredericks, 2009). Although no differences
tion and emotional distress following CABG were found between the two time points, C
surgery found that emotional symptoms and the recommendation was made that nurses
perceived cognitive difficulties were sig- assess anxiety levels before the delivery of
nificantly related at the same point in time education, implement strategies to reduce
as well as across time periods. Although high anxiety (highest level is 24 hours before
perceived cognitive difficulties at baseline discharge), and provide individualized
predicted a more negative course of emo- teaching. Several randomized controlled
tional symptoms, baseline emotional symp- trials of nursing interventions (two by tele-
toms did not predict the course of cognitive phone and one in home) examined anxiety,
difficulties (Gallo, Malek, Gilbertson, & depression, and QoL in patients following
Moore, 2005). CABG surgery (Hartford, Wong, & Zakaria,
The benefits of preoperative interven- 2002; Lie, Arnesen, Sandvik, Hamilton, &
tions have been examined in three random- Bunch, 2007; Rollman et al., 2009). one of the
ized controlled studies of patients awaiting telephone interventions, which consisted of
CABG surgery (Arthur, Daniels, McKelvie, information and support to assist patients
Hirsh, & Rush, 2000; Garbossa, Maldaner, and their partners in meeting their needs,
Mortari, Biasi, & Leguisamo, 2009; McHugh found decreased anxiety in the intervention
et al., 2001). Arthur et al. (2000) found that the group 2 days after discharge but no signifi-
treatment group receiving exercise training cant differences at Weeks 4 and 8 (Hartford
twice weekly, education, reinforcement, and et al., 2002). The second study (Rollman et al.,
monthly nurse-initiated phone calls spent 2009) examined the impact of an 8-month
less time in the hospital overall and less telephone multidisciplinary intervention for
time in intensive care units. Intervention treating depression post CABG surgery. The
group patients reported improved QoL nurse care manager called patients to review
both pre- and postoperatively. In the study their psychiatric history, to provide basic psy-
by McHugh et al. (2001), care provided in choeducation about depression and its effect
patient’s homes by nurses led to decreases in on cardiac disease, and to describe treatment
cardiovascular disease risk factors as well as options. Compared with usual care, patients
levels of anxiety and depression. A study of in the intervention group reported greater
the effects of physiotherapeutic instruction improvements in HRQL, physical function-
on anxiety of CABG patients (Garbossa et al., ing, and mood symptoms at 8 months of fol-
2009) found that preoperatively patients in low-up. In addition, men benefited more than
the intervention group reported lower lev- women from the intervention. In a study on
els of anxiety, whereas postoperatively both the effects of a home-based intervention pro-
groups reported decreased levels of anxiety gram on anxiety and depression 6 months
without a significant difference between the after CABG surgery (Lie et al., 2007), inves-
groups. Anxiety was higher preoperatively tigators found significant improvements in
for female patients, and higher postopera- both the intervention and the control groups
tive anxiety led to longer lengths of hospital at 6 weeks and 6 months but no differences
stay. between groups. In a randomized controlled
There is a general agreement that early pilot of cognitive behavioral therapy with 15
postoperative intervention should be offered depressed women after surgery, investiga-
to patients experiencing depression and/ tors found that cognitive behavioral therapy
or anxiety. A randomized controlled trial yielded moderate to large effects for improv-
examined the timing (before or after dis- ing depression and immunity and reducing
charge) for delivering individualized patient infection and inflammation after surgery
94 n CoST AnALYSIS oF nURSInG CARE
(Doering, Cross, vredevoe, Martinez-Maza, &
Cowan, 2007). Cost analysis oF
C Several studies have explored the effect nursing Care
of relaxation techniques for CABG patients
post surgery. Investigators found improve-
ment in emotional well-being, state and Cost analysis of nursing care reflects a body
trait anxiety, daily activities, several social of administrative studies that focus on quan-
parameters, and QoL (Dehdari, Heidarnia, tifying nursing costs needed to deliver care to
Ramezankhani, Sadeghian, & Ghofranipour, individual clients or aggregates in a variety
2009; Trzcieniecka-Green & Steptoe, 1996). of settings, using a variety of practice models
Data are also accumulating about the and analysis tools. All cost analysis is based
efficacy of selective serotonin reuptake inhib- on assumptions that must be examined and
itors (SSRI) on the treatment of depression in made explicit when reporting findings.
patients with cardiovascular disease. In one Much of the research on cost analysis of
study (Xiong et al., 2006), SSRI use before nursing care has focused on “costing out”
CABG was associated with a higher risk of nursing services for the purpose of measur-
postoperative rehospitalization and long- ing productivity, comparing costs of various
term mortality. Investigators noted that the nursing delivery models, charging individ-
explanation for the adverse effects could be ual patients for true nursing costs, and relat-
due to incompletely treated depression, SSRI ing nursing costs to other cost models, most
use, or another complex mechanism. Another notably diagnostic-related group categories.
study (Kim et al., 2009) found that the preop- The need and the motivation for these cost-
erative use of SSRIs did not increase the risk ing efforts have evolved with the economic
of bleeding or in-hospital mortality. underpinnings of the health care system, as
Evidences that depression and anxiety have the methodologies and setting focuses.
have prognostic importance in determining Cost analysis of nursing care focuses
CABG surgery outcomes support the devel- on justifying the cost-effectiveness of pro-
opment of pre- and postoperative nursing fessional practice models, evaluating rede-
assessment strategies to identify patients at sign efforts, and monitoring and controlling
risk for adverse events. nurses can play piv- nursing costs within an ever-tightening,
otal roles in identifying patients who need cost- conscious health care environment.
further evaluation, providing education Within the context of rising capitation pen-
about the effects of depression and anxiety etration, cost analysis is essential to accurate
on CABG surgery outcomes, and develop- capitation bidding and financial viability of
ing and evaluating interventions aimed at the parent organization. As “best practices”
ameliorating the effects of these risk factors benchmarking pushes the envelope of com-
on postoperative morbidity and mortality. petitive bidding, demonstrating cost-effective
The challenge for intervention research is to nursing practice becomes essential to secur-
address anxiety and depression rather than ing managed care contracts. Cost analysis
either in isolation and to assess and treat research is a type of nursing administrative
these both pre- and postoperatively. Clearly, research that evaluates aspects of the deliv-
there is a need for large, randomized trials of ery of nursing care.
both antidepressants and psychosocial inter- Cost analysis studies have been relevant
ventions after CABG surgery to determine to decision making by nursing administrators
their efficacy with treatment of anxiety and in selecting delivery models, treatment pro-
depression. tocols, and justifying budgets, but such stud-
Susan H. McCrone ies may become central to the survival of the
CRITICAL CARE nURSInG RESEARCH n 95
entire profession for the future. Questions of have cost and resource savings as we move
appropriate skill mix cannot be determined to “best demonstrated practices.”
solely on a cost per hour of service, cost per Finally, we must move toward a cost– C
case, or cost per diagnostic-related group benefit analysis model that incorporates the
basis. new studies are needed that will com- outcomes of practice. This aspect has been
bine traditional cost analysis with differential especially elusive, given the “generic” and
outcome analysis to secure a larger picture of group nature of nursing practice. With mul-
the “true cost–benefit ratio” for specific nurs- tiple nursing providers impacting a patient’s
ing models. care, how do we separate the relative contri-
The most notable characteristic of cost butions of each person or each subspecialty
analysis studies is the variety of definitions, of nursing practice that a patient may expe-
variables, and measurement tools used in the rience in the course of their care from con-
studies. Length of stay and nursing turnover tributions of other disciplines? Additionally,
are major variables included in cost studies. we need to quantify the costs of increased
A major area of dispute for costing studies is patient mortality and failure to rescue asso-
the lack of a standard acuity measure because ciated with changes in nurse/patient ratios.
of the proprietary nature of most acuity sys-
tems. Cost and efficiency of nursing proce- Mary L. Fisher
dures or treatments continue to be studied.
Another important area for cost analysis is
to evaluate cost differences among profes-
sional practice models. However, most of CritiCal Care
these studies use proprietary practice mod-
els that are difficult to duplicate in other set- nursing researCh
tings. variables are identified in these studies
that do impact nursing costs, such as nursing
turnover, ratio of productive to nonproduc- In the history of nursing, the development
tive hours, and nursing satisfaction. of the specialty of critical care is fairly
Given the growth of capitation, cost anal- recent, paralleling the growth and devel-
ysis of nursing services will need to take new opment of intensive care units (ICUs) in the
directions. As critical pathways (benchmark 1960s and 1970s. The first ICUs were areas
performance tools) evolve as care guides, the in the hospital designated for the care of
costs of pathway changes on nursing deliv- patients recovering from anesthesia who
ery, patient outcomes, and case costs must required close monitoring during a period
be calculated. What are the most efficient of physiological instability. Recognition
and effective pathways toward resolution of of the efficiency and effectiveness gained
a given health problem? What practice set- from segregating any patients who required
ting is appropriate for patients at each step intensive nursing care for a short period of
of the pathway? For example, when is it safe time was spurred by experiences in manag-
to transfer a fresh open heart patient from ing groups of critically ill patients, such as
critical care to a step-down environment? those injured in the Boston Coconut Grove
(Earliest transfer to a least costly delivery fire of 1942 and victims of the polio epidem-
mode saves money.) These calculations may ics of the 1950s (Lynaugh & Fairman, 1992).
be critical for institutions to secure managed- The development of the mechanical venti-
care contracts in a cost-competitive environ- lator and advances in coronary care led to
ment. Determining what activities can be recognition of the need for specialized skills
safely eliminated from a pathway without and knowledge bases among nurses caring
negatively impacting care outcomes will for these patients.
