Encyclopedia of Nursing Research

118 n DEPRESSion in oLDER ADULTS



30% of older adults seen in primary care clinical depression into major depressive dis-
settings (Alexopoulos, 2005) to up to 42% of order and dysthymic disorders. Major depres-
D residents of long-term care facilities (Blazer, sion refers to a depression that meets specific
2003; Djernes, 2006; Fiske, Wetherell, & Gatz, diagnostic criteria for duration, impairment
2009). Approximately 50% of older adults of functioning, and presence of a cluster of
who are hospitalized for medical illnesses physiological and psychological symptoms
or receiving long-term care experience clin- (American Psychiatric Association, 2000).
ically significant depression (Alexopoulos, The DSM-IV-TR recognizes five further sub-
2005). older adults are vulnerable to depres- types of major depressive disorder, called
sion for a number of reasons. Approximately specifiers, in addition to noting the length,
80% have at least one chronic medical con- severity, and presence of psychotic features,
dition that can trigger depression (Jang, namely, melancholic, atypical, catatonic,
Bergman, Schonfeld, & Molinari, 2006; Sable postpartum, and seasonal affective disorder.
et al., 2002). in addition, approximately 6 mil- Dysthymia is a chronic, milder mood distur-
lion older adults need assistance with their bance in which a person reports a low mood
daily activities (Sable et al., 2002), and inabil- almost daily over a span of at least 2 years.
ity to meet one’s own personal needs has The symptoms are not as severe as those for
been associated with increased vulnerability major depression, although people with dys-
to late-life depression (Fiske et al., 2009). thymia are vulnerable to secondary episodes
Although depression is often viewed as of major depression (sometimes referred to
a clinical syndrome with specific diagnostic as double depression; American Psychiatric
criteria, depression has also been concep- Association, 2000).
tualized as a mood state or as a collection Diagnosing depression in older adults
of symptoms (Goodwin & Jamison, 2007). is fraught with challenges. Depressed mood
Because older adults may not meet the diag- is one of the depressive symptoms that older
nostic criteria for the clinical syndrome, adults may experience, but others may also
studies of older adults commonly use the experience a range of affective responses such
term depression to mean depressive symp- as hopelessness and loss of interest in living
toms (Fiske et al., 2009; Martin et al., 2008). (Fiske et al., 2009). indeed, many studies have
Clinical depression is usually qualified by an reported that in older adults, a predominant
adjective to specify a particular type or form, depressed mood may not be as prominent as
including reactive, agitated, and psychotic. symptoms of irritability, anxiety, or physical
in addition, on the basis of etiology, depres- or somatic symptoms and changes in func-
sion is classified as endogenous (because of tioning (Alexopoulos, 2005; Fiske et al., 2009;
internal processes) or exogenous (because of Sable et al., 2002). in addition, symptoms of
external factors). Depression is termed pri- cognitive impairment that may occur in elders
mary when it is not preceded by any phys- with depression may be mistaken for demen-
ical or psychiatric condition and secondary tia (Charney et al., 2003; olin et al., 2002;
when preceded by another physical or psy- Sable et al., 2002). it is estimated that approx-
chiatric disorder. Finally, depression is clas- imately 15% of older adults have depressive
sified as acute (less than 2 years duration) or symptoms that do not meet diagnostic crite-
chronic (more than 2 years). Clinical depres- ria specified by the DSM-IV-TR (American
sion consists of characteristic signs and Psychiatric Association, 2000) for diagno-
symptoms as well as type of onset, course, sis of major depression (Alexopoulos, 2005).
duration, and outcome. The Diagnostic and nevertheless, these older adults can experi-
Statistical Manual of Mental Disorders, Fourth ence functional deficits in activities of daily
Edition, Text Revision (DSM-IV-TR; American living and instrumental activities of daily
Psychiatric Association, 2000) classifies living that compromise their independence

DEPRESSion in WoMEn n 119



and quality of life. indeed, the symptoms of however, its symptoms may not be consis-
depression can lead to total inability of the tent across racial/ethnic groups, making
older individual to care for self and to relate early diagnosis and treatment challenging. D
to others. There is also a potential for persons Research on depression among older
with depression to negatively affect family adults was ignored in the past and is still a
members and others around them. neglected area. Clearly, much more nursing
not surprisingly, few elders in the com- research is needed. it is critical that nurses
munity seek mental health services. Most assume leadership in disseminating infor-
depressed elders are seen by general prac- mation about the outcomes of a variety of
titioners for psychosomatic complaints. treatments that can be used for depression in
Part of the symptomatology of depression later life. There is a particular need to exam-
is a focus on physical problems, and this ine suicide in late life and to develop better
requires practitioners to carefully assess for assessment instruments for detecting sui-
depressive symptoms. Suicide is a risk factor cidal ideation in elders.
for depressed older adults. The suicide rate
for individuals 80 years and older is twice as Jaclene A. Zauszniewski
that of the general population and is particu- Abir K. Bekhet
larly high in older White males. interestingly, May L. Wykle
most suicidal elders recently visited a general
practitioner before their suicidal act.
Studies of risk factors for late-life depres-
sion have examined the effects of gender, Depression in woMen
age, and race/ethnicity. Like earlier depres-
sion, late-life depression more commonly
strikes women than men (Chen, Chong, & Depressive disorders (DDs) are widely occur-
Tsang, 2007) at an approximately 2:1 ratio ring psychiatric illnesses that account for
(Kockler & heun, 2002). Recent population- significant suffering and disability world-
based studies have estimated the prevalence wide. Women have significantly higher rates
of geriatric depression at 4.4% for women of DD than do men, and the illness course
and at 2.7% for men, whereas the estimated is longer and more debilitating for most
lifetime prevalence for clinical depression women. Well-established gender differences
is approximately 20% in women and 10% in the precipitants and outcomes of DDs fur-
in men (Kockler & heun, 2002; Sable et al., ther underscore the need to address DDs
2002). Although female gender is a risk fac- as a specific health problem for women. As
tor for depression throughout the life span, these disorders first emerge in adolescent
gender differences decrease with increasing girls, commonly occur pre- and postpartum,
age (Sable et al., 2002), and White men ages and in menopause, and co-occur with a host
80 to 84 years are at greatest risk for suicide of chronic illnesses, nurses in most practice
(Kockler & heun, 2002). settings will encounter women with DD and
Cohort studies have shown that the may be the sole available treatment provider.
oldest-old, those older than 85 years, are Gender disparities in the rates of DD are
more likely than the younger-old, those most pronounced for major DD (MDD) and
between 65 and 74 years, to experience dysthymia (DYS) so these psychiatric ill-
depressive symptoms (Blazer, 2003; Mehta nesses are discussed here. note that gender
et al., 2008; van’t Veer-Tazelaar et al., 2008). does play a role in the manifestations and
Depression is thought to afflict older adults outcomes of other kinds of DDs (e.g., bipo-
of all racial and ethnic backgrounds simi- lar disorder), but the overall incidence and
larly (Alexopoulos, 2005; Bruce et al., 2002); presentation is similar for women and men

120 n DEPRESSion in WoMEn



(hendrick, Altshuler, Gitlin, Delrahim, & in the etiology of DD (Abramson & Alloy,
hammen, 2000). MDD is defined as the pres- 2006; Bromberger et al., 2010; Brummelte &
D ence of five or more symptoms (weight sleep, Galea, 2010; hammen, 2003; noble, 2005;
motoric, and cognitive changes) co-occurring Stone, Gibb, & Coles, 2010).
nearly every day over a 2-week period Similarly, the preponderance of gender-
(American Psychiatric Association, 2000). At specific theories of MDD and DYS are derived
least one of the symptoms experienced must from the biomedical model and focus on the
include depressed mood or a loss of inter- type and amount of stressors women expe-
est or pleasure in usually enjoyed activities. rience and factors that mediate and moder-
DYS is diagnosed when depressed mood is ate stress perception. Several investigators
present nearly all of the time for two or more have determined, for example, that women
years and other depressive symptoms are also have higher rates of interpersonal distress
present (American Psychiatric Association, than do men, and these stressors contribute
2000). Rates of DD in women ranges from to their risk for depression (Brown, 2002;
7% to 15%, 1.5 to 2 times higher than rates hammen, 2003; hammen, Brennan, & Shih,
obtained for men in developed countries 2004; Kendler, Thornton, & Prescott, 2001;
(Seedat et al., 2009; Van de Velde, Bracke, & Sanathara, Gardner, Prescott, & Kendler,
Levecque, 2010; Wang et al., 2010; Williams 2003; Zlotnick, Kohn, Keitner, & la Grotta,
et al., 2010); in low- and middle-income coun- 2000). The most specific of these models is
tries, rates of DD are considerably higher based on two decades of empirical work by
(World health organization, 2008). Brown (2002) and Kendler, hettema, Butera,
Although gender disparities in DD Gardner, and Prescott (2003), which shows
have long been recognized, the role gender that when stressors are central to a woman’s
plays in its development and maintenance identity and contain elements of entrapment,
is still evolving and remains hotly contested humiliation, or loss, DD is likely to follow in
(hammarstrom, Lehti, Danielsson, Bengs, & the subsequent year. Cognitive vulnerability
Johansson, 2009; Piccinelli & Wilkinson, 2000; models that propose alterations in stress per-
Ussher, 2010; Wittchen, 2010; World health ception also have been proposed to account
organization, 2009). The most dominant for gender disparities in DD (Brown, 2002;
framework for understanding DD is the bio- hyde, Mezulis, & Abramson, 2008; Kendler,
medical model (hammarstrom et al., 2009), Gardner, & Prescott, 2002; nolenhoeksema,
organized around the concepts of allostasis 1994; Stone et al., 2010). Perceived hopeless-
and hypothalamic–pituitary–adrenal dysreg- ness, neuroticism, brooding rumination, and
ulation in individuals (Brummelte & Galea, negative self-evaluations are cognitive vul-
2010; Mcewen, 2003; Sterner & Kalynchuk, nerabilities that have been shown to contrib-
2010). in broad strokes, it contends that DD ute to risk for DD in women (Abramson &
is attributable to uncontrolled stressors, the Alloy, 2006; Brown, 2002; Crane, Barnhofer, &
perception of stressors as threats, and conse- Williams, 2007; hyde et al., 2008; Kendler
quent excessive physiological response. The et al., 2002; nolen-hoeksema, 1994; Treynor,
resulting wear and tear on stress regulatory Gonzalez, & nolen-hoeksema, 2003). Social
organs in the central nervous system and support also has been shown to be a key
periphery eventually leads to neurotrans- variable in moderating the effects of stress-
mitter disarray, hypothalamic–pituitary– ful events (Agrawal, Jacobson, Prescott, &
adrenal dysregulation, and subsequently Kendler, 2002; Brown, 2002; Kendler, Myers,
depressive symptoms. For women, uncon- & Prescott, 2005). Brown (2002), for example,
trolled and/or excessive stressors, cognitive has shown that having a confident or other
schemas that alter stress perception, and key relationship reduces the likelihood of a
gonadal hormones all have been implicated depressive outcome following humiliation

DEPRESSion in WoMEn n 121



and entrapment. note that a primary ques- self-care and social engagement (Lafrance &
tion underlying all of these studies is how Stoppard, 2007; Stoppard, 1998; Ussher, 2010).
DD in women is different from DD in men. Randomized controlled trials that estab- D
in contrast, feminist and other postmod- lish the evidence base for treatment largely
ern scholars assert that the search for gen- neglect the role of gender in treatment design,
der differences inspired by the biomedical response, or outcome. The national institute
model of DD disavows and decontextualizes of Mental health Treatment of Depression
women’s experience of DD and the sociocul- Collaborative Research program, for example,
tural circumstances in which it is embed- examined treatment differences in outcome
ded (Lafrance, 2007; Marecek, 2006; Metzl & among those treated with medication and
Angel, 2004; Stoppard, 1998). Social construc- different types of psychotherapy; none of the
tionists and critical social theorists (Burr, treatments tested were specifically modified
2003; Fleming & Moloney, 1996; o’Grady, to address factors that may contribute to DD
2005), for example, contend that women’s in women (Elkin et al., 1989). Still, follow-up
identity is centered in and shaped through studies showed that were no gender-related
their relationships with others, and these differences in outcomes from treatment, even
relationships are constrained by social and when several gender-related factors were
cultural norms about women that are rein- examined (Zlotnick, Shea, Pilkonis, Elkin,
forced by moral judgments made by the self & Ryan, 1996). Similarly, the Treatment for
and by others (Gilligan, 1982; Ridgeway & Adolescents with Depression Study tested
Smith-Lovin, 1999; West & Zimmerman, medication and cognitive-behavioral ther-
1987). Women’s choices in those relationships apy without regard to gender (Domino et al.,
are further compromised by gendered work- 2009). no published accounts of the effects
place and social institutions that contribute of gender in this study were noted. Gender-
to economic deprivation and other resource sensitive treatments also were not used in
limitations (Belle & Doucet, 2003; Chen, several randomized trials conducted in pri-
Subramanian, Cevedo-Garcia, & Kawachi, mary care settings examining collaborative
2005; Gray, 2005). numerous studies on the care for DD; gender differences in outcomes,
basis of women’s accounts of DD validate a when reported, were not found (Bush et al.,
gendered view of depression showing that 2004). The Sequenced Treatment Alternatives
identity loss, gender-based interpersonal to Relieve Depression study is the most recent
demands including caregiving, and moral of the randomized controlled trials to estab-
judgments about the proper role of women lish evidence-based treatment for DD, again
all contribute to the profound sadness and using treatments unmodified for gender con-
despair women experience, characterized as cerns or based on women-centered theoret-
depression in biomedical models (Beck, 1993; ical approaches (Fava et al., 2003). Although
hurst, 2003; Jack, 1991; Lewis, 1987; McMullen, specific gender differences in the anteced-
2003; Scattolon & Stoppard, 1999; Schreiber, ents and course of MDD were evident in the
2001). Such woman-centered perspectives on Sequenced Treatment Alternatives to Relieve
DD have been extended to include embodi- Depression study participants, the investiga-
ment as an important concept in under- tors do not discuss the need for interventions
standing women’s experiences of depression that target women’s concerns (Marcus et al.,
(Fuchs & Schlimme, 2009). Such a “material- 2005). it is important to note that although
ist-discursive perspective” of DD is a begin- no gender differences in outcome are noted
ning attempt to explain how the physical and among the evidence-based treatments used
emotional demands associated with fulfilling in these major treatment studies, the primary
gender expectations leaves women with so outcome of number and severity of depres-
few resources that they become incapable of sive symptoms used in these studies may be

122 n DESCRiPTiVE RESEARCh



sufficiently imprecise to ascertain true dif- about causality, treatment, and outcome,
ferences in short- and long-term functioning, the impasse between the two has prevented
D especially given the ongoing gender-related the development of theory and practice that
challenges women face. would serve to reduce the rates and impact
There is little guidance in the research of DD on women. Yet careful examination
literature about what constitutes women- of scholarship and research emerging from
centered treatment for DD, and no effective- both traditions shows overlap in findings.
ness studies of such treatment were detected. For example, both traditions note the cen-
Theorists writing in this area agree that nar- trality of interpersonal distress to women’s
rative therapy informed by feminist prin- identity and how relationship disruption
ciples may be the most fruitful approach to can contribute to DD in women (Brown,
addressing the causes and outcomes of DD 2002; hammen, 2003; hammen et al., 2004;
experienced by women (Gremillion, 2004; Jack, 1991; Ridgeway & Smith-Lovin, 1999).
Lee, 1997; McQuaide, 1999). Such an approach Both theory and practice would be advanced
begins to uncover individual, social, and cul- when women-centered and biomedical per-
tural level gender influences on women who spectives are brought together to under-
are experiencing DD that define their identity stand how DD develops and is maintained
and determine their actions within important in social and cultural systems of inequality
relationships. Therapy then focuses on iden- and how treatment can be directed at the
tity work that results in a new definition of individual, family, social, and cultural level
self and self-in-relationship that contains less to improve outcomes (Stoppard, 1998; Ussher,
rigid boundaries and moral judgments about 2010). Should that occur, women- centered
gender roles and responsibilities. it is instruc- approaches can be designed and tested
tive that the studies focusing on women’s alongside conventional treatments to effect
experience of recovery from DD consistently long-term reduction in the suffering and dis-
report that rejection of gender stereotypes ability experienced by women.
as a model for the self, establishing a new
self-narrative, and improving self-care in the Emily J. Hauenstein
context of a therapy relationship initiated an
ongoing recovery process (Berggren-Clive,
1998; Chen, Wang, Chung, Tseng, & Chou,
2006; Chernomas, 1997; Lafrance & Stoppard, DesCriptive researCh
2006; Peden, 1993; Schreiber, 1998). A few
intervention studies using women-centered
strategies to treat depression in women Descriptive research involves collecting and/
are beginning to appear in the literature or analyzing data to characterize a group,
(Laitinen & Ettorre, 2004; Ussher, hunter, & concept, or phenomenon. it can use quan-
Cariss, 2002) but significant work is required titative or qualitative (including naturalis-
to establish evidence that women-centered tic) methodologies. Quantitative descriptive
interventions contribute to the long-term methodologies include surveys, measure-
well-being for women. ment tools, chart or record reviews, physio-
Women-centered models of DD are based logical measurements, meta-analyses, and
on different epistemologies and use different secondary data analyses. Qualitative descrip-
methodological approaches to interpret the tive methodologies include interviews, focus
manifestations and outcomes of DD. With groups, content analyses, reviews of liter-
women-centered understandings of DD posi- ature, observational studies, case studies,
tioned in opposition of the biomedical model life histories, grounded theory studies, con-
and the latter dominating extant research cept analyses, ethnographic studies, and

DESCRiPTiVE RESEARCh n 123



phenomenological studies. Many qualitative the logical positivist view of science helped
methodologies use exploratory as well as clarify linkages between philosophy, the-
descriptive techniques. ory, and method. At one extreme, nurse sci- D
Descriptive studies are often used when entists and theorists argued that the future
little research has been done in an area to of nursing knowledge development lay in
clarify and define new concepts or phenom- empirical studies that allowed for repeated
ena, to increase understanding of a phenom- observational statements under a variety of
enon from another experiential perspective, conditions. it was believed that one ultimate
or to obtain a fresh perspective on a well- truth could be found after repeated objective
researched topic. Also, the formulation and observations, which would eventually lead
the testing of measurement tools (e.g., to to discovery of universal laws.
measure depression, anxiety, or quality of Critics of the logical empiricist approach
life) use descriptive research techniques. The argued that truth is influenced by history,
development and refinement of these tools context, and a chosen methodology and is
will continue, with increasing emphasis on constantly in a state of flux. What is humanly
outcomes research as nurses are required to unobservable one day may be observable
demonstrate how their interventions make a with the help of technological innovation
difference for patients. another day. Although logical positivism is
Descriptive research has comprised the no longer espoused in nursing theory and
majority of nursing studies, although exper- science, its role was crucial in initiating dia-
imental and quasi-experimental studies in logue about what nursing knowledge is and
nursing are on the rise. Early research efforts how research in nursing should be advanced.
were focused on descriptive epidemiological These dialogues have helped swing the pen-
studies. nightingale’s pioneering work is a dulum from valuing experimental research
well-known example of this type of research. as the gold standard in nursing to recog-
Well schooled in mathematics and statistics, nizing the important role of descriptive and
nightingale created elaborate charts demon- exploratory research.
strating morbidity and mortality trends of over the years, nursing leaders have
soldiers during and after the Crimean War. struggled to establish which approach to
her detailed record keeping and graphic rep- knowledge development is appropriate and
resentation of these data convinced officials necessary for nursing. Dickoff, James, and
of the need to improve sanitary conditions Wiedenbach’s (1968) four levels of theory for
for soldiers, which drastically reduced mor- nursing included the most basic type, factor-
tality rates (Cohen, 1984). isolating theory, as the product of descriptive
The progress in descriptive research studies, with higher level theories built on
activity in nursing has been influenced by the necessary base of this first level of theory.
several events and movements over the past Therefore, descriptive research is a necessary
several decades: advanced degree educa- base to provide a foundation of support for
tion in nursing, philosophical debate about intervention studies, with the ultimate goal
the role of nursing and nursing research in of using research findings in practice. Meta-
the scientific community, establishment of analysis, which is a useful tool that synthe-
centers for nursing research, and formation sizes extant nursing research, was initially
of an agenda for knowledge development in applied to experimental studies. Application
nursing. of this technique to descriptive studies can
With the help of federal traineeship also help determine when a phenomenon is
money, the earliest doctorally prepared ready for testing with intervention studies.
nurses obtained degrees in basic science Synthesis of qualitative research, typically
programs. The adoption and rejection of called qualitative metasynthesis (Thorne,

