Encyclopedia of Nursing Research

218 n HeMODyNAMIc MONITOrING



reduction of overall hospital length of stay diastole using the ecG simultaneously. The
have significant economic impact upon hos- respiratory cycle must also be considered
H pital organizational throughput efforts and and all pressures must read at end-expiration
financial goals. to negate the effects of changes in intratho-
Nursing research has kept pace with new racic pressure. rizvi et al. (2005) have shown
enhancements to the original balloon-tipped, the effectiveness of airway pressure display
flow-directed catheter. Initial research stud- in the assessment of vascular pressures in
ies focused on the technical and clinical patients with acute respiratory distress syn-
variables that affect accuracy of pA pressure drome. The study helps resolve the technical
monitoring such as the seminal study by difficulty of measuring hemodynamic indi-
Woods and Mansfield (1976) that examined ces in ventilated patients with severe respira-
the effect of body position upon pA and pul- tory variation and high levels of positive end
monary capillary wedge pressure in non- expiratory pressure.
critically ill patients. These and subsequent A recent study by Walsh et al. (2010)
studies laid the groundwork for evidence- examined iced temperature versus room tem-
based practice protocols for referencing perature for cardiac index measurement in
(leveling the air/fluid interface) and the zero- hypothermic and normothermic patients. The
ing the system at the phlebostatic axis, per- study found that patients with normal cardiac
forming the square wave test to assess the index during hypothermia did not have a sig-
system dynamic response, and stipulat- nificant difference in cardiac index regardless
ing the frequency that leveling and zero- of type of injectate (iced vs. room tempera-
ing must be performed to insure accuracy ture). However, significant differences were
of hemodynamic measurements. research found between iced and room temperature
studies also examined accuracy of hemody- injectate in patients with low cardiac index
namic pressures in various backrest posi- (<2.5 l/min) during hypothermia. The use
tions and side-lying positions. The accuracy of iced injectate is the current standard of
and reliability of hemodynamic pressures practice for patients with low cardiac out-
has been shown to be valid in patients with put. Because of the significant difference in
backrest elevations (head of bed) between cardiac index in low output hypothermic
0° and 60° if patients remain supine in bed patient, use of iced injectate under conditions
and the air/fluid interface is maintained at of hypothermia was recommended.
level of the phlebostatic axis. Similarly, it has Of note is a study that examined com-
been shown that accuracy is maintained for plications related to pAc removal by critical
patients in various lateral recumbent/side- care nurses as compared with medical doc-
lying positions using an angle-specific refer- tors (Oztekin, Akyolcu, Oztekin, Kanan, &
ence point at 20°, 30°, or 90°, as long as the Goskel, 2008). The results of the study vali-
air/fluid interface is maintained at the desig- dates previous studies and the importance
nated phlebostatic axis. The impact of these of training and competency of critical care
studies is immense, given that turning and nurses in the procedural aspects related to
positioning are essential in the prevention safe removal of pAc by the registered nurse.
of complications such as hospital-acquired The American Association of critical
pressure ulcers and contractures, atelecta- care Nurses (AAcN, 2004) has recently pub-
sis, and nosocomial pneumonia. research lished a document entitled, AACN Practice
has also shown that hemodynamic measure- Alert on Pulmonary Artery/Central Venous
ments must be obtained using a strip recorder Pressure Measurement, that would be help-
rather than reading directly from the digital ful to those interested in the conduct of
monitor. Furthermore, the reading must be research related to hemodynamic monitor-
correlated with the ecG and timed with end ing. It outlines expected practice for nursing

HeNDerSON’S MODel n 219



practice and provides an excellent, compre- the most widely used nursing textbook in
hensive, and extensive literature review of english- and Spanish-speaking worlds. A
the research related to pA and central venous third book, The Nature of Nursing (Henderson, H
pressure and is ranked according to the 1966, 1991), included implications for how
strength of evidence. nursing could provide direction for four
There is a growing body of evidence and essential functions of a profession: ser-
support for less invasive methods of hemody- vice, education, research, and leadership.
namic monitoring as a result of continued con- Henderson’s model of nursing is most suc-
troversy regarding the safety and efficacy of cinctly presented in the International council
the traditional pA. Minimally invasive/non- of Nurses’s Basic Principles of Nursing Care, a
invasive forms of hemodynamic monitoring work available in 30 of the world’s languages.
are on the forefront providing new insights Basic nursing care means helping patients
into the dynamic rather than static mea- with activities such as eating and drinking
surements of the heart. critical care nurses adequately, eliminating body wastes, and
must be well trained, knowledgeable in the- moving and maintaining desirable pos-
oretical concepts, and competent in techni- tures or providing conditions under which
cal aspects of the catheter to ensure patient he can perform them unaided. Henderson
safety and appropriate use of the technology. also described conditions in persons that
Nurses must therefore continue their conduct always affect basic needs such as nursing
of research in hemodynamic monitoring to care of a newborn or the dying. According to
reexamine existing practices and traditions, Henderson’s model, the nurse is temporarily
and replication studies on the knowledge the consciousness of the unconscious, the love
and clinical competency of nurses caring for of life for the suicidal, the leg of the amputee,
patients with pA catheters are encouraged. the eyes of the newly blind, a means of loco-
Studies examining new technology in hemo- motion for the infant, the knowledge and con-
dynamic monitoring will add to the growing fidence for the young mother, and a “voice”
body of knowledge and continue to advance for those too weak to speak (Henderson, 1997,
the art and science of nursing. pp. 23–24).
Nite and Willis (1964) explicitly tested
Maureen Keckeisen the Henderson model of nursing in clinical
experiments of effective nursing care for car-
diac patients. Brooten and Naylor (1995) and
Naylor et al. (1999) implicitly examined this
HenDerson’s MoDel model in clinical research. The “nurse dose”
that they seek to measure may indeed be some
quantified measure of this unique function.
Since 1960, when the International council Three of Henderson’s papers extend
of Nurses first published the Basic Principles her model: two by validation and the other
of Nursing Care, a work their Nursing by contradiction. The Concept of Nursing
Service committee commissioned, Virginia (Henderson, 1978) specifically addressed
Henderson’s description of nursing and the her work as a model. Preserving the Essence of
unique function of the nurse has been used Nursing in a Technological Age (Halloran, 1995,
throughout the world to standardize nurs- p. 96) extended her ideas to include services
ing practice. The Basic Principles of Nursing nurses provide in intensive care units and
Care was written just after the 1955 publica- was organized using the four essential pro-
tion of Harmer and Henderson’s Textbook of fessional functions first depicted in The Nature
the Principles and Practice of Nursing, fifth edi- of Nursing: practice, education, research, and
tion (Henderson, 1955), which until 1975 was leadership. In Nursing Process—Is the Title

220 n HerMeNeUTIcS



Right?, Henderson (Halloran, 1995, p. 199) grant a practical familiarity with phenom-
contradicted what had become the accepted ena. Heidegger called this sense of phenom-
H alternative to the use of the word “nursing” ena (familiarity) fore-having. Background
by arguing that the word “process” unnec- practices also form the perspective (foresight)
essarily constrained professional vision and from which we understand phenomena.
precluded experience, logic, expert opinion, Fore-conception describes our anticipated
and research as bases for practice. sense of what our interpreting will reveal.
This too is shaped and framed by our back-
Edward J. Halloran ground practices. Understanding is circu-
lar, and humans as self-interpreting beings
are always already within this interpretive
(hermeneutic) circle of understanding. Thus,
HerMeneutiCs “interpretation is never a presuppositionless
grasping of something previously given”
(Heidegger, 1927/1962, p. 141) but is an expli-
Historically, hermeneutics described the art cation of temporal understandings of the
or theory of interpretation (predominantly engaged, dynamic relating of beings and
that of texts) and was prevalent in disciplines world.
such as theology and law. German philoso- Hermeneutic researchers do not attempt
pher Wilhelm Dilthey (1833–1911) redefined to isolate or “bracket” their presuppositions
hermeneutics as a science of historical under- but rather to make them explicit. Hans-
standing and sought a method for deriving Georg Gadamer (1960/1989), a student of
objectively valid interpretations. Martin Heidegger’s, has extended hermeneutical
Heidegger (1889–1976) recast hermeneutics research in this area. The essence of herme-
from being based on the interpretation of his- neutics lies not in some kind of mystic rel-
torical consciousness to revealing the tempo- ativism but in an attitude of respect for the
rality of understandings (palmer, 1969). impossibility of bringing understanding of
Hermeneutics is an approach to schol- the engaged openness of being to some kind
arship that acknowledges the temporal situ- of final or ultimate closure. rather, the way
atedness of researchers, participants, and of hermeneutics is to be underway, to be
phenomena of study. Time as it advenes, or drawn into the “mediating immediacy (open-
time as lived, is central to the work of her- ness, between) of concerned involvements”
meneutics. The centrality of time is what (Diekelmann & Diekelmann, 2009, p. 155).
differentiates hermeneutic phenomenology The work of the hermeneutic phenom-
from traditional forms of Husserlian phe- enologist moves beyond the traditional
nomenology. The hermeneutic scholar works logical structures and presuppositions of
to uncover how humans are always already realisms and idealisms to reveal and expli-
given as time. Hermeneutics has no begin- cate otherwise hidden (taken-for-granted)
ning or end that can be concretely defined but understandings. calling attention to human
is an experience of persistently questioning practices, concerns, and experiences, her-
phenomena (matters of concern manifested meneutics is closely related to critical social
temporally and historically; Diekelmann & theory, feminisms, and postmodernism.
Diekelmann, 2009; Gadamer, 1960/1989). Unlike these, however, hermeneutics does
Interpretation presupposes a threefold not posit politically or psychologically deter-
structure of understanding, which Heidegger mined frameworks as the modus operandi
(1927/1962) called the fore-structure. The pre- of method, nor does the hermeneutic phe-
mise of the fore-structure is that all interpre- nomenologist attempt to posit, explain, or
tation is based on background practices that reconcile an underlying cause or essence