96 n CRITICAL CARE nURSInG RESEARCH
The first specialty organization was their nursing practice, driven by the needs
formed by nurses working in coronary care, of patients and their families. Guided by
C originally named the American Association these expectations, the AACn research pri-
of Cardiovascular nurses, was formed in orities for the year 2010–2011 are broad yet
1969 (Lynaugh & Fairman, 1992). As electro- concrete:
cardiographic monitoring became a routine
tool in the care of many patients and critical • Effective and appropriate use of technol-
care broadened to include the care of patients ogy to achieve optimal patient assessment,
other than postanesthesia and those with management, and/or outcomes
cardiac disease, the name was changed to • Creation of healing and humane environ-
the American Association of Critical-Care ments
nurses (AACn). Today, AACn is the largest • Processes and systems that foster the opti-
specialty nursing organization in the world, mal contribution of critical care nurses
with more than 80,000 nurses in the United • Effective approaches to symptom man-
States and 45 other countries (retrieved agement
August 16, 2010, from http://www.aacn.org). • Prevention and management of compli-
The organization has had a major role in cations (AACn, 2010).
encouraging research through its own small
grants program, through joint funding ini- nurse researchers often rely on their
tiatives with corporations. AACn publishes specialty organization to highlight future
American Journal of Critical Care, a scientific research needs and identify gaps in the lit-
research journal, and Critical Care Nurse, a erature. Interdisciplinary, systematic reviews
clinical journal featuring research. AACn of the scientific literature are now consid-
also publishes evidence-based resources for ered essential to shine a light on important
the clinical practitioner, including standards areas of research that deserve more attention
of care, defined as “authoritative statements or require greater rigor in methodological
that describe the level of care or perfor- design. During the past decade, the nursing
mance common to the profession of nursing discipline has shifted away from the concept
by which the quality of nursing practice can of simple research utilization to evidence-
be judged” (retrieved August 16, 2010, from based nursing (EBn; Ackley, Ladwig, Swan,
http://www.aacn.org/wd/practice/content/ & Tucker, 2008). Compared with its precursor,
standards.pcms?menu=practice). EBn emphasizes the complexity of variables
other nursing journals publishing crit- to consider before application to practice;
ical care research include Heart and Lung, leveling and grading of scientific evidence,
Nursing Research, and Biological Research for patient preference, staffing requirements,
Nursing. nurse researchers have increas- cost-effectiveness, clinician’s experience, and
ingly published in medical research jour- environmental factors are all considered in
nals, such as Critical Care Medicine, published a systematic review of the literature and in
by the Society of Critical Care Medicine. the decision-making process for application
The International Society of Critical Care to practice.
Medicine is the largest multiprofessional The leadership roles and resources
organization of critical care practitioners. within the critical care environment as well
AACn is committed in its vision and as the overall organizational climate of the
mission to the promotion of a “culture of institution influence the degree to which
inquiry” so that optimally no gap exists staff nurses are able to make effective use of
between research and practice. The research research findings for the implementation of
vision encourages critical care nurses to EBn (Halm, 2010). In a systematic review of
actively question the scientific base for the literature on the effect of leadership on
CRITICAL CARE nURSInG RESEARCH n 97
the likelihood of research utilization, Halm to five interventions that, when performed
(2010) concluded that several factors were collectively and reliably, have been proven
critical to the practice of EBn: (1) the transfor- to improve patient outcomes (Resar et al., C
mational leadership behaviors, particularly 2005). A bundle has the effect of conceptu-
among nurse executives in Magnet hospitals; ally and behaviorally linking idiosyncratic
(2) the positive impact of the local unit culture; and seemingly unrelated nursing interven-
and (3) the quality of the unit leader–nurse tions into a package of interventions that
interactions with staff nurses. An interesting clinicians know must be followed for every
aspect of successful transformations to EBn patient, every single time. Compared with a
is in the redefinition of “real work” from that checklist, the bundle is based on and deter-
of a “doing” culture, that is, that values the mined by Level 1 evidence. Examples include
practical busyness of accomplishing tasks, to the Central Line Bundle and the ventilator
that of a “being” culture, that is, reflecting on Bundle (IHI, 2010).
practice, integrating research into practice. Critical care has been a research-inten-
Collaborative projects in critical care sive discipline, both in medicine and in nurs-
are valued more explicitly, as the contribu- ing. The initial narrow focus on maintaining
tions from the disciplines of psychology, physiological stability of the cardiopulmo-
medicine, gerontology, respiratory care, nary system undoubtedly contributed to the
and social work often overlap with those early commitment to research-based prac-
of nursing. In 2009, the AACn’s Evidence- tice. Critical care nurse scientists have been
Based Practice Resource Work Group pub- extraordinarily productive, creative, and
lished an updated evidence-leveling system sophisticated in their investigations. A recent
used to grade scientific studies and other search of grants currently funded in 2010 by
sources of information for application to the national Institute of nursing Research
critical care practice (Armola et al., 2009). yielded 592 federally funded studies of pedi-
The intent of this review was to evaluate atric and adult patients. This author identi-
grading systems adopted by other specialty fied 33 studies (6%), which were focused on
organizations, to consider the quality of the critical care patient population (Project
prioritized research design in the leveling Reporter, 2010). The low percentage of funded
process, and to evaluate the inclusion of grants for the critically ill patient popula-
meta- synthesis as an additional research tion may be underestimated because nurse
design. The new system ranks meta-analysis researchers do apply to other Institutes for
and meta- synthesis as the highest level in funding. Studies were focused on end-of-life
the hierarchy of evidence for recommenda- decision making for dying and chronically
tion. AACn’s future priorities for 2010–2011 critically ill patients, identification of cellu-
focus on concerns related to topics essential lar biomarkers of critical illness and patient
to excellence in practice, including medica- outcome, improvement of nursing assess-
tion management, hemodynamic monitor- ment of patient symptoms and symptom
ing, healing environments, palliative care management, relationship among mechani-
and end-of-life issues, mechanical venti- cal ventilation, oral care, and infection, and
lation, monitoring neuroscience patients, facilitation of communication, learning, and
and noninvasive monitoring of critically ill practice improvement in the ICU (Project
patients (AACn, 2010). Reporter, 2010).
Increasingly, nursing care interventions Clinical research in intensive care set-
in the ICU are bundled. A bundle is a struc- tings presents multiple challenges because
tured way of improving the processes of of the ethical concerns of obtaining informed
care and patient outcomes. It consists of a set consent, the demands of time and availabil-
of evidence-based practices, usually three ity at the bedside, the need for institutional
98 n CULTURAL/TRAnSCULTURAL FoCUS
access to vulnerable subjects, and the over-
whelming number of intervening variables Cultural/transCultural
C that pose threats to the explanatory power of FoCus
study findings. Such factors include patient-
related factors, such as differences in gender,
age, previous access to health care, socioeco- Cultural/transcultural focus is the study of
nomic status, presence of comorbidities, vari- the environment shared by a group seeking
ations in mental status, baseline nutritional meaning for its existence. nurse investigators
adequacy, immune function, and unique pursue this focus to understand the asso-
psychological responses to the illness and the ciation of culture to health and to provide
environment, for example, agitation, delir- culturally competent care. Although this
ium, and pain. Intervention-related factors focus is growing within research, its impact
are difficult to control for because critically on patient care has been limited. Culture
ill patients receive multiple interventions at receives only cursory emphasis in most cur-
once, such as diagnostic and surgical proce- ricula or practice settings, and few nurses are
dures, mechanical ventilation, and power- cultural experts. In light of projections that
ful medications as well as nursing activities racial and ethnic minorities will be the major-
related to complications of immobility. The ity in the United States by 2030 and the per-
potential for infection, injury, medication sistence of major health disparities between
errors, sensory deprivation and overload, Euro-Americans and others, more and better
and effect of noise on quality of sleep are nursing research on culture is needed.
particularly formidable environmental fac- Different perspectives on the meaning
tors that can impact the patient’s outcome. of cultural/transcultural research (C/TCR)
Finally, known and unknown variations in exist. To some, the terms are essentially
patient management by the health care team synonymous, and questions of disciplin-
can alter patient outcomes, and then it is up ary origin are unimportant. Researchers in
to the investigator to decide how to handle the Leininger tradition regard transcultural
the problem. nursing as the proper term for a formal,
To address some of these concerns, Sole worldwide area of study and practice about
(2010) recommends the following strategies culture and caring within nursing.
to new investigators: (1) be self-directed, C/TCR is found in a great variety of
focusing on a clinical question which is research and clinical journals. Some C/TCR
important to you, such the effect of position- studies (particularly interventions and ran-
ing; (2) develop an initial study on basic and domized controlled trials) may be found in
familiar clinical concepts, such as airway, the Cochrane database for evidence-based
breathing, and circulation; (3) seek out col- practice using a keyword search on the basis
laborators and mentors who can support you of such terms as the disease name, nurs* and
and become coinvestigators; and (4) plan a care, nurs* and intervention, and names of
simple pilot study within the context of the racial or cultural groups. Searchers are cau-
team, which is “most essential part of the tioned that (a) the names of racial or ethnic
infrastructure” (p. 333). The days of the lone groups are often used only descriptive labels,
researcher are over. Future research in criti- and findings do not advance true cultural
cal care nursing will continue to require the knowledge; (b) race, culture, and ethnicity
multidisciplinary efforts of all health care lack consensual definitions and are often
providers who make such a difference in used interchangeably; (c) acceptable names
patient outcomes. for groups change over time (e.g., negro,
Black, Afro-American, African American);
Carol Diane Epstein (d) the name of the highest stage of cultural
CULTURAL/TRAnSCULTURAL FoCUS n 99
knowledge changes over time, with cultural and programmatic research are becoming
competence or cultural proficiency being cur- more frequent.