124 n DiABETES RESEARCh



2009), continues to evolve and develop. in this entry is to review major historical, soci-
addition, methods for research integration etal, economical and contemporary practice
D and mixed methods synthesis are develop- issues, theoretical and research perspectives,
ing to combine both qualitatively and quan- and future directions.
titatively derived findings (Thorne, 2009). The care and treatment of individuals
Despite the complex nature of this synthesis, with diabetes was revolutionized with the
work on these approaches continues because discovery of insulin in 1921 by Drs. Frederick
nurses are motivated to extend nursing Banting and Charles Best at the University of
knowledge. Toronto. one year later, insulin for human use
Public and private funding of nursing was administered to save the life of a 14-year-
research has allowed for an expansion of old boy who was dying from the disease
nursing knowledge based in research. of (Banting, Best, Collip, Campbell, & Fletcher,
the many studies funded by the national 1922). The health care community, persons
institute of nursing Research, Sigma Theta living with diabetes, and their families owe
Tau, and private foundations, descriptive much to Banting et al. (1922) for their ground-
research continues to command a large por- breaking discovery. Since then, tremendous
tion of research dollars. strides in scientific discovery for diabetes
Many nursing organizations and asso- treatment have occurred to allow optimal
ciations have delineated priorities for a glycemic control. Despite these advances, our
nursing research agenda that include health society is faced with a significant economic
promotion, disease prevention, and wellness, burden because of the increasing numbers of
eliminating health disparities, improving individuals diagnosed with diabetes annu-
quality of life, and improving end-of-life care ally. According to the most current available
and research on minority groups and cul- data from the National Diabetes Statistics 2007
turally different views of health and illness. fact sheet (national institute of Diabetes and
Adding to nursing’s knowledge base in these Digestive and Kidney Diseases [niDDK],
areas will require using descriptive research 2008), diabetes was the seventh leading cause
along with other research methodologies and of death as reported on U.S. death certificates
incorporating the results of these studies into in 2006. The major contributor to mortality
nursing practice and research endeavors. risk was cardiovascular disease, which has
rates two to four times greater for adults
Anita J. Tarzian with diabetes than those without the disease.
Marlene Zichi Cohen Estimated U.S. diabetes prevalence rates total
23.6 million people, with 17.9 million diag-
nosed and 5.7 million who remain undiag-
nosed (niDDK, 2008).
Diabetes researCh The major types of diabetes are type 1
and type 2 diabetes. in adults, approximately
90% have type 2 diabetes, with the remain-
Diabetes is a chronic, debilitating disease der diagnosed with type 1 diabetes. The
affecting individuals of all ages and diverse etiology of type 2 diabetes includes insulin
ethnic populations. nurses deliver evidence- resistance and insufficient insulin secretion.
based care for persons living with diabe- Type 1 diabetes is caused by autoimmune
tes in primary care settings, hospitals, and pancreatic beta-cell destruction that requires
long-term care facilities. Key research efforts exogenous insulin administration. Although
are imperative to ensuring optimal health the majority of persons with type 1 diabe-
outcomes for those afflicted by this poten- tes develop the disease during childhood,
tially, devastating disease. The purpose of increasing numbers of youth have been

DiABETES RESEARCh n 125



diagnosed with type 2 diabetes in the past Medicine (2009a) recently identified national
decade, particularly because of childhood priorities for comparative effectiveness
obesity, inadequate nutrition, and sedentary research to aid in the translation of best prac- D
lifestyles. Similar to the higher rates of obe- tices for preventing, treating, monitoring and
sity that are seen in African Americans and delivering care. Best practices result from the
hispanics (ogden, Carroll, Curtin, Lamb, most informed decisions of clinicians, con-
& Flegal, 2010), the incidence of type 2 dia- sumers of care, and policy makers generated
betes is also greater in these populations by well-designed investigations that explore
than in non-hispanic Whites (Mayer-Davis, alternative therapeutic approaches. The
2008). Epidemiological trends show that one conundrum facing nurse researchers is how
in three youth in the 2000 U.S. birth cohort best to participate in transdisciplinary teams
will develop diabetes during their lifetime to develop and to evaluate interventions
(narayan, Boyle, Thompson, Sorensen, & that promote effective, individualized self-
Williamson, 2003). management for optimal glycemic control in
Projections of the numbers of individu- persons with diabetes and to also implement
als who will be diagnosed with diabetes screening procedures for early detection and
indicate steady growth to epic proportions in prevention in those most at risk for develop-
elders older than of 65 years and in African ing diabetes.
and native Americans and hispanics (Boyle Tighter glycemic control is shown to
et al., 2001; Engelgau et al., 2004). in 2007, the decrease the progression of microvascular
estimate for the prevalence in adults of pre- diabetes complications in persons with type
diabetes, a condition where fasting blood 1 and type 2 diabetes (Diabetes Control and
glucose levels are higher than normal (i.e., Complications Trial [DCCT] Research Group,
100–125 mg/dl) but not yet at the level to 1993); United Kingdom Prospective Diabetes
be deemed diabetes (i.e., >126 mg/dl), was Study [UKPDS] Group, 1998). Longitudinal
57 million (niDDK, 2008). Diabetes-related follow-up of individuals enrolled in the
complications such as heart disease, stroke, DCCT, called the Epidemiology of Diabetes
kidney disease, blindness, and premature interventions and Complications (EDiC) trial
death are all more common in African and (nathan et al., 2005) and the UKPDS studies,
native Americans or hispanics versus non- demonstrated that intensive glucose control
hispanic White adults (niDDK, 2010). in early in the course of the disease decreased
2007, the total estimated cost of diabetes the incidence of myocardial infarctions and
was US$174 billion, including US$116 bil- cardiovascular mortality (Brown, Reynolds,
lion in excess medical expenditures and & Bruemmer, 2010). in contrast, the Action
US$58 billion in reduced national productiv- to Control Cardiovascular Risk in Diabetes
ity (American Diabetes Association [ADA], (ACCoRD) trial (Gerstein et al., 2008), the
2008). Given these sobering statistics, there Action in Diabetes and Vascular Disease:
is strong evidence that the United States Preterax and Diamicron Modified Release
will face ongoing public health challenges to Controlled Evaluation (ADVAnCE) trial
address the potential burgeoning onslaught (Patel et al., 2008), and the Veterans Affairs
of individuals who face declining health sta- Diabetes Trial (VADT; Duckworth et al.,
tus, quality of life (QoL), and lost productiv- 2009) results suggested that intensive glyce-
ity related to an earlier onset of diabetes. mic control to near normoglycemia (e.g., A1C,
With the continual onslaught of persons 6%–6.5%) in older adults with type 2 diabe-
afflicted with diabetes, research funding tes had either no effect on cardiovascular
for newer pharmaceutical agents, technolo- outcomes or potentially detrimental effects
gies, monitoring devices, and clinical trials because of severe hypoglycemia (Brown
is needed more than ever. The institute of et al., 2010).

126 n DiABETES RESEARCh



on the basis of evidence from the of Texas at Austin has revealed that cultur-
UKPDS, DCCT, and EDiC trials and the ally competent self-management education
D current recommendations of the ADA, the interventions resulted in improved glycemic
American College of Cardiology Foundation, control, with greater improvement related
and the American heart Association, the to session attendance (Brown et al., 2005).
target A1C level for adults should remain her current work consists of systematically
at 7% (Skyler et al., 2009). To minimize risks synthesizing the extant research on psycho-
of hypoglycemia, the ADA recommends logical, motivational, and behavioral factors
A1C levels <8% for school-age children and affecting diabetes outcomes using meta-
<7.5% for adolescents (ADA, 2010). To pre- analysis and model testing to best inform
vent microvascular or macrovascular com- clinical guidelines. Sandra Dunbar at Emory
plications in adults with type 2 diabetes <10 University is developing and testing an inte-
years, a more stringent A1C level <7% may grated self-care intervention for heart fail-
be appropriate. however, on the basis of post ure patients with diabetes for its effects on
hoc findings of the VADT, persons older than health-related QoL, physical function, health
60 years with 12 years of diabetes duration resource utilization, and cost- effectiveness.
experienced cardiovascular events that were With a focus on prediabetes, Deborah
either unchanged or increased with intensive Vincent at the University of Arizona is
glycemic control (Duckworth, 2009). Current examining the feasibility of translating and
evidence supports the need for further inves- culturally tailoring the Diabetes Prevention
tigation of individualized goals for diabetes Program (Knowler et al., 2002) into a commu-
self-management, particularly for those with nity-based program for overweight Mexican
longstanding diabetes and with consider- American adults and estimating the effect on
ation of comorbid conditions, risks for severe weight loss.
hypoglycemia, and life expectancy. Studies of youths with diabetes are
nurse researchers are addressing major addressing the needs of adolescents and their
strategies for developing and evaluating families. Family and developmental per-
interventions to improve self-management spectives are incorporated into the designs
and diabetes outcomes. Presented here is an of these studies. Margaret Grey at Yale
overview of some of the current theoretical University is conducting a longitudinal study
approaches, study aims, and outcomes of using QoL and glycemic control to evaluate
nurse-led investigations. Although this infor- the effects of an internet coping skills train-
mation is not intended to provide an exhaus- ing program in youths with type 1 diabetes.
tive review, it does demonstrate a focus on This investigation is an extension of the lon-
studies supported by the national institutes gest ongoing clinical trial specifically testing
of health and information retrieved from the efficacy of an intervention for youths who
the national institutes of health Research have type 1 diabetes. in the original face-to-
Portfolio online Reporting Tools (http:// face intervention, teens who received coping
projectreporter.nih.gov/reporter.cfm). skills training and intensive diabetes man-
Theoretical perspectives used to guide diabe- agement had significantly better glycemic
tes research conducted by nurse researchers control and QoL than youths receiving inten-
are based on the concepts of social learn- sive management alone after 1 year (Grey,
ing, self-efficacy, coping, self-management, Boland, Davidson, Li, & Tamborlane, 2000).
cultural competence, stages of change, and Carol Dashiff at the University of Alabama at
chronic care. Birmingham is conducting a feasibility trial
The majority of nursing studies focus on of a joint parent and adolescent (ages 15–17
adults with type 2 diabetes. Research con- years) psychoeducational multifamily group
ducted by Sharon Brown at the University autonomy support program to facilitate

DiSCoURSE AnALYSiS n 127



adolescent self-management of type 1 dia- research methodology is defined in a most
betes during the transition from middle to simplistic form as that encompassing analyt-
late adolescence. Consistent with the overall ical approaches applied to written or spoken D
aim of preventing long-term diabetes-related linguistic texts to derive knowledge regard-
complications as teens make the transition ing language use and meanings in text in
to adulthood, Melissa Spezia Faulkner at relation to contexts of discursive acts and
the University of Arizona is investigating texts (Alba-Juez, 2009). Specific analytic pro-
personalized exercise interventions for ado- cedures within discourse analysis are varied
lescents with diabetes and has shown that according to philosophical and paradigmatic
those who attain 60 minutes of exercise bouts orientations.
improve their overall cardiovascular fitness Discourse is viewed as an appropriate
(Faulkner, Michaliszyn, & hepworth, 2010). subject matter for research by various dis-
improvements in glycemic control ciplines, including linguistics, philosophy,
through individualized interventions devel- anthropology, sociology, psychology, infor-
oped and tested through scientific inquiry mation science, literary criticism, journal-
will increase the odds for minimizing compli- ism, and practice disciplines such as nursing
cations of diabetes, which affect personal QoL and medicine. Although the term discourse in
and productivity and contribute to the eco- relation to discourse analysis is defined and
nomic burden associated with diabetes care. used differently in linguistics and in other
Future research must embrace not only better disciplines, discourse refers to language in
outcomes, including decreasing health dis- use as connected speech or written texts pro-
parities in minorities, but also the enormous duced in social contexts rather than in terms
need for prevention in those predisposed to of single sentences considered in terms of
the disease. newer technologies for insulin grammar and syntax. Discourse analysis
delivery, continuous glucose sensing, and deals with texts of conversations and written
genetic engineering for individual therapies texts produced among individuals as well as
are on the horizon. Through their leadership those produced within larger social and his-
in transdisciplinary science, nurse research- torical environments, such as journal articles
ers will remain integral to the advancement or newspaper accounts that are not directed
of evidence-based diabetes care. to specific individuals as their audiences.
Discourse as the object of analysis is usually
Melissa Spezia Faulkner obtained from natural occurrences rather
than from constructions designed solely for
the purpose of analysis.
The term discourse in discourse analysis
DisCourse analysis is commonly accepted as a complex noun
with the previously mentioned definition.
however, the use of “a discourse” or “dis-
Discourse analysis is a methodology that has courses” can be often found in discourse
multiple meanings referring to a wide range analysis with the poststructural, critical
of analytical procedures. Such methodo- perspective. however, the current literature
logical diversity has resulted not only from abounds with both usages of the term (i.e.,
various philosophical traditions that treat “discourse” and “a discourse”), not neces-
discourse differently but also from concep- sarily used consistently within one specific
tualization of discourse analysis by diverse perspective.
disciplines that emphasize different aspects Discourse analysis has its historic origin
or meanings of discourse. From its multidis- in the ancient Greek differentiation of gram-
ciplinary orientation, discourse analysis as a mar and rhetoric in language use (van Dijk,

128 n DiSCoURSE AnALYSiS



1985). Although the study of rhetoric was dif- speech competence with respect to discur-
ferentiated from the study of grammar in lin- sive rules, text grammar, discourse compre-
D guistics throughout the centuries, it was not hension, or discourse organization.
until the middle of the twentieth century that Sociolinguistics as a branch of sociology
a more formal approach to discourse analysis is a study of language use within the func-
gained its appeal in linguistics. hence, “prag- tional paradigm of sociology, which views
matics” in linguistics emphasizing discourse social life in relation to larger social struc-
analysis has been separately developed, in tures such as gender, status, social class, role,
contrast to the study of language proper that and ethnicity. Sociolinguists are concerned
focuses on formal grammatical, syntactical, with ways in which people use different lin-
and morphological structures. Following guistic forms according to macrostructural
this modern revisit in linguistics, many other and contextual differences.
disciplines have begun to take discourse as Anthropological approaches in the lin-
the proper subject of their scientific study. guistic perspective are ethnopoetics and eth-
Although there are cross-disciplinary dis- nography of communication. Ethnopoetics is
cussions of the methodology and application the study of oral discourse as speech art in
of various approaches of discourse analysis, the tradition of literary analysis and is con-
there is no unified, integrated approach to cerned with the structures of verbal aesthet-
discourse analysis. The literature across the ics. The focus is on the poetic patterning of
disciplines suggests that there are at least discourse within different cultures. on the
three general perspectives within discourse other hand, ethnography of communication,
analysis: (a) the linguistic perspective, (b) the advanced by hymes (1964), is concerned with
conversation perspective, and (c) the ideol- general language use as practiced in spe-
ogy/critical perspective. cific sociocultural context. Ethnography of
The linguistic perspective takes dis- communication, done either from the cross-
course as text produced by language use in cultural, comparative orientation or from the
either speech or writing. Thus, discourse text single-culture orientation, is based on the
for this perspective can be from interpersonal assumption that discourse should be stud-
conversations, written texts, or speech expo- ied, positing it within the dynamics and pat-
sitions such as testimonies. This perspective terns of discourse events in a given cultural
encompasses the formal pragmatics in lin- context. in all these branches of the linguistic
guistics, sociolinguistics in sociology, and perspective, the emphasis is on the linguistic
ethnography of communication and ethno- forms as used in social life.
poetics in anthropology. hence, within this The conversation perspective takes dis-
perspective, there are several different meth- course as conversational texts; it has been
odological approaches to discourse analysis. developed from the ethnomethodological
Even within each orientation, there are varia- tradition of Garfinkel (1967) in sociology. in
tions in the ways discourse texts are ana- this tradition, Sacks (1992) and others pio-
lyzed, depending on the frame within which neered conversation analysis as a form of
various contextual features are brought into discourse analysis. Conversation analysis
the analytic schema. views discourse as a stream of sequentially
The formal pragmatics that had its begin- organized discursive components that are
ning with Z. S. harris (1952) has been recast designed jointly by participants of conver-
by the speech act theory in the philosophical sation applying a set of social and conversa-
tradition of J. L. Austin (1975) and J. R. Searle tional rules. Conversation analysis studies
(1979) and by the poetics of the literary study. rules that participants in conversation use
Discourse analysis from the formal prag- to carry on and accomplish interaction, such
matics orientation addresses such aspects as as topic organization, turn taking, and use

DoCToRAL EDUCATion n 129



of response tokens. in recent years, how- multidisciplinary. in nursing, discourse anal-
ever, conversation analysis has extended to ysis is being applied with all three perspec-
include behavioral aspects of interaction (e.g., tives. Discourse analysis with the linguistic D
gesture, gaze, and laughter) as its analyti- perspective has been applied to study dis-
cal components. The use of transcripts and course comprehension in client–nurse inter-
transcription symbols has been extensively actions or discourse organization of nurses’
developed in this perspective. notes and to analyze various discourses on
Discourse analysis in the ideological/ such topics as abortion, individualized care,
critical perspective differs from the other two and professionalism in the nursing litera-
perspectives in its emphasis on the nature of ture related to macrostructural or contextual
discourse as historically constructed and con- factors.
strained by idea and knowledge. Discourse on the other hand, discourse analysis
in this perspective is not considered in terms with the conversation perspective has been
of linguistic form or interactive patterning. applied to the study of turn taking and topic
Rather, discourse is not only what is said or organization in client–nurse interactions
written but also is viewed within the discur- and to examine the dynamics of home visit-
sive conditions that produce imagined forms ing. Within the ideological/critical perspec-
of life in given local, historical, and sociocul- tive, discourse analysis has been applied to
tural junctures and thus is embedded in and examine nursing documentation as a form
with power and ideology. of power relations, to analyze discourse of
This perspective was represented by nursing diagnosis in the nursing literature,
poststructuralists such as Foucault (1972), and to explicate the language of sexuality,
Derrida (1978), and Lyotard (1984), who menopause, and abortion as power relations
viewed discourse analysis not simply as and ideology. Written texts produced by cli-
an analytical process but as a critique and ents and nurses and client–nurse conversa-
intervention against marginalization and tions as well as texts in the public domain
repression of other forms of knowledge and are the rich sources for applying discourse
discursive possibilities. Discourse analysis analysis to study the language-in-use from
in this perspective is oriented to revealing these perspectives.
sociohistorical functions and power rela-
tions embedded in statements of talks and Hesook Suzie Kim
texts as well as what Foucault called “sys-
temic archives,” of which statements form a
part. Specifically, critical discourse analysis
from this perspective takes up the approach DoCtoral eDuCation
to reveal and critique how power systemat-
ically entrenches into human’s discursive
acts and their products (i.e., texts) through The landscape of doctoral nursing edu-
domination, abuse, and distortions and is cation has changed markedly during the
open to applying various analytic techniques past decade. Doctoral education in nurs-
(Fairclough, 1995; Power, 1996; van Dijk, 2001; ing includes two general types of programs
Wodak & Krzyzanowski, 2008). offering distinctly different types of degrees.
The foregoing discussion indicates that The basic differentiation is between research-
discourse analysis is not a unified approach focused and practice-focused programs.
to studying language use. Although three Research-focused doctoral programs, tradi-
perspectives are identified for this method, tionally the most numerous, are designed to
there is a blurring of differences among the prepare the graduate for a lifetime of scholar-
perspectives. The method, however, remains ship and research and are often the preferred