HerMeNeUTIcS n 221



of a particular experience. rather, the rich the overall understanding of the phenom-
descriptions of common practices and shared enon. Team members share their written
meanings are intended to reveal, enhance, or interpretations, including excerpts from H
extend understandings of human situations the data. Dialogue among team members
as they are experienced (Smythe, Ironside, clarifies, expands, and refines the identified
Sims, Swenson, & Spence, 2008). themes and accompanying interpretation.
The thinking that accompanies herme- As the team analyzes subsequent interviews,
neutical scholarship is reflective, reflexive, they read each new text against those that
and circular in nature (Smythe et al., 2008). preceded it. This enables new themes to
However, describing the process of herme- emerge and previous themes to be contin-
neutical research may suggest a linearity uously refined and expanded or challenged
and stepwise structure that belies the seam- and overcome. Team members clarify any
less, fluid nature of this approach to inquiry. discrepancies in the interpretations by refer-
On the other hand, not describing the pro- ring to the interview text or reinterviewing
cess implies a thoughtless or haphazard participants. Through dialogue, the team
approach that does not reflect the scholarli- members strive to explicate and refine the
ness of hermeneutical research. Therefore, often subtle and nuanced understandings
although a brief summary of one approach across the data that reveal new possibilities
to herme neutical analysis is given here, the for thinking and practice.
reader is referred to several authors who dis- As the analysis continues, team mem-
cuss hermeneutical methodologies in more bers identify and explore themes that cut
detail (Diekelmann & Diekelmann, 2009; across interview texts. They reread and study
Gadamer, 1960/1989; Heidegger, 1988/1999; interpretations generated previously to see if
palmer, 1969). similar or contradictory interpretations are
Hermeneutical researchers often work present in the various interviews. Although
in teams to study areas of shared interest a presupposition of hermeneutical analysis
and expertise. Teams often include content is that no single correct interpretation exists,
and methods experts, practitioners, students, the team’s continuous examination of the
and participants. Team members hone the whole and the parts of the texts with con-
interpretation of study data by participat- stant reference to the participants ensures
ing in dialogue and debate wherein emerg- that interpretations are warranted (focused
ing insights can be shared and extended and and reflected in the text).
“blind spots” illuminated. reading widely across postpositivist,
Although sources of data vary (e.g., feminist, critical, postmodern, and philo-
existing texts, written or retold accounts, sophical texts, team members situate their
individual interviews, focus groups, art, pho- analysis and hold the identification and
tographs), verbatim transcriptions of non- interpretation of common practices (themes)
structured interviews are the most common open and problematic. In other words, bring-
in the nursing literature. Data gathering and ing this literature to bear on the analysis,
analysis often occur throughout the course of team members critique their interpretations
the study. to extend, support, or overcome identified
Analysis of the text begins when team themes.
members read each interview to obtain an During the interpretive sessions, pat-
overall understanding of the experiences terns may emerge. A pattern is constitutive
being shared by each participant. From this and present in all the interviews, express-
reading, team members identify themes ing the relationship of the themes. patterns
within each interview and explicate the are the highest level of hermeneutical anal-
meaning and significance of this theme to ysis. The hermeneutic approach provides

222 n HISTOry OF NUrSING reSeArcH



an opportunity for team members and
researchers not on the team to review the History of nursing researCH
H entire analysis for plausibility, coherence,
and comprehensiveness. In addition, par-
ticipants in the study may be asked to read The first public health policy act was signed
team members’ interpretations to confirm, to on July 16, 1798, by president John Adams.
extend, or to challenge the analysis. Others, A public health service organization, later
not included in the analysis but likely to be named the U.S. public Health Service
readers of this study, may also review the (USpHS), would operate hospitals and rest
written interpretations. This review process homes for sick merchant seamen. The act was
often extends the analysis and exposes any expanded in 1877 as a result of a yellow fever
unsubstantiated and unwarranted interpre- epidemic in New Orleans that required the
tations that are not supported by the texts. passage of the Quarantine Act of 1878.
The purpose of the research report is to pro- In 1879, a national Board of Health was
vide a wide range of explicated text so that established to monitor public health regularly,
the reader can recognize common practices especially in the area of sanitation. A weekly
and shared experience and participate in the report that later became the Public Health
analysis. Reports was published. The board had the
Diekelmann and Diekelmann (2009) authority to intervene in case of an epidemic.
suggest presenting the insights gleaned In the late nineteenth century, robert Koch
from hermeneutic analysis in converging and louis pasteur made important discover-
conversations as a way of keeping themes ies about the nature of infectious diseases that
and patterns “in motion” (p. xvii). A con- explained the transmission of such diseases
verging conversation brings excerpts from and aided in controlling their spread. In this
multiple interviews into conversation with control, government had a significant role.
each other, the literature, and the themes, Although the role of the federal gov-
patterns and questions illuminated by the ernment became significant in 1938 through
analysis. This approach draws the reader grants-in-aid to universities under a research
into the conversation with the phenomenon grants program, it is generally held that
of study (rather than presenting “findings” nursing research began after World War II,
as an implied end point or last word) and although the work of Florence Nightingale
retains the historical/temporal situatedness (1820–1910) introduced the use of statistics in
of understanding. analyzing nursing data. Beginning in 1920,
Hermeneutic phenomenology was intro- the Goldmark study was the first of the land-
duced to nursing more than 25 years ago by mark studies of nursing. research developed
patricia Benner in her studies of expertise into nursing education, time studies, salaries,
in nursing practice (Benner, 1984; Benner, supply and demand, employment condi-
Tanner, & chesla, 1996). Since that time, her- tions, costs, status of nurses, job satisfaction,
meneutics has emerged as a significant area needs, and resources. In 1955, the Nursing
of scholarship in nursing and is being used research Grants and Fellowship program of
in diverse areas such as nursing education the Division of Nursing (USpHS) was estab-
(Diekelmann & Diekelmann, 2009; Ironside, lished; it awarded grants for nursing research
2006), chronic illness (ellett, Appleton, & projects, nursing research fellowships, and
Sloan, 2009; Sloan & pressler, 2009), cancer nurse-scientist graduate training. In 1978, the
care (Alqaissi & Dickerson, 2010), and sexual Division of Manpower Analysis was estab-
violence (ratchneewan et al., 2010). lished within the Division of Nursing in
the Bureau of Health Manpower to conduct
Pamela M. Ironside research on manpower.

HISTOry OF NUrSING reSeArcH n 223



In the nineteenth century, Florence service provided adequate patient
Nightingale, a founder of modern nursing, care. The result was the classic report,
was the first nurse to do research in connec- Nurses, Patients, and Pocket-books. H
tion with nursing, when she used statistics 1934 The second project of the committee
in the analysis of her data. She was the first on the Grading of Nursing Schools
biostatistician in nursing. Nightingale did was a job analysis reported in An
her work alone and not until after World Activity Analysis of Nursing. The grad-
War II was there an organized, continuing ing of nursing schools was not real-
effort to conduct further nursing research. ized until the establishment of the
Nursing care research is defined as research National Nursing Accrediting Service
directed to understanding the nursing care in 1950.
of individuals and groups and the biological, 1935 The American Nurses Association
physiological, social, behavioral, and envi- (ANA) published Some Facts About
ronmental mechanisms influencing health Nursing: A Handbook for Speakers and
and disease that are relevant to nursing care. Others, which contained yearly compi-
Nursing research develops knowledge about lations of statistical data about regis-
health and the promotion of health over the tered nurses.
life span, care of persons with health prob- 1936 The ANA scrutinized the economic sit-
lems and disabilities, and nursing actions uation of nurses by studying incomes,
that enhance the ability of individuals to salaries, and employment conditions; it
respond effectively to actual or potential excluded public health nurses.
health problems. The following is a sum- 1939 The second project of the committee
mary of major hallmarks in the history of on the Grading of Nursing Schools was
nursing research: a job analysis reported in An Activity
Analysis of Nursing. The grading of nurs-
1920 Josephine Goldmark, under the direc- ing schools was not realized until the
tion of Haven emerson, conducted establishment of the National Nursing
a comprehensive survey that identi- Accrediting Service in 1950.
fied the inadequacies of housing and 1940 pfefferkorn and rovetta compiled basic
instructional facilities for nursing data on the costs of nursing service and
students. nursing education.
1922 In a time study of institutional nursing, 1940 The American Nurses Association
the New york Academy of Medi cine (ANA) published Some Facts About
showed wide discrepancies in the costs Nursing: A Handbook for Speakers and
of nursing education and services. Others, which contained yearly compi-
1923 The committee for the Study of lations of statistical data about regis-
Nursing education conducted the tered nurses.
first comprehensive study of nurs- 1941 The USpHS conducted a national cen-
ing schools and public health agen- sus on nursing resources in coopera-
cies. The final report was published tion with state nursing associations as
as Nursing and Nursing Education the World War II loomed.
United States. 1943 The National Organization of public
1924 The first nursing doctoral program Health Nursing surveyed needs and
was established at Teacher’s college, resources for home care in 16 commu-
columbia University. nities. The work was reported in Public
1926 May Ayres Burgess was com missioned Health Nursing Care of the Sick.
by the committee on the Grading of 1948 The publication of the Brown report
Nursing Schools to ensure that nursing identified issues facing nursing

224 n HISTOry OF NUrSING reSeArcH



education and nursing services for 1954 The ANA established a committee on
the first half of the century. The rec- research and Studies to plan, to promote,
H ommendations led to much research and to guide research and studies relat-
during the next 10 years, for example, ing to the functions of the ANA (1968
studies on nursing functions, nursing published) ANA Guidelines in ethical
teams, practical nurses, role and atti- Values.
tude studies, nurse technicians, and 1955 The ANA established the American
nurse–patient relationships. Other Nurses’ Foundation, a center for
studies rooted in the Brown report research to receive and administer
were on the hospital environment funds and grants for nursing research.
and economic security as well as the The foundation conducts its own pro-
report Nursing Schools at Mid-Century, grams of research and provides con-
from the National committee for the sultation to nursing students, research
Improvement of Nursing Services. The facilities, and others engaged in
Division of Nursing resources (now nursing research. Twenty Thousand
the Division of Nursing) of the USpHS Nurses Tell Their Story was published.
conducted statewide surveys and devel- The Nursing research Grants and
oped manuals and tools for nursing Fellowship programs of the Division
research. Major breakthroughs in nurs- of Nursing, USpHS, were established
ing research were made by such stud- to stimulate and provide financial sup-
ies as (a) patient satisfaction, (b) patient port for research investigators and
classification studies, and (c) problem- nursing research education.
oriented record. These studies laid the 1956 The study of Patient Care and Patient
groundwork for nursing research for Satisfaction in 60 Hospitals was published.
the next 2 decades. 1957 The Department of Nursing, estab-
1949 The ANA conducted its first national lished at Walter reed Army Institute of
inventory of professional registered research, provided opportunities for
Nurses in the United States and growth in military nursing research.
puerto rico. An Interim classification The Western Interstate commission
of Schools of Nursing Offering Basic for Higher education sponsored the
programs was prepared with classifica- Western Interstate council on Higher
tions I, II, and III according to specific education for Nursing to improve the
criteria. quality of higher education for nurs-
1950 The National Nursing Accrediting ing in the western United States, focus
Service established a system for accred- on preparing nurses for research, and
iting schools of nursing. develop new scientific knowledge
1952 The journal Nursing Research was pub- and communicate research findings.
lished in June 1952. It was the ANA’s Other such groups were the Southern
first official journal for reporting nurs- regional education Board, the New
ing and health research. england Board of Higher education,
1953 leo Simmons and Virginia Henderson the Midwest Alliance in Nursing, and
published a survey and assessment of the Mid-Atlantic regional Nurses
nursing research, which classified and Association.
evaluated research in nursing during 1959 The National league for Nursing
the precious decade. Teachers college, (NlN) research and Studies (later the
columbia University, established the Division of research) was established
Institute of research and Service in to conduct research, to provide consul-
Nursing education under Helen Bunge. tations to NlN staff, and to maintain