rently preferred; (e) databases on special pop- Methodological research, including C
ulations are often nonexistent or inadequate; studies of recruiting and retaining subjects
(f) although reports specify a focus on a cul- and instrumentation, is growing rapidly.
tural group, discussion may not relate find- The quality of measurement in C/TCR is
ings to that group; and (g) findings ascribed improving steadily. The standards for rig-
to culture are often not distinguished from orous translation are widely recognized,
the effects of socioeconomic status, history, and both the cultural fit of items and the
or political structures. psychometric properties of an instrument
Most quantitative C/TCR is theory for the target group are increasingly being
based. Frequently used frameworks include reported and studied. Instruments such
Leininger’s culture care theory, self-care, as the Cultural Self-Efficacy Scale and the
health-seeking behavior, health belief mod- Cultural Awareness Scale are being devel-
els, stress and coping, self-efficacy, and transi- oped to measure the outcomes of programs
tions. The transtheoretical model of behavior to promote multicultural awareness.
change is becoming popular. Reports are now There are three major needs in C/TCR.
appearing on the cultural appropriateness of First is the need for more intervention stud-
existing frameworks for particular groups. ies (Douglas, 2000). Recent estimates of the
For example, health belief models have been proportion of interventions in the C/TCR lit-
criticized for inadequately recognizing real erature range from 3.6% to 14%. More investi-
(rather than perceived) barriers to care, spir- gators must move from descriptive studies to
ituality, and the interconnectedness (rather interventions to randomized controlled tri-
than the individuality) of African American als. The sheer volume of very similar studies
women. Studies seeking explanatory mod- of the health beliefs, family values, sex roles,
els of illness are increasing, a welcome trend and importance of family decision making,
because this approach, which parallels an folk remedies, or spirituality within certain
intake history and involves all aspects of the groups suggests a sufficient base for inter-
disease course and clinical encounter, seems vention studies. A second great need is for
relevant and practical to clinicians as well as application of existing guidelines for cul-
researchers. Although most data collection turally competent research. Research needs
strategies, including physiological measure- to be planned to be culturally competent.
ments, are used in C/TCR, the most frequently Culturally competent research is broader
used are focus groups, interviews, ethnogra- than efforts to select culturally appropriate
phies, participant observation, and written instruments or to recruit appropriate sub-
questionnaires. Qualitative approaches have jects. Application of these guidelines should
long been recognized as well suited to C/TCR mesh nicely with the third great need of C/
and are frequently used. TCR, which is for research to be planned and
The overwhelming majority of C/TCR conducted with greater community involve-
has been intracultural, descriptive, small ment. More studies, particularly program-
scale, and nonprogrammatic. The typical matic studies, are needed of native American
study is an interview or survey on health health. Studies of multiracial or multiethnic
knowledge, health beliefs, and practices or persons are rare but urgently needed, given
a concept-like self-efficacy within one desig- the growing numbers of people who iden-
nated group conducted by a single investiga- tify themselves as having multiple heritages.
tor. However, cross-national nursing studies, Studies of rural, occupational, and sexual
studies with large sample sizes, studies done subcultures (groups not defined by race or
by interdisciplinary or international teams, ethnicity) are needed, as are comparative
100 n CURREnT PRoCEDURAL TERMInoLoGY–CoDED SERvICES
explorations of cultural perspectives on eth- Part B providers (Robinson, 2009; Robinson,
ics. Folk and alternative healing practices and Griffith, & Sullivan-Marx, 2001).
C their possible combinations with biomedical The Physician Payment Review Com-
approaches need systematic, sensitive study. mission was created in 1986 to advise the
Studies of cultural adaptations of care in Congress on reforms of the methods used
homes, development of brief rapid strategies to pay physicians under the Medicare Part
for cultural assessment, and development of B program, a program that includes the pay-
the economic case for culturally competent ment regulations for health care professionals
care are needed to insure that culture is con- who are eligible to receive direct reimburse-
sidered in this era of managed care, case man- ment through the Medicare program. Carol
agement, and ever briefer inpatient stays. Lockhart, PhD, Rn, FAAn, the first nurse to
serve on the Commission, expressed concern
Sharol F. Jacobson about the lack of nursing data available that
would reveal how many services are deliv-
ered by a nurse but billed under the physi-
cian’s name (Griffith & Fonteyn, 1989).
Current proCedural In an attempt to identify whether CPT
terMinology–Coded codes might explain nursing work and
thereby provide the needed data, studies
serviCes were conducted to look at how many billable
CPT activities were performed by nurses
(Griffith & Robinson, 1993; Griffith, Thomas,
Current Procedural Terminology (CPT)– & Griffith, 1991; Robinson & Griffith, 1997).
coded services include more than 8,000 Initially, Griffith and Fonteyn (1989) pub-
services listed in the Physicians’ Current lished a questionnaire, in the American Journal
Procedural Terminology manual pub- of Nursing, addressing the performance of
lished annually by the American Medical CPT-coded procedures by registered nurses;
Association (AMA). Developed by the AMA 4,869 nurses returned the questionnaire and
in 1966, the CPT coding system, which mainly 150 made telephone calls or wrote letters.
describes physician procedures, is intended The average number of coded services per-
to provide a uniform language that accu- formed by the respondents was 27, with a
rately describes medical, surgical, and diag- range of 0 to 60 (Griffith et al., 1991). There
nostic services (AMA, 2007). The CPT serves are currently approximately 8,000 published
as a method for payment by public (Medicare codes in the manual, but at the time of the
and Medicaid) and private (commercial survey in 1989, only 107 codes comprised
insurers) payers. It is also used by policy 56.9% of all Medicare procedures (Health
makers in their deliberations on reforming Care Financing Administration and Bureau
the payment system. CPT is revised annu- of Data Management and Strategy, 1990).
ally to reflect changes in medical practice Survey results revealed that associate and
and technology. Reimbursement to a ser- baccalaureate degree nurses performed sig-
vice represented by individual CPT codes is nificantly more coded services than nurses
based on the Resource-Based Relative value with diplomas and masters degrees. overall,
Scale, which was originally implemented the nurses reported very little physician
to establish a Medicare fee schedule for supervision when performing the coded
Part B physician payment. This system now services. As one would anticipate, nurses
extends to payment for services provided by working in hospital settings performed more
advanced practice nurses (APns) and other services (Griffith et al., 1991).
CURREnT PRoCEDURAL TERMInoLoGY–CoDED SERvICES n 101
Building on the American Journal of services provided by the entire team. There
Nursing exploratory study survey, which are CPT codes that describe preventive ser-
described activities of generalist nurses, sur- vices and counseling; however, they do not C
veys were conducted to estimate the degree specifically describe nursing practice and are
to which nurses in nine specialties were not generally reimbursed by payers. In a study
performing CPT-coded services. Results comparing the frequency with which nurs-
revealed that 493 of approximately 7,000 CPT ing activity terms could be categorized using
codes were performed by school nurses, nursing Interventions Classification (nIC)
enterostomal nurses, family nurse practi- and CPT codes, findings revealed evidence
tioners (nPs), critical care nurses, oncology that nIC was superior to CPT for categorizing
nurses, rehabilitation nurses, orthopedic those activities in a study population of AIDS
nurses, nephrology nurses, and midwives patients hospitalized for Pneumocystis carinii
(Griffith & Robinson, 1992, 1993; Robinson & pneumonia. nursing activity terms were cate-
Griffith, 1997). The number of CPT codes per- gorized into 80 nIC interventions across 22
formed by specialty nurses ranged from 233 classes and into 15 CPT codes. These findings
for family nPs to 58 for school nurses. The supported the importance of nursing-specific
mean number of coded services performed classifications for categorization of health
by individual respondents ranged from 79 care interventions in an effort to demonstrate
for family nPs to 18 for school nurses; indi- nursing’s contributions to quality and cost
vidual respondents performed 0 to 162 codes. outcomes (Henry, Holzemer, Randell, Hsieh,
Supervision by physicians for these groups of & Miller, 1997). However, Sullivan-Marx and
nurses was infrequent. Charges to Medicare Mullinix (1999) believed that a better option
in 1988 for the coded services included in the would be to introduce nursing services into
survey were $22,793,427.34 (aggregate allow- CPT if they are not otherwise described in
able charges). another CPT code. In fact, since 1993, the
The Department of veterans Affairs (vA) American nurses Association has had a rep-
nursing Workload Capture Task Force, in an resentative on the Health Care Professional
attempt to identify and inventory current Advisory Committee to the CPT Editorial
mechanisms and/or methods of capturing Panel and has been directly involved in the
APn inpatient and outpatient vA workload, process of CPT code development and revi-
surveyed APns practicing in vA facilities sion (Sullivan-Marx & Keepnews, 2003).
across the country (Robinson, Layer, Domine, The Balanced Budget Act of 1997 (Public
Martone, & Johnston, 2000). Participants Law no. 105–33), which became effective
reported that their workload was being cap- January 1, 1998, amended the Social Security
tured primarily by using encounter forms, Act to grant direct Medicare reimbursement
CPT/ICD-9 codes, and productivity reports; to nPs and clinical nurse specialists in all
only a minimum of inpatient workload geographic areas and health care settings
was being captured. Sullivan-Marx, Happ, at 85% of the physician rate. This enactment
Bradley, and Maislin (2000), in another survey precipitated a study by Sullivan-Marx and
of nPs’ use of the CPT billing codes, found Maislin (2000) to ensure that there were no
that nPs performed services not identified significant differences in how nPs and phy-
in CPT codes that addressed comprehensive sicians assessed work values for commonly
patient care, attention to social factors, and used primary codes. The researchers com-
capturing the teaching moment. pared relative work values between nPs and
A longstanding criticism of the CPT family physicians for commonly used office
codes is their limitation to describe only phy- visit codes and found no significant differ-
sician services and not the full range of health ence between the two groups for establishing
102 n CURREnT PRoCEDURAL TERMInoLoGY–CoDED SERvICES
relative work values, therefore providing an and the nurse representative served as chair
indication that services provided by nPs of the PEAC in 2006 (Sullivan-Marx, 2008).