130 n DoCToRAL EDUCATion



preparation for faculty positions, particularly students to study instructional technology
in research-intensive institutions. Research- and pedagogy and to have practicum expe-
D focused doctoral programs offer either the riences teaching students. Typically, half or
academic doctorate (doctor of philosophy more of the credits focus on research meth-
[PhD]) or the professional doctor of nursing odology and actual conduct of research. on
science (DnS, DSn, or DnSc) degree; one the average, full-time students complete their
research-focused program offers the doctor doctoral study in 4 years: 2 years to complete
of education (EdD). Practice-focused doctoral the course work and an additional 2 years to
programs, which are increasing very rap- complete the dissertation.
idly in number, are designed to prepare the An important trend in nursing is the
nurse for specialized advanced practice and rapid increase in the number and size
administrative roles and for practice leader- of practice-focused doctoral programs.
ship. They often prepare individuals for fac- Stimulated by position papers and policy
ulty roles focused in clinical teaching. The statements by the American Association of
degree title that is most commonly offered Colleges of nursing (in 2004) and several
by practice-focused programs is the doctor of other professional organizations, practice-
nursing practice (DnP or DrnP). Currently, focused doctoral programs are now viewed
more than 120 institutions in 36 states plus as a viable alternative to the academic doc-
the District of Columbia offer DnP pro- torate for individuals who wish to attain the
grams, and more than 161 are planned. The highest level of expertise in clinical practice.
number of research-focused doctoral pro- Enrollment in DnP programs currently out-
grams has also increased but more slowly; numbers that in PhD programs in nursing.
they currently number 120, and 8 more are The curricula differ considerably from those
being developed. Many institutions offer of the research-focused programs, with the
both types of doctoral programs. major differences being that practice-focused
Most research-focused programs offer programs typically include fewer credits
the PhD. it is the doctoral degree that is addressing research and require both an
universally recognized and accepted and intensive practicum experience and a final
enjoys considerable prestige, particularly project that differs from a dissertation. Areas
in academia. Curricula for programs lead- of content that are common to virtually all
ing to research-focused doctorates typically of the practice-focused doctoral programs
contain a core of required courses address- include the following: the scientific under-
ing nursing theory and theory development pinnings for practice; ethical underpinnings
strategies and various aspects of research for practice; advanced practice in a given
methodology and statistics. in addition, specialty area of nursing; organization and
students usually are required to deepen system leadership, including organizational
their substantive expertise in a specialized change strategies and quality improvement;
area of nursing knowledge and research analytic methodologies related to the evalu-
by selecting courses in nursing and related ation of practice, application of evidence to
disciplines (cognates), becoming involved practice, and practice-focused scholarship;
in hands-on research-related experiences use of technology and information; develop-
such as research residencies or practice and ment, application, and evaluation of health
research assistantships and conducting a policy; health promotion and disease pre-
major independent research project that cul- vention for individuals and populations; and
minates in a written dissertation. Because interdisciplinary collaboration. in addition,
graduates of research-focused doctoral pro- programs provide the basis for advanced spe-
grams often are employed as faculty, many cialized expertise in at least one area of nurs-
PhD programs provide opportunities for ing practice. A dissertation is generally not

DoMESTiC VioLEnCE n 131



required; however, most programs include importance of growing the body of substan-
a practice-related project and a residency tive knowledge that underpins nursing prac-
experience. Some practice-focused doctoral tice and to doing so in an environment of D
programs limit their specialty areas to those cross-disciplinary team science.
concerned with the direct care of patients as in addition to the growing interest in
implemented in advanced practice nursing practice-focused doctoral programs, an
roles (i.e., nurse practitioner, nurse midwife, important trend is that increasingly stu-
nurse anesthetist, clinical nurse specialist), dents are being encouraged to progress as
whereas others also include specialty prep- quickly as possible toward the terminal
aration in administration or executive prac- degree. Fueled in part by a growing faculty
tice, informatics, or health policy. shortage and the need to produce more doc-
Entry into practice-focused doctoral pro- toral graduates, programs are increasingly
grams can be either postbaccalaureate or streamlining progression between degree
postmaster’s degree. Some postmaster’s pro- levels, combining more than one degree in a
grams require students to enter with specialty program (e.g., MS and PhD), and eliminating
preparation and/or specialty certification. in work experience as a prerequisite to admis-
all cases, graduates are expected to provide sion. As a result, the profile of the “typical”
visionary leadership in the practice arena as doctoral student is changing. The average
advanced practice nurses, program managers age of doctoral nursing students is gradually
and evaluators, administrators, or information decreasing, and students often enter doc-
specialists. Graduates of practice-focused doc- toral study from clinical as well as academic
toral programs frequently assume positions backgrounds.
as clinical educators in schools of nursing. Doctoral education continues to be an
Consequently, many programs include a fac- arena of excitement and innovation in nurs-
ulty role preparation option. ing education. The need for doctoral gradu-
historically, doctoral nursing educa- ates continues to escalate, yet the challenge to
tion began at Teachers College, Columbia maintain quality in the face of rapid change
University, and at new York University in the is of paramount concern. For individuals,
1920s. After a 30-year hiatus during which no the doctorate is the pinnacle of attainment
new programs were opened, interest in doc- in nursing education, and for institutions, it
toral education was rekindled; by the end of is the pinnacle of academic attainment. The
the 1970s, a total of 18 programs had been virtually universal acceptance of the doctor-
initiated. During the 1980s, the number of ate as the terminal degree signifies nursing’s
programs more than doubled, and with the status as a true academic discipline.
rapid increase in programs and enrollments
came concern about maintaining high qual- Elizabeth R. Lenz
ity. The American Association of Colleges
of nursing took and continues to maintain
a leadership role in developing indicators of
quality regarding student and faculty quali- DoMestiC violenCe
fications, curriculum content, administrative
patterns, research support, and other sup-
port resources. Maintaining high quality has Domestic violence, also called intimate part-
remained a consistent focus, and over time, ner violence or partner violence, is violence
ideas about the nature of scholarship and doc- perpetrated by one partner against the other
toral education have been refined. Emphasis partner in an intimate relationship. An inti-
has expanded from focusing primarily on mate partner may be a current or former
the tools of scholarship to addressing the spouse, a cohabiting partner, a boyfriend

132 n DoMESTiC VioLEnCE



or girlfriend, or a dating partner. Domestic intimate relationships. For more than three
violence may occur in opposite-sex or same- decades, there have been debates about
D sex relationships and can continue after the whether domestic violence is primarily per-
relationship has ended. Domestic violence petrated by men against women (Dobash &
may take a variety of forms, including phys- Dobash, 1993), or whether women are as vio-
ical violence (e.g., shoving, grabbing, hitting, lent as men in intimate relationships (Straus
kicking, choking, beating, threatening with & Gelles, 1990). More recently, Johnson (1995,
or using a gun or knife), psychological abuse 2006) has proposed a typology of domestic
or maltreatment (e.g., shouting, insulting, violence to address the long-standing dis-
ridiculing, isolating, monitoring, or threat- pute. Central to Johnson’s (2006) typological
ening harm), and sexual assault (e.g., forced approach is the assertion that domestic vio-
or coerced sex). lence is not a unitary phenomenon and that
Domestic violence is pervasive and a distinctions among the types can be made
global problem. Worldwide, lifetime prev- on the basis of whether violence is part of
alence rates of physical violence, sexual the tactics to control an intimate partner. of
assault, or both by an intimate partner range the types of domestic violence proposed by
between 15% and 71%, with most estimates Johnson (2008), situational couple violence
falling between 30% and 60% (Garcia- is considered to be the result of escalation of
Moreno, Jansen, Ellsberg, heise, & Watts, specific conflicts and is not part of a general
2006). in the United States, population-based pattern of control over the partner. in inti-
estimates of lifetime physical and sexual mate terrorism, however, violence is used
domestic violence prevalence range from as one of the many tactics to gain control
25% to 50%, with most between 25% and over the partner. Almost always perpetrated
35% (Coker et al., 2002; Tjaden & Thoennes, by men, this type of systematic, controlling
2000). Variations in prevalence estimates abuse is the kind of violence seen in emer-
may be due to the following: (1) how domes- gency departments, domestic violence shel-
tic violence is defined and measured because ters, and the criminal justice system. nurse
some studies may focus on physical and sex- researchers have long recognized the use of
ual violence only (e.g., Garcia-Moreno et al., deliberate and repeated physical aggression
2006) whereas others may also include psy- and/or sexual assault, with minimal provo-
chological abuse (e.g., Bonomi et al., 2009); cation, by a man against his intimate partner
(2) whether lifetime (e.g., Coker et al., 2002) with the intention of exerting coercive control
or past year (e.g., Thompson et al., 2006) is (Campbell, 1989; Campbell & humphreys,
used as the time frame for measurement; 1993). Frye, Manganello, Campbell, Walton-
and (3) which population or setting is used Moss, and Wilt (2006), using a representa-
(e.g., national samples vs. shelter samples, as tive sample of women living in 11 north
in Johnson, 1995). in health care settings, the American cities, also found that a majority of
prevalence rates of violence against women the women who experienced physical assault
by an intimate partner are reported to be by an intimate partner experienced control-
between 10% and 23% (Bonomi et al., 2009; ling behaviors by that partner as well.
Coker et al., 2002; Thompson et al., 2006). This Women’s responses to domestic violence
serves as a reminder to nurses that a substan- are complex. Although learned helplessness
tial number of women in their care could be (Walker, 1984) was used to explain women’s
in violent intimate relationships. passivity and helplessness in the face of vio-
The etiology of domestic violence is com- lence in intimate relationships, contempo-
plex, and there are many theoretical frame- rary theory and research tend to see abused
works explaining the causes of violence in women as resilient and resourceful survivors

DoMESTiC VioLEnCE n 133



(Campbell, Rose, Kub, & nedd, 1998; irwin, risk of contracting a sexually transmitted dis-
Thorne, & Varcoe, 2002). nurse researchers ease (Alvarez et al., 2008; Silverman, Decker,
have identified a variety of strategies used Saggurti, Balaiah, & Raj, 2008) and cervical D
by abused women to resist abuse during the cancer (Coker, hopenhayn, DeSimone, Bush,
process of living in, and eventually leaving, & Clifford, 2009). Even after leaving the abu-
an abusive relationship (Ford-Gilboe, Wuest, sive relationship, women are still at risk
and Merritt-Gray, 2005; Wuest, Ford-Gilboe, for long-term health problems. For exam-
Merritt-Gray, & Berman, 2003) and how ple, Wuest et al. (2008) found that women
abused women strategize to protect their who have left an abusive relationship for
children’s safety and emotional well-being 20 months or longer continue to experience
(Ulrich et al., 2006). chronic pain.
Research indicates that women are most More recently, nurse researchers have
at risk for homicide from an intimate partner begun to explore the link between exposure
when they leave the battering relationship to domestic violence, chronic stress, and
(Wilson & Daly, 1993). nurse researchers poor overall health at the cellular level. in a
have made important contributions to this study involving formerly abused and nona-
body of knowledge. The Danger Assessment bused women, humphreys et al. (2011) find
was developed by Campbell (1986) to help that the length of telomeres (the protective
abused women realistically appraise their components that stabilize the ends of chro-
risk of homicide and enhance their self- mosomes and modulate cellular aging) is
care agency and has been tested in different significantly shorter among formerly abused
samples of abused women (Campbell, 1995; women. in addition, they find that the length
Campbell, Soeken, McFarlane, & Parker, of time in an abusive relationship is associ-
1998; McFarlane, Parker, & Soeken, 1995). ated with telomere length.
in a review of the research related to inti- Domestic violence also has economic
mate partner homicide, Campbell, Glass, consequences. health care costs are higher for
Sharps, Laughon, and Bloom (2007) iden- abused women compared with nonabused
tified prior domestic violence as the major women (Rivara et al., 2007; Snow-Jones et al.,
risk factor, with perpetrator gun ownership, 2006; Varcoe et al., 2009). Also, more severe
estrangement, stepchild in the home, forced abuse is associated with greater use of health
sex, threats to kill, and choking as the other care services (Ford-Gilboe, hammerton,
risk factors. Burnett, Wuest, & Varcoe, 2009).
There is overwhelming evidence that nurses can play a key role in effectively
women exposed to domestic violence expe- identifying domestic violence and providing
rience a wide range of long-term health follow-up referrals and supportive interven-
problems. Research has shown that domes- tions for women experiencing domestic vio-
tic violence is a significant risk factor for lence. Screening guidelines such as those
psychological and emotional health prob- developed by the Family Violence Prevention
lems, including depression (Dienemann Fund (2004) for health professionals and clin-
et al., 2000), substance abuse (Walton-Moss ical tools such as the Abuse Assessment
et al., 2003), and posttraumatic stress dis order Screen developed by the nursing Research
(Woods, hall, Campbell, & Angott, 2008). Consortium on Violence and Abuse (http://
Abused women have a 50% to 70% increase www.nnavwi.org) can help nurses to inte-
in gynecological, central nervous system, grate assessment of domestic violence in
and stress-related problems compared with their everyday practice. increasingly, nurses
nonabused women (Campbell et al., 2002). have developed interventions to ensure
Domestic violence also increases women’s abused women’s safety and to address their

134 n DRinKinG AnD DRiVinG AMonG ADoLESCEnTS



complex health and social needs. For exam-
ple, an empowerment intervention, that is, a Drinking anD Driving
D brief protocol-driven nursing intervention,
was developed by Parker, McFarlane, Soeken, aMong aDolesCents
Silva, and Reel (1999) to help abused women
address the violence including danger
assessment and safety planning. Supporting Drinking and driving is rooted in the central
abused women to develop strategies for role that alcohol plays in American life and
managing distressing symptoms may help culture. Alcohol is commonly found at cel-
them to better access supportive networks ebrations, parties, and leisure activities.
and to strengthen personal resources (Ford- in addition, advertisements on television,
Gilboe, Wuest, Varcoe, & Merritt-Gray, 2006). magazines, and billboards present messages
More interventions are emerging, including that shine a positive light on drinking. Given
the DoVE intervention (Sharps, Bullock, & this situation and despite drinking laws,
Campbell, 2010) and the i-hEAL intervention adolescents drink and drive, and adoles-
(Ford-Gilboe et al., 2006). cents who have been drinking are involved
in summary, domestic violence is a seri- in fatal crashes at twice the rate of adult
ous public health problem with far-reaching drivers (national highway Traffic Safety
health consequences. Recent progress in the- Administration, 2005).
ory and research has led to the better under- in spite of decreasing rates of driving after
standing of the complex dynamics of domestic drinking reported by high school students,
violence; nurses have made important contri- the problem of riding with a driver who has
butions to the development of theories and evi- been drinking has not changed in the past
dence-based practice concerning violence in 2 years. in 2003 and again in 2005, almost one
intimate relationships. nursing has a unique third of high school youth reported engaging
role to play in responding to the needs of in the risk of riding with a driver who had
domestic violence survivors while at the same been drinking (Centers for Disease Control,
time nurses are in an excellent position to col- 2005). Three teens are killed each day when
laborate with other professionals in domestic they drink and drive (national highway
violence prevention and intervention. Much Traffic Safety Administration, 2005).
is still to be learned about domestic violence. Although national trends in riding with
nurses have the potential to enhance under- a driver who has been drinking alcohol
standing of this complex phenomenon and have decreased since 1991, there has been no
to adopt a culturally competent approach to change from 2003 to 2005 in the percentage
develop more comprehensive evidence-based of students who rode with a driver who had
interventions. Research that combines the been drinking (30.2% in 2003 and 28.5% in
study of biological measures and intervention 2005; Centers for Disease Control, 2005). Maio
models in survivors experiencing the stress et al. (2005) reported that of 671 adolescents,
of domestic violence is needed to inform the 22% indicated they rode with a driver who
development of interventions to potentiate had been drinking. having access to a car
survivors’ strengths and health potential. increases drinking–driving and drinking in
Some groups may be at additional risk for cars (Walker, Waiters, Grube, & Chen, 2005).
domestic violence (e.g., women with disabili- Passengers offer potential for break-
ties), and more research is needed to further ing the link between drinking and driv-
develop and test theories of violence that are ing. isaac, Kennedy, and Graham (1995)
specific to such at-risk groups. reported that 5% to 10% of 10,277 drunk-
driving fatalities had sober passengers who
Agnes Tiwari could have intervened and half of the 16- to

DRinKinG AnD DRiVinG AMonG ADoLESCEnTS n 135



19-year-old drivers had a least one sober driver, nygaard, Waiters, Grube, and Keefe
passenger in the car. out of 16,694 alcohol- (2003) found that parents, friends, and
related crashes, approximately 50% of the peers influence a decision to get involved in D
fatalities were drunk drivers and 17% of the drinking–driving situations, no peer pres-
fatalities were passengers in the car (national sure to drive after drinking or to get into
highway Traffic Safety Administration, a car with a drinking driver was reported,
2005). Youth who are involved with drinking and convincing drinkers not to drive is dif-
peers are more likely to ride with a drink- ficult. in a study on adolescents’ propensity
ing driver; however, riding with a drinking to intervene among 2,697 5th- to 12th-grade
driver does not lead to drinking and driv- students, girls were more likely to say they
ing (Yu & Shacket, 1999). in a study of 4,380 would talk to a friend about drunkenness
respondents, passengers of drinking drivers and would take a friend’s keys than boys
were more than eight times more likely to be (Flanagan, Elek-Fisk, & Gallay, 2004).
14 to 18 years of age. Persons 16 to 20 years Situations and locations associated with
of age consume more alcohol before driv- riding with a drinking driver include out-
ing and have one or more passengers with door settings, cars, restaurants, homes of
them when they drive after drinking com- friends, and other social activities (Farrow,
pared with all other age groups (hingson & 1987; Gibbons, Wylie, & Echterling, 1986;
Winter, 2003). in an observational study of Walker et al., 2005). Riding with a drinking
471 teen drivers on 13 roadway sites around driver is related to attitudes, peer influence,
10 public schools, there was one or more pas- and having an accessible ride (Davey, Davey,
senger present in 239 of the cars, and youths & obst, 2005; Gibbons, Wylie, Echterling,
drove faster with shorter headways than 1986; Grube & Voas, 1996). Factors such as
general traffic. The presence of a male pas- accessible transportation and presence of
senger resulted in greater speed and shorter others who disapprove of drunk driving
headways (Simons-Morton, Lerner, & Singer, influence drinking and driving. Among
2005). Smith, Kennison, Gamble, and Loudin youth, there is a positive correlation between
(2004) in a qualitative study on intervening as associating with drinking peers and riding
a passenger in drinking and driving queried with a drinking driver (Grube & Voas 1996;
52 youths about drinking–driving situations Labouvie & Pinsky, 2001; Yu & Shacket,
and interventions. The findings of the study 1999).
included the following drinking–driving intervention studies among youth using
situations: the participants were entangled video media have been focused on education
with a drinking driver who was determined to avoid drinking and driving and riding
to drive, the participants were endangered with a drinking driver. Collins and Cellucci
while riding in a car with a drinking driver, (1991) examined an alcohol education and
and the participants were stranded because media component among 52 11th- and 12th-
they did not get in the car with a drinking grade students. Knowledge on drinking and
driver and had no one to turn to for a ride. driving improved, and there was no effect on
interventions described by the participants attitudes or alcohol involvement. in a study
were to persuade, to interfere, to plan ahead, focusing on drinking and driving preven-
and to threaten. tion, Kuthy, Grap, and henderson (1995) pre-
Youth passengers offer potential for sented 274 adolescents with a 20-minute slide
exerting influence on drinking drivers and show of graphic pictures of severely injured
for taking responsibility to stop a drinker victims of drinking–driving accidents. There
from driving (Assailly, 2004). in a telephone was no difference in the reported driving
interview with 44 adolescents who had either behaviors between the immediate postpro-
driven while drunk or rode with a drinking gram and a 1-month interval. A 25-minute

136 n DRinKinG AnD DRiVinG AMonG ADoLESCEnTS



interactive video intervention to prevent alco- feature peers (Leadbeater, Foran, & Grove-
hol misuse was administered to 671 youth 14 White, 2008), not be preachy, and focus on the
D to 18 years of age admitted to the emergency social consequences of drinking and driving
department for a minor injury. Using an alco- rather than life-threatening consequences
hol misuse self-report measure, there was no (DeJong & Atkin, 1995). Enhancing personal
effect for the total group; however, in a sub- and social competence in preventive youth
group of 32 drinking drivers, alcohol misuse programs is a critical aspect influencing ado-
decreased at 3- and 12-month intervals (Maio lescent risky behaviors (Pinko, 2006; Smith,
et al., 2005). Conclusions reached on inter- Atkin, & Roznowski, 2006).
vention programs are that curriculum is lim- it can be concluded that if youth passen-
ited as a stand-alone determent of drinking gers intervene and break the link between
and driving (Augustyn & Simons-Morton, drinking and driving, there is potential for
1995) and that in spite of school educational reducing drinking and driving fatalities.
programs, fear of legal consequences, and Studies on intervening in drinking and driv-
knowledge of drinking–driving fatalities, ing are called for to reduce harm among
students who drink and drive will continue adolescents.
a drinking–driving behavior (nygaard et al.,
2003). it is claimed that interventions should Mary Jane Smith