HISTOry OF NUrSING reSeArcH n 225



information about NlN research An abstract for action made recommen-
products. dations for changes in nursing such as
1960 Faye Abdellah developed the first fed- increased practice research, improved H
erally tested coronary care Unit and education, role clarification and prac-
published Patient Centered Approaches to tice, and increased financial support for
Nursing, which altered nursing theory nursing. Overview of Nursing was sup-
and practice. ported by the Department of Health,
1963 The Surgeon General’s consultant education, and Welfare, 1955–1968, to
Group on Nursing reported on the assess nursing research, knowledge,
nursing situation in the United States gaps, and future needs.
and recommended increased federal 1971 The ANA council of Nurse research-
support for nursing research and educa- ers was established by the ANA
tion of researchers. The Nursing Studies com mission on Nursing research to
Index, Volume IV, 1957–1959, was com- advance research activities and pub-
pleted as a guide to analytical and his- lished issues in research: Social, Pro-
torical literature on nursing in english fessional, and Methodology (1973). The
from 1900 to 1959. Volume I, 1900–1929, Secretary’s commission, Department
was published in 1972; Volume II, of Health, education and Welfare pub-
1930–1949, was published in 1970; and lished Extending the Scope of Nursing
Volume III, 1950–1956, was published Practice as a position of the health pro-
in 1966. fessions to support the expansion of
1964 Nursing Research: A Survey and Assess ment the functions and responsibilities of
provided a review and assessment of nurse practitioners.
research in areas of occupational health, 1973 The American Academy of Nursing
career dynamics, and nursing care. was founded with 36 charter fellows to
1965 ANA Nursing research conferences advance new concepts in nursing and
(1965 through the 1980s) provided a health care, to explore issues in health
forum for critiquing nursing research care, the profession, and the society
and opportunities for nurse research- as directed by nursing, to examine
ers to examine critical issues. dynamics of nursing, and to propose
1966 The International Nursing Index was resolutions for issues and problems in
published. One of the first textbooks nursing and health.
on nursing research was published by 1977 Nursing Research became the first nurs-
Abdellah and levine: Better Patient Care ing journal to be included in Med-line,
Through Nursing Research. the computerized information retrieval
1968 The ANA Blueprint for Research in service.
Nursing and The Nurse in Research, 1979 Healthy People, the Surgeon General’s
ANA guidelines in ethical values, were report on health promotion and dis-
published. ease prevention, was published. Clinical
1970 ANA commission on Nursing research Content of Nursing Proceedings Forum on
was established and prepared position Doctoral Education in Nursing defined
papers on human rights in research. the content of nursing research at the
papers included Human Rights Guidelines doctoral level.
for Nurses in Clinical and Other Research 1980 Promoting Health, Preventing Disease:
(1974), Research in Nursing: Toward a Objectives for the Nation was pub-
Science of Health Care (1976), Preparation of lished. ANA published a social policy
Nurses for Participation in Research (1976), statement, which defined the nature
and Priorities for Nursing Research (1976). and scope of nursing practice and

226 n HISTOry OF NUrSING reSeArcH



characteristics of specialization in administration, and education. The
nursing. center was initially located in the
H 1981 Strategies for Promoting Health for Division of Nursing, Bureau of Health
Specific Populations was published by Manpower, Health resources, and
the Department of Health and Human Services Administration, but in 1986 it
Services (formerly Department of Health, became part of the National Institutes
education, and Welfare). Diagnosis of Health (NIH). In 1993, the NcNr
related Groups were mandated by was renamed the National Institute of
Health care Financing Administration Nursing research (NINr).
for Medicare regarding reimbursement. 1988 The Agency for Healthcare policy and
This stimulated the importance of evi- research within the Department of
dence-based practical nursing. Health and Human Services was estab-
1983 The 1981 White House conference on lished to focus on the development of
Aging: executive Summary of Technical clinical practice guidelines, outcome
committee on Health Maintenance and measures, and effectiveness research.
Health promotion and the Report of the (The name was changed to Agency for
Mini Conference on Long-term Care: Report Healthcare research and Quality).
of the Technical Committee on Health Services:
Nursing and Nurse Education—Public Thirty years after the idea was first
Policies and Private Actions. report of the proposed by the NIH’s National Advisory
Institute of Medicine, National Academy council, the NcNr was established in
of Sciences, defined nursing research and 1986. Its mandate was “to advance science
delineated its direction. Magnet Hospitals: to strengthen nursing practice and health
Attraction and Retention of Professional care that promotes health, prevents disease,
Nurses was published by the American and ameliorates the effects of illness and
Academy of Nursing. Report of the Task disability.” The placement of NcNr at the
Force on Nursing Practice in Hospitals. NIH moved nursing research into a broader-
New legislation established reimburse- based biomedical research environment and
ment policies for hospitals based on pro- facilitated the collaboration between nurs-
spective payment of Diagnosis related ing and other research disciplines. On June
Groups the determined amount paid for 9, 1993, the NcNr was renamed and became
Medicare patients. the NINr, which placed nursing on an equal
1983 The first volume of the Annual Review footing with other NIH institutes. In 2010,
of Nursing Research series was published NINr celebrated its 25th anniversary.
by Springer publishing company. The NINr is the key organ for funding
1984 The ANA formed the ANA council nursing research grants and contracts and has
on computer Applications in Nursing approved priority areas for research as deter-
to focus on computer technology per- mined by its National Advisory council for
tinent to nursing practice, education, Nursing research. The NINr provides a scien-
administration, and research. The ANA tific base for patient care and is used by many
cabinet on Nursing research published disciplines among health care professionals—
Directions for Nursing Research: Toward the especially by the nation’s 2.5 million nurses.
Twenty First Century. NINr-supported research spans both health
1985 The National center for Nursing and illness and deals with individuals of all age
research (NcNr) was established groups. Nursing research addresses the issues
in the USpHS. programs would that examine the core of patients’ and families’
work to enlarge the scientific knowl- personal encounters with illness, disability,
edge underlying nursing services, treatment, and disease prevention. In addition,

HISTOry OF NUrSING reSeArcH n 227



nursing research addresses issues with a com- covers research topics that are broad and focus
munity or public health focus. NINr’s pri- on various aspects of the organization and
mary activity is clinical research, and most of administration of nursing service. Further work H
the studies directly involve patients. The basic to incorporate nursing research into the Navy
science is linked to patient problems. Nurse corps became prominent in 1987, when
The nursing programs of the USpHS the navy conducted a review of billets and iden-
stimulated the postwar expansion of nurs- tified the need for doctorally prepared nurses.
ing services through pilot studies, nursing The history of nursing research in the air
research, and community health services. force is found primarily through the review
The Division of Nursing resources, with a of unpublished mimeographed documents
modest budget of $95,000 and a small staff, covering research at the School of Aerospace
was able to undertake a number of landmark Medicine at Brooks Air Force Base, Texas.
studies to find solutions to postwar nursing Among the research topics reported are the
problems in hospitals and health agencies. development of equipment for aeromedical
During the years 1949 to 1955, a number of evacuation (such as examination lamps, oxy-
state surveys of nursing needs and resources gen and humidity apparatus, hand disinfec-
were conducted in almost all states. tion devices, patient monitoring and blood
In 1954, among the many studies and tools pressure measurement, litter lift, and trans-
developed by the USpHS Division of Nursing portable airborne stations). physiological and
resources (now the Division of Nursing) psychological changes experienced by air force
was a cooperative study carried out with the nurses associated with flying duty on jet and
commission on Nursing of cleveland, Ohio, propeller aircraft and ways to evaluate patient
to discover the reasons for the understaffing care in flight are other areas of research.
of nursing departments. A by-product of the In the fall of 1990, representatives from
study was that it produced the outcome mea- the army, navy, and air force met to discuss
sure satisfaction study. Another study involved collaborative research among the services.
the use of disease classification for nursing This group formed the Federal Nursing
planning. The diagnoses were then coded and research Interest Group, which later became
classified into 58 groups representing discrete the Tri-Service Nursing research (TSNr)
nursing problems. A similar methodological Group. The TSNr Group was made respon-
approach was followed in the development sible for finding ways to promote military
of the problem-oriented medical record more nursing research both collectively and indi-
than a decade later and in the development vidually, within and across the services.
of Diagnostic related Groups. In 1955, the The initial appropriation for the TSNr pro-
congress earmarked $625,000 for nursing gram under S.r. 102–154 was $1 million for
research and fellowships that were awarded fiscal year 1992, and it increased to $5 mil-
directly to universities, hospitals, health agen- lion in fiscal year 1996, $6 million thereaf-
cies, and professional associations. ter, authorizing the TSNr program as part
The Army Nurse corps initiated nursing of the Department of Defense Health care
research in the military and has been a major pro gram, administered by the TSNr Group
contributor to the evolution of both military and established at the Uniformed Services
and civilian nursing research. The Army University of the Health Sciences. In 2000,
developed a program designed to concen- the council for the Advancement of Nursing
trate on clinical nursing research in addition Science created the research policy and
to fostering participation in the collaborative facilitation arm of the American Academy
studies of other disciplines. of Nursing.
The history of nursing research in the
Navy (primarily unpublished master’s theses) Faye G. Abdellah

