168 n EXPLORATORY STUDiES
subjects to treatment and control conditions. the researcher has tried to cope with the vari-
Random selection is the process of randomly ous potential threats to each type of validity.
E drawing research subjects from the popu-
lation about which the researcher wants to Ivo Abraham
gain knowledge and to which the researcher Karen MacDonald
hopes to generalize the findings of a study.
Random assignment entails allocating
sampling units (e.g., patients) to treatment
and control conditions by using a decision Exploratory stuDiEs
method that is known to be random (e.g., coin
toss, random drawing, use of random tables,
computer-generated random sequences of Exploratory studies are those that investigate
options). For long, random selection was vir- little-known phenomena for which a literary
tually nonexistent in intervention studies in or experiential search fails to reveal any signif-
nursing; moreover, a large proportion (55.3%) icant examples of prior research. Exploratory
of nursing intervention studies did not even studies are useful in nursing research in find-
use random assignment methods (Abraham, ing out more about the nature of a nursing-
Chalifoux, & Evers, 1992). This is changing related problem or issue, and there usually is
with the growing emphasis on randomized a small sample that focuses on one particular
controlled trials of nursing interventions. area of interest or on one or two variables. The
in their classic text, Cook and Campbell kinds of research questions typically gener-
(1979) reviewed four types of validity of ated for exploratory studies are descriptive in
research designs, potential threats to each, nature and seek understanding (e.g., What is
and strategies to remedy these threats. it like to be a pregnant teenager? Who needs
Statistical conclusion validity addresses the home care? What health-promoting behav-
extent to which, at the mathematical/statis- iors do cafeteria workers engage in? What is
tical level, covariation is present between the lived experience of military widows and
the independent and dependent variables widowers?).
(i.e., the extent to which a relationship exists Because the intent of exploratory
between the independent and dependent research is to find out and explore unknown
variables). internal validity refers to whether phenomena, it is considered Level 1 research
an observed relationship between variables (designed to elicit descriptions of a single
is indeed causal or, in the absence of a rela- topic or population) and is reflected by many
tionship, that indeed there is no causal link. of the early research studies in nursing. An
Construct validity of putative causes and examination of early research designs used
effects refers to whether the causal relation- in nursing research includes the following:
ship between two variables is indeed “the (a) staff nurse behaviors and patient care
one” and tries to refute the possibility that a improvement (Gorham, 1962), (b) the self-
confounding variable may explain the pre- concept of children with hemophilia and
sumed causal relationship. External validity family stress (Garlinghouse & Sharp, 1968),
refers to the generalizability of an observed and (c) women’s beliefs about breast cancer
causal relationship “across alternate mea- and breast self-examination (Stillman, 1977).
sures of the cause and effect and across dif- Exploratory studies are still used in
ferent types of persons, settings, and times” nursing research and are often thought of
(Cook & Campbell, 1979, p. 37). Validity of as an initial step in the description of more
any type is not a yes/no issue of whether complex researchable problems or issues or
or not it is present. Rather, it is a matter of as part of mixed methods studies. However,
degree, determined by the extent to which exploratory studies are particularly useful
EXPLORATORY STUDiES n 169
when the investigator seeks to gather base- decision-making processes. On the other
line information on a particular variable that hand, qualitative or naturalistic designs
is difficult to measure, such as the concepts explore phenomena in the natural setting in E
of loneliness or culture. Other research- which they occur and are commonly carried
ers may wish to investigate a process about out by using semistructured or open-ended
which little is known. An example might be interviewing techniques and by observation.
the types and meanings of caring behaviors There are multiple approaches associated
among elderly nursing home residents or the with qualitative research, but they all focus
meaning of loss of a loved one. Additional on those aspects of human behavior that
rationales for exploratory studies include are difficult to measure in numerical terms.
the need to focus on one concept that has not One example of an exploratory qualitative
been described in any great detail in the lit- study that used a grounded theory approach
erature, such as isolation or comfort, or the is that by McDonnell and Van Hout (2010).
need to determine the feasibility for a more McDonnell and Van Hout sought to describe
extensive study. Lastly, exploratory research opiate users’ experiences of self-detoxifica-
can serve to establish baseline information tion by using a grounded theory approach.
for future studies. The study generated a substantive theory of
Regardless of the intent of exploratory self-detoxification as a subjective process of
research, a flexible design that enables the seeking heroin abstinence.
researcher to investigate and examine all Most critiques of exploratory research
aspects of a phenomenon is encouraged. cite a limited scope and focus, the lack of
Flexibility in the design allows exploration generalizability to a larger population, and
of emerging ideas and changing direction, the lack of a basis for prediction. in spite of
if needed, as data are collected and ana- these limitations, however, exploratory stud-
lyzed. Thus, exploratory research is not lim- ies are useful to uncover or discover infor-
ited to one particular paradigm but may use mation about little-known phenomena or
either a quantitative or qualitative approach. single concepts, to explore the existence of
Studies that propose a hypothesis and seek relationships between and among variables,
to provide a measure of a phenomenon as a to find out more about human behavior in a
description use a quantitative design such naturalistic setting, to lay the groundwork
as that described by Lagan, Sinclair, and for more systematic testing of hypotheses,
Kernohan (2010). in this study, Lagan et al. and to determine the feasibility for a more
sought to discover how pregnant women in-depth study.
used the internet as an information source
and the overall effect that it had on their Kathleen Huttlinger
F
designing the latent constructs and the rela-
Factor analysis tionship between latent constructs.
The raw data should be at or applicable
to the interval level, such as the data obtained
Factor analysis is a multivariate technique with Likert-type measures. Next, a number of
for determining the underlying structure assumptions relating to the sample, variables,
and dimensionality of a set of variables. By and factors should be met. First, the sample
analyzing intercorrelations among variables, size must be sufficiently large to avoid erro-
factor analysis shows which variables clus- neous interpretations of random differences
ter together to form unidimensional con- in the magnitude of correlation coefficients.
structs. However, it involves a higher degree As a rule of thumb, a minimum of five cases
of subjective interpretation than is common for each observed variable is recommended;
with most other statistical methods. In nurs- however, Knapp and Brown (1995) reported
ing research, factor analysis is commonly that ratios as low as three subjects per var-
used for instrument development (Ferketich iable may be acceptable. Others generally
& Muller, 1990), theory development, and recommend that 100 to 200 cases is advisable
data reduction. Factor analysis is used for (Nunnally & Bernstein, 1994).
identifying the number, nature, and impor- Second, the observed variables need
tance of factors, comparing factor solutions to vary. In other words, one category of
for different groups, estimating scores on responses for a single observed variable
factors, and testing theories (Nunnally & should not contain more than 90% of the
Bernstein, 1994). responses for that specific variable. Third,
There are two major types of factor there should be no obvious miscodes or
analysis: exploratory and confirmatory. In outliers, as indicated in a review of the fre-
exploratory factor analysis, the data are quencies of the observed variables. Outliers
described and summarized by grouping among cases should be identified and their
together related variables. The variables influence reduced either by transformation
may or may not be selected with a particular or by replacing the outlying value with a less
purpose in mind. Exploratory factor analy- extreme score. Fourth, the observed variables
sis is commonly used in the early stages of should be normally distributed, with no sub-
research, when it provides a method for con- stantial evidence of skewness or kurtosis. For
solidating variables and generating hypothe- normality, Kline (2005) recommends absolute
ses about underlying processes that affect the values for skewness less than 3 and absolute
clustering of the variables. Confirmatory fac- values of kurtosis less than 8. Fifth, there
tor analysis is used in later stages of research should be little, if any, missing data for each
for theory testing related to latent processes observed variable. Sixth, use scatterplots
or to examine hypothesized differences in to determine if pairs of observed variables
latent processes among groups of subjects. are linearly related. Seventh, instances of
Confirmatory factor analysis is typically con- multicollinearity of the variables should be
ducted with structural equation modeling, in deleted. Multicollinearity can be tested using
which an investigator has complete control of regression and testing for tolerance levels less
FACTOr ANALySIS n 171
than .10. Eighth, regression techniques can be drawn from the items and point to a latent
used to identify influential cases by examin- construct.
ing large Mahalanobis distances when all Mathematically speaking, factor analysis F
variables are included in the analysis. Ninth, generates factors that are linear combinations
there should be adequate factorability within of variables. The first step in factor analysis is
the correlation matrix, which is indicated by factor extraction, which involves the removal
several sizable correlations between pairs of of as much variance as possible through the
variables that exceed .30. Thus, the correla- successive creation of linear combinations
tion of variables within a factor should be that are either orthogonal (unrelated) or
higher with each other than with variables oblique (related) to previously created combi-
outside of the factor. nations. Other methods of factor extraction,
When planning for factor analysis, which analyze common factor variance (i.e.,
the first step is to identify a theoretical variance that is shared with other variables),
model that will guide the statistical model include the principal factors method, the
(Ferketich & Muller, 1990). The next step is to alpha method, and the maximum likelihood
select the psychometric measurement model, method (Nunnally & Bernstein, 1994).
either classic or neoclassic, that will reflect Various criteria have been used to deter-
the nature of measurement error. The classic mine how many factors account for a sub-
model assumes that all measurement errors stantial amount of variance in the data set.
are random and that all variances are unique The most important is that factors should be
to individual variables and not shared with made up of items with primary factor load-
other variables or factors. The neoclassic ings higher than .40 and without any sec-
model recognizes both random and system- ondary factor loadings higher than .30. Items
atic measurement error, which may reflect should be removed if this is violated. Another
common variance that is attributable to useful tool is examining the residual correla-
unmeasured or latent factors. The selection tion matrix. The residual correlation matrix
of the classic or neoclassic model influences is the difference between the correlation
whether the researcher chooses principal matrix of the sample and the implied correla-
components analysis (classic) or common fac- tion matrix created by the statistical program
tor analysis (neoclassic; Ferketich & Muller). to fit the data. Good fitting factor solutions
Conceptually, common factor analysis should have an average difference in residual
is based on a reflector model, in which the correlations of more than .05. It is also impor-
latent construct drives the answers given to tant to review the factor correlation matrix
the items (observed variables) that make the when using oblique rotation, correlations
model. For example, one’s level of depression between two factors by more than .60 are so
(the latent construct) drives the responses highly correlated that they could represent
to items that reflect depression. In a graphic a single factor. Another approach is to use a
model, arrows representing factor loadings screen test to identify the number of factors
would be drawn going from the latent con- above the elbow.
struct point to the items. In comparison, The first step in running any factor anal-
principal component analysis is based on ysis is to determine the number of factors to
a producer model, in which the subjects’ be tested on the basis of logic, theory, or prior
responses to the items drive the latent con- empirical evidence, and set the number of
struct. For example, responses to items on factors to be estimated. The next step is to test
the chronic illness checklist drive the total factor models with solutions of plus or minus
score of the number of chronic illnesses (the two factors above or below the number of
latent construct). In a graphic model, arrows factors originally identified. For example, if
representing the factor loadings would be four factors were originally hypothesized,
172 n FAILurE TO THrIVE (AduLT)
then models from two to six factors should Factors are interpreted by examining the
also be tested to verify the factor structures. pattern and magnitude of the factor load-
F Problematic items usually appear across the ings in the rotated factor matrix (orthogonal
various factor solutions. remove items with rotation) or pattern matrix (oblique rota-
primary factor loadings of less than .40 or tion). Ideally, there are one or more marker
with secondary factor loadings of more than variables, variables with a very high load-
.30. remove items one at a time and rerun the ing on one and only one factor (Nunnally &
factor analyses with solutions for two to six Bernstein, 1994), which can help in the inter-
factors after each item removal until a “clean” pretation and naming of factors. replication
solution is identified. No factor should have of factor solutions in subsequent analyses
less than two variables. with different populations gives increased
Factor extraction results in a factor credibility to the findings. Comparisons
matrix that shows the relationship between between factor-analytic solutions can be
the original variables and the factors by made by visual inspection of the factor load-
means of factor loadings. The factor loadings, ings or by using formal statistical procedures,
when squared, equal the variance in the var- such as the computation of Cattell’s salient
iable accounted for by the factor. For all of similarity index and the use of confirmatory
the extracted factors, the sum of the squared factor analysis (Gorsuch, 1983).
loadings for a single variable across all fac-
tors represents the communality (shared var- Christopher J. Burant
iance) of that variable. The sum of a factor’s Jaclene A. Zauszniewski
squared loadings for all variables is equiva-
lent to that factor’s eigenvalue (Nunnally &
Bernstein, 1994).
Factor rotation is commonly used when Failure to thrive (adult)
more than one factor emerges. Factor rota-
tion involves the movement of the reference
axes within the factor space so that the vari- Adult failure to thrive (FTT) syndrome is
ables align with a single factor (Nunnally & defined as a lower-than-expected level of
Bernstein, 1994). Orthogonal rotation keeps the functioning associated with nutritional defi-
reference axes at right angles and results in fac- cits, depressed mood state, and cognitive
tors that are uncorrelated. Orthogonal rotation impairment (Newbern & Krowchuk, 1994;
is usually performed through a method known Verdery, 1996). Clinically, FTT has been used
as varimax, but other methods (quartimax and interchangeably with the terms cachexia,
equimax) are also available. Oblique rotation frailty, dwindling, nonspecific presentation
allows the reference axes to rotate into acute or of illness, and decompensation. Although
oblique angles, thereby resulting in correlated it has been discussed primarily in relation
factors (Nunnally & Bernstein). When oblique to the elderly (Egbert, 1996), on the basis of
rotation is used, there are two resulting matri- the above definition, it is likely that the syn-
ces: a pattern matrix that reveals partial regres- drome crosses age boundaries and exists
sion coefficients between variables and factors, in other chronically ill patient populations,
and a structure matrix that shows variable– for example, adults with multiple sclerosis,
factor correlations. The pattern matrix is easier AIdS, or diabetes.
to interpret. The recommended rotation tech- In the International Classification of
nique is to use oblique rotation because this diseases, 10th revision, FTT is most fre-
represents the correlation of factors that occur quently classified as a pediatric diagnosis.
in real life (Fabrigar, Wegener, MacCallum, & In children, FTT is very broadly defined as
Strahan, 1999). deviation from an expected growth pattern
FAILurE TO THrIVE (AduLT) n 173
in terms of norms for age and sex (Frank & There also is relatively little published
Zeisel, 1988). Pediatric FTT is generally clas- research on adult FTT. Methodological
sified as organic, in which there is a known approaches have varied and, without a dom- F
underlying medical condition; nonorganic, inant model of adult FTT, studies have used
in which the causes are psychosocial; or different definitions of the syndrome, as well
mixed. Advances in pediatric research have as various defining criteria. In one of the earli-
also produced a theoretical framework est reported studies, Messert, Kurlanzik, and
in which malnutrition is of fundamental Thorning (1976) identified adult FTT through
importance, either as a primary cause of documentation of a cluster of symptoms in
FTT or a secondary symptom of a chronic five adult patients diagnosed with neurolog-
illness. ical disorders (age range = 24–67 years, mean
On the basis of several years of clini- = 49 years). All of the patients had irreversible
cal and research experience with the elderly, weight loss despite high caloric intake, wide
Verdery (1996) proposed two etiological fac- variations in body temperature, decreased
tors for adult FTT. The first is that the syn- levels of consciousness, unexplained rapid
drome may occur in response to an event development of decubitus ulcers, and sud-
that triggers a more rapid than normal rate of den death. A second study examined the
decline. The idea that a trigger event may be characteristics of 62 male patients admit-
a precursor to FTT needs further investiga- ted with a medical diagnosis of FTT (Osato,
tion but it is intuitively believable from both Stone, Phillips, & Winne, 1993), using ret-
a clinical and research perspective: an event rospective chart review. The patients had a
could be physiological in nature (for example, wide age range (37–104 years), an average of
a hip fracture), environmental (for example, a seven medical diagnoses, required an aver-
change in residence), psychological (for exam- age of five medications, and 62% had low
ple, death of a spouse), or a combination of levels of serum albumin (<3.5 g/dL). A third
all three. Verdery’s second proposition is that study retrospectively examined the medical
there are two categories of adult FTT. This records of 82 elders admitted with a diagno-
first is primary adult FTT, where the reasons sis of FTT (Berkman et al., 1986) and used fac-
for the patient’s decline are ambiguous or tor analysis to group FTT factors into three
obscure. In secondary adult FTT, the reasons categories: patient care management prob-
are diagnosable and potentially treatable and lems, functional problems, and patient cop-
there is a wide range of possible underlying ing problems. A fourth study followed 252
factors: (a) medical history and treatment, subjects for 2 years after new hip fracture
for example, immune function or polyphar- (Fox, Hawkes, Magaziner, Zimmerman, &
macy; (b) psychological problems, primarily Hebel, 1996). Subjects were generally older
depression; (c) nutritional factors, including (mean = 77 years) and FTT was defined as a
eating disorders; and (d) social and/or envi- decline in walking 6 to 12 months postfrac-
ronmental factors such as isolation or alcohol ture after subjects had achieved an initial
intake. Although many of the factors in the gain in mobility. results were mixed: those
secondary category of adult FTT have been classified as FTT (n = 26) were significantly
investigated in relation to health behaviors worse off than the “no decline” group in
and outcomes, few have been examined from their cognitive decline, number of hospi-
within a theoretical framework of adult FTT; talizations at 12 months, and self-reported
in part because, unlike pediatric FTT, there health at 24 months. No statistically signifi-
is no consensus on the critical concepts and cant differences were found between the two
their relationships, nor are there objective cri- groups on social interaction or depression
teria that can be used to evaluate deviation scores, mortality, physician visits, or nursing
from the norm. home stays. A fifth study also used physical
174 n FAILurE TO THrIVE (CHILd)
functioning as the primary characteristic loss due to acute illness. When a child’s
of FFT and measured associated factors in lack of weight gain is attributed to psycho-
F 34 older adults admitted to rehabilitation social factors and developmental concerns
therapy posthospitalization (Higgins & daly, rather than organic or disease-related fac-
2005). Findings indicated that participants tors, the term FTT is used. Within the last
with unexpectedly low physical functioning few years, researchers have begun to refer
were older, had decreased serum albumin to FTT as “faltering growth,” because many
levels, depressed mood, and less likelihood connote the term FTT with the occurrence of
of discharge home. maternal neglect or abuse; the term faltering
Adult FTT is not normal aging, the growth does not hold the same negative con-
unavoidable result of chronic disease, or a notations (Batchelor, 2008).
synonym for the terminal stages of dying Traditionally, the FTT syndrome has
(Egbert, 1996). Although there is no univer- been classified into two categories: organic
sally accepted definition, it appears that adult, and nonorganic. Although the term FTT
or geriatric, FTT is a multidimensional con- is used in contemporary literature, most
cept more accurately defined as a syndrome researchers agree that the classification is not
rather than a medical diagnosis. In fact, it is a so clear; especially because all cases of FTT
particularly unhelpful diagnosis if it is used have an organic etiology (i.e., undernutrition;
to provide a label for unspecified symptoms Olsen et al., 2007).
and, consequently, prompts a sense of fatal- FTT is a common problem of infancy
ism in clinicians, patients, and/or family and early childhood, and researchers have
(robertson & Montagnini, 2004; rocchiccioli documented a dramatic increase in its inci-
& Sanford, 2009). rather, we need more mea- dence since the late 1970s. FTT is most com-
surement-oriented approaches that establish mon during infancy, when nutritional needs
the syndrome’s complex underlying factors and growth are at their highest point.
and determine appropriate treatments. FTT accounts for 3% to 5% of the annual
admissions to pediatric hospitals and approx-
Patricia A. Higgins imately 10% of growth failure seen in outpa-
tient pediatrics (Schwartz, 2002). Infants with
FTT typically present not only with growth
failure, but also with developmental and
Failure to thrive (child) cognitive delays and signs of emotional and
physical deprivation, such as social unre-
sponsiveness, a lack of interactive behaviors,
Failure to thrive (FTT) is a term used to and anorexia (Sullivan & Goulet, 2010).
describe a deceleration in the growth pat- Infant factors contributing to FTT
tern of an infant or child that is directly include poor appetite regulation (e.g., not
attributable to undernutrition (Steward, waking for feedings), weak suck, difficulty
ryan-Wenger, & Boyne, 2003). Typically, the weaning to solid foods, sensory sensitivity,
deceleration is a growth deficit whereby the and poor oral-motor coordination (e.g., swal-
rate of the child’s weight gain is below the lowing or chewing difficulties; Harris, 2010).