E














self-esteem, and anxiety and stress become
Eating DisorDErs intense and cumulative in nature, food may
be used in a dysfunctional manner resulting
in serious and life-threatening forms of eat-
There is a plethora of studies related to eating ing disorders (Cyr, 2008).
disorder with women between the ages of An estimated 8 million Americans are
13 and 25 years. Conversely, there is a pau- living with some form of eating disorder;
city of these same studies with women older 7 million of whom are women. Only 30%
than 25 years. Eating disorder includes dis- to 40% of people recover from eating dis-
eases such as anorexia nervosa, bulimia ner- orders, and of 1 in 10 people who actually
vosa, overeating, and binging; however, only receive treatment, 80% do not obtain the
anorexia nervosa and bulimia are examined support needed to maintain recovery. The
in relation to women older than 25 years. documented mortality rate indicates that
Because of the complexity, overlapping symp- 5% to 10% die within 10 years whereas 18%
toms, and persistent nature of eating disor- to 20% die within 20 years of being diag-
ders, very little is understood about adult nosed (South Carolina Department of Mental
women living with this health problem. As Health, 2010). Globally, the rate of occurrence
a result, these women suffer serious mental of eating disorders is rising at an alarming
and physical health consequences. Therefore, rate in Asia, Europe, the Middle East and
primary care providers need not only to be many other parts of the globe (Watters, 2010).
able to recognize the importance of identify- This rate, however, may be just the tip of the
ing and managing the signs and symptoms iceberg given the shame, stigma, and humil-
of eating disorders but also be able to use iation associated with this health problem
anticipatory guidance strategies and inter- (Vitale, Lotito, & Maglie, 2009). Although 95%
vention to prevent eating disorder among of eating disorders occur between the ages of
middle- to older-age adult women (Lapid 12 and 25 years (South Carolina Department
et al., 2010;Marcus, Bromberger, Wei, Brown, of Mental Health, 2010), more recently, the
& Kravitz, 2007; Midlarsky & Nitzburg, 2008; disorder is now being recognized in women
Mond, Myers, Crosby, Hay, & Mitchell, 2010). 30 years and older (Carr & Kaplan, 2010).
Hence, this entry aims to define and review Historically, eating disorders were believed
the incidence and prevalence rates of eating to only affect middle- to upper-class White
disorders, to identify the most common phys- women (Robert-McComb, 2001); however,
ical signs and symptoms, and to describe recent studies (Budd, 2007; Fernandes, Crow,
potential intervention strategies for treating Thuras, & Peterson, 2010) found that eat-
and preventing eating disorders among eth- ing disorders are on the rise among various
nically diverse women. racial and ethnic groups as well as different
Although the appetite center is under social positions.
the control of the hypothalamus, culture and Two of the most common presentations
environment play an integral role in an indi- of eating disorders are anorexia nervosa and
vidual’s attitudes toward and use of food. bulimia nervosa. One half to one percent
When women experience consistently low of the U.S. population has been diagnosed

138 n EATiNG DiSORDERS



with anorexia nervosa. These women usu- seek treatment for anxiety or depression,
ally fear obesity and see themselves as over- only one third were asked if they suffered
E weight even when they are not (Cyr, 2008). from an eating disorder; however, if ques-
They have a preoccupation with eating and tioned, half of the women reported they
restrict the amount of food eaten (some- would not disclose their eating disorder to
times to the point of starvation) or regularly the health care provider (Mond et al., 2010).
engage in binge eating or self-induced vomit- Substance abuse is closely aligned to eat-
ing (Robert-McComb, 2001). Bulimia involves ing disorders, and 18% of older women with
eating excessive amounts of food followed by eating disorders admit to a substance abuse
multiple episodes of self-induced vomiting problem (Carr & Kaplan, 2010). Detection of
(Cyr, 2008) as well as the misuse of laxatives, eating disorders is difficult in that it tends to
diuretics, or enemas. Bulimia affects 1% to be hidden by the patient, but compounding
3% of the U.S. population, which is most this problem is that nurses and other health
likely an underestimation (Broussard, 2005). professionals often lack the knowledge and
Similarly, calorie restriction is controlled by insight necessary to detect and treat eating
excessive exercise. A woman may lose 50% disorders (Mond et al., 2010).
of her ideal body weight; however, women When an eating disorder is detected,
with bulimia already tend to be below, at, health care providers must identify con-
or exceed ideal body weight. Complications cerns regarding follow-up intervention par-
include dehydration, fluid and electrolyte ticularly in the 25% of older women who
imbalance, renal failure, metabolic acido- do not respond to current therapies for rea-
sis, arrhythmias, sudden death, endocrine sons yet unknown (Carr & Kaplan, 2010).
abnormalities, and neurological dysfunction Problematic is the disconnect in perceived
(Robert-McComb, 2001). recovery from eating disorders between the
Anorexia nervosa was first recognized as medical perspective and that of the patient.
a disorder in the nineteenth century and was Medical recovery has been based on the
thought to be on the rise in the twentieth cen- patient’s decreased obsession with body
tury. Treatment consisted of neuroleptics in the weight, return of a regular menstrual cycle,
1950s and 1960s and later shifted to individual and weight maintenance. Patients, however,
psychotherapy. in the 1970s, family therapy describe recovery as developing a sense of
was emphasized, and by the late twentieth control over their lives and of achieving a
century, medications were used as an adjunct renewed sense of self (Patching & Lawler,
to psychotherapy (Steinhausen, 2002). 2009). Therefore, not only is there a need for
The cost of treating an eating disorder in consensus about what constitutes recovery
the United States ranges from $500 to $2,000 but also for innovative approaches to treat-
per day. Many patients require in-patient ment as well as tailored protocols (Johnston,
treatment for at least 3 to 6 months costing Fornai, Cabrini, & Kendrick, 2007). Future
$30,000 per month or $90,000 to $180,000 research needs to focus on exploring and
for the total length of stay (Agras, 2001). understanding these disorders from the
Unfortunately, many insurance companies women’s standpoint rather than placing
do not cover the cost of treating eating disor- these women into a predetermined medical
ders (South Carolina Department of Mental treatment template which tend to be unsuc-
Health, 2010). cessful (Patching & Lawler, 2009).
Eating disorders are closely connected Women living with eating disorders
with impaired psychosocial functioning, but feel isolated and ashamed and are not able
less than 40% of those suffering from these to effectively verbalize their difficulties.
disorders have obtained treatment from a One approach that addresses these feelings
health care provider. Of the 80% who did is to increase allocation of funding directed

ELDER MiSTREATMENT n 139



toward the development of support and self- disordered eating need to be enhanced; and a
help groups for all women suffering from deeper understanding of cultural and social
eating disorders. The formation of gender systems is necessary to gain a broader and E
responsive support groups has the poten- more inclusive perspective of eating disor-
tial to alleviate feelings of shame and isola- ders (Patching & Lawler, 2009) particularly in
tion (Rortveit, Astrom, & Severinsson, 2009). light of their rampant globalization (Watters,
Efforts should focus not only on recognition 2010). And finally, future research should
and treatment of eating disorders but also examine disordered eating from a life span
toward their prevention (Patching & Lawler, approach, which is a vital next step toward
2009). A more comprehensive understand- the prevention, detection, and early treat-
ing into the role of media influence and its ment of eating disorders (Dichter, Cohen, &
relation to eating disorders requires fur- Connolly, 2002; Patrick & Stahl, 2009).
ther investigation (Vitale et al., 2009). Future
research efforts also need to determine why Deborah B. Fahs
some women perceive bulimia as normal Barbara J. Guthrie
behavior and therefore do not seek medical
attention (Broussard, 2005).
Strategies aimed at encouraging patients
to seek treatment and engage them as active ElDEr MistrEatMEnt
participants in their own care are crucial
(Kreipe & Yussman, 2003). Critical to this
process is the nature and quality of relation- Elder mistreatment (EM) is a complex syn-
ship between the woman and her health care drome that can lead to morbid or even fatal
provider. More specifically, the health care outcomes for those afflicted. Mistreatment
provider’s attitude and approach has been is the term used to describe outcomes from
found to have a positive influence on suc- such actions as abuse, neglect, exploitation,
cessful treatment (Geller, Brown, Zaitsoff, and abandonment of the elderly, and it affects
Goodrich, & Hastings, 2003). The health care all socioeconomic, cultural, ethnic, and reli-
provider should be open to conducting phys- gious groups. Prevalence estimates range
ical and mental health assessments and fam- between 3.2% and 27.5% in general popula-
ily history that include questions related to tion studies (Cooper, Selwood, & Livingston,
perception of self-esteem, perception of ideal 2009). A recent data reported from a national
and real body image, and most importantly sample of community-residing adults older
a family or personal history of disordered than 60 years using a representative sam-
eating. The information generated from the ple and random-digit dialing indicated that
assessment and family history should be 11.4% of older adults report some form of
used to tailor a plan of care. EM (Acierno et al., 2010). The national Elder
As evidenced by the documented inci- Abuse incidence Study, the only incidence
dence, prevalence, and mortality rates, disor- study, documented over 500,000 new cases
dered eating is not decreasing but rather is annually (Tatara, 1993).
steadily increasing across gender, age, ethnic The National Research Council (NRC,
background, and social positions. The rising 2003) convened an expert panel to review
cost and the conflicting evidence regarding prevalence and risk for elder abuse and neglect
curative approaches mandates the following: and concluded that EM is an intentional action
An anticipatory and preventive approach that causes harm or creates a serious risk of
must be considered; primary health care harm (whether or not the harm is intended)
provider’s knowledge and skills related to to an at-risk elder by a caregiver or other per-
understanding, recognizing, and treating son who stands in a trusting relationship to

140 n ELDER MiSTREATMENT



the elder, or EM is the failure by a caregiver the amount of care an elder person requires
to satisfy the elder’s basic needs or to pro- and is related to stressed caregiver research,
E tect the elder from harm. There are several which describes overwhelmed caregivers
types of EM described in the NRC report. who lose their control or stop providing rea-
Abuse is generally understood as physical sonable care. Conversely, there are data that
assault inflicted on an older adult resulting reflect the caregiver’s dependency on the
in harmful effects. Abusive behavior may elder (for shelter, money, etc.), which puts
include hitting, kicking, punching, and other the elder at risk. Transgenerational violence
physical contact. Neglect is the refusal or fail- theory refers to children who learn violent
ure to fulfill any part of a caregiver’s obliga- behavior as normal and then become violent
tions or duties to an older adult. Neglect may and abusive as they grow older. This might
be intentional or unintentional. Self-neglect be viewed from a learning theory perspec-
occurs when an older adult either knowingly tive, although some have looked at it as a ret-
or unknowingly lives in such a manner that ribution act; an adult child may strike back
is deleterious to his or her health. Exploitation at a parent or a caregiver who was once abu-
is fraudulent activity in connection with an sive. The psychopathology of the abuser the-
older adult’s property or assets, and abandon- ory refers to any nonnormal caregiver, such
ment is defined as the deliberate or abrupt as substance abusers (alcohol, drugs), psy-
withdrawal of services in caring for an older chiatrically impaired individuals, or men-
adult. Self-neglect has received a great deal tally retarded caregivers. The number of
of recent attention given its deleterious out- mentally retarded elders older than 65 years
comes on the older person and the opportu- has grown substantially over the past decade,
nity to intervene (Dong et al., 2009; Mosqueda creating situations where mentally retarded
et al., 2008; Poythress, Burnett, Naik, Pickens, or disabled offspring become caregivers for
& Dyer, 2006). Further, resident-to-resident very elderly parents (NRC, 2003).
EM in long-term care settings is an impor- Early studies looked at the prevalence of
tant syndrome that nurses need to under- EM from a variety of perspectives: acute care,
stand (Rosen et al., 2008). Evidence suggests community nursing care, and nursing home
that only 1 in 14 EM cases is reported to some setting. Differences in operational definitions
public agency. Nurses can do much to help and methodological approaches and the lack
in the screening and detection process of of national prevalence studies have made it
EM by doing a careful history and physical difficult to understand the conditions under
assessment with attention to the subjective which EM is likely to occur. Although EM
complaint of EM, along with any signs or education and training has improved, there
symptoms of the same. Underreporting of is still a great need for more systematic nurs-
EM is a serious concern because older adults ing assessment, care planning, and follow-up
may have disease symptoms or age-related with the older adult. The need for researchers
changes that imitate or conceal mistreatment who can contribute to this area of inquiry is
symptoms, making the assessment process great.
complex. Few clinicians have been trained in There is no Denver Developmental
EM assessment and intervention, which has screen for older adults that enables clinician
also led to underreporting. With an unprece- to understand what an 80-year-old looks like
dented number of individuals living beyond and what conditions are likely to represent
the age of 65 years and even beyond the age EM. The signs and symptoms of EM might
of 85 years, nurses must be sensitive to the include unexplained bruises, fractures, burns,
possibility of EM. poor hydration, reports of hitting or any other
Theories for EM causality have been violent behavior against the older adult, sex-
posited. The dependency theory refers to ually transmitted disease in institutionalized

ELECTRONiC NETWORK n 141



older adults, unexplained loss of money or adults. A key practice implication for EM is
goods, evidence of fearfulness around a the inclusion of family violence questions in
caregiver, or subjective report of abuse. it is every history with attention to and documen- E
especially difficult to evaluate the demented tation of any signs and symptoms of EM.
older adult for EM; a careful and thorough
interdisciplinary team approach is required. Terry Fulmer
The American Medical Association’s (1992) Sarah Pernikoff
Diagnostic and Treatment Guidelines on Elder
Abuse and Neglect, although more than
15 years old, provides excellent guidelines
for the assessment of EM, along with flow- ElEctronic nEtwork
charts for assessing and intervening in cases.
A summary of approaches for screening and
assessment of EM suggests a comprehen- in general, a network is composed of a min-
sive and highly methodical approach using imum of two connected points. For exam-
accepted screening instruments (Fulmer, ple, one person talking with another, face
2008). Special attention must be given to an to face, can constitute a network. Telephone
older adult who has diminished or absent networks connect at least two people using
decision-making capacity. Dementia has transceivers, wire, switches, and computers.
been documented as a risk factor for EM and Television networks connect large numbers
should automatically trigger EM assessment. of people. An electronic network is consid-
Cognitive status can only be determined ered to be the connection, or linking, of two
by rigorous clinical testing and use of vali- or more computers to allow data and infor-
dated instruments. Some have suggested a mation exchange. Electronic computer net-
two-step process to assess capacity for elders works may be as small as two computers or
suspected of self-neglect. The steps include as large as the internet, considered to be a
cognitive evaluation to determine the elders’ network of networks.
decision-making ability using a traditional The goal of networks is information
medical examination along with standard- exchange and may or may not be bidirec-
ized tests such as the Executive interview, tional. Person-to-person conversations, even
the Financial Capacity instrument, the Mini- if using some sort of intermediary like the
Mental State Examination, and the Geriatric telephone or computer, are usually bidirec-
Depression Scale, followed by an assessment tional. Television and some computer net-
of the elders’ executive ability to live inde- work applications may be unidirectional;
pendently in the community through review however, bidirectional computer networks
of reports by nurse practitioners, social ser- are the most common. Examples include local
vice professionals, occupational therapists, area networks, which may serve a depart-
and physical therapists (Naik, Lai, Kunik, & ment, larger networks called wide area net-
Dyer, 2008). works, and the internet. intranets, which are
Overzealous protection of a competent the internal deployment of internet technol-
elder is a form of ageism that infantilizes the ogies, are commonly found in business and
older individual and takes away their auton- other environments requiring information
omy. Each state has EM reporting laws or exchange among a department or other lim-
requirements that professionals should be ited amount of people.
familiar with. interdisciplinary care teams Electronic networks continue to be excit-
are especially important in the EM assess- ing tools for nursing, continuing to increase
ment process. Each team member is able to in importance for information acquisition
use their own expertise to the benefit of older and dispersion. Electronic networks, such as

142 n EMERGENCY NURSiNG



the internet and the World Wide Web, pro- of Nursing’s network. More up-to-date exam-
vide a means of communicating as well as ples, with limited research, include the use
E facilitating collaborative research, promot- of social media (Twitter, Facebook, and other
ing education regardless of geographic limi- similar Web 2.0 examples) providing a more
tations, allowing access and acquisition of “immediate” digital connection for nurses
needed resources, and providing a medium and patients.
for social engagement. Electronic networks As information technology increases in
continue to impact areas integral to nurs- use and health care requires increased effi-
ing, such as lifetime electronic health record, ciency, nurses will rely more and more on
nursing research, increased interdisciplin- information technology as one tool for pro-
ary collaborative research, online education viding the best possible patient care. Local
for patients and nurses, nursing knowledge electronic networks, such as clinical infor-
acquisition and information exchange, and mation systems, will include other larger
patient care. networks so nurses will have the best infor-
Although the essence of nursing has been mation resources to assist nursing care.
a network, that is, the nurse–patient relation- Research concerning the effects of electronic
ship, there is limited nursing research on networking (using Web 2.0 tools) on nurses
electronic networks. Early work by Brennan, and other health care professionals as well
Moore, and Smyth (1991) and Ripich, Moore, as on patients and their families continues
and Brennan (1992) investigated the use of to be needed. Electronic networking should
electronic net works to facilitate nursing sup- be examined as an independent variable
port of home care clients and their caregiv- through the inclusion of electronic networks
ers. They concluded that a computer network in all stages of the research process. This
is an excellent tool to facilitate support and research will promote the advancement of
information exchange among caregivers and health and patient care by providing the sci-
between nurses and caregivers for patients entific foundation for the appropriate appli-
with AiDS and Alzheimer’s disease. This cation of digital networking technologies.
type of support mechanism has grown to
other areas of health care requiring nursing W. Scott Erdley
intervention such as patients’ seeking health Susan M. Sparks
information (Dickerson et al., 2004).
There are anecdotal reports and case
studies to support nurses’ use of electronic
networks. Sparks (1993) has been instrumen- EMErgEncy nursing
tal in her advocacy and promotion of elec-
tronic networks and resource availability
for nurses (e.g., the Educational Technology As a specialty within the nursing profes-
Network, which promoted the exchange of sion, emergency nursing encompasses care
information and ideas for nurses, nurse edu- of individuals across the life span, seek-
cators, and nursing students and was the ing help for perceived or actual physical or
first international electronic network man- emotional alterations of health that require
aged by a nurse). Other early work included emergent or nonemergent interventions
Barnsteiner’s (1993) and Graves’s (1993) work (Emergency Nurses Association [ENA],
with nursing resource availability (Online n.d.-e). Emergency nurses have a special-
Journal of Nursing Knowledge Synthesis ized field of practice and unique knowledge
and the Virginia Henderson STTi Electronic and skills in emergency care that interface
Library, respectively) and DuBois and with patients during critical moments. This
Rizzolo’s (1994) work in the American Journal unique set of knowledge and skills ensures