228 n HIV/AIDS cAre AND TreATMeNT



Hiv/aiDs Care anD comorbidities. Nurse researchers have exam-
ined individual symptoms such as fatigue
H treatMent (pence et al., 2009) and peripheral neuropathy
(Nicholas et al., 2010). The UcSF International
HIV/AIDS Nursing research Network con-
Throughout the world, HIV/AIDS is emerg- tinues to conduct research and publish work
ing as a chronic illness that has a particular on self-care symptom management strategies
impact on marginalized and/or economi- for six commonly reported symptoms (anxi-
cally constrained populations. In developed ety, depression, diarrhea, fatigue, nausea, and
countries, HIV/AIDS is disproportionally neuropathy), including an intervention study
impacting communities of color, specifi- that examined the effectiveness of a paper-
cally African Americans, and persons who based symptom management manual com-
engage in behaviors such as injection drug pared with a nutrition manual in controlling
use and/or sexual behaviors that result in a multiple symptoms (Wantland et al., 2008).
high risk for infection. Many people living Treatment guidelines for HIV and
with HIV/AIDS in the developed world are related comorbidities, such as tuberculosis,
triply diagnosed with substance abuse and are examined using the most current evi-
mental illness, which impacts on treatment dence from clinical trials every 6 months
adherence (chander et al., 2009), engagement by a panel of HIV specialists (http://aid-
with the health care system, and participa- sinfo.nih.gov/Guidelines/GuidelineDetail.
tion in research. Because of the complex cul- aspx?MenuItem=Guidelines&Search=Off&
tural and political factors along with poverty, GuidelineID=7&classID=1). To suppress the
the incidence of HIV/AIDS in some devel- HIV viral load, adherence with prescribed
oping countries has impacted on projected medications is essential. Nursing research
life expectancies for persons born in those has examined different approaches to pro-
countries. Many nursing researchers have moting adherence (Holzemer et al., 2006) and
established international partnerships to (erlen & Sereika, 2006), but as treatment reg-
address specific issues of living with HIV/ imens evolved from 20 plus pills three times
AIDS in resource constrained countries par- a day with food and activity restrictions to
ticularly those located in sub-Saharan Africa. one pill one time a day with a longer half-
Articles are coauthored by nursing investiga- life, adherence challenges have decreased
tors living in diverse settings, which greatly for motivated clients.
contribute to the research and dissemination Multiple theoretical perspectives have
capacity of nurses in both settings. Through been used in nursing research with HIV/AIDS
programs such as the United Nations Global samples, including the common sense model
Fund (http://www.theglobalfund.org/en/) of illness representation (reynolds et al.,
and the pepFAr (http://www.pepfar.gov/), 2009) and the chronic care Model (http://
more HIV-infected persons throughout the www.improvingchroniccare.org/index.
world are accessing treatment for their infec- php?p=The_chronic_care_Model&s=2). The
tion. Although treatment has greatly impacted centers for Disease control and prevention
on controlling the incredible mortality rates, advocates routine screening of all patients in
it also raises issues related to adherence and health care settings (http://www.cdc.gov/
management of side effects because the avail- hiv/testing/HIVStandardcare/). As these
ability of specific antiretroviral therapy medi- guidelines become implemented in high
cations options is limited in many parts of the incidence settings such as New york State,
world because of the ongoing cost issues. research will be needed to determine organi-
Symptoms can emerge from the dis- zational structures that promote case finding
ease pathology, treatment strategies, and along with access to high-quality HIV care

HIV rISK BeHAVIOr n 229



for newly diagnosed persons who did not 2.7 million people were newly HIV infected
realize that they had engaged in a risk behav- (UNAIDS, 2009). This total number of HIV-
ior. Although vaccine development continues infected population was more than 20% H
to be a challenge, there is strong belief that a higher than the number in 2000, and the prev-
vaccine will become available and interdis- alence was roughly threefold higher than in
ciplinary research will be needed to explore 1990 (UNAIDS, 2009). This ongoing rise in
optimal delivery strategies to often invisi- the population with HIV/AIDS infection has
ble populations such as transgender youth made AIDS continue to be a major global
(Stieglitz, 2010). Stigma continues to be asso- health priority and highlighted the need to
ciated with an HIV diagnosis even in high continually advocate for the reduction of HIV
incidence settings with long established risk behaviors. Because an effective vaccine or
epidemics (Kalichman et al., 2009), and this cure for HIV/AIDS infection has still not been
stigma often results in nondisclosure and invented yet, developing effective behavioral-
compartmentalizing of treatment providers. change interventions to prevent or reduce the
Widespread adoption of electronic health key risk behaviors for HIV transmission is
records might break down some communi- extremely important. Nurses, with an oblig-
cation barriers if consumers believe that tech- atory role in providing quality health care for
nology will improve the quality of their care all, are cooperating with other professional
and health outcomes. perhaps one of the most disciplines and contributing to the preven-
pleasant surprises is that the number of older tion of HIV/AIDS infection.
people living with HIV/AIDS continues to HIV risk behavior generally refers to
grow because of effective treatment options the behaviors that lead to possible transmis-
and new infections. However, little research sions of HIV and increase the likelihood of
has examined the unique characteristics of having HIV infection. research up to date
older persons who are often living not only has identified that HIV is mainly transmit-
with HIV/AIDS but also diabetes, hyperten- ted through unprotected penetrative (vag-
sion, liver disease, and kidney issues and inal or anal) intercourse and oral sex with
who have significant social support issues an infected person; through blood transfu-
because many live alone (Nokes et al., 2011). sion with contaminated blood; by using con-
taminated syringes, needles, or other sharp
Kathleen M. Nokes instruments; and from an infected mother
to her child during pregnancy, childbirth,
and breastfeeding (UNAIDS, 2008). Among
these HIV risk behaviors, sexual contact is
Hiv risk BeHavior the major exposure to the HIV transmis-
sion in most reported AIDS-infected cases.
Studies to date have identified that unpro-
Since the recognition of AIDS and the iden- tected sexual intercourse, having multiple
tification of HIV as its contributing cause, sexual partners, and injection drug uses are
the population living with HIV worldwide the main risk behaviors for HIV transmis-
continues to increase and the HIV/AIDS pan- sion. Unsafe sexual behavior, risky sexual
demic remains a global plague that affects behavior, or sexual risk-taking behaviors are
people in almost every country. The United the terms commonly and widely used by
Nations program on AIDS/HIV (UNAIDS) scientists and researchers to represent sex-
reports that in 2009, more than 33 million ual activity or behavior that increases the
people were estimated to be living with HIV/ risk of getting sexually transmitted diseases,
AIDS globally, including approximately including HIV/AIDS infection, or becoming
2 million children and 15 million women, and pregnant. Because the tragedy of the HIV/

230 n HIV rISK BeHAVIOr



AIDS epidemic is spreading gravely, these Action (Ajzen & Fishbein, 1980), have suggested
terms in most studies specifically refer to possible mechanisms and have been popularly
H HIV/AIDS-related sexual behavior. used in the understanding and prevention of
Many psychosocial, biological, and HIV-related risk behaviors. Most of the cogni-
sociologic circumstances or cofactors have tive-behavioral interventions that stem from
been recognized as impacting the likelihood these theories report effectiveness in reduc-
of HIV risks. The personal factors, includ- ing risk of HIV infection. Strong evidence has
ing age, gender, race, developmental stage, shown that cognitive functions, such as self-
early age of initiation of intercourse, HIV/ efficacy, uniquely contribute to the rationale of
AIDS-related sexual knowledge, mental the safer sexual behaviors and especially in the
health, sexual identity, self-esteem, self- domain of condom use. The robust association
efficacy, alcohol uses, and the use of illicit between self-efficacy and practices of safer sex-
drugs, are found to be associated with ual behaviors had been revealed among people
increase or decrease risks of HIV infection. with different cultural background and across
Interpersonal factors such as discussing countries. In addition to the findings revealed
safe sex with sexual partners and asking in research participants from Western cultures,
sexual partners about his or her sexual his- African cultures, and Hispanic culture, higher
tory and being ethnic minorities may also level of HIV/AIDS preventive self-efficacy
be correlated with the risk of HIV infection. was also found to be significantly related to
environmental factors, including social eco- less HIV/AIDS-related risky sexual behaviors
nomic status, peers, schools, families, gender among people in Asian countries (lee, Salman,
roles, cultural norms, religious beliefs, polit- & Fitzpatrick, 2010).
ical and health policies, and social isolation, Numerous experts have contributed to
were also found to influence the likelihood of research in this field since the beginning of
becoming HIV infected. The variety of social the HIV epidemic. research has indicated that
and structural factors, including gender some behavioral preventive efforts have slowly
inequality, human rights violations, stigma but effectively reduced HIV prevalence across
and discrimination, poverty, and lack of HIV the world. An extensive body of research has
awareness and access to education, health, provided noteworthy information on strate-
and other services, increase people’s vulner- gies to facilitate or sustain behavioral changes
ability to HIV infection and dive the HIV epi- for HIV preventions. However, to effectively
demics (UNAIDS, 2010). oppose health disparities in HIV prevention
Many behavioral contributors that and care, many researchers have suggested
increase or decrease the risk of HIV infection that it is critical to address cultural issues in
have been explored and identified. These delivering HIV/AIDS intervention programs
contextual factors combine in dynamic ways to achieve maximum effectiveness (Faryna
to increase behavioral risk. However, the con- & Morales, 2000; Jemmott, Maula, & Bush,
textual risk factors and their casual relation- 1999). Because of their vulnerability of access-
ships with HIV risk behaviors are still not ing health services and specific cultural back-
well understood. This limited understanding grounds, ethnic minority and immigrants are
is an obstacle for developing effective behav- one of the target populations for conducting
ioral interventions to prevent or reduce HIV HIV prevention research and interventional
risk–associated behaviors. program. recruiting participants with dif-
Several health behavior theories, such as ferent ethnic or cultural backgrounds in HIV
the Social cognitive Theory (Bandura, 1994), research to enhance our understanding and
the Health Belief Model (rosenstock, 1974), the capability against HIV epidemic is essential;
AIDS risk reduction Model (catania, Kegeles, however, it is challenging. The existing num-
& coates, 1990), and the Theory of reasoned ber of research conducted to understand HIV