5th percentile for age, based on the National Parental factors contributing to FTT include
Center for Health Statistics standardized strategies to increase food intake, such
growth charts. undernutrition, or caloric as force-feeding or extending the period
inadequacy, and thus a deceleration in a between feedings to ensure the child will be
child’s growth pattern, can occur because of hungry. These strategies can exacerbate the
any number of physiological reasons, such as problem and also result in increased anxi-
nutrient malabsorption or transient weight ety in the parent/child dyad (Harris, 2010).
FAILurE TO THrIVE (CHILd) n 175
Infant nutrition has long been the focus families. These case studies were the first
of pediatric research. Holt (1897) was one of to report feeding and interactional difficul-
the first to describe marasmus, a significant ties between the mothers and their infants. F
infant nutrition problem, and a condition Feeding episodes for the mothers were anx-
similar to the FTT syndrome described in iety-provoking, which led the mothers to
contemporary literature. It was in 1915 that decrease both the frequency of infant feed-
the term FTT was first used in the pediat- ings as well as their contact with the infants.
ric literature to describe rapid weight loss, Ethnologists and child development experts
listlessness, and subsequent death in insti- began studying institutionalized and nonin-
tutionalized infants. In the early 1900s, the stitutionalized infants to further define the
mortality rate for institutionalized infants concepts of maternal deprivation and FTT.
was near 100%, and few realized the impor- On the basis of several studies, researchers
tance of environmental stimulation and then concluded that decreased maternal con-
social contact for infant growth and develop- tact directly lead to FTT in the infants. From
ment. It was during this time that the first fos- these works, the maternal deprivation frame-
ter home care program for institutionalized work for FTT was established, and the moth-
marasmic infants was developed. The home er’s role in the infant’s well-being became a
care program involved the identification and central focus. Support for this framework
training of families, by nurses, to care for the grew, as data accumulated documenting the
ill infants, and included a significant amount association between maternal neglect and
of nursing intervention to monitor the pro- FTT in infants.
gress of the infants. unfortunately, this early The maternal deprivation framework
work was not recognized by the pediatric dominated the literature until the late 1970s,
community, despite a 60% drop in the mor- when a transactional framework was devel-
tality rate of marasmic infants cared for in oped to explain the psychosocial correlates of
the foster homes. FTT. The transactional framework proposes
It was not until 1945 that the concept of that an infant’s growth and development is
FTT captured the attention of the psychiatric contingent on the quality of parental care,
and pediatric communities. In a classic study, the nature of parent and infant interactions,
Spitz (1945) described depression, growth fail- and the ecological conditions impinging on
ure, and malnutrition in 61 foundling home the family. Furthermore, the transactional
infants. He used the term hospitalism to model recognizes that the quality of the par-
describe the syndrome that he observed, and ent/infant interaction reflects infant char-
he proposed that a lack of emotional stimula- acteristics as well as parent characteristics
tion and the absence of a mother figure were (Bithoney & Newberger, 1987). Historically,
the main contributors to infant growth fail- the emotional deprivation component of FTT
ure. Spitz postulated that with adequate love, has been investigated more than the nutri-
affection, and stimulation, the infants would tional deprivation component. Although
grow. researchers demonstrated weight gain FTT experts would agree that undernutri-
in infants with hospitalism when stimula- tion is the primary biological insult, system-
tion and affection were provided. Thus, these atic studies investigating this element are
findings provided a foundation for an FTT lacking.
theoretical framework on the basis of mater- Nutritional deprivation again became the
nal deprivation in institutionalized infants. focus of FTT research in the early 1970s, when
In the mid 1950s, a number of case reports some researchers disputed the hypothesis
were published in the psychiatric literature that maternal deprivation was the principal
that documented depression, malnutrition, cause of FTT. More recent evidence suggests
and growth failure in infants living in intact that the environmental deprivation may
176 n FALLS
occur before the undernutrition. Although between the two (drewett, Blair, Emmett, &
the primary cause of FTT may never be fully Emond, 2004). However, it has been dem-
F understood, it is apparent that nutritional onstrated that school-aged children who
deficits are dependent on the environmental developed FTT in the first few months of
context in which they occur. infancy are shorter, weigh less, and have
Nurse researchers developed the eco- poorer intellectual outcomes than their
logical model describing parent/child inter- counterparts who did not experience FTT
actions, and the model is used to explain (Black, dubowitz, Krishnakumar, & Starr,
FTT (Barnard & Eyres, 1979; Lobo, Barnard, 2007; Corbett & drewett, 2004; Emond, Blair,
& Coombs, 1992). The ecological model Emmet, & drewett, 2007). This underscores
focuses on the three major interaction com- the importance of appropriate nutrition dur-
ponents of the parent/child relationship: ing infancy.
those of the child, the parent, and the envi- Because growth problems such as FTT
ronment. These interactions are synchro- in infancy place a child at significant risk for
nous and reciprocal. Barnard et al. (1989) developmental delays into toddlerhood and
emphasized the importance of the parent’s school age, it is important to investigate the
and child’s physical and emotional charac- interactional problems between parents and
teristics, as well as the supportive or non- their infants so that interventions aimed at
supportive nature of the environment in improving interactions can begin.
understanding the interactions.
researchers have examined parent/ Heidi V. Krowchuk
child interactions by means of direct, struc-
tured observations during feeding and other
situations, and have found that infants with
FTT demonstrate more difficult behavior, are Falls
less vocal, exhibit negative affect, and dis-
play more gaze aversion than infants who are
not failing to thrive (Harris, 2010; Lobo et al., Falls threaten the health, life, and indepen-
1992; Steward, 2001). Furthermore, parents of dence of older adults. Approximately one
FTT infants are less able to determine their third of older adults experience an unin-
infants’ needs, have shown a decreased abil- tentional fall to the ground (Adams, dey, &
ity to discriminate infant cues, and exhibit Vickerie, 2007). Nearly 32% of those with inju-
less social interactiveness with their infants ries require assistance with daily activities at
when compared with parents of healthy least 3 months after the fall (Schiller, Kramer,
infants (Harris, 2010; Steward, 2001). These & dey, 2007). Moreover, yearly health care
studies support that interference with the costs to treat falls are $19 billion (Stevens,
reciprocal process of the parent/child rela- Corso, Finkelstein, & Miller, 2006).
tionship disturbs the opportunity to attain Falls are preventable. The Nurse Quality
optimal growth and development. Forum has identified falls as a nurse-
Other researchers have examined post- sensitive outcome that is endorsed by the
natal factors, such as maternal breastfeed- Joint Commission for the Accreditation of
ing difficulties (e.g., infections, low milk Hospitals. Providing financial incentive to
supply), infant fussiness, and poor infant implement effective fall prevention pro-
suck, which contribute to undernutrition, grams, Medicare will not pay for hospital
and thus FTT (Emond, drewett, Blair, & expenses related to falls. The Centers for
Emmet, 2007). Maternal depression and disease Control has guidelines for the devel-
its’ link to FTT have also been investigated, opment and implementation of community-
and researchers have found no relationship based fall programs and a compendium of
FALLS n 177
interventions with sufficient research evi- Multifactorial interventions were devel-
dence to recommend their use. oped with the assumption that the more risks
In more than 30 years of research, envi- that are targeted, the greater the reduction F
ronmental, physical, and pharmacologic risk of falls. Most of these interventions address
factors for falls are well understood and have environmental and personal risk factors but
been used to design a comprehensive clini- often include exercise. Those with an exercise
cal assessment of fall risk. Clinically, this component were the most effective although
assessment is critical for identifying those not appreciably better than exercise alone
at risk for falls and targeting interventions. (Gillespie et al., 2009). Although most mul-
Comprehensive assessment interventions tifactorial interventions are not effective in
with clinical follow-up reduced the risk of the community (Gates et al., 2008; Gillespie
falls when direct care was provided but et al., 2009), they reduced falls by 27% in hos-
were not effective if the person was referred pitalized older adults (Cameron et al., 2010).
to their health care provider for follow-up In spite of this lack of research support, the
or provided information about falls (Gates, Centers for disease Control recommends that
Fisher, Cooke, Carter, & Lamb, 2008). community fall prevention programs include
risk factors for falls drove the devel- exercise, education, medication, visual assess-
opment of other interventions. reduction ment and management, and reduc tion of
of environmental hazards emerged first home hazards.
because of the many diverse hazards asso- Notwithstanding extensive falls
ciated with falls. On the basis of a meta- research, strong explanatory theoretical
analysis of studies in community-living models for fall prevention have not emerged.
older adults, a reduction of home environ- Clinically, comprehensive assessment for fall
mental hazards is not effective in reducing risk and targeted interventions are essential
falls or their risk (Gillespie et al., 2009). yet, to high-quality health care (Tinetti, 2008).
these hazards have been included in many The diversity of the single and multiple fall
multifactorial interventions. prevention programs with research evidence
recent Cochran reviews found that of their effectiveness provides challenges
exercise interventions reduced falls in com- to development of widely accepted and
munity-living older adults (Gillespie et al., standardized clinical protocols. Successful
2009), but not consistently in extended care implementation within specific types of clin-
facilities(Cameron et al., 2010). In a meta- ical settings requires quality control and
analysis of 44 randomized clinical trials supporting resources. Large-scale multisite
(Sherrington et al., 2008), exercise reduced falls translational research of well-developed and
by 17%, but walking had no significant effect. standardized fall prevention programs is
Moreover, exercise had a larger effect in pro- needed to determine the effectiveness, feasi-
grams with greater frequency and duration. bility, and cost-effectiveness as they would be
Exercise that challenged the balance control implemented in community and institution-
mechanisms had the largest effects. Tai chi ally based settings without stricter research
is an exercise that significantly challenges controls. The findings from this research are
motor skills and balance and has been found critical for health policy, public and private
to prevent falls and reduce fall risk (Gillespie funding, and insurance benefits that support
et al., 2009). In a large randomized clinical fall prevention programs and provide access
trial, tai chi significantly prevented falls and to older adults, whose numbers are expected
reduced their relative risk, even though clas- to increase significantly as the baby boomers
ses were only once a week and local instruc- move into older adulthood.
tors taught different styles (Voukelatos,
Cumming, Lord, & rissel, 2007). Beverly L. Roberts
178 n FAMILy CArEGIVING ANd THE SErIOuSLy MENTALLy ILL
be (1) laws, policies, and regulations affect-
F Family caregiving and the ing care; (2) attitudes of health care provid-
ers including psychiatrists and nurses; and
seriously mentally ill (3) consumer misinformation and stigma.
From the 1960s through the 1990s, care-
giving studies identified several negative
Serious mental disorders are common issues such as burden and related stressor
in the united States and internationally. (Maurin & Boyd, 1990). Caregivers were iden-
Approximately one in four adults suffers tified as needing much social support. Brady
from a diagnosable mental disorder whereas and McCain (2005) summarized the family
approximately 1 in 17 people suffer from a perspective regarding living with chronic
serious mental illness according to the 2004 schizophrenia through a literature review
u.S. Census (2009; http://www.nimh.nih. covering 1990 to 2005. She found that fami-
gov/health/topics/statistics/index.shtml). lies experience stigma, lack of social support,
Effective care of the mentally ill and their lack of knowledge about the disease, and
families requires early community interven- burden. Families expressed a need for a pos-
tion using a variety of integrated approaches itive relationship with health care providers,
including mental health and social service which includes respect and nonjudgmental
teams. Effective mental health treatment approaches. These studies also reported that
must encompass the sick individuals and families continue to experience difficulties
their families and take into account the com- with the mental health system and financial
plex relationship between mental illness, issues.
unemployment, homelessness, drug addic- Since the 1990s, these burdensome issues
tion, and involvement in the criminal justice continue to exist and many positive aspects
system. have also been described (Lohrer, Lukens, &
The importance of alliance building Thorning, 2007). It has now been concluded
between family caregivers, the mentally that health care professionals must develop
ill member, and the health care team was the theoretical flexibility to accommodate the
described by Kempe (1994). Families are diverse situations that family caregivers face
continuing to ask health professionals to in caring for their ill member. Encouraging
communicate with them in a reciprocal way family caregivers to listen to the experiences
(rose, Mallinson, & Gerson, 2006). As men- of others in caregiving roles and then learn to
tal health care continues to become more think creatively about themselves and their
community based, the family is required experiences has been a strategy that is help-
to assume more responsibility and care of ful (doornbos, 2002).
their mentally ill member, yet families are The sibling perspective is growing as
not getting the direction and support that more families must continue to care for their
is needed. Family caregiving for the men- mentally ill member once parents can no
tally ill involves the family steadfastly assist- longer manage the responsibilities (Hatfield
ing the mentally ill family member with & Lefley, 2005). Siblings need assistance from
basic physical and emotional needs as well health professionals to interact appropri-
as maintaining a positive relationship and ately, assess behaviors, and address areas of
environment that nurtures a sense of self and reciprocity with their ill sibling. Health care
belonging and allows the mentally ill person professionals can assist siblings and other
to strive toward educational and vocational close caregivers by destigmatizing the expe-
goals (Smith, Greenberg, & Seltzer, 2007). rience by planning outreach resources for
The roadblocks facing families attempting to all family members (Lukens, Thorning, &
care for their ill family member continues to Lohrer, 2004).
FAMILy CArEGIVING ANd THE SErIOuSLy MENTALLy ILL n 179
Chronic mental illness can affect the by acting on the informed intention to care
family in many ways, including changes in meaningful and personal ways. A genuine
in familiar roles, changes in the subsystem and focused presence opens the health pro- F
within the family, possible isolation of fam- fessional to hearing and responding appro-
ily members, increased need for problem- priately to the needs of the mentally ill and
solving skills, and adjustments with adapt- the family caregiver. An appropriate caring
ability to family role changes. Caregivers model for the mental health professional
experience more distress as the number of should include specific values, actions, and
tasks increase and the ill member is able to behaviors that meet the needs of the mental
do less in meeting their own needs (Sheehy, health consumer.
2010). The social support required is really Family caregivers have clearly identi-
a large affirming social network of support fied what they desire in terms of care. They
that includes professionals participating in expect open communication with health pro-
the care of the mentally ill person. fessionals, a strong alliance with the health
Over the past 30 years, community-based team, continuing information regarding the
and deinstitutionalized mental health care disease and resources available, which can
have been the most influential movement. come from groups or individuals, and suffi-
A push model (yip, 2006) was developed to cient reimbursement for mental illness from
summarize the problems associated with insurance providers.
caregiving of the seriously mentally ill. The More research on family caregivers of the
model describes members pushing to move mentally ill is still needed. researchers need
the responsibility for mental health care to to provide a new direction that removes bar-
others. Community and institutional care riers to quality care. Long-standing barriers
becomes overloaded and pushes the family to include mistaken public policy, insufficient
assume more responsibility. There is a result health insurance coverage, financial issues,
of families feeling unreasonable demands the attitudes and practices of health care
or burden. Care is poorly coordinated as the providers, and the attitudes and preferences
institutional and community care systems of health care consumers. One necessary
become overloaded. resulting issues include research is to determine ways to convince the
an increase in psychotic violence, public stig- political system and health insurance provid-
matization, and poorly coordinated services. ers to reimburse for mental health services in
The barriers to care are not deliberately a sufficient way.
blocked but are subtle and inadvertent. Most Families and their mentally ill member
long-term mentally ill are eligible for social must cope with stress, powerlessness, physi-
security disability. The amount provided, cal health issues, financial problems, and the
however, does not adequately meet their enormous burden borne by nonprofession-
needs. They are forced to rely on family or als attempting to provide care for the men-
community agencies to underwrite their tally ill. Meeting these needs is accomplished
monthly physical needs for housing, food, through research and the development of
and clothing. This access problem is exacer- health care models that any mental health
bated when they are so dysfunctional they professional could implement within the car-
are not able to actively seek needed services ing context.
and quality care. The politically active, National Alliance
In attempting to address more than the for the Mentally Ill, continues to be instru-
physical needs of the mentally ill and fam- mental in moving legislation, research,
ily caregiver, mental health professionals managed care, and family-focused care
need to also focus on relationship-based care into public debate to help families with a
(Koloroutis, 2004). Nursing is accomplished mentally ill member get the needed care.