C could be reliably valued in the Medicare fee In addition, in 2010, a nurse was appointed
schedule. to the prestigious federal policy commis-
To establish relative values for the prac- sion, the Medicare Payment Advisory
tice expense component of CPT codes, the Commission (MedPAC). The Congress estab-
Center for Medicare and Medicaid Services, lished MedPAC in 1997 to analyze access to
formerly the Health Care Financing care, cost, and quality of care and other key
Administration, developed and now relies issues affecting Medicare. MedPAC advises
on recommendations from AMA’s Relative the Congress on payments to health plans
value Practice Expense Advisory Committee participating in the Medicare.
(PEAC). Specialty societies that serve on McGivern, Sullivan-Marx, and Fairman
PEAC survey their members to obtain accu- (2010) reported that organized nursing’s
rate “direct input” data for the CPT codes, political profile is as high as it has ever been.
and then society representatives present Although the profession has made signif-
the data to the PEAC. The PEAC members icant strives in terms of reimbursement
critique these data, making modifications during the past decades, there is consid-
as needed. After PEAC approval, data are erable need for future research and policy
forwarded to the Center for Medicare and developments.
Medicaid Services to use to calculate the
practice expense values (AMA, 2010). The Karen R. Robinson
AnA has a voting seat on this committee Hurdis M. Griffith
D
assume) nominal or categorical data, others
Data analysis assume ordinal data, and still others assume
an interval level of measurement. Although
each test has its own set of mathematical
Data analysis is a systematic method of assumptions about the data, all statistical
examining data gathered for a research tests assume random sampling.
investigation to support interpretations and Several statistical computer programs
conclusions about the data and inferences (e.g., SPSS, SAS) are available to aid the inves-
about the population. Although applicable tigator with the tedious and complex math-
to both qualitative and quantitative research, ematical operations necessary to calculate
data analysis is more often associated with these test statistics and their sampling distri-
quantitative research. Quantitative data butions. These programs, however, only serve
analysis involves the application of logic and to expedite calculations and ensure accuracy.
reasoning through the use of statistics, an There is a hidden danger in the ease with
applied branch of mathematics, to numeric which one may execute these computer pro-
data. Qualitative data analysis involves the grams, and the investigator must understand
application of logic and reasoning, a branch the computer programs to use them appropri-
of philosophy, to nonnumeric data. Both ately. To ensure that data analysis is valid and
require careful execution and are intended appropriate for the specific research question
to give meaning to data by organizing dis- or hypothesis, the investigator also must fully
parate pieces of information into under- understand the statistical procedures them-
standable and useful aggregates, statements, selves and the underlying assumptions of
or hypotheses. these tests.
Statistical data analysis is based on prob- Most quantitative data analysis uses a
ability theory and involves using specific null hypothesis statistical test approach. The
statistical tests or measures of association logic of null hypothesis statistical testing is
between two or more variables. Each of these one of modus tollens, denying the anteced-
2
tests or statistics (e.g., t, F, β, χ , φ, η, etc.) has a ent by denying the consequent. That is, if
known distribution that allows calculation of the null hypothesis is correct, our nonzero
probability levels for different values of the findings cannot occur, but because our find-
statistic under different assumptions—that ings did occur, the null hypothesis must be
is, the test (or null) hypothesis and the sam- false. Cohen (1994) and others, however, have
ple size or degrees of freedom. argued convincingly that by making this
Specific tests are selected because they reasoning probabilistic for null hypothesis
provide the most meaningful representation statistical testing, we invalidate the origi-
of the data in response to specific research nal syllogism. Despite decades of articles by
questions or hypotheses posed. The selec- scientists from different disciplines ques-
tion of specific tests, however, is restricted to tioning the usefulness and triviality of null
those for which the available data meet cer- hypothesis statistical testing (for examples
tain required assumptions of the tests. For from sociology, psychology, public health,
example, some tests are appropriate for (and and nursing, see Labovitz, 1970; LeFort, 1993;
104 n DATA CoLLECTion METhoDS
Loftus, 1993; Rozeboom, 1960; Walker, 1986), quantitative analyses, computer programs for
null hypothesis statistical testing still domi- qualitative data analysis are merely aids for
D nates analytic approaches. the tedious and error prone tasks of analysis.
Some of the articles and arguments Using them still requires the investigator to
about the limits of null hypothesis statistical make the relevant and substantive decisions
testing have led to more emphasis on the use and interpretations about codes, categories,
of confidence intervals. Confidence intervals and themes.
provide more information about our find- Although quantitative data analysis
ings, particularly about the precision of pop- allows for statistical probabilistic statements
ulation estimates from our sample data, but to support the investigator’s interpretations
they are based on the same null hypothesis and conclusions, qualitative data analysis
statistical testing logic that generates p val- depends more exclusively on the strength
ues. Thus, confidence intervals are subject to and logic of the investigator’s arguments.
the same issues with respect to Type 1 errors nonetheless, both types of data analysis ulti-
(rejecting the null when it is true) and Type 2 mately rest on the strength of the original
errors (failing to reject the null when it is study design and the ability of the investiga-
false). tor to appropriately and accurately execute
increased attention and sensitivity to the analytic method selected.
factors that contribute to findings of statisti-
cal significance has also led to more attention Lauren S. Aaronson
to power, sample sizes, and role of effect sizes
(for substantive significance) for valid quan-
titative data analysis. if the sample size is too
small, the study may be underpowered and Data ColleCtion MethoDs
unable to detect an important finding even
if it is there. Conversely, if the sample size is
too large, the study may be overpowered and in research, data are the pieces of informa-
may result in statistically significant findings tion that are gathered in an effort to address
that are substantively or clinically insignif- a research question. Data collection typically
icant. Either could be challenged on ethical is one of the most challenging and costly
grounds, stressing the importance of appro- steps in the research process. Researchers
priately powering studies for the planned make a number of decisions in designing a
data analysis. data collection plan, and these decisions can
in contrast to quantitative data analysis have a profound effect on the quality of evi-
which requires that the investigator assign a dence that a study yields. nurse researchers
numeric code to all data before beginning the use a wide variety of methods for collecting
analyses, qualitative data analysis consists data, and these methods vary on a number of
of coding words, objects, and/or events into important dimensions.
meaningful categories and/or themes as part A fundamental dimension involves
of the actual data analyses. Because qualita- whether the data being collected are quan-
tive data analysis involves nonnumeric data, titative or qualitative in nature. Quantitative
there are no statistical probabilistic tests to data yield information about a research var-
apply to the coding of qualitative data. iable in numeric form, ranging from simple
Coding of qualitative data historically binary values (e.g., 1 = yes, 2 = no) to more
has been done manually, but computer complex numeric expressions (e.g., values
programs (e.g., QSR) are now available to for the body mass index). To collect quanti-
aid the investigator in this laborious effort. tative data, researchers use structured meth-
however, as with the computer programs for ods and formal instruments in which the
DATA CoLLECTion METhoDS n 105
same information is gathered from study asked and, often, the response options from
participants in a comparable, prespecified which respondents must choose. The instru-
way. Researchers collecting quantitative ment is an interview schedule when the data D
data typically spend a considerable amount are collected orally and a questionnaire when
of preparatory time selecting or developing the data are collected in writing. interviews
instruments and then pretesting them to can be conducted either in person, over the
ensure they are appropriate for study par- telephone, or through various electronic
ticipants and will yield high-quality data. means, such as by videoconferencing or an
Key issues of concern are whether the instru- internet link (e.g., Skype). Questionnaires can
ments are reliable (yield data that are accu- be mailed, distributed in clinical or other set-
rate measures of the concepts of interest) tings, or sent over the internet. interviews and
and valid (yield data that are truly capturing questionnaires often incorporate one or more
the focal concepts and not something else). formal scales to measure certain clinical data
Quantitative data are integrated and ana- (e.g., fatigue) or a psychological attribute (e.g.,
lyzed using statistical methods. self-efficacy, quality of life). A scale typically
Qualitative data are in narrative form, yields a composite measure of responses to
that is, in the form of words rather than multiple questions and is designed to assign
numbers. Researchers collecting qualita- a numeric score to respondents to place them
tive data tend to have a flexible, unstruc- on a continuum with respect to the attribute
tured approach. They often rely on ongoing being measured.
insights during data collection to guide the Self-report methods are also used by
course of further data collection rather than researchers who seek in-depth qualitative
having a formal instrument or even a fixed data. When self-report data are gathered in
upfront plan about the data to be gathered. an unstructured way, the researcher typ-
Qualitative data tend to be rich and complex ically does not have a specific set of ques-
and are more difficult to analyze than quanti- tions that must be asked in a specific order
tative data. Key issues of concern in collecting or worded in a given way. instead, the
qualitative data are that the data are credi- researcher starts with some general ques-
ble (generate confidence in their truth value), tions and allows respondents to tell their
dependable (stable and reliable), and authen- stories in a natural, conversational fash-
tic (communicate the mood, experience, lan- ion. Methods of collecting qualitative self-
guage, and context of the participants). report data include completely unstructured
Another important dimension of data interviews (conversational discussions on
collection methods concerns the basic mode. a topic), focused interviews (conversations
The modes of data collection most fre- guided by a broad topic guide), focus group
quently used by nurse researchers are self- interviews (discussions with small groups),
reports, observations, and biophysiological life histories (narrative, chronological self-
measures. disclosures about an aspect of the respon-
Self-reports involve the collection of data dent’s life experiences), and critical incidents
through direct questioning of people about (discussions about an event or behavior
their opinions, characteristics, and experi- that is critical to some outcome of interest).
ences. Self-reports can be gathered orally Although most unstructured self-reports
by having interviewers ask study partici- are gathered orally, a researcher can also ask
pants a series of questions or in writing by respondents to write a narrative response to
having participants complete a written task. broad open-ended questions or to maintain
Structured, quantitative self-report data are a written diary of their thoughts on a given
collected using a formal instrument that topic. Such data can be collected in person,
specifies exactly what questions are to be by mail, or by e-mail.