HIV SyMpTOM MANAGeMeNT AND QUAlITy OF lIFe n 231



risk behaviors and effective preventions in research are needed. Studies to test behav-
this population is very limited. Few research- ioral interventions for significant popula-
ers have identified barriers and facilitators of tions and to increase retention, recruitment, H
recruiting ethnic minorities to HIV-related and adherence to procedure for HIV preven-
research in hopes to provide fundamental tion are necessary as well. Methodological
information for future development of cul- issues, including criterion measures, valid-
tural sensitive HIV interventional programs ity of self-report risk behaviors, measures of
(Jemmott et al., 1999; lee, Salman, & Wang, drug use, culturally and linguistically appro-
2010). priate measurement tools, comparability, and
When examining the effectiveness of an generalizability of studies, need special con-
intervention, measurement issues regarding sideration. Studies that integrate behavioral,
the indications of the HIV risk behaviors are social, and biological measures and develop
especially important. Because of its complex improved methodologies for data collection
nature, HIV risk behaviors are measured var- including improvement of sampling, mea-
iously by researchers in terms of content and surement of risk factors, and evaluation of
form. In most of the existing correlational outcomes are considered in an urgent need.
studies, HIV risk behaviors were measured research that develops new approaches to
using “relative frequency” data collected address underrepresented or difficult-to-
through likert scales or “count data,” which reach populations in interventional studies
provided the accurate number of behav- are one top priority for future research on
ioral events used in interventional studies HIV prevention as well (OAr, 2010).
(Schroder, carey, &Vanable, 2003). The “con- Bridges between research, theory, practice,
dom use” measure is the most frequently and policy as well as with other disciplines
used indicator for HIV risk behaviors in must be built. Future nursing studies in this
many related behavioral studies. Many inter- field are suggested to include biological mark-
ventional programs also focus on improving ers that can bolster the validity of the studies
the constant condom use. and to include various cultural populations.
The critical priorities of research related Developing a specific HIV risk behavioral
to HIV risk behavior are in concerns with reduction theory from the nursing perspec-
the goals of reducing HIV incidence, increas- tive will be useful and efficacious for nurses to
ing access to care and optimizing health apply to the reduction of HIV risk behaviors.
outcomes, and reducing HIV-related health
disparities (NIH Office of AIDS research Yi-Hui Lee
[OAr], 2010). To understand how to change Ali Salman
behaviors and maintain adopted protective
behaviors for reducing HIV risks, studies
to investigate biological behavioral interac-
tions and social dynamics on changes of Hiv syMptoM ManageMent
HIV risk behaviors are needed (OAr, 2010).
It is a continuing need to conduct HIV/AIDS- anD Quality of life
related research at the community level and
within specific populations (e.g., women,
racial and ethnic populations, men who have persons living with human immunodefi-
sex with men [MSM], homeless people, peo- ciency virus (HIV) and receiving antiretro-
ple affected with psychiatric disorders, and viral (ArV) therapy often experience severe
drug users). longitudinal and multivariate physical, psychological and cognitive symp-
studies to detect causal relationships and the toms (Wantland et al., 2008). ArV therapy
changing patterns of HIV risk behaviors and has also resulted in anthropomorphic and

232 n HIV SyMpTOM MANAGeMeNT AND QUAlITy OF lIFe



metabolic complications such as body fat dis- opportunistic infections being Pneumocystis
tribution abnormalities, lactic academia, insu- carinii pneumonia and Kaposi’s sarcoma.
H lin resistance, and bone disease (corless et al., The development of more advanced medi-
2005). patients with untreated HIV infection cation regimes (e.g., ArV) in the mid-1990s
frequently experience cD4 immunity inca- resulted in the evolution of HIV into a
+
pacitation, causing viral spread and develop- chronic illness (Spirig, Moody, Battegay, &
ment of opportunistic infections. However, Geest, 2005). However, despite care innova-
for patients receiving ArV, the more pervasive tions and prospects for longer term survival,
challenges may be the advent of unwanted side individuals with HIV infection continue to
effects that can trigger anxiety and depressive experience a plethora of medication side
symptoms and lead to medication nonadher- effects, comorbidities, and opportunistic
ence (Wantland et al., 2008). Other researchers diseases. consequently, medication nonad-
concur that symptoms (e.g., nausea, diarrhea, herence continues to be pervasive and often
fatigue, depression, and confusion) often have results in exacerbation of symptoms and
profound effects on daily activities and med- development of resistant strains of the virus.
ication adherence, further exacerbating the Kremer et al. (2009) cited “the decision to
negative impact on health-related quality of take antiretroviral therapy requires a long-
life (HrQOl; Hudson, Kirksey, & Holzemer, term commitment, because patients inter-
2004; Hughes, 2004; Kremer, Ironson, & porr, rupting antiretroviral therapy compared
2009). Symptom management, including pro- to those continuing were at increased risk
viding clients with avenues to explore self-care of death, cardiovascular disease, metabolic
strategies, has become a significant part of the effects, and immune activation during viral
health care provider’s role. The focus of this rebound” (p. 127).
chapter is to provide information about select The literature is replete with citations
aspects of the symptom experience; the effects regarding how health care providers can
of ArV therapy, comorbidities, and opportu- optimally manage the care of HIV-infected
nistic infections upon HrQOl; and the symp- patients. As patients have become more
tom management strategies for those living Internet savvy and increasingly incorpo-
with HIV/AIDS. rate self-managed complementary modali-
Merriam-Webster (2010) defines a symptom ties, the need for additional patient-friendly
as “subjective evidence of disease or physical resources has emerged. The International
disturbance.” Symptom management is “care HIV/AIDS Nursing research Network,
given to improve the quality of life of patients based at the University of california at San
who have a serious or life-threatening dis- Francisco (UcSF) School of Nursing, devised
ease. The goal of symptom management is a handbook in 2004 titled The HIV/AIDS
to prevent or treat as early as possible the Symptom Management Manual. Information
symptoms of a disease, side effects caused on 21 commonly occurring symptoms was
by treatment of a disease, and psychologi- validated by clinicians working in HIV care
cal, social, and spiritual problems related to and corroborated by participants in several
a disease or its treatment” (National cancer Network-directed research studies around
Institute, 2010). Quality of life is a term defined the world (Wantland et al., 2008). The man-
as a patient’s general well-being, including ual is available for free download at http://
mental status, stress level, sexual function, www.aidsnursingucsf.org. Because of the
and self-perceived health status (Stedman’s vast numbers of symptoms and manage-
Medical Dictionary for the Health professions ment complexities, our discussion within
and Nursing, 2005, p. 1233). this chapter will be limited to one primary
Initial reports of HIV began to occur in symptom and its associations with other fre-
the early 1980s, with the most frequently cited quently reported sequelae. lipodystrophy

HIV SyMpTOM MANAGeMeNT AND QUAlITy OF lIFe n 233



(now more commonly referred to as body fat persons with body fat redistribution changes
redistribution) emerged following the incep- associated with HIV.
tion of ArV therapies (e.g., nucleoside reverse It is challenging to provide a detailed H
transcriptase inhibitors and protease inhibi- presentation of HIV-related symptoms and
tors). reports of lipoatrophy (e.g., peripheral the resulting sequelae within the confines
fat loss of the face, extremities and buttocks) of this chapter. Although the symptoms ini-
in HIV-infected persons have ranged from tially associated with HIV (e.g., Kaposi’s sar-
28% to 37% (Bernasconi et al., 2002; Santos coma, P. carinii pneumonia) now appear less
et al., 2005). In a related study, 27% of study frequently, the advent of ArV therapy has
participants (N = 745) reported lipohyper- resulted in new symptom presence that can
trophic manifestations like breast enlarge- be as troubling as those found decades ago.
ment, central hypertrophy, and buffalo hump Symptoms like nausea, diarrhea, and fever
(Heath et al., 2002). These body fat changes still persist; however, entities like lipodystro-
have frequently caused increased stigma phy have emerged as more contemporary
and diminished HrQOl, often resulting issues. The results can often be the same as
in self-image dysmorphia, development of those observed in the early 1980s. Individuals
depressive symptoms, and nonadherence to living with HIV/AIDS continue to experience
treatment regimens (rajagopalan, laitinen, & anxiety and self-image disturbances associ-
Dietz, 2008). ated with comorbidities, medication side
corless et al. (2005) conducted a descrip- effects, and body fat changes. These factors
tive, exploratory study (N = 165) to exam- can impact daily activities, affect medication
ine relationships between the presence of adherence, result in increased depressive
lipodystrophic and depressive symptoms, symptom presence, enhance disease-related
social support, quality of life, comorbidities, stigmata, and decrease HrQOl. rajagopalan
and ArV adherence. patients experiencing et al. (2008) reported similar findings regard-
HIV medication-related body fat changes ing significant reductions in HrQOl in per-
were only “moderately adherent” (p. 582) to sons experiencing lipoatrophy. They also
ArV therapy, with as many as 57.6% admit- noted that “HIV-infected individuals expe-
ting forgetting to take their medications, or rience a considerable reduction in health-
intentionally failing to adhere to the pre- related quality of life compared to the general
scribed regimen. Sixty-seven percent of the population” (p. 1201).
sample reported comorbidities, with depres- It is imperative that we continue to
sion, diabetes, hepatitis, and hypertension reshape symptom management programs
occurring most frequently. More than 80% for persons living with and affected by HIV/
of the respondents indicated significant lev- AIDS. Nurses are well positioned to assist
els of depressive symptoms, as measured by clients with symptom management, particu-
the center of epidemiological Studies larly self-care measures that have been val-
Depression Scale (radloff, 1977). There idated through numerous scientific studies
was also a significant relationship between and opinions of clinical experts in the field
the center of epidemiological Studies of HIV. Spirig et al. (2005) suggested that
Depression Scale scores and medication “nurses and researchers work together to
nonadherence (r = .275, p = .001). participants better understand patients’ social systems,
with other medical conditions demonstrated symptom experiences, adherence levels to
significant relationships with adherence and therapeutic regimens, and overall quality of
quality of life (r = .495, p = .002). This study life” (p. 342).
suggested that body dysmorphia, adherence
to ArV regimen, and diminished HrQOl Kenn M. Kirksey
are perceived as significant problems in Gayle McGlory