180 n FAMILy HEALTH
Psychiatric nurses and related health pro- that helps to maintain health, offers support
fessionals should assist and partner with a to family members, affects health decisions,
F nonprofit voice like the National Alliance for and attaches meaning to illness (rolland,
the Mentally Ill to accelerate enhanced care 1987; Pardeck & yuen, 2001; Wright & Bell,
available to families and their ill members. 2009). The ability of families to meet their
primary functions rests, at least in part, on
Alice Kempe the health of individual family members. For
example, the state of family members’ physi-
cal and mental health determines how and if
family functions are met, such as the ability
Family health for employment, to consistently monitor the
behavior of children, and to provide a safe
environment. The health of the individuals
The importance of the family to the health of and the family is essential to effective fam-
the family, individual family members, and ily interactions and relationships. Grzywacz
communities is supported by the research and Ganong (2009) note that we determine
and scholarship across several decades the health of the family by how they respond
(Feetham, 2011). The family is described as to changes in the physical and mental health
the most important social context in which status of family members and how they func-
health and illness occur, illness is resolved, tion to prevent health problems.
and as the primary unit for health. Health The World Health Organization (WHO)
has been described as a criterion for fam- sponsored an initiative to identify statisti-
ily life and as one of the primary purposes cal indices of family and health by examin-
of the family (Grzywacz & Ganong, 2009). ing family research and policy across four
How the family is defined determines the approaches: demographic, epidemiological
factors that will be examined to evaluate the (medical), social, and economic. The WHO
health of individual family members and the was not able to identify specific indices of
family unit. However, no universal defini- family health because of the complexity
tion of family has been adopted by the legal of measurement and “that family health is
and social systems, family scientists, or the more than the sum of health of individual
clinical disciplines that work with or study family members” (WHO, 1976, p. 13) and
families. In addition to the biological family, therefore family health should apply to the
when examining health in the context of the sum of the states of health of the individual
family, the family can be defined as consti- family members. Pardeck and yuen (2001)
tuting a group of persons acting together to further reported that family health is demon-
perform functions required for the survival, strated by the development of, and continu-
growth, safety, socialization, and health of ous interaction among, the physical, mental,
the family members. research on health has emotional, social, economic, cultural, and
focused primarily at the level of the individ- spiritual dimensions of the family, which
ual and has not addressed the interdepen- results in the well-being of the family and its
dence between the health of the individual members. researchers and scholars have not
family members and the family (Feetham, been consistent in building from the WHO
1999, 2011). work and its definitions, therefore limiting
The health of the family and family mem- the contributions of the research of families
bers is considered a function of the family as in the ensuing decades (Feetham, 2011).
is biological reproduction, emotional devel- Factors influencing family health include
opment, socialization, safety, and economic (a) genetics, (b) physiological and psycholog-
support. The family is a dynamic system ical responses of individual family members,
FAMILy HEALTH n 181
(c) cultural influences, and (d) the physical, respond to the increased awareness of risk,
social, economic, and political environments, new genetic risk information, or even the ear-
including resources. researchers have shown liest occurrence of symptoms. Families may F
that health and risk factors cluster in families need to accept increased surveillance, adhere
because members often have similar diets, to changes in health behaviors, or accept
activity patterns, and behaviors, such as interventions that may potentially delay the
smoking and alcohol abuse as well as a com- onset or progression of the disease. A genom-
mon physical environment. Identification ics context for the health of families can alter
of health in families has focused on family lifestyle and health behaviors, affect repro-
interaction patterns, family problem solving, ductive decision making, alter family rela-
and patterns of responses to changes in the tionships, and have familial implications.
family system. These definitions and con- researchers have focused on family
cepts of family health provide a framework responses to specific illnesses resulting in
for determining measurable outcomes of a body of literature reporting that the inter-
family health while also accounting for the actions within the family system affect
diversity in family structure (Feetham, 1999, the health outcomes of family members.
2000, 2001). research of family responses to illness in
In 2003, we entered the genomic era, family members and the role of the family in
with findings from genomic research and adaptation to illness and recovery provides
advances in genetic technologies requiring a further evidence of the importance of family
reframing of how we think of the continuum and the health of family members.
of health and illness, and even the concept of From the time of Florence Nightingale,
disease. The ways in which diseases are cate- nurses have been encouraged to consider
gorized, and ultimately how they are treated family members as important for nursing care
and managed, are changing (Feetham & (Whall & Fawcett, 1991, p. 9). However, the
Thomson, 2006). No longer named by their interdependence and importance of health
symptoms (such as asthma), diseases will and the family is accepted in theory but is not
be more specifically identified by knowing evident in research. Although our knowledge
the genetic and environmental causes lead- of this relationship has increased, it has also
ing to more focused treatments (Hamburg been limited in that research continues to
& Collins, 2010).These advances may affect focus more on measures of the negative out-
the concept of family health. Individuals comes (e.g., depression) of illness and injury
and families will be faced with reframing on the family and family members. This focus
their concept and experience with diagno- on the individual as the unit of measure, and
sis, treatment, and prevention to include the conducting research of families with physical
term “genetically linked” disorder, with the and/or mental pathology, less knowledge has
blurring of the boundary between health been generated about health, how the family
and illness (Feetham & Thomson, 2006). functions, and the strengths and resources
Genetic information may result in the need of families responding to acute and chronic
to extend the concept of “illness time” phases illness. Grzywacz and Ganong (2009) sug-
to include knowledge of a risk state, or in gest that family research should result in
some cases, a nonsymptomatic phase with a knowledge and strategies for protecting and
knowledge of risk (rolland & Williams, 2005; promoting health across the life span while
Street & Soldan, 1998). The risk state refers distinguishing the interdependence of activ-
to the time before a statistical risk is known ities of family to the health of the family and
or acknowledged or the point in time when individual family members. Effective inter-
symptoms occur. The risk state may require ventions with families incorporate an under-
interventions for individuals and families to standing of what health means to individual
182 n FATIGuE
family members and to the family as a unit, measurement in the recently released
and how the environment influences their National Institutes of Health roadmap for
F health actions. Intervention research needs research initiatives. Because nursing is cen-
to examine explanatory processes to deter- trally interested in symptoms and symptom
mine how interventions work. Because the management, fatigue is of major concern for
family is the primary social agent in the pro- nurse researchers and clinicians alike.
motion of health and well-being, our knowl- The North American Nursing diagnosis
edge of the family and its relationship to the Association (NANdA) defines fatigue as “An
health of its individual members is central to overwhelming sustained sense of exhaus-
research related to health promotion and to tion and decreased capacity for physical and
families responding to risk information and mental work at usual level” (NANdA, 2003,
experiencing illness and disability. p. 74). Although a number of nurse research-
Because of limitations in the research ers have studied fatigue and offered vari-
of families, knowledge of the significance of ous proposals for categorizing fatigue, most
family to the health of the family and family accept the NANdA definition of fatigue. An
members has not translated to policy, prac- alternative view of fatigue as “the awareness
tice in health care systems, and the education of a decreased capacity for physical and/or
of health professionals. As a result, the fam- mental activity due to an imbalance in the
ily is not the context of care and the health availability, utilization, and/or restoration
care systems do not support the health of of resources needed to perform an activity”
families. The translation of research of fam- (Aaronson et al., 1999) has also been pro-
ilies requires interdisciplinary research and posed. This definition adds a generic under-
collaboration. standing of potential causes of fatigue that
may differ in different situations, to facilitate
Suzanne Feetham studying the mechanisms of fatigue in dif-
ferent clinical conditions. This addition also
allows for a clearer conception of fatigue as a
biobehavioral phenomenon.
Fatigue With increased recognition of the impor-
tance of studying symptoms within nurs-
ing, more work on fatigue has emerged.
Fatigue is a universal symptom associated Investigators and study participants have
with most acute and chronic illnesses. It also made distinctions between acute and chronic
is a common complaint among otherwise fatigue. These distinctions are similar to
healthy persons, and often is cited as one those put forth by Piper (1989), who identified
of the most prevalent presenting symptoms acute fatigue as protective, linked to a single
in primary care practices. defining fatigue, cause, of short duration with a rapid onset,
however, has challenged scientists for years. perceived as normal, generally occurring
No clear biological marker of fatigue has been in basically healthy persons with minimal
identified and fatigue remains a perplexing impact on the person, and usually relieved
symptom for all health care providers. by rest; whereas chronic fatigue is identi-
Not only was fatigue named one of the fied as being perceived as abnormal, having
top four symptoms for study by an expert no known function or purpose, occurring in
panel on symptom management convened by clinical populations, having many causes,
the National Institute of Nursing research in not particularly related to exertion, persist-
the early 1990s, but recently, fatigue has been ing over time, having an insidious onset, not
singled out as among the symptoms or health usually relieved by rest, and having a major
outcomes needing attention for standardized impact on the person.
FATIGuE n 183
In the research and clinical literature, and fatigue experienced at the time of mea-
fatigue related to childbearing and fatigue surement. More recent concern about the
related to cancer have received the most debilitating and distressing health effects F
attention. Even these areas, however, remain of fatigue in clinical populations has led to
largely understudied and poorly understood. the development of other measures targeting
Although fatigue has been studied in numer- fatigue in ill persons.
ous chronic illnesses, such as AIdS, multiple There are now a plethora of generic mea-
sclerosis, and rheumatoid arthritis, cancer- sures of fatigue, as well as a growing list
related fatigue is somewhat unique in that it of measures of fatigue in specific illnesses
is often fatigue associated with the treatment (e.g., cancer, AIdS). However, because there
for cancer (both radiation and chemotherapy) is no known biochemical test or marker for
that is most troublesome in terms of distress fatigue, and because fatigue is first and fore-
to the individual. In fact, fatigue associated most a subjective symptom, these measures
with cancer treatment has been cited as a of fatigue generally rely on self-reports.
major reason for prematurely discontinuing A major problem with so many differ-
treatment. ent measures of fatigue is that each taps into
Fatigue has also been consistently asso- a somewhat different aspect of fatigue and,
ciated with fever and infectious processes, consequently, it is not clear whether they are
and one of the more puzzling manifestations all measuring the same thing. Some focus on
of fatigue is what is currently called chronic the emotional and cognitive expression of
fatigue syndrome (CFS). CFS is a diagno- fatigue; others include the physical expres-
sis used for cases of severe and persistent sion of fatigue. Some attempt to quantify
fatigue for which no specific cause has been the amount of fatigue; others include atten-
identified. under varying names (e.g., neur- tion to how fatigue interferes with activities
asthenia, myalgic encephalomyelitis, postin- of daily living. When different measures of
fectious or postviral syndrome, and chronic fatigue are used in different studies, it is dif-
fatigue immune disorder syndrome), a syn- ficult to know if discrepant findings are due
drome of unexplained, chronic, persistent to real substantive differences in fatigue, or
fatigue has been documented in the litera- simply to the differences in the measures.
ture since the late nineteenth century. This dilemma, in part, is why the National
difficulty in studying, understand- Institutes of Health roadmap for research
ing, and consequently, treating fatigue is initiative, aimed at patient-reported out-
largely due to its ubiquitous nature and comes, is concerned with identifying and
the unknown, but likely multiple, causes of standardizing self-report measures, includ-
fatigue. untangling the relationship between ing fatigue. Identifying a set of standardized
fatigue and depression, in particular, fur- measures of fatigue with strong psychomet-
ther confounds investigations of fatigue. ric properties that clearly address the differ-
Although fatigue is an identified symptom ent aspects of fatigue and its expression will
of depression, long-standing chronic fatigue, go far in aiding future research on this elu-
unrelated to an existing affective disorder, sive symptom.
actually may precipitate depression. There may well be many causes of
A lack of consistent, valid, and reliable fatigue and each may ultimately be traced
measures of fatigue also contribute to prob- to a specific disruption in the HPA axis, in
lems in studying and understanding fatigue. the immune system, or in both. If so, then
Early work focused on fatigue in the work- continued investigations into CFS, in partic-
place and was conducted by industrial psy- ular, may lead to a better understanding of
chologists, hygienists, and the military. These fatigue in other, more clearly diagnosed clin-
measures focused on healthy individuals ical problems. until such work is done that
184 n FEMINIST rESEArCH METHOdOLOGy
also suggests specific treatments for fatigue, Feminist research methodology ini-
nursing intervention studies that target ame- tially came to nursing in a descriptive and
F liorating fatigue in different clinical popula- explanatory form more than 20 years ago. It
tions must continue. Although rest generally was described in terms of epistemology and
alleviates acute fatigue, there are currently methods, and was significant in relationship
no known methods to eliminate the fatigue to nursing (Im, 2010). Since that time, femi-
that plagues persons with various chronic ill- nist research methodology has advanced
nesses or those whose fatigue is secondary to in nursing as a basis of feminist critique
the treatments for their chronic illness. With of nursing and research. Feminist nurse
the use of standardized measures of fatigue, researchers began to explore women’s expe-
this is a fertile area for nursing research. riences without any preconceived assump-
tions or beliefs about their experiences. This
Lauren S. Aaronson allowed researchers to be open to what the
female experience was truly like, and then
conduct systematic investigation of the area
of interest. In health care–related research,
Feminist research feminist research methodology has raised
awareness that traditional scientific meth-
methodology ods are not as objective as once thought to
be. Issues such as the exclusion of women in
health care clinical trials and the bias such
Feminist research methodology is research practice results in, has brought about some
about women, for women, and by women. change in clinical research, but it continues
Feminist principles are used as a guide for to fall short of the needed change (rosser,
the conduction of such research. In a world 2007). It remains crucial that feminist nurse
that is gender traditional and stereotypical researchers stay abreast of ongoing, rapid
in nature, feminist research methodology changes in the social context. For example,
provides different perspectives and ways cardiac symptoms defined in earlier stud-
to view and understand such a world. The ies that were conducted on men, bypass not
experience is investigated and a person’s only the biophysical differences of women,
lived experience in the context of social but also ignore the societal stress women of
frameworks which influence that experience today encounter in living within multiple
is paramount to understanding. At the base roles of working and family/personal lives.
of feminist research methodology is the view Additionally, feminist research bears light on
that gender interacts with multiple factors the work that women do (unpaid and paid)
to define situations and relationships. For that is undervalued in terms of contribu-
example, career advancement cannot be sim- tion to economical society (Sweetman, 2008).
ply viewed in the traditional male perspec- Circumstances such as when women’s sal-
tive because this excludes the experience of aries are necessary to the family’s survival,
pregnant women attempting to advance in can also stir discontent and violence toward
their careers amid a biased belief that they these women from their male counterparts.
will quit when the baby is born or, at a mini- Theoretically, feminist research guides in
mum, be distracted in their work. A feminist exploration of contexts, reasons, and formal
researcher uses the philosophical underpin- and informal structures that explain why
nings of feminism to confront these typical women experience what they do. This places
structured beliefs and assumptions that any- feminist research in the position to contin-
one, regardless of gender, can advance in a ually be evolving as society and women in
career if she or he just works hard. society continue to change over time. Because
FEMINIST rESEArCH METHOdOLOGy n 185
of societal changes in the increasing number issues surrounding pain in women with
of women in the workforce, women in the cancer (Im & Chee, 2003). In particular, bias
workforce of the 1970s faced different chal- existing within health care is being targeted F
lenges because of gender than do women in by feminist nurse researchers (Im, 2010). For
today’s workforce. example, feminist methodology could be
Feminist researchers seek to under- used to explore discrimination that might
stand women’s experiences through use of occur in an underserved female population
methods they think will reveal appropriate at a typical emergency department.
outcomes for women. Although methods despite feminist research methodology
may include the use of interviews, question- and the fit with women and health and ill-
naires, surveys, and inventories, use of group ness, research using the methodology seems
discussions, participant observation, and sto- limited. Feminist researchers also face addi-
rytelling are more empowering to women. tional pressures as they attempt to conduct
Feminist research is not composed of one studies. Feminism often carries a some-
particular method, and use of qualitative what negative connotation in society and
research methods has grown considerably in feminist researchers may be thwarted in
feminist nursing research in the last 5 years research attempts. Nurse researchers engag-
(Im, 2010). Feminist researchers gravitate ing in feminist methodology in health care
toward qualitative methods because of how may encounter conscious and unconscious
these methods fit more cohesively with the research barriers following disclosure that
philosophy of feminism. Feminist research- the study is feminist based. Feminist nurse
ers typically use several methods, such as researchers must not be deterred by such
triangulation, to obtain the best picture of barriers and seek to fully explore health care
women’s experiences. structures and systems that oppress women.
There is evidence that feminist research There are numerous issues that could be
methodology is evolving as society evolves. brought to light should this methodology
For example, some feminist nurse researchers be used to explore these issues. An exam-
are using feminist methodology to explore ple of this is menopausal symptoms among
variances in class and ethnicity, as well as women, which remains highly biomedical
disabilities and sexual preference (Im, 2010). even in nursing research (Im, 2007).
It is interactive, including the participant as The biopsychosocial model is the newly
part of the process. It is also nonhierarchical, emerging approach to explore and explain
thus confronting the traditional hierarchical how society and multiple organizational
medical field. Increased research with vary- levels of society influence health outcomes
ing groups of women, such as women of dif- (Borrell-Carrio, Suchman, & Epstein, 2004).
ferent ethnicities and socioeconomic status, The biopsychosocial model will continue to
reflect the diversity among women them- be in demand and aligns with feminist nurs-
selves. Nurse researchers in particular are ing research beliefs in putting the client at
conducting an increasing number of feminist the center of the investigation and tailoring
research methodology studies that engage health knowledge to match client needs.
female and male participants (Im, 2010). One of the basic tenets of feminist
These studies identify differences in female research is to not only provide opportunity
and male experiences in health care. for dialogue about experiences in health care
Feminist nursing research methodology for example, but also to find ways to change
is now being used to explore many different systems in health care for the improvement
aspects of women’s experiences in health and of women’s health. This counters popular
illness. In one such example, nurse research- belief that feminist research methodology
ers used a feminist perspective to look at exists only to complain about unfairness
186 n FETAL MONITOrING
rather than the purpose it serves it under- assessment to determine optimal fetal devel-
standing, explaining, and changing current opment and diagnose conditions of actual or
F experiences of women. potential fetal compromise (e.g., nonstress
test, contraction stress test, vibroacoustic
Sara L. Campbell stimulation, and biophysical profiles).
Controversies still continue over the
appropriate place of EFM in obstetric care. It
was introduced into clinical practice based on
Fetal monitoring animal studies and became widely used, with
no controlled assessment of its effectiveness
in improving the outcome of delivery, partic-
Fetal assessment is part of the process of pro- ularly in reducing the rates of cerebral palsy
viding prenatal care. It involves early iden- and neurologic injury (robinson & Nelson,
tification of real or potential problems and 2008). It was supposed to provide more accu-
enables the achievement of the best possible rate fetal assessment with the accompanying
obstetric outcomes. Fetal assessment involves prompt identification of fetal compromise.
low-tech and high-tech modalities such as The National Institutes of Child Health and
fetal movement counting (kick counts), inter- Human development (NICHd) has peri-
mittent auscultation (IA), electronic fetal odically issued guidelines for the use of
monitoring (EFM), nonstress tests, vibroa- continuous cardiotocography/EFM in fetal
coustic stimulation, auscultated acceleration, assessment, the most recent was published
contraction stress tests, amniotic fluid index, in 2008 (http://www.ncbi.nlm.nih.gov/pmc/
biophysical profiles, and doppler velocime- articles/PMC2621055/, accessed May 17, 2010).
try. The basis for all of these testing modal- Schmidt and McCartney (2000) pre-
ities is the evaluation of certain biophysical sented a thorough historical review and dis-
parameters related to the developmental and cussion of the development of fetal heart rate
health-related patterns of fetal behavior in assessment. They found that expectations
utero. Adequate uteroplacental function is of the benefits of EFM exceeded and pre-
necessary for these patterns of healthy behav- ceded research on outcomes, efficacy, and
ior. uteroplacental insufficiency has been safety. As knowledge accumulated through
shown to be the cause of at least two-thirds of research and practice, the theories of corre-
antepartal fetal deaths (Gegor & Paine, 1992). lation of causation and intrapartal events
EFM will serve as the focal point for this have changed. What were once considered to
discussion as it is the basic intervention used be significant intrapartal events cannot now
in fetal assessment. EFM, as an electronic data be linked as conclusively to brain damage
gathering and data processing device, was in neonates. Current research and improve-
developed during the 1960s. By the end of the ments continue to report the benefits of EFM:
1970s, almost all major obstetrical units had a decrease in neonatal seizures and decreased
at least one monitor, and 70% of all women operative intervention for fetal distress, with
in labor in the united States were monitored improved analysis.