EMERGENCY NURSiNG n 143



the public that emergency nurses are compe- (ENA, n.d.-e). For this reason, the research
tent caregivers who are accountable for the agenda for emergency nurses is robust.
care they deliver, responsible, and able to Data from the 2007 National Hospital E
communicate and act with autonomy while Ambulatory Medical Care Survey show
at the same time able to work in a collabora- that in 2007 there were 116.8 million visits
tive relationship with others (ENA, n.d.-e). it to hospital EDs or 39.4 visits per 100 persons
is through emergency nursing research that (Niska, Bhuiya, & Xu, 2010). in that same
emergency nurses are able to be responsive study, 12.5% of ED patients were admitted to
to changes in health care in order to deliver the hospital and approximately 39 million of
state of the art care to this very important the visits were injury related. in a study of
group of patients and their families. workforce in emergency care, Counselman
Because emergency patients often come et al. (2009) found that EDs’ annual volumes
to the emergency department (ED) with con- have increased by 49% since 1997, with a
ditions that pose a threat to life and limb or mean ED volume of 32,281 in 2007. The aver-
have a significant risk of morbidity or mor- age reported ED length of stay is 158 min-
tality, competent emergency nursing prac- utes from registration to discharge and 208
tice is a unique combination of rapid triage minutes from registration to admission. As a
and assessment of life-threatening problems, result of this surge of ED visits, many EDs
simultaneous prioritization of care, and across the nation do not have the capacity to
effective and efficient implementation of the serve the volume of patients that come for
appropriate interventions (ENA, n.d.-e). With treatment. EDs spent an average of 49 hours
the increasingly complex diagnostic and per month diverting ambulances to other
management strategies available, emphasis EDs in 2007. Boarding or holding patients for
on resource-efficient patient care requires extended length of time waiting for a hospi-
research strategies that maximize quality tal bed to open is common practice, with an
care while also controlling resources. average of 318 hours of patient boarding per
Not all patients come to the ED for life- month (Counselman et al., 2009).
threatening conditions. it is often through The 2008 National Sample Survey of
the ED that patients access the tertiary health Registered Nurses conducted by the U.S.
care system. Therefore, emergency nurses Department of Health and Services (Health
are often the first health care practitioners Resources and Services Administration,
who foster entry into the health care system 2010) found that approximately 218,339 reg-
for the general population. istered nurses were employed in an emer-
Patients often come to the ED because it is gency setting in 2008, a significant increase
the only access they have for health care and from approximately 117,514 in 2004 (Health
require primary care services during their Resources and Services Administration,
ED visit (Delgado et al., 2010). Emergency 2006). Emergency nurses enter ED practice
nurses are required to have knowledge about with a broad range of educational prepara-
the care and treatment of patients seeking tion. A study by Counselman et al. (2009)
primary care and health promotion services. found that many emergency nurses (46%)
They need to be aware of social and com- have an associate degree as their highest
munity services and must have the ability to level of education, 28% have a BSN, and 3%
collaborate effectively with prehospital and have a graduate degree (MSN or higher).
in-hospital care providers. The advanced professional nursing roles
Emergency nurses provide care to per- in the ED include nurse administrators, clini-
sons of all ages, across all levels of the health/ cal nurse specialists, and nurse practitioners.
illness trajectory, and work in an environ- The educational preparation for advanced
ment that is complex and unpredictable practice nurses requires graduate education

144 n EMERGENCY NURSiNG



and certification. The ENA (2009) has delin- of the institute is to conduct and facilitate
eated scope and standards of care for emer- research to support evidence-based practices
E gency nurses and includes a document on for emergency nursing and emergency care
advanced practice nurses in emergency care. (ENA, n.d.-c). The specific goals include the
Emergency nurses are accountable for the following: (1) to develop a culture of research
care they provide to patients. This account- to advance emergency nursing and emer-
ability requires certification. Emergency gency care by promoting knowledge genera-
nurses can receive certification in emergency tion, knowledge application, and knowledge
nursing (Certified Emergency Nurse), flight transfer; (2) to facilitate the development of
nursing (Certified Flight Registered Nurse), researchers in emergency nursing through
pediatric emergency nursing (Certified education, mentoring, networking, and col-
Pediatric Emergency Nurse), or critical care laborative research opportunities; (3) to set
ground transport nursing (Certified Trans- research priorities for the discipline of emer-
port Registered Nurse) offered by the Board gency nursing; (4) to enhance collaboration
of Certification for Emergency Nursing among researchers within ENA and counter-
(n.d.) in collaboration with other entities. parts in the public and private sectors; and
Currently, more than 23,000 nurses are certi- (5) to facilitate the generation of evidence-
fied by Board of Certification for Emergency based emergency nursing resources (ENA,
Nursing (n.d.). n.d.-c).
Established in 1970, the ENA is the pri- To provide a focus for ED nurse research-
mary organization for emergency nurses in ers, the institute developed research priorities
the United States. The mission of ENA is to for the field of emergency nursing. Research
advocate for patient safety and excellence priorities include investigations that address
in emergency nursing practice (ENA, n.d.-b) the generation, dissemination, and transla-
with approximately 37,000 members. ENA tion of research related to three broad areas:
offers education programs and courses to (1) the clinical priorities identified by ENA—
meet the needs of emergency nurses around crowding/boarding, psychiatric emergency
the world. These programs include review patient care, and workplace violence; (2) the
courses for certification as an emergency emergency nursing professional practice
nurse, the Certified Emergency Nurse. Other issues—examples of research areas include
review courses offered by the ENA include nurse orientation, continuing education, and
Trauma Nursing Core Course, Emergency assurance of competence of emergency nurs-
Nursing Pediatric Course, Course in ing practices as well as ED staffing patterns
Advanced Trauma Nursing, and Geriatric and the impact of the staffing on patient
Emergency Nursing Education. Additional outcomes; and (3) the Joint Commission’s
example programs/courses include triage, National Patient Safety Goals—examples of
orientation, educator references for profes- research areas include improving the accu-
sional and patient education, age-specific racy of patient identification, the effective-
program, family-focused programs, conduct- ness of communication among caregivers,
ing research and grant writing, and courses the safety of using medications, and the
that cross the life span for injury prevention recognition and response to changes in a
(ENA, n.d.-a). patient’s condition as well as reducing the
To expand research efforts in emer- risk of health care–associated infections,
gency nursing, ENA took the lead by initi- patient harm resulting from falls, influenza
ating an institute for Emergency Nursing and pneumococcal disease, and health care–
Research Committee and in 2009 transi- associated pressure ulcers (ENA, n.d.-c).
tioned this committee to an institute for A review of research publications and
Emergency Nursing Research. The mission presentations including posters displayed

EMERGENCY NURSiNG n 145



at the most recent annual conference of JEN is the official journal of ENA (n.d.-d). it is
ENA can give an overview of topics of inter- a peer-reviewed, bimonthly journal offering
est in emergency nursing research. Much original research and clinical articles on the E
research is generated in response to practice clinical, professional, political, administra-
issues (Li, Juarez, & Gates, 2010; Schumacher, tive, and educational aspects of emergency
Gleason, Holloman, & McLeod, 2010; Tanabe, nursing. On the basis of an examination of all
Gisondi, Barnard, Lucenti, & Cameron, 2009). issues from 2005 to October 2010, JEN pub-
Additional research areas include compe- lished a total of 90 original research articles.
tency delineation (Hoyt et al., 2010), pediatric There is a steady increase in the number of
emergency care (Qazi, Altamimi, Tamim, & original research articles published in this
Serrano, 2010), forensic nursing (MacLean, journal each year.
Desy, Juarez, Perhats, & Gacki-Smith, 2006), JTN is the official journal of the Society
emergency education (Jackson, 2010), ED of Trauma Nurses (n.d.). JTN’s mission is to
technology, injury prevention (Désy, Howard, provide original, peer-reviewed articles and
Perhats, & Li, 2010), emergency management information that reflect the practice of trauma
and preparedness (Lenaghan, Smith, & nursing in the areas of clinical practice, edu-
Gangahar, 2006), and geriatric emergencies cation, health policy and administration, and
(Roethler, Adelman, & Parsons, 2011). research. JTN is intended for nursing profes-
The ENA Foundation (n.d.) is the pri- sionals and all health care providers involved
mary source of funding for emergency nurs- in trauma care, from first responder through
ing research. The foundation offers research rehabilitation.
grants and awards to advance the special- The Advanced Emergency Nursing Journal
ized practice of emergency nursing and/or is the peer-reviewed journal for advanced
to facilitate collaborative research between practice nurses. This journal is published
nurses and physicians. Partnering with four times a year and focuses on research
other entities, the foundation offers three that deals with evidence-based practice.
research programs: Emergency Medicine Accident and Emergency Nursing, the
Foundation/ENA Foundation Team Research official journal of the Emergency Nurses’
Grant, ENA Foundation/Sigma Theta Tau Association of Australia, is published quar-
international Research Grant, and ENA terly (Elsevier, n.d.). it is a peer-reviewed
Foundation industry-Supported Research journal that caters to all levels of staff work-
Grant. Examples of recently funded research ing in emergency settings throughout the
grants include using electronic medical rec- world. The journal aims at promoting excel-
ord reminders to improve triage protocol lence through dissemination of high-quality
compliance: “Understanding Why Emergency research findings, specialist knowledge,
Department Healthcare Providers Do Not and discussion of professional issues that
Screen for Family Violence,” “The relation- reflect the diversity of this field. in additional
ship of leadership style and horizontal vio- to these three journals, original research
lence in emergency department staff nurse articles on emergency nursing can also be
retention,” and “Stress and Resilience in found in other general medical and nursing
Emergency Nurses Following Trauma Care” journals including cardiology and pediatrics
(ENA Foundation, n.d.). journals.
Research findings in emergency nurs- Journals focusing on ED nursing have
ing are published primarily in the Journal become increasingly involved in partnering
of Emergency Nursing (JEN), the Journal with nurse researchers to help disseminate
of Trauma Nursing (JTN), the Advanced research for the utilization of this special-
Emergency Nursing Journal, and the Accident ized knowledge by health care providers at
and Emergency Nursing. Published since 1975, the bedside. Emergency nurses also work

146 n EMPATHY



collaboratively with others to establish evi- seems to create an interpersonal quality that
dence-based emergency nursing resources enables individuals to release defensiveness
E for practice. Emergency nursing research and enhance health (Burhans & Alligood,
will continue increase and provide the basis 2010; Hope-Stone & Mills, 2001; Mercer &
for emergency nursing practice. Reynolds, 2002).
Emergency nurses take the lead in Carl Rogers (1957) believed that empa-
treating life-threatening and potential or thy is the ability to “sense the client’s pri-
perceived life-threatening conditions that vate world as if it were your own” (p. 4) and
face millions of patients across the nation. the ability to perceive the internal frame of
They are also prepared to deliver primary reference of another with such exactness as
care and health promotion services as well to be one with the other person’s frame of
as treating urgent care conditions. in addi- reference (Rogers, 1961). Carper (1978) cor-
tion, emergency nurses treat patients across related empathy with aesthetic knowing in
the life span from the neonate to the frail her description of fundamental patterns of
elderly. Emergency nursing is a complex knowing in nursing.
profession that encompasses a research tra- From a historical perspective, the roots
jectory that is versatile, rapidly changing, of morality are found in empathy. Being
and rigorous. Research in emergency nurs- able to empathize with potential victims
ing is growing and expanding in an effort encourages people to act and help others.
to respond to the dynamic practice of ED Empathy underlies many facets of moral
nurses. judgment and action. An instance when
empathy leads to moral action is when a
Suling Li bystander is moved to intervene on behalf
Vicki Keough of a victim; the more empathy a bystander
feels for the victim, the more likely it is that
the bystander will intervene (Goldman,
1998). The level of empathy felt toward
EMpathy another will shape one’s moral judgments
and empathic attitudes. Putting oneself in
another’s place leads people to follow cer-
Empathy is a dimension of nursing that is tain moral principles.
central to caring competence, and it is often Developmentally, there is a natural pro-
seen as an essential condition of nursing gression of empathy from infancy onward.
care. Empathy is often designated as the art At 1 year, children feel distress and will start
of nursing. Empathy in nursing is the ability to cry when they see another child cry. After
of nurses to penetrate the covert thoughts 1 year, the child will try to sooth another
and feelings of the client, to accurately inter- child that is crying. The most advanced level
pret the client’s thoughts and feelings as if of empathy emerges in late childhood when
they were their own, and to verbally and children begin to feel empathy for the plight
nonverbally convey that interpretation back of an entire group, such as the poor or the
to the client in forming a positive nurse– oppressed. During adolescence, empathic
client relationship. Empathy, appropriately understanding can reinforce moral convic-
expressed in the form of sincerity, genuine tions developed earlier in life that center on
positive regard, and sensitive understand- a desire to alleviate misfortune and injustice
ing of the client’s private world, has healing (Goldman, 1998).
potential. Empathic nursing care has been Many recent studies have explored the
shown to improve physiological and psy- biological basis of empathy. Greimel et al.
chological outcomes for clients. Empathy (2010) explored developmental changes in

EMPATHY n 147



the neural mechanisms underlying empa- Mercer and Reynolds (2002) described a
thy. Schulte-Ruther, Markowitsch, Fink, and variety of assessment and feedback techniques
Piefke (2007) significantly correlated neu- used in the delivery of holistic consultations E
ral activity with empathic abilities. Vollm and concluded that empathy improved cli-
et al. (2006) conducted a study confirming ent outcomes. They also found that empathic
that Theory of Mind and empathy stim- responses were improved in students by the
uli are associated with neuronal networks. use of experiential teaching methods. Evans,
Hurlemann et al. (2010) provided the first Wilt, Alligood, and O’Neil (1998) addressed
demonstration that oxytocin can “facilitate empathy as a multidimensional phenome-
amygdala-dependant, socially reinforced non and stressed the importance of under-
learning and emotional empathy in men” standing two types of empathy: basic and
(p. 4999). trained. They likened basic empathy to natu-
Early nursing research conducted in ral, raw, or ordinary feelings for others such
the area of empathy indicated that empathy as the innate tendency of a child to cry when
development programs had little to no effect recognizing distress in another human. They
on enhancing empathy. However, later stud- likened trained empathy to increased empa-
ies have indicated that empathy can be sig- thy as a result of knowledge and education.
nificantly improved and successfully taught They used the Layton Empathy Test and the
and that nurse educators can enhance basic Hogan Empathy Scale to measure trained
empathy among nursing students. and basic empathy in 106 nursing students
Teherani, Hauer, and O’Sullivan (2008) and found that trained empathy was not
used standardized patient simulations to sustained over time, causing the research-
assess learners’ empathic behaviors and dis- ers to call into question attempts by nursing
covered methods to enhance learner deficits faculties to teach empathy to students. They
in empathic responses. Vanlaere, Coucke, emphasized the importance of obtaining a
and Gastmans (2010) conducted empathy measurement of students’ baseline empa-
sessions in simulation laboratories with thy as a way of monitoring changes in basic
the aim of generating empathy in care pro- empathy after exposure to various empathy
viders and student nurses. The participant learning modalities. Evans et al. (1998) sug-
experiences lead to insight into their own gested new approaches to facilitate students’
perceptions and promoted ethical reflection. discovery of their basic empathy and empha-
Simulation of empathy sessions “can elicit a sized that basic empathy can be identified,
break from conformist thinking and treat- reinforced, and refined to develop expertise
ment, [initiate] a readjustment of one’s own in the expression of empathy.
visions, and often [stimulate] an adjustment Oz (2001) conducted a quasi-experimen-
of behavior” (p. 335). Webster (2010) used a tal investigation of empathy with 260 nurses
creative reflective teaching strategy in an who were randomly assigned to intervention
attempt to enhance empathy in nursing stu- and control groups. They used Dokmen’s
dents. Results of this study suggested that Scale of Empathic Skills and the Empathic
creative reflective experience facilitated the Tendency Scale to measure empathic com-
development of the nursing student–client munication skills and empathic tendency
relationship and promoted empathy. idczak levels. Their intervention consisted of educa-
(2007) used hermeneutic phenomenology to tion about empathic communication. Results
investigate how nursing students learn the indicated that nurses gained empathic com-
art and science of nursing. She concluded munication skills as a result of empathy
that empathy development is improved over training
time and that self-reflection and experience Wikstrom (2001) investigated the effect
enhanced empathic care. of an intervention program on student nurses

148 n END-OF-LiFE PLANNiNG AND CHOiCES



engagement in learning about empathy. The research and growth in our understanding of
investigator assigned subjects to intervention empathy, the art of nursing can be enhanced
E and control groups. The intervention group and improved outcomes for clients will be
received empathy exercises involving the use achieved.
of a reproduction of Edvard Munch’s paint-
ing, The Sick Girl, to stimulate discussion and Dianna Hutto Douglas
account making regarding interpretations of
empathy depicted in the painting. There was
a significant improvement in the intervention
group members’ levels of empathy as com- EnD-of-lifE planning
pared with the matched control group. The
research findings supported the use of art anD choicEs
as a complementary strategy to theoretical
knowledge on empathy to stimulate nurses’
basic empathy. The decision to choose or appoint another to
Continued research into the biological make health care and end-of-life (EOL) treat-
basis for empathy is certainly on the horizon. ment decisions for one in the event of tem-
Development of tools that more accurately porary or permanent loss of decision-making
measure empathy is required. Simulation capacity is less risky and requires less cogni-
laboratories in nursing education are a fitting tive capacity than the creation of a list of treat-
venue for continued investigation. Research ments desired and not desired at some point
into the development of scenarios that have in the future. There is no “gold standard”
been shown to enhance empathy is neces- to assess decisional capacity; mental status
sary. Research focused on interventions that assessment tests cannot be the sole criterion.
facilitate emotional development and allow Decision making is retained in early demen-
students and caregivers to develop empathic tia, especially insofar as appointing a trusted
capability and self-awareness is needed. other to make health care decisions for one’s
More research is indicated in the areas of cli- self (Kim & Karlawish, 2002). Using the tech-
ents’ perception of empathy. nique of paraphrased recall and reflection,
Over the past 40 years, empathy has Mezey, Tersei, Ramsey, Mitty, and Bobrowitz
been conceptually and empirically advanced (2002) developed a set of guidelines to deter-
in the nursing literature. Studies have raised mine if nursing home (NH) residents had the
critical questions about the nature of empathy capacity sufficient to create a Durable Power
and how empathy may or may not be teach- of Attorney for Health Care (i.e., a Health
able using various educational and experien- Care Proxy [HCP]). Analysis indicated that
tial strategies. Research findings suggest that many mild cognitively impaired residents
baseline measurements of empathy in nurses had this capacity. Mezey et al. suggest that
and nursing students can be a starting point the guidelines are more predictive than the
for developing strategies to enhance empathic Mini Mental State Examination in identi-
response to clients. Nursing as a profession fying such residents and could be used for
needs more replication of studies to identify determining decision-making capacity suffi-
basic empathy skills and to discern the dif- cient to create an HCP.
ferential impact of empathy education versus Nurses lack confidence in assisting peo-
empathy education combined with experi- ple make decisions about care preferences at
ential exercises in empathic understanding the EOL (Jezewski et al., 2005). Education of
such as simulation, reflective insight, art, health care professionals can make a differ-
film, music, and literature. With continued ence in advance direction (AD) completion

END-OF-LiFE PLANNiNG AND CHOiCES n 149



rates (Gutheil & Heyman, 2005; Patel, Sinuff, & of EOL treatment preferences with family or
Cook, 2004). significant other and knowing what friends
Myths about EOL care become barri- have gone through regarding EOL decision E
ers to care at the EOL. Such myths include making (Hirschman, Kapo, & Karlawish,
beliefs that advance care planning (ACP) 2008). Family members (i.e., surrogate decision
is the same as permission for euthanasia makers [SDMs]) of persons with moderate/
(Jeong, Higgins, & McMillan, 2007; Silviera, severe dementia, asked to make EOL treat-
DiPiero, Gerrity, & Feudtner, 2000), that life- ment decisions, are unclear about the goals
sustaining treatment (LST) at the EOL cannot of EOL, the dying trajectory likely for their
be withheld in the absence of evidence that loved one, and the lack information about
that would have been the patient’s wish, that palliative care and comfort options (Forbes,
withdrawing or withholding artificial nutri- Bern-Klug, & Gessert, 2002). Their decisions
tion and hydration (ANH) at the EOL from to withhold ANH are more influenced by
a terminally ill or permanently unconscious the interdisciplinary team, the resident’s pre-
patient is illegal, and that terminal sedation sumed quality of life, the stage of illness, and
is illegal even in the presence of intractable the comorbidities than by the AD instruc-
pain and suffering of a patient who is immi- tions (Lopez, Amella, Strumpf, Teno, &
nently dying (Meisel, Snyder, & Quill, 2000; Mitchell, 2010; The, Pasman, Onwuteaka-
Sabatino, n.d.). Philipsen, Ribbe, & van der Wal, 2002). Resi-
The most important factors for patients dents with advanced dementia are likely to
and families at the EOL in all care settings are have a feeding tube (FT) inserted if they do
pain and symptom management, information not have do not resuscitate (DNR) order, and/
about choices, preparation for death, having or there is no nurse practitioner or physician
a sense of completion, and being treated as assistant on the NH staff (Mitchell, Teno, Roy,
a whole person that includes discussion Kabumoto, & Mor, 2003). in NHs with low use
about treatment preferences (Hawkins, Ditto, of FTs—in comparison with high-use NHs—
Danks, & Smucker, 2005; Heyland et al., 2006; hand feeding is highly valued, the NH has
Steinhauser et al., 2000). Many community- a “home-like” environment that recognizes
dwelling older adults and their families are the importance of food in daily life and an
unaware of EOL care options, unable to dif- ACP process that includes family participa-
ferentiate between (physician) assisted sui- tion and palliative care options (Lopez et al.,
cide and euthanasia, misunderstand the 2010). High-use NHs have insufficient assis-
“double effect” in pain management, and do tive staff at meal times and fear both aspira-
not understand treatment refusal or treat- tion and noncompliance with regulations (in
ment withdrawal (Silviera et al., 2000). Staff regard to weight loss). Among hospitalized
and family in NHs and assisted living set- NH residents, lowest FT use was associated
tings differ regarding the kind and quality with White as compared with Black patients
of EOL care that is, or should be, provided in and those with an AD, DNR order, and no
these settings (Cartwright, 2002). information ANH orders (Teno et al., 2010).
about ACP is not coming from physicians and Although the most common reason for
other health care professionals (or the media) approving insertion of a FT was that it would
but rather from personal experience with prolong life and prevent aspiration, only
illness and death (Kahana, Dan, Kahana, & 40% of SDMs felt that it would improve the
Kercher, 2004; Lambert, McColl, Gilbert, & patient’s quality of life (Mitchell, Berkowitz,
Wong, 2005). Lawson, & Lipsitz, 2000). Most SDMs felt
Factors that facilitate ACP by persons they understood the benefits of a FT but not
with dementia include previous discussion the risks (83.0% vs. 48.9%), and less than half