106 n DATA CoLLECTion METhoDS
Self-report methods are indispensable as patients with dementia), certain types of
a means of collecting data on human beings, behavior (e.g., patients’ sleep–wake behav-
D but they are susceptible to errors of reporting, ior), or evolving processes (nurse–patient
including a variety of response biases. These interactions). however, judgmental errors
methods are also not appropriate with cer- and other biases can undermine the quality
tain populations (e.g., young children) or on of observational data.
topics about which participants themselves Data for nursing studies may also be
cannot be expected to bear witness (e.g., their derived from biophysiological measures,
level of agitation or confusion). which include both in vivo measurements
The second major mode of data collec- (those performed within or on living organ-
tion is through observation. observational isms) and in vitro measurements (those per-
methods are techniques for collecting data formed outside the organism’s body, such as
through the direct observation of people’s blood tests). Biophysiological measures are
behavior, communications, characteristics, quantitative indicators of clinically relevant
and activities. Such observations can be attributes that require specialized technical
made by observers either directly through instruments and equipment. Qualitative clin-
their senses or with the aid of observational ical data—for example, descriptions of skin
equipment such as videotape cameras. pallor—are gathered not through technical
Structured observational methods dic- instruments but rather through observations
tate what specific things the observer should or self-reports. Biophysiological measures
observe, and how to record the observations. have the advantage of being objective, accu-
in this approach, observers often use check- rate, and precise and are typically not subject
lists to record the appearance, frequency, or to many biases.
duration of preselected behaviors, events, Although most nursing research
or characteristics. They may also use rating involves the collection of new data through
scales to measure dimensions such as the self-report, observation, or biophysiological
intensity of observed behavior. in structured instrumentation, some research involves the
observation, observers must be carefully analysis of preexisting data. Clinical records
trained to identify categories of behavior or (e.g., hospital records, nursing charts) can be
actions, and the accuracy of their judgments important data sources. A variety of other
needs to be assessed using interobserver reli- types of documents (e.g., letters, newspaper
ability checks. articles) and artifacts (e.g., photographs) also
Researchers who collect qualitative can be used as data sources, particularly for
observational data do so with a minimum of qualitative researchers (e.g., ethnographers,
researcher-imposed structure and interfer- historical researchers). When a data set—
ence with those being observed. People are either qualitative or quantitative—is created
observed, typically in social settings, engag- by a researcher for a study, it may provide a
ing in naturalistic behavior. Researchers rich and inexpensive source of secondary data
make detailed narrative notes about their for further analysis by other researchers.
observations. A special type of unstruc- in developing their data collection plans,
tured observation is referred to as participant nurse researchers are increasingly triangulat-
observation: the researcher gains entry into ing data of various types in creative and pro-
the social group of interest and participates ductive ways. Triangulation has long been an
to varying degrees in its functioning while important tool for qualitative researchers as
gathering the observational data. a means of enhancing the trustworthiness of
observational techniques are an impor- their data. in particular, ethnographers and
tant alternative to self-report techniques, grounded theory researchers frequently com-
especially for certain populations (e.g., bine self-report data from interviews with
DATA STEWARDShiP n 107
observational data collected in naturalistic replaced with correct values or assigned to
settings to achieve a more complete and holis- the missing values category. outliers must be
tic perspective on the phenomena in which investigated and dealt with. if a categorical D
they are interested. in quantitative research, variable is supposed to have four categories
especially in testing the effects of clinical but only three have adequate numbers of sub-
interventions, nurse researchers often trian- jects, one must decide about eliminating the
gulate biophysiological and self-report data. fourth category or combining it with one of
For the past two decades, momentum the others. if continuous variable are skewed,
has been gaining for mixed-method research, data transformations may be attempted or
which involves the triangulation of qualita- nonparametric statistics used.
tive and quantitative data in a single study or once each variable has been inspected
a coordinated set of studies. Mixed-method and corrected where necessary, new vari-
researchers often endorse a pragmatist ables may be created. This might include the
stance in which the research question drives development of total scores for a group of
the methods of data collection rather than items, subscores, and so forth. Each of these
the methods driving the question. it seems new variables also must be checked for outli-
likely that nurse researchers will continue ers, skewness, and out-of-range values. The
to expand their repertoire of data collection creation of some new variables may involve
methods, their use of supportive technologi- the use of sophisticated techniques such as
cal tools, and their blending of different types factor and reliability analyses.
of data as a means of strengthening evidence Before each statistical test, the assump-
to guide their practice. tions underlying the test must be checked.
if violated, alternative approaches must be
Denise F. Polit sought. Careful attention to data manage-
ment must underlie data analysis. it ensures
the validity of the data and the appropriate-
ness of the analyses.
Data ManageMent
Barbara Munro
Data management is generally defined as the
procedures taken to ensure the accuracy of
data, from data entry through data transfor- Data stewarDship
mations. Although often a tedious and time-
consuming process, data management is
absolutely essential for good science. Data stewardship refers to the responsibil-
The first step is data entry. Although this ity and the accountability to manage uses of
may occur in a variety of ways, from being data that include but are not limited to data
scanned in to being entered manually, the collection, viewing, storage, exchange, aggre-
crucial point is that the accuracy of the data gation, and analysis. health data steward-
be assessed before any manipulations are ship is a responsibility, guided by principles
performed or statistics produced. Frequency and practices, to ensure the knowledge-
distributions and descriptive statistics are able and appropriate use and reuse of data
generated. Then each variable is inspected, as derived from an individual’s personal health
appropriate, for out-of-range values, outliers, information. health data stewardship has
equality of groups, skewness, and missing become increasingly important because of
data. Decisions must be made about dealing the increased use and value of electronic
with each of these. incorrect values must be health data and information technology as
108 n DATA STEWARDShiP
well as the increased awareness of potential defined as data that are structured and orga-
risks associated with incorrect or inappro- nized and that have meaning or interpreta-
D priate uses of health data. Data stewardship tion. information that has been synthesized
is the responsibility of everyone who uses so as to identify and formalize interrelation-
or interacts with health data, identified or ships is referred to as knowledge. When one
de-identified, for any purpose including, but term represents all three types of content, it
not limited to, health care, research, quality is usually information. nursing data issues
assessment, population monitoring, policy, revolve around several factors. The first
and payment. relates to identification of the universe of rel-
The national Committee on Vital and evant nursing data. Currently, there is no con-
health Statistics has worked with other sensus regarding what data elements make
organizations and agencies to develop key up a minimum nursing data set nor what
principles and practices of health data stew- data elements are required to capture nurs-
ardship to protect the rights and privacy ing diagnoses, interventions, and outcomes.
of persons whose data are involved and to Systems to label or name these elements are
assure the quality and integrity of data. These also inconsistently defined. next, the com-
practices and principles can be grouped into plex nature of nursing phenomena poses
four categories. Principles about individual measurement difficulties. Measurement is
rights address access to one’s health data the process of assigning numbers to objects
and the opportunity to make corrections, to represent the kind or amount of a character
transparency about use, and participation possessed by those objects. it includes quali-
and consent for use. Principles that address tative means (assigning objects to categories
responsibilities of the health data steward include that are mutually exclusive and exhaustive)
identification of the purpose for data use; and quantitative measures (assigning objects
de-identification (when relevant); data qual- to categories that represent the amount of a
ity, including integrity, accuracy, timeliness, characteristic possessed).
and completeness; limits on use, disclo- Unlike other biological sciences, few
sure, and retention; and oversight on uses. nursing phenomena can be measured by
Principles and practices for security safeguards using physical instruments with signal pro-
and controls require the implementation of cessing or monitoring. Measurement diffi-
administrative, technical, and physical safe- culties occur because nursing consists of a
guards to protect information and to mini- multiplicity of complex variables that occur
mize risks of unauthorized or inappropriate in diverse settings. if one is able to identify
access, use, or disclosure. And finally, princi- what significant variables should be mea-
ples of accountability, enforcement, and remedies sured, then one is challenged with the diffi-
address requirements for policies that spec- culty of isolating those variables to measure
ify appropriate use, implementation of mech- them. Ambiguities and abstract notions must
anisms to detect noncompliance and enforce be reduced to develop concrete behavioral
consequences, and remediation for individu- indicators if measurement is to be mean-
als whose data are involved. Although these ingful. Measuring nursing phenomena also
principles have been established, the work of requires the acknowledgment of the “fuzzy”
translating them into practice will continue and complex nature of nursing phenomena
to evolve as the urgency for data stewardship and the richness of the meaning contained in
grows even greater (Kanaan & Carr, 2009). the context of the data. Finally, the value and
Data and information are the symbolic use of data that are not coded or numeric,
representation of the phenomena with which such as whole text data, must be studied to
nursing is concerned. Data are defined as dis- understand their benefits and boundaries for
crete entities that are objective; information is representing nursing phenomena. Content
DELiRiUM n 109
analysis of nursing data and their usefulness Data stewardship poses challenges and
have to be further explored. responsibilities for nurses in building knowl-
Processing data implies the transfer edge bases. Standardization of terms of data D
of data in raw form to a structured, inter- is critical, and coordination and synthesis
preted information form. information has of current efforts are needed. Further study
characteristics of accuracy, timeliness, util- to focus on the following areas has been
ity, relevance, quality, and consistency. Data recommended and continues to be needed:
stewardship suggests that attention be paid (a) the definition and description of the data
to these characteristics. For example, accu- and information required for patent care,
racy is of concern at the level of judgment in (b) the use of data and knowledge to deliver
collecting data as well as at the level of the and manage patient care, and (c) how one
data collected. Quality of data and informa- acquires and delivers knowledge from and
tion is related to the ability and willingness for patient care (national Center for nursing
of clients to disclose information as well as to Research, 1993).