(Bassett, 1996). In 2002, nearly 85% of approx- The major problem is still the risk of mis-
imately 4 million live births were assessed interpretation of the EFM tracing. Schmidt
with monitoring, also known as continuous and McCartney (2000) included study results
cardiotocography (robinson & Nelson, 2008). in which, with a reassuring pattern, EFM can
In addition to its use in monitoring fetal be a sensitive tool for identifying the well-
status during labor, modifications of EFM oxygenated fetus. However, it is not a spe-
have been developed for antepartal fetal cific tool for identifying the compromised
FETAL MONITOrING n 187
fetus when a nonreassuring pattern is seen. substitute for supportive health care person-
Current concerns are focused on the best nel. Additionally, specific indications, such as
ways to prevent or reduce the inappropri- oxytocin induction or augmentation of labor, F
ate use of EFM and develop the best ways to abnormal fetal heart rate by auscultation,
assess and monitor fetal development and twin gestation, hypertension or preeclamp-
safety in labor. use of the NICHd guidelines sia, dysfunctional labor, meconium staining,
should resolve this problem. vaginal breech delivery, diabetes, or prema-
McCartney (2000) discussed the pro- turity, as noted by Smith, ruffin, and Green
posed benefits of automated EFM assessment (1993), are still applicable. A major change is
(computer analysis): it is objective, standard- the recommendation that the terms “hyper-
ized, and reproducible. She discusses the use stimulation” and “hypercontractility” have
of artificial intelligence and how it may prove no meaning and should be abandoned (2008
to be of great value along with smart monitors NICHd update).
and electronic databases in improving the Haggerty (1999) presented an extensive
interpretation of EFM. Porter (2000) reported overview of the reliability, validity, and effi-
that in May 2000, the use of fetal pulse oxim- cacy of EFM. Her work looks at both sides
etry has been approved by the FdA for clin- of the controversy and includes the recom-
ical use to provide more information about mendations of the American College of
fetal oxygen status, especially in cases of Obstetricians and Gynecologists, the united
nonreassuring fetal heart rate patterns. States Preventive Services Task Force (1996),
The American College of Obstetricians and the AWHONN that both EFM and IA
and Gynecologists (2009) and the Association have a place in fetal monitoring. Feinstein
of Women’s Health, Obstetrical, and Neonatal (2000) also researched the efficacy of IA,
Nurses (AWHONN), in cooperation with the especially with low-risk pregnant women.
NICHd, have developed standards and guide- Miltner (2002) concluded that integrating sup-
lines for practice concerning fetal assessment portive care provided by labor nurses with
and the use of EFM and other modalities of other direct and indirect care interventions
fetal heart rate assessment. These new guide- (such as monitoring modalities) may offer
lines outline a three-tier, simplified categori- the best model for providing high-quality
zation and interpretation of fetal heart rate intrapartum nursing care. The previous find-
tracings. Category 1 describes normal trac- ings are supported in more recent research
ings, category II describes indeterminate conclusions.
tracings, and category III describes abnor- Further prospective studies should be
mal tracings (robinson & Nelson, 2008). The conducted to try to determine the optimal
presence or absence of fetal acidemia is the balance of intermittent or continuous EFM
significant factor (robinson & Nelson, 2008). and auscultation and the other modalities
Additionally, AWHONN position papers of fetal assessment and pregnancy manage-
call for these standards of practice to deter- ment. rigorous study protocols and close
mine the accepted conduct of antepartal and attention to the principles of scientific inquiry
intrapartal care and provide the core of safe are needed so that study results will be reli-
practice. It is the responsibility of all nursing able and valid. The major concerns of perina-
and medical health care providers to be pro- tal care should be optimal and cost-effective
ficient in the use and interpretation of EFM outcomes for mother and infant, without
and other intervention modalities used in concern for protection of the caregiver from
perinatal health care delivery. Other recom- litigious actions.
mendations include using EFM as a diagnos-
tic rather than a screening tool and not as a Susan M. Miovech
188 n FEVEr/FEBrILE rESPONSE
cease. Finally, falling pyrogen levels lead to
Fever/Febrile response the defervescence phase, with diaphoresis and
F vasodilation.
Nurses have managed fever through-
Fever is an abnormally high body tempera- out history, yet the scientific evidence sup-
ture that occurs as part of a host response to porting care decisions is relatively recent.
pyrogens (fever producers). An alternate term The lag between basic research findings and
for fever is pyrexia, with hyperpyrexia refer- clinical application is documented in the
ring to high fever. It is misleading to define absence of evidence-based hospital proto-
fever simply in terms of temperature eleva- cols and the lack of consensus among nurses
tion, however, because it emphasizes only in some setting for appropriate fever man-
the thermal manifestations of the nonspecific agement approaches (Thompson, Kirkness,
systemic host defense called the acute phase & Mitchell, 2007). reluctance of many nurses
response. Acute phase response is triggered to change methods of care is often seated in
by endogenous release of cytokines, includ- misunderstanding. Early traditions of cool-
ing interleukin-1, interleukin-6, and tumor ing febrile patients were empirically based
necrosis factor that cause a cascade of bio- on the limited state of scientific knowledge
chemical events, autonomic reactions, and and the erroneous fear that elevated body
immune responses including heat genera- temperature was the cause, rather than the
tion. Some promote immunostimulant prop- result, of febrile illness. Intervention was
erties against infectious disease and tumors therefore geared toward lowering body tem-
(Holtzclaw, 2002). perature. Current knowledge confirms that
Pyrogens readjust hypothalamic reg- fever is the host response to illness or inva-
ulatory centers to a higher set-point range, sion. Cooling the body is counterproductive,
so that body temperature is maintained at distressful to patients, and may cause com-
higher levels. In true fever, other cytokines, pensatory overwarming. Evidence of fever’s
hormones, and endogenously produced bio- host benefits led investigators to focus on
chemicals act as cryogens with antipyretic methods to reduce distressful febrile symp-
properties that limit temperature elevation toms rather than reducing temperature.
in fever. Controlled temperature elevation Febrile shivering is among the most distress-
and intact thermoregulatory function dif- ful and energy-consuming symptoms of
ferentiate fever from hyperthermia, a poten- fever, particularly in immunosuppressed
tially lethal condition in which unregulated patients with opportunistic infections or
thermoregulatory function can produce those receiving antigenic drugs or blood
neurologically damaging high tempera- products. Vigorous shivering is sometimes
tures. Fever occurs in three phases, reflect- described by patients as “bone shaking.”
ing the rise and fall of circulating pyrogens. Nonpharmacological nursing interventions
Initially, the chill phase occurs when ther- are based primarily on thermoregulatory
mostatic mechanisms are activated to raise dynamics to (a) insulate thermosensitive
body temperature to the newly elevated areas of skin from cooling to reduce shiv-
set-point range. Vasoconstriction decreases ering, (b) facilitate heat loss from less ther-
skin perfusion, conserving heat but mak- mosensitive regions without chilling, and
ing skin feel cold. Shivering generates heat (c) restore fluid volume and improve capil-
and is stimulated by sensory inputs that lary blood flow to skin. Fear of neural dam-
detect discrepancies between existing tem- age due to protein denaturation during high
peratures and the new set point. The plateau fevers is justified at temperatures of more
phase follows when body temperature rises than 42°C. However, true fevers are usu-
to the new set point and warming responses ally self-limiting and remain well below this
FEVEr/FEBrILE rESPONSE n 189
level. Body temperatures of about 39°C may in nature, varying from laboratory studies
have added immunostimulant and antimi- of humans and animals to clinical studies in
crobial effects. These features make comfort hospitals and homes. Circadian variations in F
the primary reason for treating low-grade temperature are well documented (Bailey &
fever with antipyretic drugs. Higher set- Heitkemper, 2001), but there are few recent
point levels raise sensitivity to heat loss, studies which confirm that daily temperature
causing even mild cooling to stimulate shiv- screening in hospitals adequately detect fever
ering. Aggressive cooling with conductive in persons with abnormal cytokine expres-
cooling blankets and ice packs evokes vig- sion, such as those with HIV/AIdS. A study
orous shivering, raising energy expenditure of febrile symptom management in patients
three to five times the resting values. As the with cancer tested interventions to suppress
consistent clinical observer of patient body drug-induced febrile shivering (Holtzclaw,
temperatures, nurses find that issues of 1990) showed that insulating thermosensitive
measurement, febrile patterns, physiological skin regions during the chill phase of fever
correlates, and sensory responses are of sig- not only reduced shivering but improved
nificance to practice and research. comfort. This preliminary work provided
Febrile symptoms are nonspecific the basis for a comprehensive febrile symp-
responses to both infectious and host defense toms management protocol, tested in hospi-
activities so that many symptoms and inter- talized and home care HIV-infected persons
ventions are generalizable. Contrasted with with febrile illness (Holtzclaw, 1998a). In a
studies of fever management in other disci- controlled trial, the intervention of insulative
plines that center primarily on pharmacolog- coverings to suppress shivering was shown to
ical control of underlying infection, nursing be an effective intervention. Body water loss
research focuses on symptom management of and dehydration were monitored by body
fever responses regardless of etiology. Nurse weight, serum osmolality, and urine specific
researchers began studying interventions in gravity in hospitalized patients, whereas a
the early 1970s to cool the body during fever fever diary and home visits reported changes
without causing shivering or temperature in patients at home. No patients with insula-
“drift.” By the late 1980s, concern grew about tive wraps shivered, whereas controls expe-
the metabolic and cardiorespiratory effects rienced both shivering and higher peak
of fever on vulnerable patients with cancer temperatures. Systematic oral fluid replace-
or HIV infection (Holtzclaw, 1998b). The “set ment was not effective in replacing loss
point” theory of temperature regulation was despite metabolic, cardiorespiratory, and
central to these intervention studies, but as fever-related fluid expenditures because fever
discoveries of the 1990s identified and clar- suppressed thirst. Findings documented the
ified mechanisms of endogenous pyrogens, negative effects of fever on hydration and
cytokines and other biological messengers febrile shivering on cardiorespiratory effort.
offered new measurable biomarkers of fever Higher fatigue levels, lower thermal comfort,
as a host response. Nurse scientists contrib- higher rate pressure product and respiratory
uted significant scientific information about rate were experienced by those in the control
the febrile response using human and animal group who shivered. A growing awareness
models (McCarthy, Murray, Galagan, Gern, that cooling measures exert distressful and
& Hutson, 1998; richmond, 2001; rowsey, sometimes harmful effects has stimulated
Metzger, Carlson, & Gordon, 2009) inquiry surrounding procedures commonly
responsible nursing research on fever used to “cool” patients. The practice of sponge
draws on principles from physiology, phys- bathing with tepid water to cool down febrile
ics, biochemistry, and psychoneuroimmunol- (38.9°C) children was studied in a group of
ogy. It is often interdisciplinary and diverse 20 children, ages 5 to 68 months, seen in an
190 n FITZPATrICK’S rHyTHM MOdEL
emergency room and randomly assigned to study of fever and its management, there
acetaminophen alone or acetaminophen with remains a persistent lag in the application
F sponge bathing (Sharber, 1997). Although the of what is already known (Thompson, 2005).
sponge-bathed children cooled faster during One potential for improving application is
the first hour, rapid cooling evoked higher seen in research efforts of nurses in neuro-
distress and no significant temperature dif- science, an area in which fever management
ference between groups over the 2-hour is critical, to assess fever management prac-
study period. There is evidence that a grad- tices (Thompson, Kirkness, & Mitchell, 2007;
ual, less drastic reduction in body tempera- Thompson, Kirkness, Mitchell, & Webb, 2007;
ture evokes fewer adverse responses during Thompson, Tkacs, Saatman, raghupathi, &
aggressive fever treatment with cooling McIntosh, 2003). As in many specialty orga-
blankets. Warmer settings effectively lower nizations in nursing, the consciousness-
body temperature as well as cooler levels, raising dissemination of evidence-based
without inducing shivering (Caruso, Hadley, practical knowledge may be effective in fever
Shukla, Frame, & Khoury, 1992). Two studies management.
demonstrate that in comparisons of sponge
baths, hypothermia cooling blankets, and Barbara J. Holtzclaw
acetaminophen (Morgan, 1990) and of cool-
ing blankets versus acetaminophen (Henker
et al., 2001), no temperature-lowering advan-
tage was seen in the physical cooling treat- Fitzpatrick’s rhythm
ment, which required more nursing time,
caused shivering, and was distressful. model
Today’s nurse scientist is prepared
to investigate many of the questions that
remain unanswered in fever care. As inves- Fitzpatrick (1989) presented a rhythm model
tigators acquire skills and resources for these for the field of inquiry for nursing. Meaning
biological measurements, they can be used to is viewed as the central component of the
quantify and qualify the effects of fever and human experience and is necessary to
results of intervention. research is needed enhance and maintain life. Fitzpatrick incor-
to demonstrate the effects of elevated body porated rogers’s (1983) postulated correlates
temperature, cooling interventions, and of human development as the basis for dif-
measures to support natural temperature- ferentiating, organizing, and ordering life’s
stabilizing mechanisms. Fever may provide reality. rogers’s correlates of shorter, higher
study variables, with body temperature, frequency waves that manifest shorter
cytokines, and biochemical correlates being rhythms and approach a seemingly contin-
the outcome of interest. The febrile episode uous pattern serve as Fitzpatrick’s foci for
itself may be the context of other questions for hypothesizing the existence of rhythmic
study. Psychoneuroimmunological factors patterns.
surrounding sleep, irritability, and tolerance Occurring within the context of rhyth-
of febrile symptoms remain untapped top- mical person/environment interaction,
ics. Likewise, the metabolic toll of fever on Fitzpatrick identified indices of holistic
nutritional variables, effects of intravenous human functioning as temporal, motion,
fluid on endogenous antipyresis, and mea- con sciousness, and perceptual patterns.
sures of energy expenditure are important, Fitzpatrick has asserted that the four indi-
but relatively untouched, areas of research ces of human functioning are intricately
for nursing. In contrast with the increasing related to health patterns throughout the
opportunities for nursing research in the life span, and these indices are rhythmic in
FOrMAL NurSING LANGuAGES n 191
nature. Fitzpatrick postulated the dynamic within some larger rhythmic pattern. Shiao
concepts of congruency, consistency, and (1993) studied perceptual patterns of low–
integrity as complementary with rhythmic birth weight infants in neonatal intensive F
patterns. Fitzpatrick stated that health is a care in relation to care interrupting breath-
basic human dimension undergoing contin- ing, oxygen saturation, and feeding rhythms.
uous development. She offered heightened Several qualitative researchers have used
awareness of the meaningfulness of life as Fitzpatrick’s model, particularly in phenome-
an example of a more fully developed phase nological studies in which participants’ expe-
of human health. Nursing interventions were riences were examined (see, e.g., Chiu, 1999;
interpreted as facilitating the developmental Cowan, 1995; Criddle, 1993; Montgomery,
process toward health so that individuals 2000; Moore, 1997).
might develop their human potential. The Fitzpatrick (2008a, 2008b) describes
meaningfulness of life is manifest through meaningfulness in life as more focused on
a series of life crisis experiences with poten- a present orientation. Thus, interventions
tial for growth in one’s meaning for living. focused on present life experiences can be
According to Fitzpatrick, nursing’s central expected to enhance higher levels of health
concern is focused on the person in relation and wellness. Fitzpatrick’s rhythm model
to the dimension of meaning within health. has the potential for inclusion in nursing
Fitzpatrick’s (1989) conceptualizations research involving body rhythms; various
have been studied by graduate students in aspect(s) of temporal, motion, consciousness,
nursing at master’s and doctoral levels. Studies and perceptual patterns could be studied
of temporality among adult and elderly pop- as part of coping with life events. Also, pro-
ulations, psychiatric clients, pregnant adoles- grams of research could be developed that
cents, and terminally ill individuals provide relate the four patterns to well-being across
a base for the existence of temporal patterns. the life span.
Both younger and elderly groups have been
addressed in investigating motion (roberts Jana L. Pressler
& Fitzpatrick, 1983). Patterns of conscious- Kristen S. Montgomery
ness have been examined exclusively in older
age groups (Floyd, 1982). different types of
perceptual patterns, for example, percep-
tions of color and music, have been investi-
gated. Empirical support for the existence of Formal nursing languages
nonlinear temporal patterns emerged from a
number of research endeavors and helped to
identify the need to generate questions about The National Institute of Nursing research
ways to measure the experience of time. A Priority Expert Panel on Nursing Informatics
sense of timelessness was described as being (1993) defined nursing language as
characteristic of behaviors identified among
the dying. Thompson and Fitzpatrick (2008) . . . the universe of written terms and their defi-
found that temporal orientation in a small, nition comprising nomenclature or thesauri that
low-income, older adult sample was weighted are used for purposes such as indexing, sorting,
more toward nonfuture dominance and non- retrieving, and classifying varied nursing data in
clinical records, in information systems (for care
temporal relatedness. documentation and/or management), and in lit-
Pressler, Wells, and Hepworth (1993) erature and research reports . . . . determining the
investigated methodological issues relevant way that nursing data are represented in auto-
to very preterm infant outcomes based on mated systems is tantamount in defining a lan-
the idea of the existence of microrhythms guage for nursing. (p. 31)
192 n FOrMAL NurSING LANGuAGES
This report also differentiated between clin- (ICNP) commenced (Clark & Lang, 1992)
ical terms, which represent the language of and has continued to mature (International
F practice, and definition terms, which repre- Council of Nurses, 2010).
sent the language of nursing knowledge Testing of nursing-specific and more
comprising theory and research. The distinc- general languages for multiple clinical and
tion between language that supports practice research purposes by persons other than the
versus language that supports theory and developers followed. For example, Carter,
research is blurring as the state of the science Moorhead, McCloskey, and Bulechek (1995)
in this area moves toward definitional, con- demonstrated the usefulness of NIC in
cept representations that can be processed by implementing clinical practice guidelines for
computer algorithms and shared among het- pain management and pressure ulcer man-
erogeneous information systems (Hardiker, agement. Parlocha and Henry (1998) reported
Bakken, Casey, & Hoy, 2002). the usefulness of the Home Health Care
research in standardized language Classification for categorizing nursing care
to represent nursing concepts reflects four activities for home care patients with a diag-
generations of inquiry: (a) development of nosis of major depressive disorder. Several
organized collections of terms, (b) testing studies demonstrated the capacity of the
of nursing-specific and general health care Omaha System to predict service utilization
terminologies to represent terms from nurs- (Marek, 1996) and outcomes of care (Martin,
ing practice, (c) integration of nursing con- Scheet, & Stegman, 1993). Moreover, instead
cepts into other health care terminologies of creating new terminologies from scratch,
using reference terminology models, and groups such as the Association of periOpera-
(d) context-specific organization of nursing tive registered Nurses (2008) adopted some
concepts. Initial research on formal nurs- terms from existing terminologies and aug-
ing language focused on the development mented as needed for their specialty prac-
of standardized coding and classification tice to create the Perioperative Nursing data
systems that represented the phenomena of Set. Other investigators provided evidence
clinical practice across care settings within that nursing terminologies were useful to
the framework of the nursing minimum data retrospectively abstract and codify patient
set, comprising five data elements specific problems and nursing interventions from
to nursing: (a) nursing diagnosis, (b) nurs- sources of research data such as care logs
ing interventions, (c) nursing outcomes, (d) (Naylor, Bowles, & Brooten, 2000) or patient
intensity of care, and (e) unique rN provider records (Holzemer et al., 1997). In another
number (Werley & Lang, 1988). This resulted investigation, Holzemer et al. (2006) based
in multiple nursing language systems the documentation of their nurse-delivered
including those that persist today: the North adherence intervention on the Home Health
American Nursing diagnosis Association Care Classification to determine the dose of
International (NANdA International, 2008), the nursing intervention in a randomized
the Nursing Interventions Classification controlled trial (Bakken et al., 2005).