234 n HOMe cAre TecHNOlOGIeS



quality of life for patients and that families
HoMe Care teCHnologies overwhelmingly want these devises and
H informatics in their home (Smith, 1999, 2007).
A common requirement for placing com-
The Office of Technology Assessment, in plex technological equipment in the home
a 1987 memorandum to the U.S. congress, is that a competent and willing caregiver is
described a technology-dependent person as available to manage the equipment before
one who needs both an ongoing nursing care treatment (such as home parenteral nutrition
and a medical device to compensate for loss therapy). Technology caregiving resembles
of a vital body function, to sustain life, and to a miniature, urgent care center where fam-
avert death or further disability. Home care ilies provide complex, direct patient care,
technologies include mechanical ventilation; maintain equipment and supply invento-
apnea detection monitoring; oxygen assist; ries, obtain needed home services, negotiate
continuous positive airway pressure; nutri- for reimbursement, and manage caregiver
tion or hydration via central venous infusion; problems of fatigue (czaja & Schulz, 2006;
hemodialysis and peritoneal dialysis; spinal Day, Demiris, Oliver, courtney, & Hensel,
infusion for pain; vascular infusions for 2007). With both medical devise and infor-
chemotherapy, insulin, or antibiotics; auto- matics home care technologies, a family can
matic internal cardiac defibrillation; and left- provide the patient with daily nursing care,
ventrical heart assist devises (Smith, 2009). makes complex decisions about treatments,
Both technology devices and information and learns skills in managing machines
technology systems (Internet, cell phones, or and informatic connections (Matthew, 2006,
telehealth) are involved in home care tech- Morgan, 2004).
nologies. Information technology is used Nursing research has contributed to
to provide guides for assisting families in study of home care technologies findings in
managing home care technology treatments several areas (Smith, 2009). Smith (1995) has
and in supporting health care practitioners’ a series of studies on families, caregivers,
and patients’ visual and audio communica- and patients dependent on technology for
tions (piamjarakul & Smith, 2007; yadrich & lifelong survival (Smith et al., 2002). The eth-
Smith, 2008). Modern informatics technology ical issues in technological home care were
can achieve the goal of “establishing access to summarized and research questions posed
information about home technology care and in a Hastings center report (Arras, 1994,
overcome the discontinuity between inpa- Arthur, pang, & Wong, 2001). Family mem-
tient and home care setting.” bers reported being ill-prepared for technol-
The latest area of home technology ogy caregiving (Smith, 2008), and little has
development is assistance by robots, which been done to support caregivers with their
can remind patients about treatment sched- long-term daily technology care (Smith, 2007;
ules, medications, and even assist in walking Smith, Mintz, & caplan, 1996).
(czaja & Schulz, 2006; pollack et al., 2002). In research with home care technolo-
addition, there are now “smart” homes for gies should be systems oriented on a vari-
frail elders (pollack et al., 2010). Smart homes ety of levels: machine reliability and safety,
are wired with sensors to detect motion and compensated physiological systems, family
thus monitor safety of activities in the home, caregiving, community support, health care
such as overuse of stoves and alert emergency providers, and third-party payers’ reim-
services (Matthews, 2006; rialle, Duchene, bursement (Noel, Vogel, erdos, cornwall,
Noury, Bajolle, & Dermongeot, 2002). & levin, 2004). The most extensive research
Studies verify that various home care has been at the machine or device level,
technologies lead to added length and including manufacturers’ studies of the

HOMe cAre TecHNOlOGIeS n 235



mechanical system that has led to Food and of both published reviews are that there
Drug Administration’s approval for clinical is strong evidence indicating the benefits
trials conducted by nurses. Government reg- of home telecare for home chronic disease H
ulation also has called for research on the management and growth in these services.
manuals accompanying devices to determine picture phone use for hospice care has been
readability and effectiveness of instructions well received by caregivers and verified as
for laypersons. cost effective, although social workers have
In 1996, the National Academy of Science found it is underused (Glasgow, 2007).
presented a report to the congress from man- A cochrane review of seven clinical tri-
ufacturers, regulators, health professionals, als concluded that picture phones were reli-
families, and patients regarding findings from able, well accepted by patients and family,
research on safety and issues of home technol- and without detrimental effects but that clin-
ogies and family care. problems to be studied ical outcomes and cost research was lacking
included the impact of family caregiver quality (collins, Murphy, & Strecher, 2007; currell,
of life (Smith, Hunt, czaja, Juhn, & Kelly, 2002), Urquhart, Wainwright, & lewis, 2001; lytle,
the ethical decision making in use of technol- 2002). clinical trials of in-home picture phone
ogies, the costs of safety regulations for manu- visits by nurses found significant improve-
facturers, and the quality control measures for ment in treatment adherence in an older pop-
home care (Schulz, lustig, Hondler, & Martire, ulation at costs much lower than delivering
2002). problems to be studied included the traditional home nursing visits (Smith, Dauz,
impact of technologies on patients and fam- clements, cook, & Doolittle, 2006).
ily caregivers’ quality of life, ethical decision recently summarized clinical trials data
making in use of technologies, costs of safety identified several efficacious Internet-based
regulations for all technologies, and quality interventions related to chronic disease
control measures for home devises. patient education, interactive support, treat-
Major conclusions from research are that ment follow-up, and home problem man-
home care technologies enhance and extend agement guides (Glasgow, 2007). effective
quality of life for those who would otherwise informatics technology interventions such
succumb to illness, frailty, or disability. Further, as step-by-step algorithms for guiding daily
family members are very capable and desirous technology procedures, video scene illustra-
of home care for their technology-dependent tions of technologic health care equipment
loved one. Direct physical care and indirect assembly, and contacts between health pro-
costs (reduced income, innumerable expenses, fessionals and families have been successful
and transportation fees) are shifted to the fam- (Smith, 2011; Smith et al., 2005).
ily, and evidence of emotional and physical Future directions for research include
strain occurs in family caregivers. Delivery the need for continued study of informatics
of technology services in home care is costly technologies that can support safe, optimal
and uncoordinated, although cost savings and care. In addition, all informatics technolo-
quality improvements occurred when models gies themselves must be continuously tested
of comprehensive care were followed. In some for ease of use. Study of interventions for
communities and states and in some popula- technology home care in culturally diverse
tions of patients (e.g., ventilator dependent), populations is still needed (Smith, 2008). In
coordinated technology care services do exist. addition, policy, ethical, professional, and
The Agency for Healthcare research interdisciplinary areas of regulation and
and Quality commissioned two Technology safety issues should be researched to reduce
Assessment reports in 2001 and in 2006 to duplication and enhance resource availabil-
review the efficacy-based studies of telecare ity (Smith et al., 1996). predicting cost and
technology (HMr, 2007). Telecare Outcomes outcomes of care should be compared with

236 n HOMe HeAlTH clASSIFIcATION SySTeMS



patients’ health outcomes and families’ They increased faster than all other organized
desired quality of life. consumer demand providers in the health care industry because
H and technological advances will continue, Medicare primarily addressed the health care
one hopes, with nursing research verifying needs of the aging population. As this popula-
theoretical frameworks that guide effective tion grew, more health services were required,
home and informatics technology. resulting in an increase of health care costs that
required cost containment. As a result, health
Carol E. Smith care began to shift from acute short-term hospi-
tal care to community home-based and chronic
long-term care. patients began to be discharged
HoMe HealtH “sicker and quicker” and required more health
care services in the home.
ClassifiCation systeMs Home health systems were initially
introduced as management information sys-
tems designed to manage the flow of infor-
Home health systems are computer-based mation in the proper time frame and to
information systems designed to support assist in the decision-making process. The
care of the sick in the home. Home health early home health systems were introduced
systems primarily support home health and in large VNAs and other nonprofit HHAs
hospice programs provided by home health as billing and financial systems. They were
agencies (HHAs). Home health is more than developed for the sole purpose of improving
“care in the home.” Home care practitioners cash flow, holding down costs, and address-
offer continuity of care from the hospital to ing the federal regulatory requirements for
the community. They also use public health HHAs. They were designed to furnish the
concepts of disease prevention and health information necessary to obtain reimburse-
promotion and coordinate the services of ment for services from Medicare, Medicaid,
multiple providers, vendors, and community and other third-party payers.
agencies that may be involved in the care of Home health systems generally were
an individual or family. developed by commercial vendors who
Home care is the oldest form of health obtained the computer system hardware and
care and yet the newest. Home health nursing, developed the software to process the services
previously called care of the sick in the home, data provided by the HHAs. The computer
is one of the earliest developments in the field vendors owned the home health system and
of public and community health. care of the were responsible for maintaining and updat-
sick at home traditionally has been provided ing them. Home health computer vendors
by voluntary nonprofit agencies, such as vis- were usually contracted by the HHAs to pro-
iting nurse associations (VNAs). These agen- vide billing services and financial manage-
cies were organized to provide out-of-hospital ment, without the HHAs having to develop
services primarily to those who were sick their own system. With the introduction of
and poor. In 1885, the first VNA in the United the microcomputer and online communica-
States opened its doors in Buffalo, New york tion systems, local area networks and wide
(Maurer & Smith, 2009). area networks were introduced, designed to
In 1966, with the introduction of Medicare advance and enhance the home health sys-
and Medicaid legislation, home health pro- tems. They were used to link state and local
grams emerged from hospitals, ambulatory care units, to share hardware and software, and
facilities, and health maintenance organiza- to integrate data (Saba & Mccormick, 1996).
tions as stand-alone businesses. The programs Over time, home health systems have
and providers increased in number and size. been designed not only to collect and process

HOMe HeAlTH clASSIFIcATION SySTeMS n 237



home health data required by governmental focused, with authors presenting their expe-
and private third-party payers for reimburse- riences and lessons learned. crossen-Sills,
ment for patient services but also for the effi- Toomey, and Doherty (2009) recount the H
cient management of the HHA. Billing and transformation of a nearly century old VNA
financial applications include general ledger, into a technological leader. Their successful
accounts receivable, accounts payable, billing, journey with home health systems imple-
reimbursement management, and cash man- mentation was guided by attention to the
agement. Operations management applica- mission of the organization as well as benefits
tions, such as scheduling, patient census, visit to their home health patients. Home health
tracking, cost statistics, utilization reports, systems integration has been addressed by
accounting statements, and discharge sum- hospital- and health system–based HHAs.
maries have been developed and refined. Inpatient electronic patient care information
Newer home health systems have systems include home health applications for
emerged that are designed to focus on the seamless integration of patient care records
patient encounter and visit during an epi- and collaborative care among health care
sode of care. They include clinical applica- professionals from home health, inpatient,
tions used to assess and document the care and ambulatory care settings.
process, to generate care plans, and to pre- The U.S. Department of Veterans Affairs,
pare critical pathways or protocols that out- a recognized leader in technology and patient
line critical events. These newer systems care systems, has turned its attention to home
have the capacity to communicate patient health systems. recognition of the needs of
information for continuity of care from hos- the aging veteran population has resulted in
pital to the home, to the community, and back an increasing focus on home health care and
to the hospital. The systems also offer other associated technologies. The Veterans Affairs’
applications that focus on decision support, computerized patient record system offers a
evaluation of care, and measurement of out- well-integrated system for care coordination
comes across settings, time, and geographic and conferences for home care staff and other
locations. The systems are considered part of health care providers. Their community care
the lifelong longitudinal record containing coordination Service (Kobb, Hilsen, & ryan,
patient-specific health-related data. 2003) uses multiple technologies to maximize
Stolee, Steeves, Glenny, and Filsinger care coordination and patient satisfaction as
(2010) researched facilitators and barriers well as to identify best practices for veterans
to use of home health systems. limited with chronic health conditions. One element
research about home health systems of community care coordination Service,
inspired their effort. In conducting their home telehealth, also has gained widespread
research, they noted lack of clarity about acceptance among home health patients and
definitions and use of terminology for the providers in a variety of settings, especially
many forms of electronic systems now rural locales.
being used in HHAs. The most commonly Home health systems are expected
identified facilitators of home health sys- to enjoy growing recognition and utili-
tems were portability of technology, oppor- zation in the future. These increasingly
tunity for improved data entry accuracy, sophisticated systems will be refined and
management support, and incentives for improved as the population of the United
users. Barriers to successful implementa- States ages, the needs for home health care
tion of home health systems centered on swell, and the health care system contin-
cost and training requirements. ues to evolve.
The literature about home care systems
tends to be more discussion- than data-base Sandra Sojka