150 n END-OF-LiFE PLANNiNG AND CHOiCES



felt that the patient would have wanted tube that families are informed about what to
feeding. expect and have good communication with
E Ethnic, religious, and racial groups the physician, and patients have greater use
(considered homogeneously) differ with of hospice in comparison with patients with-
regard to EOL care and LST preferences and out an AD (Teno, Grunier, Schwartz, Nanda,
the context in, and process by which, such & Wetle, 2007).
decisions are made (Cox et al., 2006; Hopp Preferences for LSTs among older adults
& Duffy, 2000; Kwak & Haley, 2005; Mezey, are not consistent over time and appear to
Leitman, Mitty, Bottrell, & Ramsey, 2000). be associated with transient factors, such as
Close-knit families of all ethnic groups feel current health status, rather than core val-
that ADs are destructive to family cohesive- ues (Fried, O’Leary, Van Ness, & Fraenkel,
ness and find it unbelievable that there is 2007). As new health states emerge, what
a law that creates a barrier to family deci- was once intolerable and unacceptable (such
sion making (Mitty, 2001). Cultures differ as mild chronic pain and transient weak-
as well with regard to truth telling and dis- ness) becomes tolerable and acceptable,
closure (Kagawa-Singer & Blackhall, 2001). hence the instability of choices. Variability
Asian and Hispanic/Latino patients prefer was somewhat associated with treatment
family participation in decision making in burden or the risk of a (further) impaired
contrast to White and Black patients who health status.
prefer patient-centered or patient-directed Hospitalized older adults (>60 years)
decision making (Kwak & Haley, 2005). As with LWs that indicated wishes for limited
many have shown, White patients are more care or comfort care were more likely to have
informed about, interested in, and likely their preferences honored than hospitalized
to discuss treatment preference, execute a older adults without an LW (Silviera, Kim, &
living will (LW), refuse certain LSTs, and Langa, 2010). Patients with an HCP were less
appoint an HCP than Black or Hispanic/ likely to receive all care possible or die in the
Latino patients (Hopp & Duffy, 2000; Kwak hospital than were patients without a desig-
& Haley, 2005). White patients with higher nated decision maker.
education and income levels are more likely The physician orders for life-sustaining
to complete an AD than Black and Hispanic/ treatments (POLST) is intended to surmount
Latino patients with less than a high school the barriers and problems associated with tra-
education and low income levels (Mezey ditional EOL treatment orders and processes.
et al., 2000). in comparison with Mexican it not only reflects a patient’s preferences
American and Euro-Americans, Black about CPR but also includes medical orders
patients are more likely to want LST to pro- about hospitalization, antibiotics, ANH, com-
long life (Hopp & Duffy, 2000) and believe fort measures, and medical interventions (e.g.,
that having an AD legalizes denial of access iV fluids, intubation). Known by a variety of
to care (Perkins, Geppert, Gonzales, Cortez, names, such as the physician orders for scope
& Hazuda, 2002). Same-race peer mentors of treatment (POST) or the medical orders
had a positive effect on ACP among Black for life-sustaining treatments (MOLST), the
but not White patients with regard to AD POLST is associated with reduced unwanted
completions (Perry et al., 2005). hospitalization, improved documentation of
Black more than White family members NH residents’ wishes, fewer traditional DNR
report communication problems regarding orders, and fewer full-code orders (Hickman
being informed and supported for what the et al., 2010). Consistency over time has not
family says are the patient’s treatment wishes been reported.
or are stated in the patient’s AD (Welch, Teno,
& Mor, 2005). Overall, having an AD means Ethel L. Mitty

ENTERAL TUBE PLACEMENT n 151



enteral tubes to maintain the structure and
EntEral tubE placEMEnt function of the small intestine. For many cli-
ents, feeding by enteral tubes is a lifesaving E
procedure.
An enteral tube is broadly defined as any Previous studies found NG/OG/Ni tube
tube passed through the nose or mouth into placement errors to be common, with prev-
the stomach or small intestine, or directly alence rates in adults ranging from 1.3% to
into the stomach or jejunum for the pur- 89.5% depending on how narrow or broad
pose of decompression, medication instilla- the definition of error was (McWey, Curry,
tion, and/or feeding. Feeding by nasogastric Schabel, & Reines, 1988; Niv & Abu-Avid,
(NG), orogastric (OG), or nasointestinal (Ni) 1988). Studies in children found between
tubes is preferred when the gastrointestinal 20.9% and 43.5% of NG/OG tubes are placed
(Gi) system is functional and the need for incorrectly when placement error is broadly
assisted feeding is expected to be short term defined as placement of the tube tip or orifices
(usually 6 weeks or less). Thus, many prema- outside the stomach (Ellett & Beckstrand,
ture infants are fed through these tubes until 1999; Ellett, Croffie, Cohen, & Perkins, 2005;
their suck and swallow mechanisms mature Ellett, Maas, & Forsee, 1998). Although esti-
sufficiently so they are able to coordinate mates of error rates vary, there is no doubt
sucking, swallowing, and breathing. Older they are too high.
children and adults requiring enteral nutri- Errors in placement of NG/OG feeding
tional support may also be fed through NG/ tubes, which include initial erroneous place-
OG/Ni tubes until a decision can be made ments as well as displacements over time,
whether or not long-term enteral nutritional can lead to serious complications. if a tube
support will be needed. For clients requir- ends in the airway, feeding through the tube
ing longer term support, a gastrostomy or will result in pulmonary aspiration or other
jejunostomy tube can be inserted surgically, pulmonary complications. Feeding through
endoscopically, or using ultrasound guid- a tube ending in the esophagus increases the
ance into the stomach or jejunum. it is also risk of pulmonary aspiration. When an NG/
possible to insert a jejunal tube through a OG tube erroneously passes into the duo-
gastrostomy tube allowing simultaneous denum and the client is fed formula requir-
decompression of the stomach and feeding ing both gastric and pancreatic enzymes for
into the jejunum. Because placement issues complete digestion, malabsorption resulting
related to gastrostomy/jejunostomy tubes in inadequate weight gain (or weight loss),
are different, only the issues surrounding diarrhea, and possibly dumping syndrome
NG/OG/Ni tubes will be discussed herein. may occur. increasing the safety of NG/OG
Enteral feeding is physiologic, achieves feeding requires knowledge development in
a positive nitrogen balance sooner than total at least two of the following areas: predicting
parenteral nutrition, enhances gut heal- the insertion length for correct tube place-
ing, reduces bacterial translocation, is asso- ment, determining tube position once placed,
ciated with low rates of sepsis, and is less and intermittent monitoring before feeding
costly (Ackerman, Ciechoski, & Marx, 1992; and medication instillations between inser-
Jolliet et al., 1999; Kiyama, Witte, Thornton, tions. The current state of the science regard-
& Barbul, 1998; Lipman, 1995; Schroeder, ing each of these knowledge needs will be
Gillanders, Mahr, & Hill, 1991; Strong et al., reviewed.
1992; Van Leeuwen et al., 1994; Zaloga, 1991). As far as researchers have been able
Even in clients maintained primarily by total to determine, the evidence for measuring
parenteral nutrition, small amounts of nutri- from the nose to the bottom of the earlobe
ents are fed into the lumen of the gut through to the xiphoid (NEX) to predict the insertion

152 n ENTERAL TUBE PLACEMENT



length to place a gastric tube was presented in 103 older children (>1 month of age), 97%
by Royce, Tepper, Watson, and Day (1951) in inserted using NEMU, 89% of the tubes
E which they reported their 6-month experi- inserted using ARHB, and 59% using NEX
ence of feeding 30 premature infants weigh- were correctly placed in the stomach, duode-
ing less than 1,800 g with indwelling NG num, or pylorus regions (Ellett, Cohen, et al.,
tubes with 28/30 of the infants surviving. in preparation). Many tubes were inserted
What Royce et al. actually wrote was that the lengths longer than the direct distance from
NG tube was inserted until it was “estimated the gastroesophageal junction (GEJ) to the
by rough measurement to have entered the pylorus, but most followed the natural cur-
stomach” (p. 79). A nursing textbook cited vature of the stomach. A few passed into the
this article as a reference for the NEX inser- pylorus or through the pylorus into the duo-
tion-length predictor. After that, authors/ denum. There appears to be no way to pre-
editors of other nursing textbooks either dict which way a tube will curve. Therefore,
cited this nursing textbook or a previous only high tube placements in the esophagus
edition of their nursing textbook as a refer- or at the GEJ were considered placement
ence for NEX. This insertion-length predictor errors in this analysis. During insertion, five
remains the most commonly used method in tubes coiled in the esophagus leaving the tips
clinical practice. Although several research of the tubes near the entrance to the respira-
groups over the years have found the NEX tory tract. These placement errors would not
insertion-length predictor to be too short in have been known before feeding through
children frequently leaving the tube tip and the tubes without the abdominal radiograph
orifices, through which liquid feeding exits required as part of the study. A new regres-
the tube, in the esophagus (Beckstrand, Ellett, sion equation specific to neonates <1 month
& McDaniel, 2007; Ellett, Croffie, et al., 2005; corrected age was developed as an outcome
Weibley, Adamson, Clinkscales, Curran, & of this study (Ellett et al., submitted).
Bramson, 1987; Ziemer & Carroll, 1978), a Two studies investigated insertion-length
recent randomized controlled trial, involving predictors for gastric tube placement in adults.
276 children with chronological ages ranging in a study of 99 adult cadavers and 5 normal
from 27 weeks gestational age + 1.7 weeks to volunteers, Hanson (1979) concluded that the
17 years 8 months, will hopefully lead to the use of the NEX length to determine the inser-
demise of using the NEX insertion-length tion length for NG tubes was less accurate
predictor in clinical practice. This group than the formula ([NEX – 50 cm]/2 + 50 cm)
found that two NG/OG tube insertion-length adapted from a regression equation using
predictors: (a) measuring from the nose to the NEX, resulting in 91.4% accuracy for estimat-
bottom of the ear lobe to the mid-umbilicus ing the distance for placing the NG tube tip
(half way between the umbilicus and the correctly in the stomach. Ellett, Beckstrand,
xiphoid) (NEMU) and (b) age-related, height- et al. (2005) recommended a three-variable
based (ARHB) regression equations—were regression model using gender, weight, and
significantly superior to NEX in children the length measured from the nose to the
(Ellett et al., submitted; Ellett, Cohen, et al., umbilicus (NU) with the client lying supine
in preparation). in 173 neonates (<1 month with no pillow. Two nomograms, one for each
corrected age), 92% of NG/OG tubes inserted gender, were provided to make this insertion
using NEMU, 100% inserted using ARHB, distance predictor easier to use in practice.
and 61% inserted using NEX were correctly Currently, an abdominal radiograph
placed in the stomach, duodenum, or pylorus is the only consistently valid and reliable
regions (Ellett et al., submitted). in this study, way to verify the position of flexible small-
ARHB was only used in neonates >44.5 cm bore NG/OG/Ni tubes. Radiographs have
in length (Ellett et al., submitted). Similarly, been recommended by many to determine

ENTERAL TUBE PLACEMENT n 153



tube placement when an NG/OG/Ni tube Approximately 15% of the gastric aspirates
is initially inserted or changed (Ellett et al., had pH values overlapping with the pH val-
submitted; Ellett, Cohen, et al., in prepara- ues of intestinal aspirates. in addition, pH E
tion; Gharib, Stern, Sherbin, & Rohrmann, values from four tubes inadvertently placed
1996; Jackson, Payne, & Bacon, 1990; Metheny, in the respiratory tract overlapped with the
Spies, & Eisenberg, 1988; Walsh & Banks, range in intestinal placements. Metheny,
1990). However, tube location must be mon- Smith, and Stewart (2000) found that the com-
itored frequently before being used for bination of pH, bilirubin, pepsin, and trypsin
feeding or medication instillation to ensure correctly classified 100% of respiratory place-
it has not become displaced, and the summa- ments and 93.4% of Gi placements in adults;
tive radiation risk of multiple radiographs as however, no bedside tests are commercially
well as their expense makes the development available for measuring bilirubin, pepsin, or
of adequate bedside monitoring methods trypsin, severely limiting their clinical useful-
imperative. ness. Although Ellett et al. (2005) found using
Multiple methods have been recom- the pH cutoff of 5 recommended by Metheny
mended for placing tubes in the distal duo- et al. for fasting adults was helpful in differ-
denum or jejunum. These vary from client entiating gastric from intestinal placement in
positioning, use of promotility agents, pH- a preliminary study involving children, their
sensing tube, self-propelled tube, magnets, recently completed randomized controlled
electrodes, fluoroscopic guidance, sono- trial found pH to be less helpful because sev-
graphic guidance, and endoscopic guid- eral tubes located in the pylorus or duode-
ance (Ellett, 2006). These methods vary in num on radiograph had acidic aspirate pH
cost, time involved, and success rates. in the readings, which incorrectly indicated they
future, possibly some of the lower cost meth- were placed in the stomach.
ods will be found useful in determining NG/ Placing the proximal end of the tube
OG tube location either reducing or eliminat- under water and observing for bubbles in
ing the need for radiographic verification. synchrony with expirations involves risk
Several bedside methods of detecting that clients will aspirate water on inspira-
NG/OG/Ni tube placement errors have been tion, especially those being mechanically
investigated in adults, including (a) aspirat- ventilated. There is evidence that CO 2 moni-
ing gastric contents and measuring the pH, toring has the potential to differentiate respi-
bilirubin, pepsin, and trypsin levels; (b) plac- ratory from Gi placement; however, it has
ing the proximal end of the tube under water yet to be used clinically (Burns, Carpenter,
and observing for bubbles in synchrony with & Truitt, 2001; Thomas & Falcone, 1998).
expirations; (c) measuring CO 2 level at the Simple auscultation is not a reliable method
proximal end of the tube; (d) auscultating for to assess tube position because injection of
a gurgling sound over the epigastrium or left air into the tracheobronchial tree or into the
upper quadrant of the abdomen; (e) examin- pleural space can produce a sound indistin-
ing the visual characteristics of tube aspirate; guishable from that produced by injecting
and (f) measuring and recording the length air into the Gi tract (Metheny, McSweeney,
from the nose or mouth to the proximal end Wehrle, & Wiersema, 1990). Radiation of
of the tube. Unfortunately, all of the bedside sound on auscultation is an even greater
methods have limitations. Each method will problem in children because of the small
be discussed separately. in a study of 800 distances between internal organs. Metheny,
aspirates collected from 605 fasting adults, Reed, Berglund, and Wehrle (1994) demon-
Metheny et al. (1999) found that gastric aspi- strated that visual characteristics improved
rates had significantly lower pH values (mean nurses’ predictions of stomach and intesti-
= 3.5) than intestinal aspirates (mean = 7.0). nal placements but reduced discrimination

154 n EPiLEPSY



of respiratory placements. Finally, measur-
ing and recording of the insertion length EpilEpsy
E was helpful, especially if correct placement
of the tube in the stomach was verified by
radiograph at the time of insertion, as the Epilepsy refers to a chronic condition char-
length of tube extending from the nares or acterized by recurrent seizures. A seizure is
mouth can then be compared with this mea- a temporary alteration in functioning caused
sured length before each feeding or medi- by an abnormal discharge of neurons in the
cation instillation to detect slippage of the central nervous system (Holmes, 1987). The
tube in or out. This method will not detect exact nature of the seizure depends on the
tubes that have migrated internally dur- function of the brain cells that are affected
ing severe coughing, nasotracheal suction- by the abnormal discharge. Seizures are clas-
ing, retching, or vomiting with no slippage sified into two major types: partial and gen-
(Ellett, 2006). eralized. Partial seizures, which occur when
in summary, although estimates of tube the electrical discharge remains in a circum-
placement errors vary, there is no doubt scribed area of the brain, can be broken down
that they are common and high placements further into elementary or complex divisions.
(esophagus or GEJ) can lead to serious com- With elementary partial seizures, the person’s
plications. The direct NEX distance, the consciousness is not impaired. With complex
insertion-length predictor currently used in partial seizures, there is some impairment of
practice, has been found to be inaccurate in consciousness. in some persons with partial
both adults and children. Both the Hanson seizures, the abnormal discharge spreads
(1979) method and the Ellett et al. (2005) throughout the brain and is referred to as a
regression equation using gender, weight, partial seizure with secondary generaliza-
and NU have been found to be more accu- tion. Generalized seizures occur when the
rate in adults for placing NG/OG tubes in discharge affects both brain hemispheres and
the stomach on insertion. Both NEMU in results in a loss of consciousness. The two
children of any size or ARHB in all chil- most common types of generalized seizures
dren except infants <44.5 cm in length have are generalized tonic clonic and absence. in
been found to be more accurate insertion- generalized tonic clonic seizures, the per-
length predictors for placing NG/OG tubes son typically stiffens all over in the tonic
in the stomach on insertion. Verifying cor- phase, has jerking movements of the arms
rect placement of the NG/OG tube by radio- and legs in the clonic phase, and is inconti-
graph on initial insertion and whenever the nent of urine. After the seizure, the person
tube is changed is recommended in children is commonly sleepy. in absence seizures,
(Ellett et al., 2005; Ellett et al., submitted; there are a few seconds of loss of conscious-
Ellett, Cohen, et al., in preparation). Because ness. The person generally stares blankly
none of the bedside methods are sufficiently and sometimes rotates the eyes upward. An
accurate when used alone, a combination of absence seizure begins and ends abruptly
assessing whether the tube insertion length (Dreifuss & Nordli, 2001). Epilepsy affects
has changed and assessing the color (gastric more than 2 million persons in the United
fluid is usually white, tan, colorless, or green) States. The cumulative incidence to age 80
and consistency (gastric fluid is usually years is 1.3% to 3.1%. incidence rates are high-
cloudy) of tube aspirate along with pH test- est among those younger than 20 years and
ing for interim monitoring of NG/OG tube older than 60 years. The trend is for the fre-
location is recommended. quency of epilepsy to be decreasing in chil-
dren and to be increasing in the elderly. Rates
Marsha L. Ellett are slightly higher for men than for women.