(NIC; dochterman & Bulechek, 2004), the As confidence grew that the nursing-
Nursing Outcomes Classification (Moor- specific systems that had been developed
head, Johnson, & Maas, 2004), the Clinical reflected the domain of nursing and the
Care Classification (formerly known as the drivers for multidisciplinary care and care
Home Health Care Classification; Saba, systems grew, some investigators evaluated
2007), and the Omaha System (Martin, 2004). the extent to which terminologies not devel-
Internationally, the development of the Inter- oped for nursing had utility for nursing
national Classification of Nursing Practice practice. Several research studies examined
FOrMAL NurSING LANGuAGES n 193
whether or not standardized terminologies across heterogeneous information systems,
not designed specifically for nursing were research transitioned from a focus on con-
useful for encoding nursing-relevant con- tent coverage toward computable rep- F
tent such as diagnoses, interventions, goals, resentations and the goal of semantic
and outcomes. Henry, Holzemer, reilly, interoperability, that is, data collected in one
and Campbell (1994) demonstrated that the information system using one terminology
Systematized Nomenclature of Human and can be understood in another information
Veterinary Medicine (SNOMEd) was more system that uses a different terminology.
comprehensive than NANdA to describe the This involved the development and testing
problems of persons living with HIV/AIdS. of reference terminology models (Bakken
Studies by Griffith and robinson (1992, et al., 2002; Hardiker, Casey, Coenen, &
1993) provided evidence that nurses per- Konicek, 2006; Moss, Coenen, & Mills, 2003),
form many Current Procedural Terminology a core component of a concept-oriented
(CPT)–coded functions and that some func- terminology, and integration of nursing-
tions are performed multiple times in a sin- specific terminologies into large concept-
gle day. In another study, Henry, Holzemer, oriented terminologies such as SNOMEd
randell, Hsieh, and Miller (1997) compared CT (International Health Terminology
the frequencies with which 21,366 nursing Standards development Organization,
activity terms from multiple data sources 2010) and LOINC (Matney, Bakken, & Huff,
(patient interviews, nurse interviews, inter- 2003).
shift reports, and patient records) could be Since the early 2000s, researchers have
categorized using NIC and CPT codes and focused increased attention on formal lan-
provided evidence for the superiority of NIC guages in the context of other standardized
in representing nursing activity data. and formal structures such as domain mod-
Complementary to the research that els, templates, documents, and electronic
was being conducted, the American Nurses health records to decrease the ambiguity of
Association played a significant policy role meaning and increase the usefulness of the
in “recognizing” language systems (Table 2) data recorded. Goossen et al. (2004) developed
that met specific criteria related not only to a provisional domain model for the nurs-
utility for nursing but also to scientific rigor ing process for use within the Health Level
(McCormick et al., 1994). This process facili- 7 reference information model. Hyun et al.
tated the inclusion of selected nursing termi- (2009) tested the utility of the Health Level
nologies into the unified Medical Language 7—LOINC Clinical document Ontology for
System (Humphreys, Lindberg, Schoolman, & representing nursing document names. Hoy,
Barnett, 1998). The 2010 version of the unified Hardiker, McNicoll, Westwell, and Bryans
Medical Language System Metathesaurus (2009) described the process of develop-
(http://umlsks.nlm.nih.gov) includes the ing clinical nursing templates as a national
following terminologies recognized by the resource and highlighted the need for inter-
American Nurses Association: NANdA, NIC, national collaboration. Within the context of
Nursing Outcomes Classification, Clinical electronic health records, additional research
Care Classification, Omaha System, Perio- focused on the development of a preliminary
perative Nursing data Set, SNOMEd Clinical set of requirements centered on how struc-
Terms (CT), ICNP, and Logical Observation tured data is presented to users for selection;
Identifiers, Names, and Codes (LOINC™). how to mediate between a variety of con-
In the third generation, with the ceptual structures including terminologies,
increasing sophistication in terminolog- information models, user interface models,
ical science and the need for data sharing and models of the clinical process; and how
194 n FOrMAL NurSING LANGuAGES
Table 2
Standardized Terminologies With utility for Nursing Care
F Terminology Contents ANA UMLS HL7 SNOMED Availability
Nursing-Specific
Clinical Care Nursing diagnoses, x x x x Public domain
Classification 1 interventions, outcomes,
goals
International Nursing diagnoses, x x Public domain
Classification of interventions, outcomes
Nursing Practice
Omaha System Problems, interventions, x x x x Public domain
outcomes
North American Nursing diagnoses x x x x License
Nursing diagnosis
Association Taxonomy
Nursing Interventions Nursing interventions x x x x License
Classification
Nursing Outcomes Patient/client outcomes x x x x License
Classification
Patient Care data Set Patient problems, care x x x Only at
goals, care orders Vanderbilt
university
Perioperative Nursing Nursing diagnoses, x x x x License
data Set interventions, patient
outcomes
Others
Current Procedural Medical services x License
Terminology Codes
Logical Observation Vital signs, obstetric x x x Laboratory Copyrighted,
Identifiers, Names, measurements, clinical LOINC only but free for use
and Codes assessment scales, research
instruments, Nursing
Management Minimum
data Set
SNOMEd Clinical Md/rN diagnoses, health x x x x License
Terms care interventions,
procedures, findings,
substances, organisms,
events
1 Formerly the Home Health Care Classification.
ANA, recognized by the American Nurses Association; uMLS, Included in unified Medical Language System; HL7,
registered with Health Level 7; SNOMEd, Included in SNOMEd Clinical Terms.
to reuse modeling constructs (Hardiker & LOINC) to a focus on developing and test-
Bakken, 2004). ing of other formal conceptual structures for
Over the last three decades, research organizing collections of nursing concepts
related to formal nursing languages has of various data types. The last is still in the
evolved from naming and organizing the formative stages but is essential for efficient
major concepts of the nursing domain to and reliable integration of nursing concepts
integrating nursing concepts into larger into computer-based systems in a man-
nursing-specific (e.g., ICNP) and health ner that supports nursing practice as well
care terminologies (e.g., SNOMEd CT and as the reuse of concepts for practice-based
FuNCTIONAL HEALTH PATTErNS n 195
generation of evidence and patient-centered individual, family, or community. data from
outcomes research. research on formal all 11 FHPs are assessed within the context
nursing languages provides a means toward of age and stage of development, culture and F
using computer-based systems to achieve ethnic background, current health status, and
the ultimate outcomes of high-quality care environment. Each individual FHP reflects a
delivery and improved health and quality unique response to a particular health/ill-
of life. ness experience.
A health pattern may be described as
Suzanne Bakken functional, potentially dysfunctional, or dys-
Jeeyae Choi functional. A FHP is both mutually exclusive
and interactive, reflecting a holistic perspec-
tive. Often, data obtained about one pattern
may be best understood in relation to infor-
Functional health mation assessed in other patterns. Behaviors
(cues) obtained during an FHP assessment
patterns can be used to generate and support a tenta-
tive nursing hypothesis (e.g., nursing diagno-
sis). To identify a clinical judgment (nursing
Functional health patterns (FHP) provide diagnosis), data from all 11 functional pat-
an organized framework for assessment terns must be obtained and synthesized.
that reflects the disciplinary perspective Clinical judgments are described as a state-
of nursing and integrates concepts linked ment of probability rather than a causal state-
to the focus of the discipline including ment. The more evidence that is obtained
health, caring, consciousness, mutual pro- during assessment to support a clinical judg-
cess, patterning, presence, and meaning as ment, the greater the confidence in the judg-
described by Newman, Smith, Pharris, and ment. The nurses’ confidence in a judgment
Jones (2008). The typology of the 11 FHPs is enhanced by the amount of evidence pro-
identifies and defines each pattern under the vided by assessment data.
following categories: (a) health perception– Historically, assessment tools were
health management, (b) nutritional meta- developed to evaluate and monitor clini-
bolic, (c) elimination, (d) activity–exercise, (e) cal populations. Frequently, they duplicated
cognitive–perceptual, (f) sleep–rest, (g) self- information obtained by the medical teams.
perception–self-concept, (h) role–relationship, The lack of a consistent nursing assessment
(i) sexuality–reproductive, (j) coping–stress framework resulted in the collection of an
tolerance, and (k) value–belief (Gordon, inadequate database and limited the infor-
1994, 2010). mation available to make an accurate nurs-
rodgers (2006) states that nurses share ing judgment. This compromised nursing’s
the same values about persons in that they visibility and contribution to patient care
are whole, dynamic, relationship-centered, outcomes. The National League for Nursing
and complex beings with physical, emotional, was the first to support a movement away
spiritual, and social dimensions. The FHP from nursing’s task focus to one that was
assessment integrates these dimensions into patient-centered and problem-based. Forty
each assessment and provides a structure to schools of nursing participated in a survey
examine the whole person as well as behav- that generated a classification list of nursing’s
iors and responses within each pattern over 21 problems (Abdellah, 1959). Later, in 1966,
time. Subjective and objective data obtained Henderson classified 14 basic needs related
during the assessment of each health pat- to patient care. This work focused on the
tern facilitate pattern construction for the identification of human needs, articulated
196 n FuNCTIONAL HEALTH PATTErNS
nursing functions, and helped direct nursing reported that findings help predict nurse and
care toward patient responses. patient mix, help identify patient problems,
F Gordon’s (1994) typology of the 11 FHPs link nursing interventions with evidence-
was informed by this work and provided based outcomes, and ultimately help cost out
nurses with a structure for organizing and care more accurately.
documenting patient behavior over time. The Nursing educators have used FHP
FHP framework offered nurses a consistent assessment data to evaluate clinical reason-
framework for identifying human responses ing skills and diagnostic accuracy (Levin,
(nursing diagnoses) that resulted in the artic- Lunney, & Krainovich-Miller, 2005; Lunney,
ulation of autonomous nursing interven- 2008, 2010). Collectively, findings from this
tions and evidence-based patient outcomes. research continue to contribute to the refine-
This focus continues to be consistent with ment of a unified nursing language. Much of
Nursing’s Social Policy Statement (American the ongoing work in this area is published in
Nurses Association, 2003). the International Journal of Nursing Knowledge,
The FHP framework provides nurses formerly the International Journal of Nursing
with an opportunity to know the patient Terminologies and Classifications.
in a unique way. Through a series of semi- Currently, research continues to test and
structured interview questions (Gordon, refine a standardized assessment screening
1994, 2010; Jones, 1986), each of the 11 FHPs tool for use in research investigations. The
is assessed as the individual’s story unfolds. FHP Assessment Screening Tool (FHPAST)
When additional information is required, the originally developed by Barrett and Jones
nurse uses branching questions to elicit new (1999) uses screening questions to evalu-
perceptions. This descriptive approach to ate each of the 11 FHPs. The original tool
data collection is then subjected to analysis was modified from an 83-item tool to a reli-
in which data bits (or cues) are isolated and able and valid three-factor, 57-item, patient-
data are synthesized, leading to the formu- completed tool, with responses to each item
lation of tentative diagnostic statements that organized on a 4-point Likert scale. The
reflect phenomena of concern to nursing. three factors are health risk/threat, general
Internationally, use of the FHP frame- well-being and self confidence, and health
work as a structure for data collection, patient promotion/protection, with α coefficients for
problem identification, and evaluation of care each factor at .97, .93, and .78, respectively.
outcomes has grown. Investigations in many The tool provides a quantitative measure
countries describe high-frequency nursing of the patient’s functional health responses
diagnoses and isolated patient responses to and identifies cues that can be used to guide
phenomena (e.g., eating disorders, sleep dis- further assessment by the nurse. To date,
turbances) and linked intervention strategies the FHPAST has been used in research in
to specific nursing diagnoses. Others have the united States and England in a variety
used the FHP framework to validate cues of populations including healthy adults and
associated with a particular nursing diag- those with chronic illnesses. The FHPAST
nosis. Nurses working in clinical specialties has been translated into several languages
(e.g. ambulatory surgery, oncology, rehabil- including Portuguese, Spanish, and Japanese.
itation, and cardiovascular nursing) have The continued testing and refinement of the
used the FHP framework to identify patient FHPAST will improve the use of a valid and
responses (nursing diagnoses) throughout reliable instrument to measure the patient’s
illness experience and recovery at home functional health over time.
(Flanagan & Jones, 2009). Nurse adminis- Movement toward the use of a stan-
trators, using data from FHP assessments, dardized nursing language and continued
FuNCTIONAL HEALTH PATTErNS n 197
refinement of standardized nursing lan- using such a framework provide consis-
guage classifications (NANdA, NIC, NOC, tency and continuity to evaluating patients
and the International Classification of from a nursing perspective. The FHP assess- F
Nursing Language) will promote the use ment framework can help expand nursing
of a consistent database for communicating knowledge, isolate human experiences in
nursing assessments, diagnoses, interven- illness and wellness, promote creative inter-
tions, and outcomes across countries. The ventions, and help articulate evidence that
FHP framework offers a comprehensive is nurse-sensitive.
approach to capturing human experiences
of individuals and groups. data from a stan- Dorothy A. Jones
dardized approach to nursing assessment Jane Flanagan
G
and on institutional review boards to ensure
Genetics that patients’ rights are duly protected. In
addition, they are leaders in providing evi-
dence-based personalized health care that
The genomic era of health care began in April recognizes the importance of genetics and
2003, with the completion of the sequencing genomics for individual health promotion
of the human genome. The human genome while at the same time being careful that
uses four proteins: adenosine, cytosine, gua- genomic information is placed in perspective
nine, and thymine that replicate indefinitely. with other individual, familial, and environ-
This double helix is the basis of DNA and, mental attributes.
along with RNA, which substitutes uracil
for thymine, makes up approximately 20 Judith A. Lewis
different amino acids. These amino acids
regulate all bodily functions. Clinicians can
determine the risks of transmitting herita-
ble conditions to offspring and can use the Grandparents raisinG
principles of genetics to further understand
complex multifactorial somatic conditions Grandchildren
such as diabetes and heart disease. Nurses
are expected to apply the core competen-
cies (Consensus Panel on Genetic/Genomic In the United States, there are 2.5 million
Nursing Competencies, 2006) in all clinical grandparents who are responsible for the
settings. These competencies are relevant basic needs of the grandchildren who live
regardless of the educational preparation, with them (U.S. Census Bureau, 2008b). Of
clinical setting, or level of practice of the pro- these caregivers, 1.6 million are grandmoth-
fessional nurse ers and 896,000 are grandfathers. According
Nurses are key players in genetics and to the U.S. Census Bureau, an estimated 6 mil-
genomics research. Nurses are involved in lion or 8.4% of children live with nonparental
biobehavioral clinical research, basic sci- relatives, a 173% increase since 1970 and a
ence research, and translational research in 78% increase since 1990 (U.S. Census Bureau,
all areas of genetics and genomics. They also 2001). Nationally, there are an estimated
have been at the forefront of research that 963,000 children younger than 18 years liv-
examines the ethical legal and social implica- ing under the primary care of grandparents,
tions of the Human Genome Project. Nurses in parent-absent households (U.S. Census
are principal investigators on dozens of Bureau, 2005). This phenomenon impacts
NIH-funded studies in genetics research. all racial and economic groups; however,
Nurses are involved in translating the African American and low-income grand-
implications of the genomic era of health parents are disproportionately represented
care to patients and their families. They (Bailey, Letiecq, & Porterfield, 2009; Minkler
serve on scientific review committees & Fuller-Thomson, 2005). Although children
designed to evaluate the state of the science are raised by grandparents for a plethora of
GRANDPAReNTS RAISING GRANDCHILDReN n 199
reasons, the most common include abandon- Dowdell (2004) found that 40% of partici-
ment, neglect, substance abuse, incarcera- pants self-reported their health as only fair
tion, mental health issues, and HIV/AIDS or poor. G
(Kelley, Whitley, Sipe, & Yorker, 2000; Weber On the basis of a large nationally rep-
& Waldrop, 2000). resentative sample, researchers found that
Although caregiver burden has been grandmothers raising grandchildren were
studied extensively with regard to caring for more likely than noncaregiving grand-
elderly parents, ailing spouses, and chroni- mothers to report their health as either fair
cally ill children, caregiver burden among or poor (Fuller-Thomson & Minkler, 2000).
grandparents raising grandchildren has only These grandmothers were also more likely
been studied fairly recently. Researchers to report physical limitations when perform-
studying this phenomenon represent a vari- ing activities of daily living. In a prospective
ety of disciplines including nursing, soci- cohort study as part of the Nurses’ Health
ology, gerontology, and psychology. Nurse Study, researchers found that providing high
researchers have made important contri- levels of care to grandchildren increased the
butions related to grandparents raising risk of coronary heart disease (Lee, Colditz,
grandchildren, particularly with regard to Berkman, & Kawachi, 2003).
their physical and emotional well-being In addition to being at increased risk for
(e.g., Caliandro & Hughes, 1998; Dowell, health challenges, research findings indi-
2004; Musil & Ahmad, 2002; Kelley et al., cate that custodial grandparents experience
2000; Kelley, Whitley, & Sipe, 2007; Kelley, increased levels of psychological distress,
Whitley, & Campos, 2010; Musil, Warner, including depression (Force, Botsford, Pisano,
Zauszniewski, Wykle, & Standing, 2009). & Holbert, 2000; Fuller-Thomson & Minkler,
Research findings reveal that raising 2000; Kelley et al., 2000; Musil et al., 2009). In
grandchildren is associated with a nega- a study of grandmothers with three levels of
tive impact on caregiver well-being, with child care responsibilities, researchers found
numerous studies indicating that they are that primary caregiver grandmothers had
at an increased risk for poor health (Dowell, more depressive symptoms than grandmoth-
2004; Hughes, Waite, LaPierre, & Luo, 2007; ers who shared parenting in three genera-
Minkler & Fuller-Thomson, 2005; Musil & tion households and those with no caregiver
Ahmad, 2002; Whitley, Kelley, & Sipe, 2001). responsibilities (Musil et al., 2009). Primary
Using both objective and subjective data, caregivers also reported more intra family
researchers studying 100 African American strain than the other groups. In another
grandmothers found that almost one quar- study, researchers found that nearly 30%
ter were diagnosed with diabetes and high of grandparents raising grandchildren had
cholesterol, over one half were hypertensive, psychological distress scores in the clinical
and over three quarters met criteria for obe- range, which is indicative of a need for pro-
sity. When compared with the national nor- fessional mental health intervention (Kelley
mative sample, the participants self-reported et al., 2000). Predictors of increased psycho-
significantly worse health. Musil and Ahmad logical distress in that study included lack of
(2002) had similar findings when comparing family resources, physical health status, and
the health reports of 86 custodial grandmoth- lack of social support. Using data from the
ers to grandmothers who had partial care- National Survey of Families and Households,
giver responsibilities as well as those with no researchers found that, in comparison with
caregiver role. Custodial caregivers reported noncustodial grandmothers, custodial grand-
worse self-assessed physical health than the mothers are more likely to have significantly
other two groups. When examining care- higher levels of depressive symptomatology
giver burden in 104 custodial grandmothers, (Fuller-Thomson & Minkler, 2000).