238 n HOMe HeAlTH SySTeMS



resulting in an increase of health care costs
HoMe HealtH systeMs that required cost containment. As a result,
H health care began to shift from acute short-
term hospital care to community home-based
Home health systems primarily support and chronic long-term care. patients began to
home health and hospice programs provided be discharged from inpatient settings “sicker
by home health agencies (HHAs). Home and quicker” and required more health care
health is more than “care in the home.” It services in the home.
focuses on the continuity of care from the hos- As the number and type of HHA
pital to the community, public health concepts increased, technological systems were
of disease prevention and health promotion, needed to manage the flow of informa-
and out-of-hospital acute illness services. tion in the proper time frame and to assist
Home care is the oldest form of health in the decision-making process. They were
care and yet the newest. Home health nursing, designed to furnish the information required
previously called care of the sick in the home, for payment by Medicare, Medicaid, and
is one of the earliest developments in the field other third-party payers for reimbursement
of public and community health. care of the for services. They were developed for the
sick at home traditionally has been provided sole purpose of improving cash flow, holding
by voluntary nonprofit agencies, such as vis- down costs, and addressing the federal regu-
iting nurse associations, organized to provide latory needs for HHAs.
out-of-hospital services (Martinson, Widmer, Systems were generally developed by
& portillo, 2002). However, care is now also commercial vendors who obtained the com-
provided by profit-based organizations. puter system hardware and developed the
The systems involved in the delivery of software to process the services data provided
patient care in the home have changed since by the HHAs. The computer vendors owned
1883 when lillian Wald established the first the home health system and were responsible
home health nursing agency in the United for maintaining and updating them. Home
States (Martinson et al., 2002). However, the health computer vendors were usually con-
principles that guide home care continue to tracted by the HHAs to provide billing ser-
be holistic and focused on helping people vices and financial management, without the
remain in their homes despite or following HHAs having to develop their own system.
a serious or acute illness or condition. In the With the introduction of the microcomputer
beginning, services were provided as charity and online communication systems, local area
to the poor. Today, in many HHAs, provision networks and wide area networks were intro-
is made for a small group of people who do duced, designed to advance and enhance the
not have insurance and who cannot afford home health systems. They were used to link
fee-for-service care. However, visits are usu- state and local units, to share hardware and
ally very limited, and patients are provided software, and to integrate information.
with resources to help them once they are These systems are designed not only
discharged from the agency. to collect and process home health data
In 1966, after Medicare and Medicaid leg- required by the federal government and
islation were introduced, home health pro- third-party payers for reimbursement of
grams began to increase in number and in size. services but also for the efficient manage-
They increased faster than all other organized ment of the HHA. They focus on billing and
providers in the health care industry because financial applications, such as general led-
Medicare primarily addressed the health care ger, accounts receivable, accounts payable,
needs of the aging population. As this popula- billing, reimbursement management, and
tion grew, more health services were required, cash management. They also may include

HOMeleSS HeAlTH n 239



other management applications, such as As more nurses have moved into home
scheduling, patient census, visit tracking, care settings, they are often finding themselves
cost statistics, utilization reports, accounting overwhelmed, especially if they have previ- H
statements, and discharge summaries. ously worked only in inpatient settings. Home
Newer technological systems have care is unstructured, and the nurse is often
emerged that are designed to focus on the called on to make autonomous decisions. A
patient encounter and visit during an episode research-based theory of home health nursing
of care. They include clinical applications (Neal, 1999; Neal-Boylan, 2009) was developed
used to assess and document the care process, to help nurses and administrators understand
to generate care plans, and to prepare critical the characteristics needed to be a successful
pathways or protocols that outline the criti- home health nurse and to help guide nurses
cal events. These newer systems are using the new to home care as they transition.
electronic information superhighway to com- Home health has increasingly become
municate patient information for continuity of the focus of myriad research studies as
care from hospital to the home, to the commu- researchers strive to discover how to retain
nity, and back to the hospital. The systems also home health nurses given an environment of
offer other applications that focus on decision increased demand and complicated expecta-
support, evaluation of care, and measurement tions regarding documentation. researchers
of outcomes across settings, time, and geo- are also evaluating home health nursing
graphic locations. The systems are considered practices to determine whether they are evi-
part of the lifelong longitudinal record con- dence-based and protect the patient and the
taining patient-specific health-related data. nurse in the home environment.
Tele-health home monitoring systems
are being used with increasing frequency to Leslie Neal-Boylan
monitor the status of patients who reside in
remote locations or who need frequent super-
vision. These systems vary and include their
own manufacturer guidelines. However, cri- HoMeless HealtH
teria for patient enrollment are fairly con-
sistent, such as the ability of the patient to
physically and cognitively participate in the The global economic recession and the contin-
program, a safe home environment, a pre- uing ongoing declared and undeclared wars
dicted extended stay on service, a useable have caused a marked increase in the number
phone system, and a willing caregiver. Staff, of homeless people worldwide. Homelessness
patients, and caregivers must receive train- is a complex phenomenon that has many
ing in the use of the equipment (Visiting intersecting causes: historical, social, eco-
Nurse Associations of America, 2008–2009). nomic, political, and educational; but regard-
The Outcomes Assessment and Set emerged less of the cause, the loss of “your” home and
in an attempt to accurately assess the home its connections with your life is a major stress-
health patient’s status on admission to home ful assault on the personal identity of individ-
care and at various intervals throughout the uals, families, and population subgroups.
home care stay. The data gleaned are used by The impact of this disruption in
Medicare, Medicaid, and private insurances health increases dramatically when a per-
to determine reimbursement for home visits. son becomes homeless. These detrimen-
The Outcomes Assessment and Set includes tal effects include diminished mental and
several versions of forms that include ques- physical health (Savage, lindsell, Gillespie,
tions ranging from functional ability to lee, & corbin, 2008), lack of access to both
wound status and more. preventive (Bonin, Fournier, Blais, perreault,

240 n HOMeleSS HeAlTH



& White, 2010), acute and chronic health research tools: methodologies, instruments,
services (Gelberg et al., 2009), diminished and designs; and (3) the new subpopula-
H ability to resist high-risk drug and sex- tions studied: elderly (Joyce & limbos,
ual behaviors (Hudson et al., 2009; Stein, 2009), youth (Haldenby, Berman, & Forchuk,
Nyamathi, & Zane, 2009), and increased 2007; Stewart, reutter, & letourneau, 2007),
vulnerability to both injury through vio- runaways (Martinez, 2006), teen moms
lence (Busen & engebretson, 2008; Johnson, (Meadows-Oliver, 2006a, 2006b; Meadows-
rew, & Kouzekanani, 2006) and most impor- Oliver, Sadler, Swartz, & ryan-Krause, 2007),
tantly mortality. The life expectancy of the and those transitioning from homeless to
homeless is shorter than for their housed housed (Drury, 2008; Heliker & Scholler-
counterparts. In the Dying Without Dignity: Jaquish, 2006; Montgomery et al., 2008).
Homeless Deaths in Los Angeles County Although mental health and drug abuse
2000–2007 report, life expectancy was issues are still a research interest, studies
reported as 36% shorter on average and 49% now are directed toward understanding
shorter for latina females (Hawke, Davis, & the “bigger picture” by focusing on envi-
erlenbusch, 2007). A similar 5-year study in ronmental and other barriers to treatment
Scotland concluded that “homelessness is (Forchuk, Brown, Schofield, & Jensen, 2008)
an independent risk factor for deaths from and the use of preventive health services
specific causes” (Morrison, 2009). rather than targeting individual abuse/
previous research in this area is not rehab issues (Darbyshire, Muir-cochrane,
robust. The homeless are complex, vulner- Fereday, Jureidini, & Drummond, 2006). The
able, mobile, difficult populations to study studies now span the continuum from iden-
and resources are scarce. consequently, tifying objective and subjective factors that
many of the published studies have been facilitate individual participation in hepati-
poorly funded, descriptive in nature, and tis vaccination (Stein & Nyamathi, 2010) and
use small convenience samples in nonexper- latent tuberculosis treatment (Nyamathi,
imental designs. The NIH-funded studies christiani, Nahid, Gregerson, & leake,
focus on the mentally ill and substance abus- 2006; Nyamathi et al., 2008) to cost analyses
ers (Zerger, 2005). of various nurse managed care intervention
Nurses historically have been on the front- treatment programs (Greengold et al., 2009;
lines of caring, advocating, and conducting larimer et al., 2009).
research on the health of the homeless. Since An evolving new direction of research
2005, the panorama of nursing homeless health is toward seeking the perspectives of home-
research has expanded in both breadth and less individuals regarding concrete topics
depth. Homelessness is a worldwide phenom- related to their personal health and health
enon. recent nursing research reflects this fact status (Anthony & Barry, 2009; Daiski, 2007;
with publications from South Korea, Australia, Gelberg et al., 2008), access to and utiliza-
Nigeria, pakistan, Nepal, Japan, england, tion of care (DiMarco, 2007; Forchuk et al.,
Australia, South Africa, and canada. Although 2008), health care provider experiences
the majority of nursing research studies are (Hudson, Nyamathi, & Sweat, 2008), and
authored by U.S. researchers, multicultural experiences of caring for children while
and international studies provide insights into homeless (Meadows-Oliver, 2006a, 2009).
homeless health issues, which reveal both the Studies on more esoteric topics such as the
universal and the unique cultural aspects of personal meaning of becoming homeless
homelessness and health (lee, 2008). (Finfgeld-connett, 2010), discovering per-
The expanding depth of nursing sonal strengths living in an abuse shelter
research is shown in (1) the new directions (Hemphill, 2005), being uprooted and dis-
of inquiry; (2) the wider use of various located (Berman et al., 2009), and social