the nurse’s ability to observe, to collect, and
to record it. Reliability refers to random mea- Carol A. Romano
surement errors such as ambiguities in data
interpretation. These measurement errors
that affect clinically generated data can occur
at the point of care delivery, the time of doc- DeliriuM
umentation, and when data are retrieved or
abstracted for studies (hays, norris, Martin,
& Androwich, 1994). Delirium is an acute, fluctuating disturbance
With the advent of automated data pro- of attention with disorganized thinking
cessing and computerized information sys- and altered psychomotor activity (Meagher,
tems, decisions about data content, control, MacLullich, & Laurila, 2008). it frequently
and cost need careful consideration. The con- accompanies acute physical illness and
tent and design decisions concern format, is found in all care settings and all ages.
standardized languages, level of detail, data Estimates of the incidence of delirium range
entry and retrieval messages, and interfaces from 11% to 42% for all hospitalized adults
with nonclinical data systems. A primary and 10% of hospitalized children referred
concern of clinicians is the amount of time to psychiatry, up to 66% of pediatric inten-
invested in harvesting data and recording it. sive care patients referred to psychiatry,
Minimum time investment, with maximum 46% for older adults receiving home health
clarity and comprehensiveness of data col- care services, and 14% to 39% for residents
lected and recorded, is needed. Redundancy in long-term care settings. in a community-
must be eliminated. Decisions related to con- based adult sample, delirium was found to
tent of data demand stewardship to ensure be superimposed on dementia in 13% of the
privacy, confidentiality, and security, espe- cases (Fick, Kolanowski, Waller, & inouye,
cially when data are in electronic form. 2005; heatherill & Flisher, 2010).
Requirements for legitimate access to data Previously, delirium was thought to be
must be managed to facilitate the flow of clin- self-limiting and benign. Recent discover-
ical data while simultaneously restricting ies indicate that delirium is associated with
inappropriate access. There is a cost associated cognitive and functional impairments in
with the use and development of automated adults and children persisting for weeks
databases; however, accuracy, reliability, and to months after the index incident of delir-
comprehensiveness of information should ium. Moreover, delirium portends poorer
not be sacrificed because of cost. outcomes, greater costs of care, and greater
110 n DELiRiUM
chances for death. Despite these profound Severity Scale, and Breitbart’s Memorial Deli-
negative consequences for patients, families, rium Assessment Scale (Maldanado, 2008).
D health care providers, and society, delirium Each has its advantages and disadvantages; the
remains understudied, especially in children selection of which instrument to use depends
and adolescents. in part on the purpose and patient popula-
Delirium is frequently underrecognized tion. The most frequently used instrument
and misdiagnosed, although more health in research and clinical practice with adults
care providers than that in the past report is inouye’s Confusion Assessment Method
screening for delirium (heatherill & Flisher, and in children and adolescents, Trzepacz’s
2010; Kuehn, 2010; Patel, 2009). Recognition Delirium Rating Scale. The Diagnostic and
of delirium continues to be problematic in Statistical Manual of Mental Disorders, Fourth
elderly patients with an underlying dementia Edition, Text Revision diagnostic criteria for
or those with the hypoactive-hypoalert vari- delirium remains as the gold standard in com-
ant of delirium. Explanations for the under- paring all instruments. Research supports the
recognition and misdiagnosis of delirium use of brief, standardized bedside screening
include the fluctuating nature of delirium; measures as timely, effective, and inexpen-
the variable presentation of delirium; the sive methods for assessing cognitive status
similarity among and frequent co-occurrence and diagnosing delirium. Current standards
of delirium, dementia, and depression; and for surveillance of delirium are to screen for
the failure of providers to use standardized the presence of delirium on admission to the
methods of detection. hospital and at a minimum daily. others rec-
improving the recognition of delirium ommend brief screening every shift as an
requires a complex and dynamic solution. element of the standard nursing assessment.
Knowledge of delirium and skill in its detec- Additionally, when there is evidence of new
tion are necessary starting points for improv- inattention, unusual or inappropriate behav-
ing the recognition of delirium. however, ior or speech, or noticeable changes in the way
knowledge and skill alone are insufficient, the patient thinks, it is recommended that the
given the profound impediment to the assessment be repeated.
recognition of delirium posed by negative The only other testing reported is the
ageist stereotypes. These conclusions are use of the electroencephalogram to confirm
supported by the work of McCarthy (2003) the presence of delirium in any age group.
and neville (2008), which also highlight however, the electroencephalogram has
the powerful influence of the practice envi- been only modestly diagnostic and is not
ronment on how providers think about and practical in all situations. Pharmacological
respond to delirium. and nonpharmacological strategies to pre-
Several instruments have been developed vent and/or treat delirium in patients of
to screen for or diagnose delirium. Such instru- various ages and in settings have resulted in
ments include inouye’s Confusion Assessment only modest benefits, in particular with chil-
Method, Vermeersch’s Clinical Assessment dren and adolescents (heatherill & Flisher,
of Confusion—Form A, Albert’s Delirium 2010). The prevailing principles guiding pre-
Symptom interview, Trzepacz’s Delirium vention and treatment consist of multifacto-
Rating Scale, neelon and Champagne’s nEE- rial interventions that (a) identify patients
ChAM Confusion Scale, o’Keefe’s Deli rium at risk, (b) target strategies to minimize or
Assessment Scale, hart’s Cognitive Test for eliminate the occurrence of precipitating
Delirium, Robertson’s Confusional State Eva- factors as primary prevention accomplished
luation, otter’s Delirium Detection Score, through risk reduction, and (c) identify, cor-
McCusker’s Delirium index, Bettin’s Delirium rect, or eliminate the underlying cause(s)
DELPhi TEChniQUE n 111
while providing symptomatic and support- outcomes of care in delirium remain incon-
ive care. sistent, indicating that much work remains to
For adults, proactive geriatric consul- improve the care of individuals at risk for or D
tations and multicomponent interventions experiencing delirium. Guidelines for delir-
targeting several risk factors, rather than ium prevention, management, and treatment
targeting a single risk factor for delirium, in children do not exist.
and interventions with surgical versus med- on the basis of this summary of the state
ical patients have proved more successful in of knowledge of delirium, the need for fur-
reducing the incidence, severity, or duration ther study of delirium in all ages and care
of delirium. however, interventions have had settings is clearly documented. Such study
no effect on the recurrence of delirium or on should focus on all aspects of delirium,
outcomes 6 months after discharge from the including the epidemiology and natural his-
hospital. tory of delirium, to improve our understand-
To better understand why these interven- ing of the duration, severity, persistence, and
tions for adults have not been more success- recurrence of delirium and to better target
ful, some investigators have conducted post and time interventions. Greater insight into
hoc analyses to identify the characteristics of the underlying pathologic mechanism(s) of
patients for whom these interventions have delirium would enable more rigorous devel-
failed. These analyses have indicated that opment and testing of the efficacy and effec-
these interventions were less successful with tiveness of interventions to prevent and treat
patients who are at greatest risk for delir- delirium.
ium: those who are demented, functionally
impaired, and frailer. however, it is difficult Marquis D. Foreman
to determine how to improve these inter- Patricia E. H. Vermeersch
ventions because these studies have been
conceptually confused: Efficacy has been
confused with effectiveness, changing pro-
vider behavior has been confused with pre-
venting or treating underlying causal agents Delphi teChnique
for delirium, and primary prevention has
been confused with secondary prevention.
Moreover, interventions have targeted risk The Delphi technique is a research method
factors rather than the underlying pathologic used to identify key issues, to set priorities,
mechanisms (i.e., the metabolic and physio- and to improve decision making through
logic deviations that disrupt neurotransmit- aggregating the judgments of a group of
ter synthesis and functioning). Also, these individuals. The technique consists of using
studies have not been designed or powered a series of mailed questionnaires to develop
in such a way as to determine which of the consensus among the participants with-
multicomponents actually contributed to the out face-to-face participation. it provides
positive outcomes. the opportunity for broad participation
To improve the recognition, prevention, and prevents any one member of the group
and treatment of delirium in adults, sev- from unduly influencing other members’
eral professional organizations have devel- responses. Feedback is given to panel mem-
oped practice guidelines. These guidelines bers on the responses to each of the question-
tend to be comprehensive and are based on naires. Thus, panel members communicate
research and expert clinical opinion. Despite indirectly with each other in a limited, goal-
the existence of guidelines, the process and directed manner.