200 n GRANDPAReNTS RAISING GRANDCHILDReN
Given the leading antecedents to being social isolation typically reported by grand-
raised by grandparents (e.g., child mal- parents raising grandchildren is significant,
G treatment, abandonment, death or incarcer- given that social support is a mediator of psy-
ation), it is not surprising that researchers chological distress in grandparents raising
have found increased behavior problems in grandchildren (Kelley et al., 2000).
children raised by grandparents when com- Although research has documented that
pared with national normative groups (Smith grandparents raising grandchildren are at
& Palmieri, 2007). Other research suggests increased risk for compromised health and
that they may be at increased risk for devel- increased psychological distress, few studies
opmental delays, often related to prenatal related to interventions with this population
substance exposure (Whitley & Kelley, 2008). are available. The majority of intervention lit-
Undoubtedly, the increased demands of par- erature is limited to descriptions of programs
enting children with behavioral problems that lack outcome data or intervention stud-
and special needs contribute to the increased ies with very small sample sizes (Dannison
distress levels found in custodial grandpar- & Smith, 2003; edwards & Sweeney, 2007;
ents. In one study, researchers found that Kolomer, McCallion & Overeynder, 2003;
grandparents raising special needs chil- Kopera-Frye, Wiscott, & Begovic, 2003).
dren reported poorer mental health than Furthermore, the majority of the interven-
those raising children without special needs tions are limited to support groups and edu-
(Brown & Boyce-Mathis, 2000). Other stud- cational programs (Cox, 2002; edwards &
ies have found that grandparents raising Sweeney, 2007; Hayslip, 2003; Kolomer et al.,
grandchildren with behavior problems expe- 2003; Kopera-Frye et al., 2003).
rienced more distress than grandparents Several health-related intervention stud-
raising children without behavior problems ies are available in the literature. Researchers
(Hayslip, emick, Henderson, & elias, 2002; conducted a pilot study to explore the impact
Pruchno & McKenney, 2002). of a group educational program on nutri-
By assuming full-time parenting respon- tion and physical activity knowledge of
sibilities, grandparents are often faced with African American custodial grandparents
increased financial pressures at or near a (Kicklighter et al., 2007). Results indicated an
time in their lives when income is dramat- increase in knowledge among participants;
ically decreased. This decrease in income however, changes in behavior were not mea-
is often related to retirement and living on sured. Another study assessed the efficacy
fixed incomes or from having to leave full- of an interdisciplinary, home-based inter-
time employment because of the demands vention involving nurses and social workers,
of full-time parenting, especially when the with the goal of improving the well-being of
grandchildren have special needs. Although custodial grandmothers (Kelley et al., 2007).
some families may be entitled to Temporary The researchers found improvements in the
Assistance to Needy Families cash benefits, areas of psychological distress, resources,
the monthly payments are typically nomi- social support, and coping, but not physical
nal and insufficient for adequately housing, health.
clothing, and feeding children. In a study involving 529 predominantly
Findings from several studies portray low-income custodial, African American
grandparent caregivers as socially isolated grandmothers, researchers implemented
from peers because of the demands of raising a home-based intervention designed to
children at a point in their lives when they improve the well-being of grandmother
would otherwise have few childcare respon- caregivers (Kelley et al., 2010). The inter-
sibilities (Fuller-Thomson & Minkler, 2000; vention involved home visits by registered
Kelley & Damato, 1995; Musil, 1998). The nurses and social workers as well as other
GRANTSMANSHIP n 201
support services over the course of a year. with their topic. Reviewers have competing
Results indicated significant improvements responsibilities and priorities and greatly
in a number of health attributes, including appreciate a well-written, clear proposal that G
vitality, physical role functioning, emotional flows logically and answers their questions
role functioning, and mental health. before they have a chance to stumble on the
Further research on the well-being of question.
custodial grandparents is needed, includ- The grant writer wants to impress the
ing longitudinal studies to determine the reviewer with the soundness, importance,
long-term impact of this form of caregiving. and creativity of the proposal. Among the
Randomized clinical trials are required to major evaluative criteria for most grant appli-
identify intervention strategies that are effec- cations, particularly ones submitted to fed-
tive in improving the health of this popula- eral funding agencies, is the significance and
tion. Policy-related research is necessary to innovation of the proposed project. A good
address the impact of the 2010 federal health grant writer strives to stimulate an excitement
care reform legislation as well as the finan- that turns the reviewer into an advocate or
cial, social service, and housing needs of enthusiastic champion of the proposed pro-
grandparents raising grandchildren. ject. Achieving a balance between generating
enthusiasm and adhering to somewhat rigid
Susan J. Kelley form requirements in writing grant applica-
tions is an artful enterprise.
Grant writing, itself, is not particularly
creative. Rather, it may be viewed as a type
Grantsmanship of formula writing where good basic writing
skills are essential. The grant writer cannot
afford a lengthy, boring, or flowery intro-
Grantsmanship is the art behind the sci- duction. Rather, the grant writer should grab
ence. Although the focus here is on research the reviewer with the first sentences of the
grants, grantsmanship skills apply equally to proposal. When it comes to grant writing,
writing grants to fund social and health pro- one never gets a second chance to make a
grams and grants to fund training and educa- good first impression. These first sentences
tion programs. Artful grantsmanship cannot should communicate the importance of the
make bad science or bad programs fundable, proposed project and quickly set the stage
but poor grantsmanship can keep good sci- for the specific aims of the proposed pro-
ence and good programs from receiving the ject. The specific aims of a project are just the
favorable review needed to be funded. A clear, specific goals that the investigator will
sound programmatic or scientific plan is a accomplish with the proposed project. They
necessary prerequisite for success in obtain- are critical to and drive the rest of the pro-
ing funding, but good grantsmanship is what posal and application. The reviewer should
makes it shine. As such, grantsmanship can have no questions about what the investiga-
be viewed as a type of salesmanship. tor intends after reading this first part of the
everything a grant writer does to make proposal.
the grant reviewer’s job easier is part of good The grant writer also must methodically
grantsmanship. Grant writers can become walk the reader/reviewer through a well-
extremely immersed in their particular constructed logical argument and plan. The
proposed project. This creates blind spots reviewer should be able to picture exactly
and the grant writer needs to constantly what the investigator plans to do and how
step back and remember that reviewers are the investigator will do it. As previously said,
not as invested in or as intimately familiar a good grant writer anticipates reviewers’
202 n GRANTSMANSHIP
questions and answers them before the ques- grant writing is to read and follow the direc-
tion is raised. tions. Although this seems simple enough, it
G Repetition of important content is is surprising how many would-be grant writ-
another key aspect of good grant writing. If ers neglect to carefully read all instructions
it is an important point, it is worth repeat- for a particular grant application and/or to
ing to ensure that a reviewer does not miss follow them faithfully. Grant application
it. Repetition also is essential in the choice directions are not suggestions; they must
of words for key concepts. Once a concept is be followed exactly or risk rejection before
named and defined, the grant writer should going to review.
stick with the identified word, term, or Most grant applications come with very
phrase. Altering a phase or using alternative specific guidelines about such things as who
terms to provide some variety only serves to is eligible to apply, budget limits, allowable
confuse a reviewer trying to follow the spe- costs, page limits, margins, font sizes, sec-
cific ideas presented. tion sequencing, type of content expected,
Good grantsmanship also requires a number of references allowed, what may go
thick skin. Many more grant applications in appendices (if allowed), who must sign
are written and submitted than are actually where and what, and so forth. It is imperative
funded. A good grant writer will seek multi- that the grant writer adhere to all identified
ple reviews from colleagues before actually specifications. Some funding agencies return
submitting a grant to the funding agency. grants unreviewed if the directions are not
It is wise to seek reviewers for a variety of followed. Moreover, not following directions
purposes. Some reviewers should be famil- raises questions about the careful attention to
iar with the content area of the grant appli- detail needed to carry out most projects and
cation to be able to identify important errors thus may reflect poorly on the applicant.
or gaps in content. Other reviewers should be A second cardinal rule and basic element
unfamiliar with the specific content area to of good grantsmanship is to know and to
protect against assumed knowledge by insid- understand the goals and mission of the par-
ers and to determine if the grant is written ticular funding agency to which one plans to
in a manner that convinces a knowledgeable submit the grant application. For example,
but otherwise uninformed reviewer about each institute in the National Institutes of
the worthiness of the proposed project. Still Health (NIH) has a specific mandate to fund
others may be used for things such as gram- certain types of research. Within these man-
mar, editing, and typos not found by com- dates, each institute sets priorities identify-
puter spell-checks. A thick skin is needed to ing specific areas in which they are seeking
request and receive a brutal review and to proposals. Similarly, foundations and other
respond to all concerns and criticisms with- grant funders have specific missions and
out defensiveness. Although we all like to funding priorities. Before writing a grant
hear the positives about our work, it is far application, one should investigate and deter-
better to hear from a colleague about the mine what funding agency would be the best
flaws and concerns raised by our proposal match for the intended project. Doing so also
and to be able to revise the grant application allows tailoring the proposal to the needs
accordingly than to have the very same con- and desires of the funding agency.
cerns raised in the official review and result The grant writer needs to convince the
in a poor evaluation and no funding. funding agency or foundation that the pro-
Although the specific proposal is the posed project is exactly what they want to
heart of the grant, good grantsmanship support and that it specifically addresses the
involves much more than just writing the funder’s stated priorities and goals. This is
actual proposal. The first cardinal rule in true for all grant applications. One helpful
GROUNDeD THeORY n 203
strategy is to use the exact language from the social life, called core variables or basic social
program announcement or the foundation’s processes. According to its sociologist origi-
mission statement when describing the pro- nators, Barney Glaser and Anselm Strauss G
posed plan. It is not in the grant writer’s best (1967), grounded theories should be relevant
interest to try to convince a foundation or and should work to explain, predict, and be
other funding entity that they should want to modified by social phenomena under study.
fund a project not clearly within their man- Data are not forced to fit existing theories but
date just because it is a worthwhile project. rather are used to develop rich, dense, and
Thus, the first challenge for all grant complex analytic frameworks.
writers is to find the most appropriate fund- Grounded theory as an original mode
ing agency, foundation, or professional orga- of inquiry oriented to the discovery of
nization for their proposed project. Although meaning emerged from the social philos-
the NIH (http://www.nih.gov) is the major ophy of symbolic interactionism and an
large funder of health-related research in intellectual tradition in social science called
the United States, other funding opportuni- pragmatism. Both emphasize (a) the impor-
ties may be found at the following Web sites: tance of qualitative fieldwork in data col-
http://fundingopps.cos.com, http://www. lection to ground theory in reality, (b) the
grantsnet.org, and http://fdncenter.org. nature of experience as a process of contin-
Finally, there are a number of references uous change, and (c) the interrelationships
to assist grant writers, and several recent among conditions, interpretive meaning,
articles from the nursing literature are and action. Knowledge is viewed as rela-
cited here. The NIH also has Web sites with tive to particular contextual circumstances.
helpful hints for grant writers. These can Such a worldview was in contrast to the
be accessed through Office of extramural dominant paradigm that emphasized stabil-
Research at the NIH at the following Web ity and regularities in social life.
site: http://grants.nih.gov/grants/writing_ Grounded theory, as a qualitative, non-
application.htm. This Web site not only mathematical analytic process, is particu-
provides detailed information for writing larly well suited to nursing studies that are
grants, particularly those to be submitted to conducted to uncover the nature of clinically
the NIH, but also has a direct link to grant relevant phenomena such as chronic illness,
writing tip sheets provided by different caregiving, and dying in real-world rather
institutes throughout NIH. than laboratory conditions. The resulting
theoretical formulation not only explains
Lauren S. Aaronson human experience and associated meanings
but also can provide a basis for nursing inter-
vention research and nursing practice.
The influence of grounded theory meth-
Grounded theory ods has been particularly striking in the evo-
lution of nursing research because Glaser and
Strauss, who developed the method, were
Grounded theory refers to a method of professors in the School of Nursing at the
qualitative research that seeks to explain University of California, San Francisco, start-
variations in social interactional and social ing in the 1960s. Consequently, many of the
structural problems and processes. The goal seminal methodological references and land-
is to generate theory from the data and resul- mark publications of findings in the nursing
tant conceptual schema. The grounded the- literature can be traced to nursing doctoral
ory approach presumes the possibility of students who studied and collaborated with
discovering fundamental patterns in all of them in the 1970s and 1980s. Subsequently,
204 n GROUNDeD THeORY
those early colleagues mentored several schema provides an outline for integrating
nurse researchers. and then reporting the grounded theory
G Grounded theories are focused on what discovered.
may be unarticulated phenomena discov- The outcome of analysis is a dense, par-
ered through observation and interview simonious, integrative schema that explains
data. The researcher does not begin with most of the variation in a social psychological
a preconceived theory and experimentally situation. Properties, dimensions, categories,
prove it. Rather, the researcher begins by strategies, and phases of the theory are inex-
studying an area under natural conditions. tricably related to the basic social process.
Data are usually derived from qualitative Grounded theory may be context bound to
data sources—interviews, participant obser- a specific substantive area (substantive the-
vation (fieldwork), and document analysis— ory) or may be at a more conceptual level and
although quantitative data can also inform applicable to diverse settings and experi-
the emerging analysis. Sensitizing questions ences (formal theory; Glaser, 1978).
are asked to learn what is relevant in the situ- The grounded theory approach has reso-
ation under study. Sampling is not conducted nated with a wide variety of social scientists
according to conventions of probability, nor and professional practitioners interested in
is sample size predetermined. Instead, pur- human experiences with health and illness.
posive, theoretical sampling is used so that In their book, Discovery of Grounded Theory,
concepts emerging from the data guide addi- Glaser and Strauss (1967) acknowledged that
tional data collection. it was a “beginning venture” and did not offer
Doing grounded theory research departs “clearcut procedures and definitions” (p. 1).
from the typically linear sequence of theory Over time, grounded theory, as an approach
verifying research because data collection to the generation of theory from data, has
and analysis go on simultaneously. As soon undergone some major transformations.
as data are available, an orderly, rigorous, Some of the changes that were designed to
constant comparative method of data analy- promote rigor in the method have been crit-
sis is initiated. Analysis proceeds through icized as diverting the research from gener-
stages of in vivo (or substantive) coding in ating theory directly from data, for risking
which themes and patterns are identified in theoretical sensitivity in the investigator,
the words of participants themselves, coding and for eroding the method. Others are of
for categories in which in vivo codes are clus- the opinion that assuming that grounded
tered together in conceptual categories, and theory was taught and conducted from a sin-
theoretical coding in which relationships gle unified perspective is erroneous and that
among concepts are developed. Memos are the ongoing discourse among qualitative
written detailing each of the codes and cat- researchers is part of an intellectual move-
egories and linking them to exemplars from ment essential to grounded theory’s refine-
the data. Concepts and propositions that ment and evolution. The hallmarks, however,
emerge from the data direct subsequent data continue to be data–theory interplay, making
collection. constant comparisons, asking theoretically
The sample is considered complete when oriented questions, conceptual and theoret-
saturation is achieved. Saturation refers to the ical coding, and developing a theory.
point at which no new themes, patterns, or
concepts appear in the data. Sorting memos Holly Skodol Wilson
(conceptual notes about codes and categories Sally A. Hutchinson
and their data exemplars) into an integrative Updated by Deborah F. Lindell
H
of nursing for the future. In this context,
HealtH ConCeptualization the intention of the descriptive analysis is
to understand the aims, goals, and crite-
ria of success in current nursing practice.