ETHiCS OF RESEARCH n 155



The prevalence of active epilepsy, defined Problems most commonly found in children
as having had a seizure in the past 5 years include attention problems, anxiety, social
or taking daily antiepileptic medication, is isolation, depression, behavior problems, E
between 4.3 and 9.3 per 1,000. in approxi- and academic underachievement (Austin &
mately 70% of new cases of epilepsy, there is Dunn, 2000). Research in children suggests
no specific identified cause. in the remaining that behavior problems are already evident
30%, the risk factors for epilepsy are severe at the time of the first recognized seizure
head trauma, infection in the central nervous (Austin et al., 2001). The most common prob-
system, and stroke. in the United States, the lems found in adults with epilepsy are unem-
prevalence of epilepsy is lower in Whites ployment, depression, social isolation, and
than in non-Whites, although the reasons problems with adjustment. Unemployment
for these differences are not clear (Hauser & may be twice as high in persons with epi-
Hesdorffer, 1990). lepsy as in the general population (Hauser &
Remission of epilepsy, defined as 5 years Hesdorffer, 1990). Factors generally associ-
without seizures, is more common among ated with quality-of-life problems are severe
persons with generalized seizures, those and frequent seizures, presence of comor-
with no neurological deficits, and those with bidities, cognitive deficits, negative attitudes
a younger age of onset. Approximately 70% toward having epilepsy, and lack of a sup-
of persons with epilepsy can be expected to portive family environment.
enter remission (Hauser & Hesdorffer, 1990). Research to provide an evidence base
The major treatment of epilepsy is anti- for care of persons with epilepsy is grow-
epileptic medication. Most epilepsy is well ing. However, studies are still needed (a) to
controlled with such treatment, but approxi- understand the factors that lead to quality-
mately 20% of persons continue to experience of-life problems, (b) to test nursing interven-
seizures despite treatment with medications. tions that prevent or reduce quality of life
When partial seizures originate from a well- problems, and (c) to test self-management
defined focus in an area of the brain that interventions for adults as well as children
could be excised without serious neurolog- with epilepsy and their families. Diiorio
ical deficits, surgery to remove the affected et al. (2009) have developed and pilot tested
part of the brain is an option. Other treat- an innovative Web-based, self-management
ments for epilepsy have been tried with some intervention for adults with epilepsy. Nurses
success. The ketogenic diet, which consists of should play a major role in developing
food high in fat and low in carbohydrates, knowledge to guide nursing practice in with
has been used since the 1920s. Recently, there persons with epilepsy.
has been increased interest in the ketogenic
diet as a treatment. Another recent treatment Joan K. Austin
is the vagus nerve stimulator, which sends
electrical energy to the brain via the vagus
nerve (Epilepsy Foundation, n.d.).
Most nursing research has been devoted Ethics of rEsEarch
to the impact of epilepsy on the quality of
life. Some persons have severe quality-of-life
problems that prevent them from engaging Over the years, violation of human rights
in fully productive lives. The exact preva- along with advances in science and technol-
lence of these problems is difficult to estab- ogy has led to important codes of conduct,
lish because most studies have been carried policy statements, and ethical guidelines
out on clinic samples, that is, on persons with that influence the ethics of research. Outside
seizures that are more difficult to control. of nursing, important past codes of conduct

156 n ETHiCS OF RESEARCH



include the Nuremberg Code, the Declaration autonomous means overall capacity for vol-
of Helsinki, and the National Commission untariness, for comprehension of infor-
E for the Protection of Human Subjects of mation, and for freedom from controlling
Biomedical and Behavioral Research (also influences during the research experience
known as The Belmont Report). Within nurs- (Beauchamp & Childress, 2009, chap. 4). if
ing, important past policy documents one or more of these factors is missing, ethi-
include the 1980, 1995, and 2003 American cal issues of autonomy arise.
Nurses Association’s (ANA, 2010c) social investigators support research partici-
policy statements. Past ethical guidelines pants’ autonomy by ensuring that voluntar-
for nursing research include the ANA’s 1975 iness, comprehension, and freedom from
and 1985 Human Rights Guidelines in Clinical controlling influences are operationalized
and Other Research as well as the ANA- through informed consent statements. These
sponsored Ethical Guidelines in the Conduct, statements typically contain purpose of the
Dissemination, and Implementation of Nursing research, duration of participants’ involve-
Research (Silva, 1995). ment, data collection processes and proce-
Current ANA documents implicitly or dures, research benefits and risks, contact
explicitly related to the ethics of research information, and information related to vol-
include (a) Code of Ethics for Nurses with untariness, anonymity, and confidentiality.
Interpretive Statements (ANA, 2001, Provision The informed consent statement also may
7), (b) Nursing: Scope and Standards of Practice ask research participants to verify that they
(ANA, 2010b), (c) Nursing’s Social Policy substantially comprehend what the research
Statement: The Essence of the Profession (ANA, entails before their written, audio, or video
2010c), (d) Guide to the Code of Ethics for Nurses: consent to participate in it. The preceding
Interpretation and Application (Fowler, 2008, informed consent process should be dynamic
chap. 7), and (e) the Center for Ethics and and ongoing.
Human Rights Web site that contains more in addition to informed consent state-
than 20 position statements on ethics and ments, and when appropriate, participants
human rights (ANA, 2010a). information may be asked to sign the Health insurance
about the preceding documents is available Portability and Accountability Privacy Rule
at the http://www.nursingworld.org Web Authorization for research (U.S. Department
site. information about federal regulations of Health and Human Services, 2004). This
and guidelines for ethical research is avail- authorization permits a covered entity to
able at the http://www.hhs.gov and http:// use or disclose a participant’s protected
www.fda.gov/oc/gcp Web sites. health information as specified by the
The ethics of research, defined as what authorization.
one morally ought to do or be in conduct- Not all research participants are sub-
ing, evaluating, disseminating, and apply- stantially autonomous. Exceptions include
ing research to practice, are based primarily pregnant women, children (unless emanci-
on ethical principles and on moral charac- pated minors), persons who are institutional-
ter. Ethical principles focus on respect for ized, and persons with mental impairments
autonomy, nonmaleficence, beneficence, and or terminal illnesses. To ensure such situa-
justice, whereas moral character focuses on tions are ethical, proxy consents are needed
virtues (Beauchamp & Childress, 2009). and, with children older than 7, both proxy
The first ethical principle—that of respect consents and children’s assent are often
for autonomy—focuses on how investigators obtained.
support substantially autonomous research Some investigators omit informed con-
participants’ decisions on whether or not to sent when the internet is used in research,
participate in research. Being substantially when informed consent could affect the

ETHiCS OF RESEARCH n 157



validity of study results, and/or when min- (what should be allocated to one). The latter is
imal or no harm to research participants known as distributive justice. Fairness often
is anticipated. However, other investiga- focuses on selection or omission of research E
tors consider omission of informed consent participants. The guiding principles are that
unethical. participants are selected only on the basis
The second and third ethical principles— of the research requirements and that these
those of nonmaleficence (do no harm) and requirements be ethical. Characteristics of
beneficence (prevent harm and do good)— subject selection such as gender, race, reli-
focus primarily on minimizing risks and gion, and socioeconomic status may present
maximizing benefits. Risks may be psycho- ethical issues of justice as fairness. They also
logical (e.g., anxiety), physiological (e.g., side may present ethical issues of power imbal-
effects of drugs), social (e.g., ostracism), or ances. These imbalances are often explored
economic (e.g., child care costs). To minimize by feminist ethicists.
these risks, investigators assess their nature, Whereas nonmaleficence and benefi-
number, and severity. in addition, organi- cence focus on risks and benefits, the ethi-
zations involved with research mandate cal principle of distributive justice focuses
institutional reviews—often operational- on allocation of them, that is, whether they
ized through institutional review boards— should be allocated equally or according to
to ensure that research being conducted need, merit, contribution, or market demand
is ethical. The overriding ethical principle (Beauchamp & Childress, 2009, chap. 7). For
regarding nonmaleficence in research is this: example, if equal allocation is chosen, inves-
Take the smallest amount of risk possible to tigators may ask research participants to sub-
meet the research purpose. mit to a routine blood test with an equal risk
As with risks, benefits also may be psy- for all (e.g., a painful needle prick) or to com-
chological (e.g., decreased anxiety), physi- plete participation in a study with an equal
ological (e.g., increased muscle relaxation), benefit for all (e.g., a gift of a bookmark).
social (e.g., access to support services), or eco- The ethics of research also focus on one’s
nomic (e.g., financial compensation). Benefits moral character, namely, on who one ought
may help individual study participants, other to be as an investigator. One response is that
individuals, or society. They should be maxi- investigators ought to be persons who aspire
mized to prevent harm or to do good. toward moral excellence in research through
The ethical principles of nonmaleficence possession of virtuous traits such as com-
and beneficence also apply to research with passion, caring, trustworthiness, and integ-
animals. investigators should (a) use ani- rity (Beauchamp & Childress, 2009, chap. 2).
mals for research only when necessary, (b) Compassionate investigators possess aware-
obtain approvals of regulatory agencies and/ ness of the stresses and sufferings of research
or animal-care-and-use committees before participants and do not negate their welfare
research, (c) use the least-sentient animals for sole pursuit of the research. Caring inves-
that serve the research purpose, (d) inflict the tigators possess commitment to research
least amount of harm to the fewest animals, participants through concerned connections
and (e) provide the animals with necessary and responsible relationships with them.
care and protection. Despite these safe- Trustworthy investigators possess moral
guards, some investigators oppose animal reliability, allowing research participants to
research; they claim that harming animals is believe with confidence that investigators
never morally justifiable. will follow through with commitments. High
The fourth ethical principle—that of integrity investigators possess completeness
justice—focuses both on fairness (what one and steadfastness of character in their per-
deserves or is owed) and on distribution sonal and professional lives.

158 n ETHNOGERiATRiCS



Because integrity integrates several of risk, and on decisions of allocation. These
virtues inherent in moral character, ethi- are familiar ethical issues. However, in the
E cal investigators prize it and avoid lapses future, as ethical issues related to societal
in integrity. One such lapse is scientific changes and to advances in science and tech-
(research) misconduct, which may take the nology intensify, they will present unprece-
forms of plagiarism, data falsification, data dented and compelling moral challenges for
fabrication, irresponsible authorship, and investigators and for the ethics of research.
questionable research practices. Plagiarism Two such challenges are transgenics and
refers to passing off as one’s own the ideas or synthetic DNA. Nevertheless, regardless
words of another. Data falsification refers to of the challenges, the one uncompromising
manipulating research results by altering or principle underlying all research is that it be
omitting them so that their validity is ques- ethical.
tionable. Data fabrication refers to making up
of research results. irresponsible authorship Mary Cipriano Silva
refers to claiming authorship credit when
one’s role as author and/or researcher is neg-
ligible. Questionable research practices refer
to deviating from acceptable ethical stan- EthnogEriatrics
dards in the conduct, evaluation, dissemina-
tion, or application of research into practice.
To deter unethical behavior related to the Ethnogeriatrics, an evolving geriatrics sub-
preceding five components of scientific mis- specialty, is a multidisciplinary approach
conduct, individuals and organizations have to eldercare focusing on the interrelated-
instituted safeguards for research. These ness of aging, health, ethnicity, geriatrics,
safeguards include the U.S. Department ethno-gerontology, and transcultural health,
of Health and Human Services Office of specific to quality health care and quality
Research integrity, research review boards, of life in racial/ethnic minorities. The U.S.
policy documents and guidelines, peer and Census Bureau (2008a) categories for racial/
editor reviews of research publications, use ethnic groups are Black/African American,
of best research evidence for practice, and American indian and Alaska Native, Asian
opportunities for Magnet status. American, Hispanic/Latino, and Native
Future directions for research include (a) Hawaiian/Pacific islander. By 2050, one
generation of ethical research guidelines for third of the population 65 years and older
unprecedented advances in science and tech- from this group is projected to be Black/
nology that pose moral issues, (b) selection African American, Hispanic/Latino, and
of interdisciplinary teams of researchers and “other races” category, mainly of Asian and
ethicists to monitor the impact of unprec- Pacific islander groups (Administration on
edented advances in science and technol- Aging, 2009). These growth rates, persistent
ogy on research participants and on human health disparities, health literacy, and cul-
rights in research, and (c) further develop- tural and language challenges underscore
ment of ethical position statements on the an ethnogeriatric imperative (institute of
current and future use of tele-health and the Medicine, 2008; Smedley, Stith, & Nelson,
internet in research. 2003; Yeo, 2009).
in summary, the ethics of research are Some key concepts in ethnogeriat-
primarily based on ethical principles and on rics include heterogeneity, cultural values
moral character. Within these parameters, and traditions, health beliefs and practices,
ethical issues arise. Examples included herein health literacy, access to health care, accul-
focused on nature of autonomy, on severity turation, language and communication,

ETHNOGERiATRiCS n 159



cohort historical experiences, explanatory Association and the Philippine Nurses
models, spirituality, and access and utiliza- Association of America (Mezey, Stierle,
tion of health care (Yeo, 2001). These topics Huba, & Esterson, 2007). E
are important in relation to human responses More research is essential to understand
to health and illness, management of chronic the factors and cultural contexts that influ-
physical and mental illnesses, caregiving, ence health beliefs and illness, availability
sensory loss, elder abuse, disaster prepared- and accessibility of health care, patient–pro-
ness, decision making, advance directives, vider trust, and confidence in achieving the
end-of-life care, and other health care events desired outcomes. These factors include
(Adler, 2006; Adler & Kamel, 2004; Gerdner, indigenous practices, English-language profi-
Cha, Yang, & Tripp-Reimer, 2007; Graves, ciency, health literacy, cohort historical expe-
Rosich, McBride, & Charles, 2010; Grudzen, riences, immigration patterns, family and
2008; Hendrix & Swift Cloud-LeBeau, 2006; support network, internet technology, econ-
Lewis & McBride, 2004; McBride, 2006; omy, and changes in public policies (Adler,
McBride & Lewis, 2004; McBride, Fee, & 2006; Adler & Kamel, 2004; Graves et al, 2010;
Yeo, 2004; Talamantes, Trejo, Jimenez, & institute of Medicine, 2008; McBride & Lewis,
Gallagher-Thompson, 2006). 2004; Pavalko & Wolfe, 2009; Smedley et al.,
in 1987, the Stanford Geriatric Education 2003; Yeo et al., 1998).
Center introduced ethnogeriatrics to the Although racial/ethnic populations may
national multidisciplinary network of geri- share some values, belief systems, and
atric education centers and health sciences behavioral norms, the mode of expression
programs (Lewis & McBride, 1996; Wallace & varies among the groups across historical,
McBride, 1996). The Stanford Geriatric social, psychological, and health domains.
Education Center multiethnic, multidisci- This heterogeneity requires that health pro-
plinary faculty developed core competen- viders become more aware and sensitive to
cies to guide curriculum development and cultural nuances to tailor health care to the
research and produced Web-based resources ethnic elders’ needs (Adler, 2006; Adler &
available at http://sgec.stanford.edu/. in Kamel, 2004; Xakellis et al., 2004). Thus, cul-
1997, a chapter on ethnogeriatrics was part tural context adds an important dimension
of a publication of priorities for geriatric to the complexity of decision making related
education from a national workshop of fed- to health promotion, long-term care, advance
erally funded Geriatric Education Centers directives, end-of-life care, and other health
(Henderson et al., 1996). care issues (Adler, 2006; Adler & Kamel, 2004;
Mather institute on Aging, one of Gerdner et al., 2007).
the three Health Resources and Services in 2008, approximately 1.89 million
Administration grantees, trained advance older adults, 65 years and older, lived in
practice nurses to teach geriatrics, focus- households with a grandchild and 25%
ing on ethnogeriatrics and managed care had primary parenting responsibility for
(Hollinger-Smith, 2003). in 2002, the Nurse their grandchildren or great grandchildren
Competency on Aging project, developed (Administration on Aging, 2009). Divorce,
a Web-based, on-demand geriatric nursing illness, substance abuse, or incarceration
modules including one on ethnogeriatrics. often lead to this role. Diversity and struc-
The Nurse Competency on Aging’s out- ture of contemporary families brought about
reach to minority nurses organizations to by teenage pregnancy, delayed parenting
increase members’ knowledge and skills by women, childlessness, stepgrandparent-
on eldercare resulted in small grants to two ing, and same-sex couples have implications
groups that focused on ethnogeriatrics— for social support, caregiving patterns, and
the Asian American Pacific islander Nurses family economics. immigrants 65 years and

160 n ETHNOGRAPHY



older who potentially may choose to live The anticipated peak in population for
with family are Hispanic and Asian immi- older adults by 2050 underscores the trend
E grants mostly from Mexico, Central and of obvious growth in the number of eth-
South America, india, and Pacific islands nic elders and a critical need for research
(Bengston, Kim, Meyers, & Eun, 2000; in ethnogeriatrics. it is imperative that such
Wilmoth, 2001). knowledge is part of the foundation for
The health belief model and the tran- evidence-based nursing care for ethnically
stheoretical model discussed by McBride diverse communities. There is much to learn
and Lewis (2004) were adapted for research about the cultural context of health issues to
on preventive health and health promotion, inform the development of effective guides
respectively, in ethnic elders. The trans- for cultural competence and cultural humil-
cultural assessment evaluates effects of six ity to increase health literacy and eliminate
cultural phenomena on health and illness health disparities in the older racial/ethnic
behaviors (communication, space, social minority groups (McBride & Lewis, 2004;
organization, time, environmental control, Xakellis et al., 2004). A new challenging fron-
and biological variations). These frameworks tier, the American society of the twenty-first
are attractive knowledge silos to initiate eth- century, is an in vivo laboratory for ethno-
nogeriatric nursing research. geriatric nursing research.
The chronic care model (Wagner et al.,
2001), a systems-change guide with six Melen R. McBride
components (community, health systems, Irene Daniels Lewis
self-management support, delivery system
design, decision support, and clinical infor-
mation systems), can be adapted for ethno-
geriatric nursing research. Exploring the Ethnography
interplay between health disparities, health
literacy, health beliefs, and internet technol-
ogy to improve health care for ethnic elders The term ethnography translates as “the writ-
especially the disenfranchised, underserved, ten description of the folk” and refers to
or hard-to-reach groups would contribute to both a specific naturalistic research method
changes in nursing systems. and the written product of that method. As
To assess health literacy level, SPEAK a research process, ethnography is a com-
(Speech, Perception, Education, Access, and parative method for investigating patterns
Knowledge) is a useful guide in working of human behavior and cognition through
with minority elders (Kobylarz, Pomidor, observations and interactions in natural set-
& Heath, 2006). Care models that resonate tings. As a written product, ethnography is
with nursing values are also important a descriptive or interpretive analysis of the
frameworks for ethnogeriatric research. The patterns of beliefs, behaviors, and norms of a
patient-centered care model individualizes culture. Culture, in the ethnographic sense, is
health care, respects the patient’s values an integrated pattern of human knowledge,
and perspectives, and considers the patient symbolic thought, everyday practices, and
to be an expert of his or her illness (Lorig material artifacts that is created, shared, and
et al., 2001). The relationship-centered care modified by people who interact with each
model incorporates the provider’s person- other. The focus on culture and cultural pro-
hood, self-awareness, cultural humility, and cesses is central to ethnography and is one of
empathy into building trust relationships the ways in which ethnography differs from
for a health outcome (Beach & inui, 2006; other naturalistic methods such as grounded
Suchman, 2006). theory (the study of basic social processes)