112 n DEPRESSion AnD CARDioVASCULAR DiSEASES
The first questionnaire that is mailed predictions than roundtable discussions. The
asks participants to respond to a broad ques- technique was later used to solicit opinions
D tion. The responses to this questionnaire of experts on atomic warfare as a means of
are then used to develop a more structured defense. it has since been applied in diverse
questionnaire. Each successive question- fields, such as industry, social services, and
naire is built on the previous one. The sec- nursing because of its usefulness and accu-
ond questionnaire requests participants to racy in predicting and in prioritizing. Also,
review the items identified in the first ques- the Delphi technique has been used in nurs-
tionnaire and to indicate their degree of ing studies to identify priorities for practice
agreement or disagreement with the items, and research.
to provide a rationale for their judgments,
to add items that are missing, and to rank Alice S. Demi
order the items according to their perceived
priority. on return of the second question-
naire, the responses are reviewed, the items
are clarified or added, and the mean degree Depression anD
of agreement and the ranking of each item
are computed. in the third questionnaire, CarDiovasCular Diseases
participants are asked to review the mean
ranking from the second questionnaire and
again to indicate their degree of agreement The American heart Association has esti-
or disagreement and give their rationale if mated that more than one third of American
they disagree with the ranking. Additional adults have at least one form of cardiovascular
questionnaires are sent until the group disease (Lloyd-Jones et al., 2009). Depression
reaches consensus. Many variations of this and cardiovascular disease are major pub-
procedure have been used, the number of lic health problems that affect considerable
questionnaires used ranging from three to percentage of American population and are
seven. among the top leading sources of functional
To be eligible to participate as a panel- impairment and disability. The annual eco-
ist in a Delphi study, the respondent should nomic burden of cardiovascular disease and
(a) be personally concerned about the prob- depression are estimated to be approximately
lem being studied, (b) have relevant infor- 500 and 70 billion, respectively (Lloyd-Jones
mation to share, (c) place a high priority on et al., 2009; Soni, 2009).
completing the Delphi questionnaire on Depression has been investigated
schedule, and (d) believe that the informa- through a variety of theoretical viewpoints,
tion compiled will be of value to self and including psychodynamic, cognitive, socio-
others. Several disadvantages of the Delphi logic, biologic, and the crisis models (Frank-
technique limit its application. First, there Stromberg & olsen, 1997). Clinical depression
must be adequate time for mailing the ques- is a mood disorder in which the patient typ-
tionnaires, their return, and their analysis. ically experiences depressed mood or anhe-
Second, participants must have a high level donia for at least 2 weeks. Depression may
of ability in written communication. And present either as a primary disorder or in
third, participants must be highly motivated association with other comorbid chronic
to complete all the questionnaires. conditions including cardiovascular dis-
The Delphi technique was first developed ease. Most nurses working in outpatients or
by the Rand Corporation as a forecasting tool inpatients health care delivery settings have
in the 1960s, when investigators found that witnessed cardiac patients with depressed
results of a Delphi survey produced better mood.
DEPRESSion AnD CARDioVASCULAR DiSEASES n 113
Depression is a common and impor- depression and major depression on heart
tant contributing risk factor of morbidity disease mortality. They found that patients
and mortality in patients with cardiovas- with major depression, when compared with D
cular disease. Several studies have found those who had minor depression, had signifi-
that depression is a significant predictor of cantly higher risk for cardiac mortality. These
adverse patient outcomes in a variety of car- findings suggest that the severity of depres-
diovascular conditions such as heart failure, sion is related to higher cardiac mortality. in
coronary artery disease, stroke, and myocar- another study, Schulz et al. (2000) reported
dial infarction (Gump, Matthews, Eberly, & that depressed participants with heart fail-
Chang, 2005; Penninx et al., 2001; Rutledge ure at baseline had the highest mortality risk
et al., 2006; Schulz et al., 2000; Williams followed by stroke, intermittent claudication,
et al., 2002). Findings from a large sample angina pectoris, and myocardial infarction
of Framingham heart Study participants patients. Further, Cox proportional hazards
show that depressive symptom was associ- regression model demonstrated that depres-
ated with increased risk of developing stroke sive symptoms were an independent pre-
(Salaycik et al., 2007). Participants who were dictor of mortality. in another study of the
on antidepressant medications had similar relationships between depression, coronary
risk level for developing stroke to those with- heart disease (ChD) incidence, and mor-
out medications (Salaycik et al., 2007). other tality, Ferketich, Schwartzbaum, Frid, and
research results provide evidence of the Moeschberger (2000) found that depressed
role of hypothesized common genetic path- men and women were at increased risk for
ways for both depression and heart disease incident of ChD events compared with non-
(Scherrer et al., 2003) and depressive symp- depressed counterparts. Moreover, unlike
toms and inflammatory markers in twin depressed women, depressed men had
studies (Su et al., 2009). increased risk of cardiac mortality.
Scientific research has provided several Prospective population-based studies of
valid and reliable instruments for assess- depression also found an increased risk for
ing depression in cardiovascular patients, ChD because of depression. Using data from
such as the Center for Epidemiological the Yale health and Aging Project (Williams
Studies Depression Scale (Griffin et al., et al., 2002) revealed that depressed individu-
2007; Lesman-Leegte et al., 2009), the als had demonstrated a 69% increase in the
Cardiac Depression Scale (hare & Davis, risk for incident of heart failure in compari-
1996; Wise, harris, & Carter, 2006), the son with nondepressed individuals. in addi-
hamilton Depression Rating Scale (Koenig, tion, depressed participants were more likely
Vandermeer, Chambers, Burr-Crutchfield, & to be women; consequently, depression was a
Johnson, 2006), the Beck Depression inven- significant risk factor of heart failure among
tory ii (Frasure-Smith et al., 2009), and the women but not in men.
Geriatric Depression Scale (Salman & Lee, Research findings suggest that depres-
2008), and has also provided evidence of sion is a risk factor for cardiac morbid-
favorable health benefits for depression miti- ity and mortality. however, interventions
gation in cardiac population. however, there that may reduce depression have failed to
is no sufficient evidence that depression reduce depression-related cardiac outcomes
treatment reduces cardiovascular events (Berkman et al., 2003; Salaycik et al., 2007).
(Rees, Bennett, West, Davey, & Ebrahim, Recognition of the overlap between
2004; Salaycik et al., 2007). depression and cardiovascular disease has
Several large-scale community-based led to increased interest in finding plausi-
studies have been conducted. Penninx ble biobehavioral mechanisms and genetic
et al. (2001) examined the effect of minor basis that link them together. in fact, there
114 n DEPRESSion AnD CARDioVASCULAR DiSEASES
is evidence to indicate that depression may investigate the relationship between inflam-
contribute to increased incidence of cardio- mation, depression, and cardiovascular dis-
D vascular events. This effect may be mediated ease are justified. Large, randomized clinical
by other behavioral and biological factors trials are needed to determine whether early
that play major roles in the development of detection of depression coupled with early
negative cardiac outcomes. There are several intervention can prevent the development of
known behavioral risk factors (e.g., sedentary cardiac disease or reduce the risk for inci-
life style, smoking, high-fat dietary intake) dent of negative cardiac events. Another
among depressed individuals that may con- research priority is to elucidate the poten-
tribute to the development of cardiac disease. tial mediating factors related to depression,
in addition, recent research findings suggest such as failure to comply with medical care,
that several biomarkers are implicated in both sedentary life style, eating habits and smok-
depression and cardiac disease pathogenesis. ing. Also, biological studies are needed to
First, research showed that the hypothalamic– quantify the latent effect of the alterations
pituitary–adrenocortical axis is activated in the level of risk biomarkers (e.g., homo-
during depression, which increases sym- cysteine, iL-6, tumor necrosis factor α, iL-2,
pathoadrenal activity. Consequently, some serotonin, dopamine, cortisol, heart rate
risk markers such as catecholamines, cortisol, variability, and platelet activation), which
and serotonin are elevated in both depression could have negative effect on cardiac func-
and some cardiac diseases. Second, depressed tion. Moreover, depression seems to be more
patients are at increased risk for rhythm dis- of a problem for women with cardiac dis-
orders. Recent evidence indicates that cardiac ease than for men. Therefore, future studies
patients who are depressed exhibit reduced are needed that focus on whether there is
heart rate variability, a known risk factor for indeed a disproportionate weight of comor-
sudden death in patients with CVD (Carney bid depression and cardiac outcomes among
et al., 1995). Third, depressed patients are women.
more likely to have platelet dysfunction that Designing large-scale clinical trials that
may have negative impact on the develop- test biobehavioral research models along
ment and prognosis of cardiovascular dis- with considering both physiologic and
ease such as atherosclerosis, acute coronary behavioral outcomes is essential to a better
syndromes, and thrombosis. Finally, the understanding of the depression–cardiac
research demonstrated a close relationship disease communication. in addition, stud-
among proinflammatory cytokines such as ies designed to develop a more clear account
interleukin-6 (iL-6), tumor necrosis factor α, of psychosocial risk factors to cardiac dis-
depression, and incident of negative cardiac ease are urgently needed. Finally, in an era
outcomes. Briefly, any single mechanism will of genetic research, identifying genes or
fall short of capturing the underlying patho- gene expression mechanisms that may link
genesis processes of depression and cardiac depression and cardiac disease may pave the
disease. Therefore, several mechanisms are path for ultimate understanding of the link
needed to account for the development and between depression and cardiovascular dis-
progression of the two. eases. Studies of effectiveness of depression-
This overview from biopsychosocial specific interventions that address the need
perspective reveals that there is sufficient to improve mood status in cardiac patients
evidence to support an important asso- are relevant to clinical nursing practice and
ciation between depression and cardiac research.
disease. it also suggests a number of signif-
icant directions for future research. Genetic Ali Salman
studies to establish the cellular basis and to Yi-Hui Lee
DEPRESSion in FAMiLiES n 115
if five out of the following nine symptoms
Depression in FaMilies are present for a minimum of 2 weeks most
of the day, nearly every day: (a) depressed D
mood, (b) loss of interest or pleasure in all
Depression is a major mental health prob- activities, (c) decrease or increase in appetite
lem affecting 25 million Americans and their or significant weight change, (d) insomnia
families. By 2020, depression will be the third or hypersomnia, (e) psychomotor retarda-
leading cause of disability worldwide (http:// tion or agitation, (f) fatigue or loss of energy,
www.int/healthinfo/global_burden_dis- (g) feelings of worthlessness or excessive
ease/2004_report_update/en/index.html). guilt, (h) difficulty concentrating or inde-
Most people suffering from depression live cisiveness, and (i) recurrent thoughts of
with their families, usually their spouses and death, recurrent suicide ideation or attempt
children, and the negative impact of depres- (American Psychiatric Association, 1994).