The concept of health is a critical concept for Investigators are trying to understand, sys-
nursing as it informs the profession’s goals, tematize, and render coherent what nurses
scope, and outcomes of practice. The goals understand themselves to be doing and to
of nursing are to restore, to maintain, and to clarify the different forms that disease or
promote health; the scope of nursing’s con- failures of health can take. Assessing the
cern is with problems of health. When nurs- results of this approach amounts to deter-
ing practice assists people back to a healthy mining which conception makes better
condition, successful outcomes are correctly sense of nursing practice and how the differ-
declared. To be effective, nurses must have ent parts of nursing practice fit together.
an understanding of health. To most nursing clinicians and research-
Health has been conceptualized in ers, regardless of specialty area, the concep-
many ways in our society, including physi- tion of health most applicable to practice is
cal, emotional, mental, spiritual, and social health as the absence of signs and symp-
well-being; what people in a culture value or toms of physiological malady and disability.
desire; maximization of potential; high-level Most nurses spend their careers observing,
wellness; fulfillment of personal goals; suc- administering, modifying therapies, inter-
cessful performance of social roles; success- preting conditions, and treating people who
ful interaction with the environment; and are sick and need to be restored to health
proper functioning. Health has also been or teaching them how to stay free of those
viewed as subjective or relative (self-report), signs and symptoms. There are many the-
objective (measured against an agreed-upon ories that illustrate this approach. These
standard), comparative (a more-or-less con- include Florence Nightingale’s conceptual-
dition viewed as a continuum or gradation), ization of health as an innate process that
classificatory (a dichotomy), holistic (indi- could be influenced by education, lifestyle
visible), a state (condition), and a process changes, and improvement of environment
(continuous change over time). Thus, with (Nightingale, 1860/1969). Smith’s (1981) clini-
such multiple, sometimes overlapping, often cal, role performance, and adaptive models of
redundant, sometimes contradictory concep- health also illustrate this approach as do the
tions of health, the term has to be understood conceptual models, including the self-care
in terms of the purposes to which it is being framework (Orem, 2001). Orem identified
applied. health as the state of being whole and sound,
What is the meaning of health for nurs- where sound means strength and absence of
ing science, that is, for human responses to disease and whole means nothing is missing.
actual and potential health problems? The She conceptualized health as an outcome
concept of health has been dominated by of self-care and as an influencing factor on
two broad approaches: (a) descriptive analy- both self-care agency and self-care demand.
sis and (b) visioning the goals and practice Finally, theories focused on stability, balance,
206 n HeAlTH DISpArITIeS IN rAcIAl AND eTHNIc MINOrITIeS
and adaptation (e.g., Johnson, 1990; roy & a person although the standard clinical con-
Andrews, 1999) also illustrate this approach cepts are not at issue. There are cases in the
H clearly. Johnson (1959) identified health as a second approach where success in practice
constantly moving equilibrium during the has not been achieved, yet success in prac-
health change process, whereas roy and tice implicitly determines what health is. If
Andrew’s (1999) model of health emphasizes someone does not have any signs and symp-
well-being rather than illness. toms of malady or disability and is still not
The second approach visions the goals actualized, the nurse has not done her job.
and practice of nursing for the future. What Does this make the nurse’s job unbounded?
currently passes for nursing is fundamentally Is the nurse being set up for burnout? Does
inadequate; only by articulating a proper con- nursing practically and theoretically want to
ception of health can we clearly explain what claim that its domain covers all of the actual
nurses should be doing. Assessing the results and potential health problems inherent in all
of this approach is much more difficult and of these meanings of health? The profession
controversial. In part, this is because some of must be clear about what a health problem is
the particular proposals reflect specific theo- so that it can determine who has the problem
ries of human nature or philosophical orien- and who does not.
tations, like existential phenomenology, that Nursing is not the only profession ana-
have assessments that are a matter of dispute. lyzing the idea of health. Much work is also
In addition, these nondescriptive approaches being done in the philosophy of medicine,
disagree not only in their proposals for what public health, and public policy. For exam-
nursing should be but also in what they iden- ple, some theories of health care allocation
tify as fundamentally wrong with current rest on specific conceptions of health and
nursing practice. disease—why there might be a right to ade-
Holistic theories of health are one type quate health care but not necessarily a right to
illustrating this second approach. Some of convenient transportation (e.g., having a car)
these are based on rogers’s (1994) science of gets explained in terms of the details of what
unitary human beings. They are attempts to is health and why it is important. Nursing
operationalize what rogers meant by health researchers should try to integrate these con-
as a state of continuous human evolution to cerns into current theories or at least explore
ever higher levels. examples are health as common themes in this work.
a process of becoming as experienced and
described by the person (parse, 1992) and Updated by Mary T. Quinn Griffin
as the totality of the life process, which is
evolving toward expanded consciousness
(Newman, 1990, 1994). In Fitzpatrick’s life-
perspective rhythm model, health is identified HealtH Disparities
as a basic human dimension in continuous in raCial anD etHniC
development (pressler & Montgomery, 2005).
The concept of health as self-actualization Minorities
is another type illustrating this approach, as
in Smith’s (1981; née Baigis) eudaimonistic
model and pender’s (1996; pender, Murdaugh, The term health disparity has been widely
& parsons, 2006) definition of health in her used to refer to inequalities in health sta-
health promotion behavior model. tus and access. For example, the National
How are these theories applicable to Institutes of Health (NIH) defines health dis-
practice? Within the context of these theories parities as differences in the incidence, prev-
of health, there can be something wrong with alence, mortality, and burden of diseases and
HeAlTH DISpArITIeS IN rAcIAl AND eTHNIc MINOrITIeS n 207
other health conditions that exist among spe- Since that time, there have been numer-
cific population groups in the United States ous national policy initiatives to address
(Keppel et al., 2005). Health disparities have health disparities. Healthy people 2000, for H
been discussed in relation to health care example, called for a reduction in health dis-
access and quality, health status, burden of parities, whereas Healthy people 2010 set as
disease, and excess deaths (carter-pokras a national priority the elimination of health
& Baquet, 2002). Health disparities in the disparities among segments of the popula-
United States have been associated with age, tion that occur by gender, race or ethnicity,
gender, income, educational level, sexual ori- education or income, disability, geographic
entation, disability, geographic location, and location, or sexual orientation (U.S. DHHS,
racial and ethnic minority status. Similarly, 2000). currently, the proposed objectives
inequities that refer to differences in health for Healthy people 2020 are under review.
status and outcomes that are unjust, unfair, In addition to many of the health condi-
inhumane, unnecessary, and unacceptable tion–related objectives in Healthy people
express that difference unfairness or injus- 2010, a newer objective is focused on social
tices (Hebert, Sisk, & Howell, 2008). Thus, a determinants of health in which the “U.S.
related term as opposed to health disparities Department of Health and Human Services
is health equity. recognizing that categories intends to develop objectives for the social
of inequities and inequalities are not mutu- determinants and ensure their integration
ally exclusive, the focus on this section will across all Healthy people 2020 objectives”
be on health disparities of racial and ethnic (U.S. DHHS, 2009).
minority groups. Despite the improvement in over-
In the 1980s, the U.S. Department of all health of the U.S. population, profound
Health and Human Services (DHHS) cre- disparities in the burden of illness and
ated the Task Force on Black and Minority mortality continue to be experienced by
Health. It was convened “in response to a African Americans, Hispanics, American
national paradox of phenomenal scientific Indians, Alaska Natives, Asians, and Native
achievement and steady improvement in Hawaiians and pacific Islanders. The most
overall health status, while at the same time, striking of these disparities include shorter
persistent, significant health inequities exist life expectancy, higher rates of infant mortal-
for minority Americans” (U.S. DHHS, 1985, ity, cardiovascular disease, cancer, diabetes,
p. 2). The Task Force examined mortality data stroke, sexually transmitted infections, and
between minority groups and nonminority mental illness (Adler & Newman, 2002; Adler
groups to determine excess deaths. cancer, & rehkopf, 2008; Murray et al., 2006). These
cardiovascular disease and stroke, cirrhosis, disparities are believed to be a result of com-
diabetes, homicide and unintentional injuries, plex interactions among, social inequalities
and infant mortality accounted for more than in income, educational opportunities, hous-
80% of the mortality among minority popula- ing/environment, individual health behav-
tions. president clinton in 1998 focused atten- iors, and biological factors.
tion on health disparities confronted by racial Although there is no denying that health
and ethnic minority groups, which were disparities exist for racial and ethnic minori-
remarkably similar to those identified in 1985, ties, the cause of disparities and therefore the
with the exception of HIV/AIDS and pneu- design of appropriate strategies and interven-
monia and influenza. Finally, the creation tions to eliminate disparities is the subject
of the National center for Minority Health of many debates. Despite advances in med-
and Health Disparities within the NIH helps ical technology and health care spending
to focus research priorities and resources exceeding the amounts per capita of the GDp
toward eliminating health disparities. of many developing countries, overall health
208 n HeAlTH DISpArITIeS IN rAcIAl AND eTHNIc MINOrITIeS
care quality and access remained unchanged means by which health disparities develop.
or worsened for poor and racial and eth- Additionally, biological and other social the-
H nic minority populations (2008 National ories have been proposed to further exam-
Healthcare Quality and Disparities report). ine the disparate health outcomes between
The complexity in identifying the root cause Whites and racial and ethnic minorities
of health disparities include several social (e.g., Krieger, 2005), using frameworks that
factors (e.g., living in hazardous environ- have examined psychosocial stressors (e.g.,
ments, limited educational opportunities, Williams & Mohammed, 2009), allostatic
lack of employment, and linguistic and load, and “weathering” (Geronimus, Hicken,
other cultural barriers; Adler & Newman, Keene, & Bound, 2006; Juster, Mcewen, &
2002; Adler & rehkopf, 2008; laVeist, 2005; lupien, 2010).
Williams, Neighbors, & Jackson, 2008). In The social determinants of health frame-
addition to societal barriers, additional bar- work proposed by laVeist provides a suitable
riers related to the health care system exist. lens in which to examine multiple theoretical
These include barriers to access, differen- frameworks that have been grouped together
tial treatment courses, biases and prejudices on a continuum across the life span. There
among consumers and providers, and insti- has been an increasingly growing body of
tutional racism within the health care system literature within the fields of sociology, psy-
as a whole, all of which disproportionately chology, and public health that are using
affect the health of poor and racial and ethnic social determinants of health as a framework
minority populations (Jones, 2000; Smedley, to examine health disparities (laVeist &
Stith, & Nelson, 2003). lebrun, 2010; Marmot & Bell, 2009; Smedley,
The challenge in addressing racial and 2006; Williams & Mohammed, 2009). As a
ethnic disparities in health and health care result of consistent findings and worsening
is in part due to methodological concerns disparities in health among the poor and
of measuring health disparities and consis- racial and ethnic minorities, there have been
tency of language. For example, health indi- initiatives by the World Health Organization,
cators are usually measured in terms of rates, the U.S. federal government, the federal and
percentages, proportions, means, and other private funding agencies, such as the NIH,
quantifiable measures, such as infant mortal- and the robert Wood Johnson Foundation to
ity (Keppel et al., 2005; Murray et al., 2006). make the elimination of health disparities a
Additionally, health disparities are typically high priority.
measured from a specific point of reference Using social determinants of health as a
or using models, such as demographic facts framework in nursing research can be useful
(e.g., age), individual behaviors, health indi- for extending existing nursing knowledge
cators (e.g., Healthy people 2010), and health and care beyond the traditional nurse–cli-
care system (Hebert et al., 2008; Keppel et al., ent relationship because it assumes a holis-
2005; laVeist, Nuru-Jeter, & Jones, 2003). tic approach to examining the impact of
eliminating health disparities will socioenvironmental factors that contribute
require an understanding of not only health to health disparities, thus moving us from
but also the social environment, political description of the conditions of individuals
systems, norms, and policies, which impact with disparate health, to making visible the
the health of individuals, families, and com- social processes that contribute to them, and
munities. Frameworks grounded in critical consequently engaging nurses to become
social theory (Mohammed, 2006) and crit- advocates for change in health and social
ical race theory (Delgado & Sefancic, 2001, policies (lynam et al., 2008).
as cited in Ford & Airhihenbuwa, 2010) have The challenge for nurses in addressing
sought to address many of the structural racial and ethnic disparities in health and
HeAlTH DISpArITIeS: THeOreTIcAl AND MeTHODOlOGIcAl ApprOAcHeS n 209
health care are many. Although not unique strategy for national health promotion and
to nursing, there is an insufficient breadth prevention to improve lives of the U.S. pub-
and depth of nursing research with racial lic. Using measurable health indicators, the H
and ethnic minority populations that is ade- Healthy people strategy advances two pri-
quate to guide practice. certainly, the lack of mary goals for the American public: (1) to
research in this area is not unique to nurs- improve length and quality of life and (2) to
ing. This issue is compounded by the limited eliminate health disparities (DHHS, 2010b).
racial and ethnic diversity within nursing. For 30 years, the Healthy people agenda
It is critical that nurses increase their lead- has alerted the nation’s health community
ership and their knowledge by collaborating about gaps in the provision of health care.
with other disciplines, with a mutual inter- Nonetheless, segments of the U.S. population
est in eliminating health disparities among continue to experience pervasive inequities
racial and ethnic minorities as well as other in health care beyond poor access to care and
segments of the population. recognizing the financial inability to pay for health care and
influence of social determinants on health other services. efforts exclusively focused on
and health care, acknowledging and work- increasing technology and improving the
ing toward the elimination of institutional quality of health care lack the capacity to off-
racism and discrimination in health care set- set societal gradients of age, gender, racial
tings and schools, increasing the racial and or ethnic differences, education, and socio-
ethnic diversity within the nursing work- economic status (SeS; Barr, 2008; Gresenz,
force, and the need for true partnerships rogowski, & escarce, 2009). Mandated by
with racial and ethnic minority communities congress since 1999, the most recent National
are several of the needed strategies needed to Healthcare Disparities report (Agency for
eliminate disparities. Healthcare research and Quality, 2009) once
again described a continuing decline in
Antonia M. Villarruel health performance measures for minority
Brandon N. Respress and populations with low SeS. As a remedy,
the report urges particular attention to rais-
ing awareness of health disparities, training
minority providers, and forming public–
HealtH Disparities: private partnerships to identify and test solu-
tHeoretiCal anD tions to this dilemma (DHHS, 2010b). The
MetHoDologiCal future health of minority and low-income
populations is the focus for improvement.
approaCHes SeS describes the interplay of income,
education, and occupation (Barr, 2008).
Socioeconomic insecurities, especially in
The 1948 United Nation’s Universal neighborhoods with limited employment
Declaration of Human rights set forth the opportunities, lack of resources, and poor
right of all individuals to have “a standard availability of health care services, exacer-
of living adequate for health and well-being.” bate health inequities. As an example, a low-
However, when unacceptable global ineq- income, minority community lacking grocery
uity in health status was recognized, the stores that offer healthy and fresh food selec-
World Health Organization in 1978 set a goal tions contributes to chronic obesity, a mount-
of primary health care for all people by the ing problem for many Americans (cyzman,
year 2000. By 1985, the U.S. Department of Wierenga, & Sielawa, 2009; Sloane et al., 2006).
Health and Human Services (DHHS, 2010a) community-based action to reduce obesity
began developing the 10-year Healthy people calls for coordination of policy, resources,
210 n HeAlTH DISpArITIeS: THeOreTIcAl AND MeTHODOlOGIcAl ApprOAcHeS
and innovative research to bring healthy tion, nurse researchers are contributing to
solutions to such a neighborhood. the elimination of health disparities by incor-
H The 2000 U.S. census Bureau forecasted porating the contexts of disparity in the theo-
a demographic transition to older age among retical frameworks that guide their research
U.S. born citizens and a mushrooming as well as the research methodologies they
growth of minority populations by the year select to address the complex health needs
2050. racial stereotyping in clinical interac- of marginalized and underserved groups.
tions and related sociocultural conditions, Using community-based participatory
such as language differences and poor health research and participatory action research
literacy, seriously undermine equitable health (pAr), qualitative methodologies, and fem-
care provision for minority populations inist and environmental frameworks, nurse
(laViest, 2005). A recent study confirms that researchers are investigating the root causes
health care providers perceived their care of health disparities (Butterfield & postma,
to racial or ethnic minorities as being less 2009; esperat, Feng, Owen, & Green, 2005;
than that provided for white clients (Blendon etowa, Bernard, Oyinsan, & clow, 2007; Kelly,
et al., 2008). Thus, increasing minority health 2009; Sullivan-Bolyai, Bova, & Harper, 2005;
care professionals to reflect the diversity of Walker, Sterling, Hoke, & Dearden, 2007).
the U.S. population is a strategy to improve As an example, Butterfield and postma
the nation’s health. Improved concordance (2009) developed the translational environ-
of minority providers and patients has mental research in rural areas (TerrA)
been associated with greater access to care, framework to investigate the environmen-
improved educational experiences, and bet- tal health risks affecting the rural poor. The
ter patient satisfaction among minority indi- TerrA framework locates environmental
viduals (Smedley, Butler, & Bristow, 2004). health risks within physical, economic, and
The landmark health legislation, called cultural contexts to develop family-level
the Affordable Care Act, passed in 2010 under interventions that positively influence rural
the direction of president Barack Obama, public health. Knowledge developed through
establishes a 5-year plan (2010–2015) to trans- the TerrA framework stopped the use of
form U.S. health care. The chief goals of the chat, a toxic material, in construction and
health care reform act emphasize affordable road projects.
insurance coverage to the uninsured, advance- The transformation for health frame-
ment of science and innovation to benefit work integrates Freire’s transformational
public health and health care provision, and framework with community-based par-
enhancement of the safety and well-being of ticipatory research to develop family-level
the American public through prevention and interventions for childhood obesity in latino
emergency response preparedness (DHHS, communities (esperat et al., 2005). The trans-
2009). continuing evaluation of health status formation for health interventions promotes
indicators for all segments of the population the development of “critical consciousness”
will help to guide the course for such a chal- or an individual’s deeper understanding
lenging undertaking. The impact of health of her realities. Interventions that encour-
care reform on health disparities will only be age critical consciousness have the greatest
clear over time, as evidenced by the ameliora- impact because participants achieve a trans-
tion of health status indicators and improved formational power that leads them to action
health performance measurements among that is initiated by them and for which they
those populations experiencing health dis- claim ownership.
parities today. Aside from using theoretical approaches
In addition to those trying to advance to guide research in health disparities, nurse
health policy through government legisla- researchers are engaging in refreshing
HeAlTH pOlIcy AND HeAlTH SerVIce DelIVery n 211
methodological approaches. etowa et al. directly influence sustainable infrastructure
(2007) used pAr to investigate health sta- and systematic assessment and attention to
tus and health care access among African organizational complexities. H
canadian women in rural Nova Scotia. The Advanced knowledge of genetics can
study used community research facilita- have a dual effect. On one hand, such knowl-
tors who were members of the communities edge can broaden discrimination in commu-
where the research took place. Trained in nities of color by assigning erroneous genetic
every aspect of the pAr process, commu- contributions to diseases without fully con-
nity facilitators ensured that study findings templating the systemic social contributions
closely reflected the community’s health con- to health (Bonham et al., 2009). However,
cerns and they interacted sensitively with the if genomics research would include longi-
public and with policy makers. tudinal cohort studies that consider envi-
Health disparity research is expanding. ronmental exposures, lifestyle, and genetic
Highlighting the perspectives of the com- risk factors among others, while integrating
munity as a partner and training lay pro- participatory action methodologies, a fuller
viders to overcome barriers to health care visualization of health disparities might be
access and promote emotional support are appreciated.
in vogue (Balcazar et al., 2010; Nyamathi This summarized research provides
et al., 2011). latest examples include the use nurse researchers with viable frameworks
of photovoice to capture shared perceptions and methodologies for addressing health
of characteristics that influence the health inequities. Such frameworks consider the
and well-being of the community, followed contexts and systems in which health ineq-
by concept mapping, wherein active involve- uities occur and provide opportunities for
ment of residents promotes the organiza- nurse researchers to take an active role in
tion and building of consensus, leading to correcting health disparities. collaborative
solutions in poor immigrant communities research involvement is essential if the health
(Haque & rosas, 2010). Use of creative arts of vulnerable populations is to equal that of
with visual voices with African American the most privileged in our society.
youth is another example that informed
researchers about issues related to environ- Adey Nyamathi
mental safety (yonas et al., 2009).