ETHNOGRAPHY n 161



and phenomenology (the study of individu- is typified by long-term field studies of an
als’ lived experience). entire culture. The researcher seeks to dis-
Anthropologists developed ethnography tinguish a single group of people from other E
to understand people who lived in other cul- cultural groups by describing the people’s
tures and practiced traditions different from lifeways, language, religion, kinship pat-
their own. Although ethnography remains terns, economic system, geographic habitat,
the primary research method in anthropol- health systems, and technologies. in con-
ogy, it is also used by researchers in many trast, focused ethnography takes a micro-
other disciplines, most notably sociology, level approach to understanding cultural
psychology, education, management science, processes, often from within the researcher’s
and nursing. As the method was adopted own society and for the purpose of applying
outside anthropology, the focus of study cultural knowledge to solving practical prob-
shifted from small-scale or tribal societies to lems. Through short-term, immersive field
topical subjects more closely linked with the visits and key informant interviews, focused
interests and scientific foci of the adopting ethnographers gather background informa-
discipline. For example, the study of small tion about people within a particular cultural
urban social communities was undertaken context and on a narrowed subject matter.
by sociologists from the Chicago School, Although more than a dozen distinct
investigations of schools as microcosms of research traditions are subsumed under the
society were addressed by educators, and term ethnography, each method emerged
ethnic health beliefs and lay systems of care within a particular historical context to
were targeted by nurse anthropologists. address somewhat different elements of cul-
in the discipline of nursing, ethnography ture. Nurse researchers may use any of these
was introduced into the literature primar- approaches given the appropriate research
ily by nurse anthropologists beginning in question. Five examples are presented to
the late 1960s. Seminal articles by Elizabeth demonstrate the utility and flexibility of
Byerly (1990) and Antoinette Ragucci (1990) diverse ethnographic approaches to nursing
were published in Nursing Research and research.
laid the foundation for future nurse eth- An early ethnographic approach devel-
nographers. As the federally funded Nurse oped by Boas around the turn of the twenti-
Scientist Program sponsored doctoral edu- eth century is termed Historical Particularism.
cation for registered nurses, many recipients The central tenet of this approach is that each
chose anthropology as their focus of study. culture has its own long and unique history
This first generation of nurse ethnogra- and that all elements of a culture are wor-
phers included pioneers such as Madeleine thy of documentation. Typical products of
Leininger, Agnes Aamodt, Pamela Brink, ethnographies conducted within this frame-
Margarita Kay, and Oliver Osborne. A sec- work are descriptive narratives and cultural
ond generation of nurse anthropologists inventories. Nurse researchers have used
included Juliene Lipson, Evelyn Barbee, this approach to identify specific folk heal-
JoAnn Glittenberg, Marjorie Muecke, Janice ing treatments used within ethnic groups
Morse, and Toni Tripp-Reimer. Later, as doc- and to generate items for the construction of
toral programs in nursing developed, some questionnaires.
nurses were trained in ethnography within Functionalism, which is associated
schools of nursing. with the anthropologists Malinowski and
Researchers using ethnographic frame- Radcliffe-Brown, is a second ethnographic
works may assume either a whole culture per- tradition and, historically, the approach used
spective in their investigations or take a more most often in nursing research. Here, the task
focused approach. Macro-level ethnography of ethnography is to describe the structural

162 n ETHNOGRAPHY



elements and their interrelated functioning investigator’s immersion in the target com-
in a culture. Prominent functionalist ethnog- munity for long periods of time to gain
E raphies in nursing include studies guided understanding for contextualizing the ethno-
by Leininger’s Culture Care Theory and its graphic data gathered about a cultural group.
attendant Sunrise Model. The stages of fieldwork include (a) field entry,
The goal of ethnoscience, a third ethno- (b) development of relationships, (c) data col-
graphic tradition, is to discover folk systems lection, (d) data manipulation, (e) data analy-
of classification to determine the ways peo- sis, and (f) departure. Many fieldwork stages
ple perceive and structure their thinking (particularly items b–e) overlap in time, thus
about their world and to identify the rules allowing for iterative relationship building,
that guide decision making. The taxonomy data gathering, and interpretation.
of nursing activities known as the Nursing in conducting fieldwork, an investigator
Interventions Classification was derived using may use multiple data collection strategies
an ethnoscience approach. Through such including participant observation, informal
strategies as cognitive interviews and pile interviews, structured interviews, photo-
sorts, researchers identified how clinical graphs and videotapes, material artifacts,
nurses conceptualized their work-related census and other statistical data, historical
tasks and patient care responsibilities. documents, projective tests, and psychoso-
Symbolic or interpretive ethnography is cial surveys. The variety of research strate-
a fourth approach that is growing in appli- gies that are appropriately used is another
cation in nursing. Here, culture is viewed as way in which ethnography differs from most
a system of shared meanings and symbols. other naturalistic methods. Further, ethnog-
Ethnographers working within this tradition raphers may use quantitative data to aug-
such as Geertz, Turner, and Douglas believe ment qualitative data. However, the mainstay
that cultural knowledge is embedded in “thick strategies of ethnography rest in participant
descriptions” of human behavior. Cultural observation and informant interviews. if the
members are interviewed to provide a social focus of the ethnography concerns the cogni-
context for observed actions and to interpret tive realm (attitudes, beliefs, schemata) of the
cultural symbols and relevant motifs. Nursing members of the culture, then interviewing is
research on explanatory models of illness and the primary strategy. On the other hand, if
health or on the meaning of the body often the focus of the ethnography involves struc-
is based within the symbolic or interpretive tural features or patterns of behavior, then
ethnographic tradition. observations are the primary strategy. The
institutional ethnography was intro- majority of ethnographies, however, use a
duced by Smith to investigate the social orga- combination of strategies.
nization of everyday life. As communication Data manipulation methods include field
and information media have assumed dom- notes and memo systems, coding strategies,
inant positions in human interactions, insti- and indexing systems. Recently, computer-
tutional ethnographers use their method to ized software programs such as NVivo and
map how texts, technologies, and informa- ATLAS.ti have aided in the management of
tion flows coordinate social relations and data in ethnographic projects. Methods used
govern the daily activities of people within in data analysis include matrix, thematic,
institutions. institutional ethnographies have and domain analysis.
explored decision-making processes in long- in summary, ethnography is a naturalis-
term care and the role of patient satisfaction tic research method designed to describe the
discourse within health care reform. culture of a social group or organization. The
Fieldwork is the hallmark of ethno- ethnographer seeks to understand another
graphic research. Fieldwork involves the way of life from the perspective of a person

EVALUATiON n 163



inside the culture (emic view) rather than same level of attention given to any research
from the positions of outsiders (etic view). method.
Participant observation and informant inter- Evaluations serve one of three purposes: E
viewing are the major data collection strat- (1) to conceptualize and design interven-
egies used during ethnographic fieldwork. tions, (2) to monitor implementation of some
The specific ethnographic tradition used by intervention, or (3) to assess the utility of
the investigator determines the appropriate some action. in the first type of evaluation,
form of the ethnographic product. studies focus on (a) the extent of the prob-
lem needing intervention, (b) who should
Toni Tripp-Reimer be involved in or targeted for the interven-
Stacie Salsbury Lyons tion, (c) whether the intervention proposed
Bernard Sorofman will address the problem or the needs of
Jimmy Reyes individuals, and (d) whether the chance for
successful outcome has been maximized. in
the second type of evaluation, studies focus
on what is done; they generally are referred
Evaluation to as process evaluation studies. These stud-
ies also determine whether the interven-
tion is reaching the targeted population
Evaluation is a method for measuring the and whether what is done is consistent with
effect of some purposeful action on a par- what was intended. Process evaluations are
ticular situation. it is often described as an essential for determining cause and effect,
assessment of worth. in evaluation, both although they are not sufficient by them-
anticipated and unanticipated outcomes are selves for measuring impact. That is where
important and are included in the discussion evaluation researchers often get into trouble.
of findings and the publication of results. They stop collecting data once they describe
The purpose of evaluation is to provide what was done; therefore, process evaluation
information for decision makers who usu- methods have tended to be viewed with dis-
ally have some stake in the outcome of the favor, which is unfortunate. Although they
intervention. are insufficient by themselves, they are abso-
Evaluation methods have been catego- lutely necessary for determining whether the
rized along a continuum ranging from sim- intervention caused the outcome and if so,
ple assessment, in which informal practices how—and if not, why not. in the third type,
are used to look for indication of outcome, studies determine both the degree to which
to evaluation research, in which research an intervention has an impact and the benefit
methods are used to allow for generalization of the intervention in relation to the cost. The
to other comparable situations. in actuality, degree of impact is referred to as the inter-
the use of informal practices for determin- vention’s effectiveness, and the degree of cost
ing intervention outcome is never appropri- is referred to as its efficiency.
ate. Consequently, the term evaluation should Recent writings on evaluation focus on
suffice for all efforts in which a systematic the need for theory to guide the investigation
process is used to determine the effect of and frame the results. Authors have identi-
some intervention on some anticipated out- fied theories that range from those targeted
come. The research component of the term solely for the purposes of designing evalua-
is assumed. No matter what the purpose of tions to those directed at the expected rela-
the evaluation, the issue of rigor is always tionships between intervention and outcome.
foremost, and the methods and measure- For example, behavioral theories often are
ment approaches used should involve the used to develop interventions targeted at

164 n EViDENCE-BASED PRACTiCE



changing health behaviors; they also are used attention to these aspects of the evaluation
to select measures for determining impact. process, evaluations become an effective
E Evaluation theories, on the other hand, focus means for extending nursing science.
on the purpose of the study—whether it is for
determining what goals or outcomes should Gail L. Ingersoll
be examined, how the treatment should be
developed and delivered, or under what
conditions certain events occur and what
their consequences will be. Measuring the EviDEncE-basED practicE
true effect of the intervention often is dif-
ficult. Evaluation studies are subject to the
same measurement and analysis problems Evidence-based practice (EBP) is the consci-
associated with other designs. in addition, entious use of current best evidence in mak-
ingersoll (1996) has summarized several oth- ing decisions about patient care (Sackett,
ers that are important to evaluation research. Straus, Richardson, Rosenberg, & Haynes,
Among these is the need to measure the 2000). it is a problem-solving approach to
extent of the intervention introduced, which the delivery of health care that integrates the
is frequently absent from reports of evalua- best evidence from research with a clinician’s
tion studies. This information assists in dem- expertise and a patient’s preferences and
onstrating cause-and-effect relationships values (Melnyk & Fineout-Overholt, 2011).
and clarifies what magnitude of the inter- When delivered in a context of caring and
vention is required before an effect is seen. in an organizational culture that supports
it also helps to prevent the potential for Type EBP, the best patient outcomes are achieved.
iii, iV, and V evaluation errors, which affect Although it is well recognized that EBP
statistical conclusion validity and generaliz- improves the quality and safety of health
ability validity. care as well as decreases hospital costs and
Type iii evaluation error is an error in patient morbidities, evidence-based care is
probability and results in solving the wrong not consistently implemented by point of care
problem instead of the right problem. it usu- clinicians and health care systems across the
ally occurs when the program is not imple- United States (McGinty & Anderson, 2008;
mented as planned and when insensitive Pravikoff, Tanner, & Pierce, 2005; Williams,
measures are used to determine effect. Type 2004). Unfortunately, it typically takes well
iV error occurs when the evaluator provides over a decade to translate findings from
information that is useless to stakeholders. research into clinical practice to improve
Type V error involves confusing statisti- care and patient outcomes. Recognition of
cal significance with practical significance, the long research-practice time lag resulted
which ultimately leads to Type iV error. in the institute of Medicine setting a goal
Evaluation is the key to measuring inter- that by the year 2020, 90% of clinical deci-
vention magnitude and effect. To assure that sions will be supported by the best available
evaluations are useful, however, steps must evidence (McClellan, McGinnis, Nabel, &
be taken to design them according to some Olsen, 2007).
meaningful conceptual framework, and For clinicians to use evidence to make
close attention must be paid to maximizing daily decisions about patient care, there
the rigor of the methods, analysis, and rejec- must be an understanding of the two types
tion of alternative hypotheses. Approaches of evidence in EBP: (1) external evidence
to quality control recommended for other that is generated through rigorous research
nonexperimental, quasi-experimental, and and (2) internal evidence that is generated
experimental designs are appropriate. With through quality improvement, outcomes

EViDENCE-BASED PRACTiCE n 165



management, and EBP implementation proj- in the United States, the U.S. Preventive
ects within clinicians’ own practice settings. Services Task Force, an independent panel of
internal evidence is important in evidence- experts in primary care, research, and pre- E
based decision making to demonstrate out- vention systematically reviews the evidence
comes from evidence-based interventions as of effectiveness and develops gold standard
well as when rigorous studies do not exist to recommendations for clinical preventive
guide best practices. Evidence for interven- services that include screening, counsel-
tions is leveled from Level 1 (i.e., systematic ing, and preventive medications (Agency for
reviews of randomized controlled trials), Healthcare Research and Quality, 2008). The
which is the strongest level of evidence to U.S. Preventive Services Task Force produces
guide clinical practice, to Level 7 (i.e., evi- a Guide to Clinical Preventive Services every
dence from expert opinion). The level of the year that includes its updated evidence-
evidence plus the quality of that evidence based recommendations for primary care
as determined from critical appraisal deter- providers.
mines the strength of the evidence, which in EBP, there are 7 steps that include the
provides clinicians the confidence to act following:
upon the evidence and implement best prac-
tices (Melnyk & Fineout-Overholt, 2011). 1. Cultivate a spirit of inquiry
Dr. Archie Cochrane, a British epide- 2. Ask the burning clinical question in PiCOT
miologist, is credited with starting the EBP format
movement when he challenged the public 3. Search for and collect the most relevant
to pay only for health care that had been evidence
supported as efficacious through research 4. Critically appraise the evidence (i.e.,
(Enkin, 1992). in 1972, he criticized the med- rapid critical appraisal, evaluation, and
ical profession for not providing rigorous synthesis)
systematic reviews of evidence so that orga- 5. integrate the best evidence with one’s clin-
nizations and policy makers could make ical expertise and patient preferences and
decisions about health care. He contended values in making a practice decision or
that thousands of low-birth-weight prema- change
ture infants had died needlessly because 6. Evaluate outcomes of the practice decision
the results of several randomized controlled or change based on evidence
trials were not synthesized into a system- 7. Disseminate the outcomes of the EBP
atic review to support the practice of rou- decision or change (Melnyk & Fineout-
tinely providing corticosteroid injections to Overholt, 2011).
high-risk women in preterm labor to halt the
premature birth process. Archie Cochrane Without a spirit of inquiry, clinicians
considered systematic reviews to be the may find it challenging to ask burning clin-
strongest level of evidence to guide practice ical questions about their practices (e.g., in
decisions (Cochrane Collaboration, 2001). intensive care unit patients, how does early
Although he died in 1988, Dr. Cochrane’s ambulation compared with delayed ambu-
influence was responsible for the launching lation affect the number of ventilator days?
of the Cochrane Center in Oxford, England, in orthopedic patients, how does analgesia
in 1992 and the founding of the Cochrane administered by the triage nurse compared
Collaboration (2001) a year later. The pur- with waiting for physician ordered analgesia
pose of the Cochrane Collaboration is to affect pain and length of time in the emer-
provide and routinely update rigorous sys- gency room?). Asking questions in PiCOT
tematic reviews of health care interventions (P = patient population, i = intervention or area
to guide best practices. of interest, C = comparison intervention or group,

166 n EViDENCE-BASED PRACTiCE



O = outcome, and T = time) format leads to a at point of care), and (d) EBP mentors (i.e.,
more time efficient and effective search for advanced practice nurses with expertise in
E evidence. Articles from the search are then EBP as well as organizational and individ-
rapidly critically appraised, evaluated, and ual behavior change strategies) who work
synthesized to determine whether a prac- directly with clinicians at the point of care
tice change on the basis of the best evidence in implementing EBP (French, 2005; Kitson
is indicated. Relevant, reliable evidence is et al., 2008; Melnyk, 2007; Melnyk, Fineout-
then integrated with the clinician’s expertise Overholt, & Mays, 2008; Melnyk, Fineout-
and patient preferences and values in mak- Overholt, Stillwell, & Williamson, 2009).
ing a practice decision or change. Clinician There are several conceptual models that
expertise involves health care provider skills have been developed to facilitate a change to
and interpretation of patient assessment EBP in individuals and health care systems.
data, internal evidence, use of health care These models include (a) the EBP decision-
resources, and other important information making model by DiCenso, Ciliska, and
that is relevant to the clinical decision and Guyatt; (b) the Stetler model of EBP; (c) the
outcome. Once an evidence-based change is iowa model of EBP to promote quality care
made in clinical practice, measurement of key by Marita Titler and colleagues; (d) the model
outcomes is necessary to demonstrate that for EBP change by Rosswurm and Larabee;
the impact expected of the change indeed (e) the Advancing Research and Clinical
occurred in a clinician’s own practice setting. Practice Through Close Collaboration
The final step in EBP is disseminating the model by Melnyk and Fineout-Overholt;
outcomes of the evidence-based change so (f) the Promoting Action on Research
that others might benefit from the process. implementation in Health Services frame-
Although EBP produces better outcomes work by Rycroft-Mallone, Kitson, and col-
than care that is steeped in tradition and a leagues; (g) the clinical scholar model by
known process exists for implementing evi- Schultz; and (h) the Johns Hopkins nursing
dence-based care, there are multiple barriers EBP model by Newhouse and colleagues
that exist within individuals and institutions (Ciliska et al., 2011). it is increasingly recog-
that are slowing the widespread adoption of nized that efforts to change practice should
evidence-based care. Barriers in individuals be guided by conceptual models (Graham,
include (a) the perception that EBP takes too Tetroe, & the KT Theories Research Group,
much time, (b) the inadequate knowledge 2007). As these models are supported by evi-
and skills in EBP, and (c) a lack of confidence dence from research, they will become even
to implement change. System barriers include more valuable in helping clinicians deliver
(a) contextual environment and culture that evidence-based care.
does not support EBP, (b) lack of resources in summary, EBP is necessary to ensure
required for EBP, (c) lack of EBP mentors who the highest quality of cost-effective care
can assist with EBP implementation at point and the best patient outcomes. Efforts in the
of care, and (d) nurse administrators and future must be accelerated and placed on
managers who do not model EBP. Conversely, (a) educating both practicing clinicians and
there are a number of factors that facilitate health professional students in the EBP pro-
the implementation of EBP, including (a) EBP cess with emphasis on the building of EBP
knowledge and skills, (b) beliefs about the skills; (b) creating cultures of EBP that pro-
value of EBP and the ability to implement it, vide resources, EBP mentors, and support to
(c) a context and culture that supports EBP clinicians to engage in and sustain evidence-
and provides the necessary tools to support based care; (c) providing incentives for EBP;
evidence-based care (e.g., time to search and (d) establishing evidence-based clini-
for evidence, access to computer data bases cal practice guidelines and policies that are

EXPERiMENTAL RESEARCH n 167



incorporated into technology (e.g., electronic treatment at a particular time” (Cook &
health records) to facilitate best practice by Campbell, 1979, p. 8). This refers to control
clinicians at the point of care (Melnyk & over two processes that determine who gets E
Williamson, 2010). what at what time. The first process is the
researcher’s use of randomization methods
Bernadette Mazurek Melnyk to assign subjects to treatments. This is the
Ellen Fineout-Overholt preferred method of exerting control over
subjects and their treatment as, theoretically,
it ensures that known and unknown extrane-
ous forces inherent to subjects are dispersed
ExpEriMEntal rEsEarch equally across the different treatment arms.
This may not always be possible, in which
case the second process comes into play—
True experiments have the potential to pro- that of structuring the assignment process
vide strong evidence about the hypothesized in such a way that major, known extraneous
causal relationship between independent forces are controlled.
and dependent variables. Experiments are Commonly used design strategies
characterized by manipulation, control, and include blocking, fixed and propensity
randomization. The quality of experiments matching, and counterbalancing. in block-
depends on the validity of their design. ing, the potentially confounding variable
Manipulation means the researcher is incorporated into the study design as an
actively initiates, implements, and terminates independent variable. The levels of this var-
procedures. in most instances, manipulation iable are considered blocks, and subjects are
is linked to the independent variable(s) under assigned to blocks on the basis of their value
consideration. Essential to manipulation is on the blocking variable. Next, in each block,
that the researcher has complete control over subjects are randomly assigned to the study
the process. The researcher decides what is to arms. in fixed matching, a weaker but com-
be manipulated (e.g., selected nursing inter- mon method of control, the researcher iden-
vention protocols), to whom the manipula- tifies one or more extraneous (usually up to
tion applies (e.g., samples and subsamples of three) variables to be controlled. As soon as
subjects), when the manipulation is to occur a subject is recruited for one of the treatment
according to the specification of the research groups, the researcher then tries to find sub-
design, and how the manipulation is to be jects for the other group(s) identical to the
implemented. first subject on the specified matching vari-
Manipulation implies and is impossible ables. in propensity matching, all known or
without researcher control over extraneous presumed confounding variables are used to
sources that might affect and lead to incorrect calculate a propensity score for each subject.
scientific conclusions. Control aims “to rule Subjects are then matched on this propen-
out threats to valid inference.” it also adds sity score. Counterbalancing occurs when
precision, the “ability to detect true effects of the researcher is concerned that the order
smaller magnitude” (Cook & Campbell, 1979, in which treatments are administered influ-
p. 8). Unlike laboratory studies where total ences the results. When counterbalancing
control is often possible, in clinical research is used, all subjects receive all treatments;
control is a relative matter. The researcher however, the order of administration of treat-
has the responsibility for ensuring as much ments is varied.
control over extraneous forces as possible. Randomization entails two separate pro-
Control also includes “the ability to cesses: (a) random selection of subjects from
determine which units receive a particular the population and (b) random assignment of