sion on families has been well documented one of the five symptoms must be depressed
(Bulloch, Williams, Lavorato, & Patten, 2009; mood or loss of interest or pleasure. Together,
Feeny et al., 2009; herr, hammen, & Brennan, these symptoms cause significant functional
2007; Keitner, Archambault, Ryan, & Miller, impairment. in addition to MDD, depres-
2003). nursing has long viewed families as sion is further classified in the Diagnostic and
a context for caring for the individual with Statistical Manual of Mental Disorders, fourth
depression but only recently has focused on edition (American Psychiatric Association,
the whole family (e.g., Ahlström, Skäsäter, & 1994) into other diagnostic subtypes such
Danielson, 2009, 2010). as minor depression or dysthymia by signs
Depression is a rather vague descriptive and symptoms, onset, course, duration, and
term with a broad and varied meaning rang- outcomes.
ing from normal sadness and disappointment Family refers to any group that func-
to a severe incapacitating psychiatric illness. tions together to perform tasks related to
William Styron (1990) describes in Darkness survival, growth, safety, socialization, or
Visible the unsatisfactory descriptive nature health of the family. Family members can
of the term depression: “a noun with bland be related by marriage, birth, or adoption
tonality and lacking any magisterial presence, or can self- identify themselves as family.
used indifferently to describe the economic This definition is sufficiently broad to be
decline or rut in the ground, a true wimp of a inclusive of all types of families; however,
word for such a major illness” (p. 37). it is recommended that researchers provide
Depression is a universal mood state specific definitions of family appropriate to
with all people experiencing a lowered mood their research.
or transient feelings of sadness related to Genetic–biological research of depres-
negative life events such as loss. For most, the sion in families includes genetic and bio-
feelings of sadness or disappointment resolve logical marker studies (holmans et al., 2007;
with time and normal functioning resumes. Raison, Capuron, & Miller, 2006). The four
in contrast, the symptoms associated with the research approaches to the genetics of mood
psychiatric illness of depression can disrupt are as follows: (a) familial loading studies
normal functioning, influence mortality and (e.g., comparing families with depression
morbidity, and can cause a myriad of prob- to families without the disease), (b) stud-
lems within the family (hammen, Brennan, ies evaluating the inheritability of mood
& Shih, 2004; Katon, 2009; Katon, Lin, & disorders (e.g., twin studies), (c) studies of
Kroenke, 2007; Patten et al., 2008; Uebelacker incidence of the risk for but not yet ill from
et al., 2008). The psychiatric illness of major mood disorders to determine biological or
depressive disorder (MDD) is diagnosed psychological antecedents, and (d) in theory,
116 n DEPRESSion in FAMiLiES
studies using genetic probes to determine all areas than matched control families and
which relatives and which phenotypes are families whose members are diagnosed with
D associated with the genetic contributants alcohol dependence, adjustment disorders,
to mood disorders (Suppes & Rush, 1996). schizophrenia, or bipolar disorders (Keitner
The results of the familial loading studies et al., 2003). it is not surprising that depres-
are clear, whether the approach used is the sion has its most negative impact on fami-
“top-down” (i.e., studies of children with lies during acute depressive episodes (Miller
depressed parents; Currier, Mann, oquendo, et al., 1992), yet families with depressed mem-
Galfalvy, & Mann, 2006) or the “bottom- bers consistently experience more difficulties
up” approach (i.e., studies of relatives of than matched control families even after ini-
depressed children; Mondimore et al., 2007; tial treatment. Family members living with
Silk et al., 2009). Children with depressed members with depression report greater
parents have a significantly greater risk of health problems, with family members often
developing depressive disorders and other being sufficiently distressed themselves to
psychiatric disorders than do children with require therapeutic intervention (Abela et al.,
parents without depression (Abela, Zinck, 2009; Ahlström et al., 2009).
Kryger, Zilber, & hankin, 2009; Gibb, Benas, A related and important body of psy-
Grassia, & McGeary, 2009). Biological marker chosocial research focuses on depression
studies have focused on growth hormone, as a coexisting condition for those suffer-
serotonergic and other neurotransmitter ing with a chronic or life-threatening illness
receptors, sleep, and hypothalamic–pituitary (e.g., cancer, diabetes, and dementia). As an
axis (Gibb et al., 2009; Raison et al., 2006; example, researchers have focused on the
Sunderajan et al., 2010; Uher & McGuffin, negative health outcomes of family caregiv-
2008). There is increasing evidence from ers in cancer and how caregiver outcomes
genetic studies about the genetic inheritance also influence the cancer survivor’s health
of depression (holmans et al., 2007; Kendler, outcomes (e.g., Kurtz, Kurtz, Given, & Given,
Gatz, Gardner, & Pederson, 2005) and the fact 2005; Manne, ostroff, Winkel, Grana, & Fox,
that abnormalities in biological markers per- 2005; northouse et al., 2007; Segrin et al.,
sist throughout the life span. The majority of 2006). These studies provide additional evi-
studies on genetic and biomarker studies in dence of the negative impact of depression
recent years have focused on maternal trans- on the entire family when family members
mission (e.g., Gibb et al., 2009; hammen et al., are living with members with depression
2004) rather than paternal transmission of plus chronic or life-threatening illness and
depression. Currier et al. (2006) is an excep- for the importance of including family mem-
tion in that they examined sex differences bers in treatment interventions (Segrin &
in parental transmission to both male and Badger, 2010).
female offspring. Familial transmission rate Few studies have used qualitative
of mood disorders from female probands approaches to understand family members’
was almost double that of males. perspectives and treatment needs of living
Psychosocial research of depression with a depressed person (Ahlström et al.,
in families has focused on communica- 2009, 2010; Badger, 1996a, 1996b). Ahlström
tion, marital problems and dissatisfaction, et al. (2009) found, in their qualitative descrip-
expressed emotion, problem solving, coping, tive study of seven families with an adult
and family functioning (Feeny et al., 2009; member who had MDD, five themes describ-
Lazary, Gonda, Benko, Gacser, & Bagdy, ing living with major depression. Family
2009; Silk et al., 2009). The evidence strongly members (n = 18) described being forced to
supports that families who contain members relinquish control in everyday life because
with depression have greater impairment in the family members lost their energy and
DEPRESSion in oLDER ADULTS n 117
could not manage daily life. Further, feel- prevent depression from becoming a recur-
ings of uncertainty and instability affect rent and chronic illness for the entire family.
the atmosphere within each of these fam- The majority of studies continue to focus D
ilies. Families also described living on the on either the environmental or genetic fac-
edge of the community as they isolated or tors that increase risk for depression in fam-
secluded themselves from the wider commu- ilies, but future studies need to examine the
nity. Daily life was hard because responsibil- relationships between genetic–biological
ities shifted between members, including the predisposition and environment on preven-
children within the family, because the adult tion or treatment of depression (Jaffe & Price,
depressed member could not assume usual 2007; Rutter, 2010). There have been fewer
roles and responsibilities. Finally, families clinical trials validating the effectiveness of
describe that despite everything, the family family interventions in treating depression,
as a unit and individually had ways of coping and future research should develop and test
and finding some kinds of satisfaction. These psychoeducational and support interven-
results support findings from previous stud- tions with families. Although a common con-
ies (Badger, 1996a) and provide perspectives cern with research with families remains the
of family members not normally included in unit of analysis (individual, dyad, or family
depression research. as a whole), research representing all per-
The role of the family in the treatment spectives is needed for nursing to more fully
process has received less attention (e.g., understand and treat depression in families.
Cardemil, Saeromi, Pinedo, & Miller, 2005).
Systematic family interventions are few and Terry A. Badger
are modeled after programs used with peo-
ple with other psychiatric disorders and
their families or after programs used with
people with other illnesses (e.g., diabetes, Depression in olDer aDults
dementia) and their families (Judge, Yarry, &
orsulic-heras, 2010; Rosland, heisler, Choi,
Silveira, & Piette, 2010; Rosland & Piette, Depression is the most common mental dis-
2010). For example, Ryan et al. (2010) found order among older adults in the United States
that the Management of Depression Program and one of the most disabling conditions
was effective in helping patients with diffi- among elderly persons worldwide (Kohler
cult-to-treat forms of depression and their et al., 2010; Sable, Dunn, & Zisook, 2002). it
family members to deal more effectively is estimated that of the 35 million people 65
with persistent depression. The disease years and older, 2 million (approximately 6%)
management approach, which was similar suffer from severe depression and another
to approaches used in cancer or diabetes, 5 million (14%) suffer from less severe forms
improved perceived quality of life and func- of depression (national institute of Mental
tioning, reduced depressive symptoms, and health, 2007; Varcarolis & halter, 2010). The
improved perceptions of family function- prevalence of clinical depression ranges
ing. Families continue to identify the need from approximately 5% to 10% in commu-
for information about how to facilitate com- nity samples (medical outpatients), from 10%
munication, decrease negative interactions, to 15% in medical inpatients, and from 10%
handle stigma, and learn strategies for fam- to 25% in hospice and palliative care patients
ily coping with depression (Ahlström et al., (Blazer, 2003; Djernes, 2006, King, heisel, &
2009; Badger, 1996b). in theory, education, Lyness, 2005). Furthermore, the rates of major
support, and partnering could move family depression among older adults range from
members more quickly into recovery and 20% in nursing home residents and nearly
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