Future direction needs to focus on adapt-
ing the latest innovations in pAr to under-
stand more fully the many contextual issues HealtH poliCy anD HealtH
that influence the health status of impover-
ished communities. For example, the ongo- serviCe Delivery
ing use of pAr as well as the more innovative
examples of studies that combine genetic
sequencing with integration of participatory policy is a general statement of aims or goals
research methods results in building a con- that can be described at different levels of
sensus framework of health-affecting factors abstraction and can range in scope. They
leading to improved health of a neighbor- can serve as a broad guideline to a specific
hood. Moreover, engaging researchers to action. policy encompasses choices that soci-
conduct pilot studies that bring together like- ety as a whole, segments of society, or orga-
minded organizations to focus on education nizations make regarding their goals and
and training programs to improve commu- priorities and reflect the values, attitudes,
nity capacity can be a powerful strategy and beliefs of those designing the policy. A
(Gwede et al., 2009). Such outcomes can more policy guides the allocation of resources that
212 n HeAlTH pOlIcy AND HeAlTH SerVIce DelIVery
are used to attain the policy goals. policy public entities that create laws and regula-
can be described as public, institutional, or tions impacting how health care systems
H organizational. public policy is formulated, should operate, be reimbursed, and mea-
adopted, and implemented by the authorities sure quality and safety of care. professional
in a political system often in the form of laws organizations set standards related to the
and regulations. Institutional policy governs education, practice, and work conditions for
workplaces and guides programs and pro- nurses.
cedures. professional organizations, such as Health service delivery can broadly be
the American Nurses Association, adopts viewed as a pyramid of four broad services
policies that are often n the form of position with population-based public health ser-
statements. vices at the base. Building from the base to
The World Health Organization (WHO, the pyramid’s peak are primary health care,
2003) defines health as “a state of complete secondary health care, and tertiary care ser-
physical, mental and social well-being and vices. population-based public health ser-
not merely the absence of disease or infir- vices include health promotion and disease
mity.” Health service delivery encompasses prevention activities at the community level,
activities that focus on health promotion and primary health services involve clinical pre-
prevention of disease, treatment, and reha- ventive services and care for common medi-
bilitation of individuals or populations in cal conditions, secondary health care services
a variety of settings. WHO (2007) identifies have a focus on specialized care and include
health services delivery as one of the build- support services for people with chronic
ing blocks of a national health system. Other or long-term health problems, and tertiary
building blocks include human resources, services are provided in facilities. The use
information, medical products, technol- of the pyramid to represent health services
ogy, and financing. Inputs such as human implies that each level serves a different por-
resources and finances combine to the deliv- tion of the total population. Since the passage
ery of health services. The higher the degree of Medicare and Medicaid in 1966, the U.S.
of health service delivery integrated, the health care delivery system has focused on
greater the continuity of care and the more services at the secondary and tertiary level.
efficient the organization of care is in attend- Health care delivery has occurred in silos,
ing to patient needs. Because efficiency gains with each silo providing different levels of
have an upper limit, many would argue that service.
there may be a trade-off with effectiveness public policy, specifically the 2010
that leads to vertical programs. patient protection and Affordable care Act,
The WHO definition of health services will change the U.S. health service deliv-
delivery focuses on a national perspective. In ery by shifting reimbursement from fee for
thinking of health services delivery at a more services at the top of the pyramid to a more
local level, Donabedian’s (1966) structure– coordinated health service delivery model
process–outcome framework and system’s with threads of health promotion and dis-
theory can be used to examine the impact ease prevention woven through all levels of
that health policies have on the health ser- delivery. The goal is to eliminate the silos
vices delivery. In systems theory, elements and to have an integration of health delivery
inside and outside the system are open and services. For example, a national voluntary
interrelated. They interact, adapt, and are pilot program for bundled payments will
constrained and in need of feedback. Health be developed by 2013. Under this program,
service delivery is embedded within a health services during one episode of care (for yet
care system. The health care system interacts to be identified diagnoses) will be reim-
with a variety of outside elements, such as bursed in one payment. The Act defines an
HeAlTH pOlIcy AND HeAlTH SerVIce DelIVery n 213
episode of care as the time period starting interventions and services that focus on the
3 days before hospital admission and end- patient’s behavioral change.
ing 30 days after discharge, but the Secretary Nurse researchers are also building evi- H
of the U.S. Department of Hunan Services dence to address human resources issues
has an option to change the time period for that impact health service delivery. evidence
the pilot program. Services provided dur- is critical for planning educational needs. We
ing an episode of care include primary care must be able to predict how many nurse edu-
providers, hospitals, outpatient hospital ser- cators and the competencies nurses will need
vices, emergency room services, postacute to address the variety of patient problems the
care services, and others as identified by the type of nursing services that will be needed
Secretary (Berenson & Zuckerman, 2010). In with health care reform and care delivery
preparation for this change in public pol- models that will result in high-quality, effi-
icy, hospitals are restructuring their health cient, cost-effective care. currently, there is
delivery models. They are integrating pri- significant evidence as to the work environ-
mary care providers into their systems and ment characteristics that enable nurses to
initiating use of electronic medical records. deliver high-quality patient care in hospitals,
Medical homes are also emerging as a model but evidence is sorely lacking in settings such
for health service delivery. This model uses a as home health, long-term care, and public
team of providers to provide comprehensive, health.
coordinated care that fosters a collaborative To produce evidence that will be
provider–patient relationship. It supports accepted by policy makers and be sustain-
patient outreach and education, especially able, nurse researchers are using a variety of
for patients with chronic conditions. research methods, including nontraditional
Some of the changes proposed in this methods such as s action research and com-
legislation have occurred because of the evi- parative effectiveness. Stringer (2007) defines
dence provided by nurse researchers and action research as “a collaborative approach
others on the value of prevention and health to inquiry or investigation that provides peo-
promotion. Nurse researchers have provided ple with the means to take systematic action
evidence on the effectiveness of nurse practi- to resolve specific problems” (p. 8). Action
tioners as primary care providers and coordi- research can be community-based and
nators of care. They have contributed to the starts with an interest or problem identified
body of knowledge on underuse of health by a group, community, or organizations.
services by people with lower incomes, lack Findings may indicate a need for policy
of health insurance, and gender and racial changes, which are more apt to be accepted
differences. Some of this work has lead to a and sustained if the there is collaboration
better understanding as to why health ser- among stakeholders from the inception of the
vices are not used appropriately by specific problem. comparative-effectiveness research
groups of people. Moreover, findings from can provide evidence on the effectiveness
studies conducted by nurse researchers pro- and benefits of health services. evidence can
vide evidence of effective interventions for be found through systematic reviews or spe-
patients with chronic diseases, which are of cific studies (Agency for Healthcare policy
high concern to policy makers. Almost 75% and research, 1998).
of U.S. health care dollars spent each year The nurse researchers’ ability to effect
is on four chronic diseases: obesity, type 2 change may be challenging. Inhibiting
diabetes, heart disease, and cancer. Nurses change factors include the policy maker’s
are contributing to the evidence that these lack of skills and knowledge, poor timing,
chronic diseases can be prevented, delayed, lack of perceived relevance, use of jargon,
or alleviated and are building evidence-based and only presenting and publishing findings
214 n HeAlTH SerVIceS reSeArcH
to a scholarly audience. Knowledge trans- influencing policy decisions that address the
lation models provide a framework that financing, organization, management, and
H can facilitate the use of research findings delivery of health care services. Findings
by policy makers. Knowledge exchange is from health service research are used to
the exchange, synthesis, and application guide organizational, institutional, and pub-
of knowledge by relevant stakeholders for lic policy decisions. For example, the centers
the purpose of health system improvement. for Medicare and Medicaid Services uses
Knowledge transfer models range from lin- health services research to inform payment
ear to complex organic depictions of inter- and benefit issues. professional associations,
actions from identification of the problem advocacy and interest groups, organizations,
through dissemination (Sudsawad, 2007). and others looking to change or create policy
A framework that can be used to plan use findings from health services research to
dissemination activities is Kingdon’s (2003) support their position.
model of three families of agenda setting The roots of health services research
processes: problems, policies, and politics traces to the 1920s. philanthropic founda-
streams. When the three streams converge, tions funded research to improve lives of
the greatest agenda change occurs. Kingdon’s those living in poor socioeconomic condi-
framework can help researchers strategize tions (Mullner, 2009). It was not until the mid-
when to disseminate their findings. Windows 1960s that health services research emerged
open quickly in policy streams and provide as a discipline (Institute of Medicine [IOM],
opportunities for action. One of the strategic 1979). In 1967, president lyndon B. Johnson
goals of the American Academy of Nursing created the National center for Health
is to “influence policy through dissemina- Services research charged with coordinat-
tion of nursing’s contribution to improved ing research efforts to reach national health
health outcomes and care delivery” (Gilliss, care objectives. currently, health services
2010). The American Academy of Nursing research is positioned within the Department
acknowledges that nursing needs to be pol- of Health and Human Services as the Agency
icy ready and that nursing can influence pol- for Healthcare policy and research (AHrQ),
icies that impact our health. although many branches of the government
also house health services research. Some
Susan Tullai-McGuinness include the centers for Disease control, the
centers for Medicare and Medicaid Services,
and the Veterans’ Administration. The
congress often sets direction for allocation
HealtH serviCes researCH of health services research dollars. As part
of the 2003 Medicare Modernization Act,
the congress mandated AHrQ to conduct
Health services research is defined as a mul- and support the comparative-effectiveness
tidisciplinary field of inquiry that studies research on specific issues.
how a broad range of social, financial, tech- The IOM (1979) identified four levels
nological, and organizational factors and of health services research: clinical, insti-
personal behaviors impact the accessibility, tutional, systematic, and environmental.
cost, efficiency, and quality of health care at clinically oriented studies examine charac-
the individual, population, organization, and teristics of providers, patients, and resources
institution levels (lohr & Steinwachs, 2002). that impact the processes and outcomes of
The overall goals of health services research care. The focus is on the broader range of out-
are to reduce disparities and to improve comes, such as patient satisfaction, cost, and
safety, quality, and cost-effectiveness by effectiveness of care. Institutional studies
HeAlTH SerVIceS reSeArcH n 215
focus on administration and the organiza- training programs with funding available
tion, such as differences in quality of care in from a variety of sources including AHrQ,
home health agencies of different sizes and the robert Wood Johnson Foundation, the H
service areas or the differences in cost of care Veterans Administration, and the National
provided in the home versus nursing home. Institute of Nursing research (ricketts, 2009).
Systematic studies examine the characteris- Health services researchers use a num-
tics of the health care system as they relate to ber of frameworks to guide their studies
the interrelationships between the demand (Mullner, 2009). Avedis Donabedian’s struc-
for health care services, providers, and health ture–process–outcome framework examines
care institutions. System characteristics of how structures of health care organizations
interest may be the type of financing, regula- impact the processes of care and patient and
tory programs, or practice sites. The aims of nurse outcomes (such as satisfaction and
environmental studies are to understand the retention). Anderson’s Behavioral Model
larger political, social, and economic contexts measures how predisposing, enabling, and
that shape the health services system and need factors at the individual and organiza-
define its societal functions. These include tional level contribute to access, patient sat-
studies of the legal and ethical responsibili- isfaction, and quality of care. Hochbaum’s
ties of health care organizations and the pop- Health Belief Model focuses on factors that
ulation’s expectations of the health services lead to individual motivation health-related
(IOM, 1979) behavioral changes. The Theory of reasoned
Health services research does not call for Action has been used to guide studies that
a specific mix of disciplines, rather research- focus on behavioral attitudes and their effect
ers from multiple disciplines bring compli- on intention to act.
mentary skills to address the questions being Health disciplines conduct the major-
studied (ricketts, 2009). There is an overlap ity of health services research. Nursing has
of health services research with a number of more recently been recognized as a signifi-
other fields, such as environmental health, cant contributor to health services research.
behavioral sciences, biomedical research, russell and Fawcett’s (2005) conceptual
and epidemiological research (IOM, 1979). model provides a framework that can be
The uniqueness of health services research used in discussing nursing and health pol-
can be exemplified by looking at smoking icy. each of the models’ four interacting
research. Biomedical research informed us levels addresses concepts of human beings,
of the effect of smoking on health, whereas environment, health, and nursing and can be
health services research provided data on the used to evaluate access, cost, and quality that
financial impact of health problems related to are outcomes of concern to health services
smoking. Data were then used to support the researchers. levels focus on the individual,
argument for smoke-free legislation. family, group, or community (level 1); the
AcademyHealth, the professional home nursing practice subsystem or health care
for health services researchers, has recently delivery system (level 2); the health care sys-
held several conferences to identify compe- tem (level 3); and the world health adminis-
tencies in health services research education. trative practice (level 4).
consensus on core training requirements has A review of nursing and health services
not been reached (ricketts, 2009). preparation research on health care organizations (level
to conduct health services research var- 2—the nursing practice subsystem) between
ies. There are more than 124 health services 1950 and 2004 shows that the majority of
research graduate programs in the United nursing’s research contributes to health ser-
States and canada, pre- and postdoctoral vices research in the area of the organization
training programs, and clinician-specific and how organizational factors impact care
216 n HeMODyNAMIc MONITOrING
delivery, nurse staffing, and patient safety The patient protection and Affordable
and quality outcomes (Mick & Mark, 2005). Act, signed into law in 2010, may play a sig-
H Moreover, these researchers may not use nificant role in the focus of health services
health services research language and may research. Under this Act, the patient-centered
not publish in health services research jour- research Institute, a nonprofit corporation,
nals. Some of the gaps identified in the review was formed. In part, the institute’s role will
include the lack of frameworks connecting be to identify research priorities. They must
organizations factors to work processes and take into account the disease incidence, prev-
the need for more sophisticated analytical alence, and burden with a focus on chronic
methodologies (Mick & Mark, 2005). diseases; the gaps in evidence of clinical
In 1999, nurse health services researchers outcomes; the potential new evidence to
began meeting informally at AcademyHealth improve health and quality of care; and the
conferences. They formed the Working Group effect of conditions, treatment, and patient
on Health Services research and Nursing in needs, preferences, and outcomes on national
2001, and in 2003, the group became an inter- expenditures. The Act provides a manda-
est group of AcademyHealth. Their goals are tory funding stream for comparative clini-
to further the knowledge of health services cal effectiveness research and also ensures
research in practice and education through that demographic data on health disparities
interdisciplinary community with interest be collected and made available to research-
in health services research issues impor- ers to help understand health disparities. It
tant to nursing and with the skills needed is yet unclear how the patient protection and
to conduct rigorous health services research Affordable Act will impact health services
(Havens & Brewer 2003). Areas where nurse research. yet, nursing is becoming well posi-
health services researchers can contribute tioned in playing a key role in health services
include access and utilization of health care, research (A report from the coalition for
health behaviors, patient safety and quality Health Services research, 2010).
of care, cost and cost-effectiveness of care,
and organization and care delivery (Jones & Susan Tullai-McGuinness
Mark, 2005).
Health services research does have
unique challenges. Although numerous data
sets are available through state and federal HeMoDynaMiC Monitoring
agencies, they can present multiple problems.
Often there is a lack of published evidence
related to reliability and validity of instru- Hemodynamic monitoring is the use of crit-
ments used to collect data. linking various ical care technology to enhance the clini-
data bases is often challenging, and nurse cal assessment of the patient’s cardiac and
researchers may have difficulty finding stat- pulmonary status and guide appropriate
isticians skilled in multimethod analysis. therapeutic interventions. Hemodynamic
To build capacity, nurse leaders in health monitoring devices such as the pulmo-
services research have identified the need nary artery catheter (pAc), first introduced
for interdisciplinary training, postdoctoral by Dr. Jeremy Swan (Swan et al., 1970), are
opportunities for training in health services commonly used in the intensive care unit.
research, integration of theories from mul- The standard catheter is 7.5F and 110 cm
tiple disciplines in training programs, and long with multiple lumens to monitor var-
exposing nurses to a variety of methods and ious pressures within the heart. It is used
analytical approaches used in health services to assess ventricular function, differentiate
research. shock states, and cardiac and pulmonary
HeMODyNAMIc MONITOrING n 217
disorders and to facilitate early identification Doppler monitors measure aortic blood flow
of sepsis and organ dysfunction. and assess stroke volume (SV) and heart rate–
The tip of the catheter is positioned in the adjusted cardiac output via a probe placed H
distal pulmonary artery (pA) and attached to within a nasogastric tube. exhaled cO 2 tech-
a pressure transducer system that converts nology measures blood flow from exhaled
physiologic/mechanical signals to electrical cO 2 , and cardiac output is derived using a
signals and provides a continuous display modified Fick equation. clinical application
of pulmonary systolic, diastolic, and mean requires use of controlled ventilation and has
pressures. The distal balloon port is used primarily been limited to the operating room
to measure the pA wedge (occlusive) pres- setting.
sure, an indirect measure of left ventricular A new less invasive device uses arterial
end diastolic pressure. The proximal lumen pressure–based SV to derive cardiac output
is used to monitor right atrial pressures and measurements. It is based on the Stewart–
used as an injectate port for cardiac output. Hamilton equation but uses a dilution curve
The catheter’s thermistor port provides a from an arterial tracing via a sensor attached
continuous display of the blood (core) tem- to an existing arterial line. The device mea-
perature. Additional enhancements include sures SV variation to guide fluid adminis-
specialized catheters for continuous mon- tration and is considered a more sensitive
itoring of cardiac output, fiber optic moni- indicator compared with traditional static
toring of mixed venous oxygen saturation measures of preload using the pA catheter
(SvO 2 ), right ventricular end diastolic volume (Headly, 2005, 2006). SV is derived from the
and ejection fraction, and intracardiac atrio- arterial line waveform using an equation
ventricular sequential pacing. (SV = K × pulsatility). The constant takes
Hemodynamic indices are obtained by into account the vascular resistance, arterial
the critical care nurse and used in conjunc- compliance (based on sex, height, weight,
tion with derived parameters such as sys- and age and pulse pressure waveform char-
temic vascular resistance and pulmonary acteristics), and pulsatility (based on an
vascular resistance. Nurses make assess- analysis of the contour of the arterial pres-
ments and in collaboration with physician sure waveform; Manecke, 2005). This tech-
colleagues institute goal-directed therapy to nology has limitations, and many factors
optimize the heart rate, preload, afterload, affect the accuracy. The majority of research
and contractility to improve overall cardiac was done under controlled situations with
output and tissue perfusion. Nurses must the patients on controlled ventilation and
be trained with the requisite knowledge and specific tidal volume settings (Bridges, 2008).
skills to work with these invasive devices and The accuracy of this technology requires that
hemodynamic monitoring remains a funda- the patient is intubated with fixed tidal vol-
mental component of critical care nursing ume and respiratory rate. Irregular rhythm
curriculum. with variability in heart may affect accuracy.
Historically, the gold standard for hemo- There is great opportunity for future nurs-
dynamic monitoring has been the use of the ing research to examine the risks versus
pAc for the assessment and management of benefits of the new less invasive options and
critically ill patients. Questions continue to to examine the impact of nurse-driven goal-
be raised in medical journals and within the directed therapy to optimize patient out-
critical care community about the relative comes. clinical outcomes such as decreased
risks versus benefits of the using the invasive number of ventilator days and reduced blood
catheter. As a result, there is a distinct trend stream infection using noninvasive methods
toward minimally invasive and noninvasive are important outcome measures. Decreased
methodology in the last decade. esophageal number of intensive care unit days and a
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Encyclopedia of Nursing Research
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