HOSpIce n 241



support (Meadows-Oliver, 2005) are also care, (3) the increasing use of technology,
emerging. These insights will facilitate bet- and (4) the Housing First movement. These
ter understanding of the homeless and more factors are directed at changing the health of H
relevant research interventions. the homeless by preventing the occurrence
Few new validated instruments for of homelessness and by making rapid stable
homeless health research have been devel- rehousing the primary care focus. This will
oped. However, one new instrument, the change the direction of research on homeless
ccH consumer Outcome Scales, is promis- health funding.
ing. It measures six major areas of homeless Future funding opportunities will focus
functioning (housing, employment, ben- on new preventive and alternate care modali-
efits, medical, medical health, and substance ties such as medical respite (public and private;
abuse) and includes three outcome scales Zerger, 2005), innovative care management
related to homeless health (cook, Farrell, & models (cooperative, case management, and
perlman, 2007). This instrument may facil- care via assistive technologies—cell phones,
itate larger studies comparing the health of Health Buddy; Zimmerman & Barnason,
homeless groups nationally. 2007), and remote visualization (ludden,
chiu and DiMarco (2010) report a novel 2010). Documentation of quality care, cost
use of instruments to assess the growth analyses, and tracking efficiencies (larimer
and development of preschool homeless et al., 2009) will dominate future research
sheltered children. Their study compared funding decisions.
the results of a nurse administered Denver
Developmental Screening Test II and the Mary J. McNamee
mother’s assessment of her child using the Marilyn Wegehaupt
Ages and Stages Questionnaires instrument.
They report a high degree of comparability
(95%) for nurses and mothers in both gross
motor assessment and personal social devel- HospiCe
opment and 67% comparability in language
development assessment. Although a small
study, this may be a new way for both easier Hospice research in the United States began
and earlier identification of developmental with studies of the differences between hos-
delays in homeless children and foster more pice care and care received in traditional set-
parent educational support. This study needs tings for the terminally ill. Although these
to be replicated with a larger population. studies examined the impact of care provided
In summary, nursing homeless health by hospice, largely nursing care, such studies
research is more diversified than ever with were not nursing research. In canada, Mary
recent publications from five of the six con- Vachon, a U.S.-trained nurse, was invited by
tinents. Most of the studies are small and the palliative care team at the royal Victoria
descriptive, use convenience samples, and are Hospital in Montreal, canada, to investi-
not theory based. research using ethnograph- gate stress in the caregivers who composed
ical-phenomenological study frameworks the palliative care team. Other researchers
(Hubbert, 2005; Martins, 2008; Meadows- examined pain pathways, medications for
Oliver, 2006b; Hunt, 2007) and meta-synthesis pain, and the impact of music therapy. In
(Meadows-Oliver, 2006b) have increased. england, Dame cicely Saunders, trained as
The future direction of homeless health a physician, social worker, and nurse, and
research will be shaped by (1) the patient others examined the impact of medications
protection and Affordable Health care Act for symptom relief. These early studies had
(Hr3590) of 2010, (2) the economics of health as their focus the improvement of care of the

242 n HOSpIce



dying and, in the United States, the evalua- In an attempt to validate the impact of a
tion of whether hospice care improved such hospice palliative care unit on perceived fam-
H care and was fiscally sound so as to be wor- ily satisfaction and to examine the demograph-
thy of a new benefit to fund such care. These ics of patients, Kellar, Martinez, Finis, Bolgar,
studies were conducted by researchers from and von Gunten (1996) surveyed 240 families
a number of disciplines. of patients of the program. The most frequent
Nursing research about hospice has been response to an opened-ended question about
conducted using a variety of methodologi- the advantage of the program was the profes-
cal approaches including qualitative ones— sional nursing care. Few remarks were made
ethnography, observations, semistructured about disadvantages, and these had to do with
interviews, and interviews—and quantitative the parking facility expenses, the distance
ones—quasi-experimental, questionnaires/ families had to travel, and the potential for
surveys, and audit as well as a combination patient transfer because of the facility’s desig-
of methods. research about hospice covers nation as an acute-care facility. Of the 92 eli-
an array of topics. Topics include organiza- gible surveys returned, the researchers found
tional methodologies, demographic data, that 88% (81/92) considered the hospice to be
social support, physiological, psychosocial, very helpful to the patient, 9% (8/92) found
and spiritual issues, self-care, how patients the program to be helpful, and 1% (1/92) were
spend their time, grief, bereavement, stud- neutral. This type of study is representative
ies of nurses and their knowledge, and the of a host of studies conducted by hospice pro-
impact of hospice care. Some of these top- grams to assess their audience and the satis-
ics use hospice as a setting for research but faction with the program.
are not about hospice per se. Topics for such Hospice referral remains crucial to the
studies include an examination of cancer viability of such programs. Although interest
pain in home hospice patients, a comparison is usually expressed in the attitudes of physi-
of nurses’ knowledge about AIDS by prac- cians, Schim, Jackson, Seely, Gruinow, and
tice setting, training, and educational pro- Baker (2000) examined the attitudes of home
grams where the focus is the program and care nurses to hospice referral. Attitudes of 160
not the hospice patients and nurses, and the nurses were assessed with a 15-item survey
grief experience of older women. In this case, that was completed by 75 nurses for a response
the husbands had received hospice care, but rate of 46.9%. Home care nurses saw little dif-
that was not the focus of the study. Indeed ference between home care and hospice ser-
the researcher suggested that a future study vices. Many (42.6%) of the respondents thought
might compare the experience of women insurance with a hospice benefit was necessary
whose husbands had received such care and for referral. These and other misperceptions
those who had not (Jacob, 1996). A similar underscored the importance of home care
study in Finland examined the adjustment of nurses understanding the requirements and
relatives after the death of a hospice patient. components of hospice care. The importance
Again the focus was on the adjustment and of attitudes as well as knowledge was under-
not the differential impact of the hospice scored by a study investigating the factors that
program on such adjustment. An examina- increased the likelihood that nurses would
tion of the relationship between depressive discuss terminal illness care and hospice care
symptoms and symptom distress in patients with patients and families. cramer, Mccorkle,
with cancer who are newly admitted to hos- cherlin, Johnson-Hurzeler, and Bradley (2003)
pice home care does not compare the effect of found that prior experience with hospice,
settings on the variables of interest. rather, greater knowledge, and religiosity as well as
hospice home care is irrelevant to the analy- greater comfort in initiating such discussions
sis (McMillan & rivera, 2009). were related to their initiation by nurses.

HOSpIce n 243



length of survival in hospice continues yorkshire puddings, yogurt, eggs, fruit
to be an area of concern given that refer- juices, and beer. Three major comments con-
rals are often made closer to the death of the cerned the size of the portions (too large), H
patient. younnis and colleagues in a study of the foods not the right temperature (not hot
180 patients with cancer referred from a com- enough), and the time of food service (pre-
prehensive cancer center found that both low ferred later in the day). This study, although
palliative performance Scores and male gen- used to help nurses understand the research
der were associated with shorter lengths of process, had an impact on patient care in the
stay. Although participation in prior clinical facility where the research was conducted.
trials did not affect the results of this retro- Although not commented on by the authors,
spective study, the authors note the impor- it would be helpful in future research if a
tance of a prospective study to investigate larger sample of patients were included in
the impact of clinical trial participation on the study where closeness to death was taken
length of hospice stay. into account in examining food preferences
The factors that affect whether a certi- of hospice care recipients.
fied Medicare hospice is present in a rural The needs of family caregivers also
community were examined by campbell, have been of concern to hospice providers.
Merwin, and yan (2009). They found that Harrington, lackey, and Gates (1996) studied
rural communities were less likely to have a the needs of caregivers of both hospice and
Medicare-certified hospice. The higher the rate clinic patients. results indicated that the top
of physicians in the area, however, the more information need of the caregivers of clinic
likely a Medicare-certified hospice would be patients was for honest and updated informa-
present. The authors note that the requirement tion and specifically information regarding
of the Medicare hospice benefit for physician treatment side effects. In contrast, the infor-
certification of terminal illness may constitute mation needs of hospice caregivers concerned
a barrier to the presence of hospices in rural the symptoms to be expected. These needs
areas, an absence that may impede quality represent the differences in the point in the
end-of-life care for residents of rural areas. illness trajectory of the two sets of patients.
Volunteers constitute an important pro- Spiritual needs were the second most fre-
grammatic aspect of hospice. In a study of 32 quently noted for both groups of caregivers.
hospices in the southwestern United States, personal needs included the need for adequate
351 volunteers responded to a mailed sur- rest for both groups of family caregivers, but
vey (planalp & Trost, 2009). Their motivation these were not considered to be as important
for volunteering included helping others and by the family caregivers as the need for care
learning, fostering social relationships, feel- of the patient. The authors recommend a lon-
ing better, and pursuing career goals. Age had gitudinal study on this subject.
an impact on these motivations with younger Tang (2009) examined hospice care-
volunteers being more career oriented and giver quality of life (QOl) with an emphasis
older volunteers more socially oriented. on those providing care at home. As Tang
Another example of program-related observes, the caregivers both provide sup-
research is a study on patient-focused port and need support placing those provid-
menu planning (Fairtlough & closs, 1996). ers of care in a somewhat unique position in
Over a 4-week period, 108 interviews were health care but an acknowledged aspect of
conducted related to specific meals. Foods hospice care. The focus by hospice programs
not liked included those difficult to swal- on the family care provider is essential to the
low, tough or fried foods, or those with effective provision of hospice care and par-
bones. patients indicated they wanted sea- ticularly home care and thus is an important
food including salmon and prawns, beef, area of investigation.

244 n HOSpIce



The congruence between patient and in hospice spend their time. It was found
caregiver reports of symptom intensity was that family members and nurses spend
H examined by McMillan and Moody (2003). The more time with patients in hospice than in
symptom intensity of pain, dyspnea, and con- oncology units but the time nurses spend
stipation was evaluated by both patients and is concerned with “tasks.” If hospice nurses
their family caregivers. Symptom intensity of increased their time with patients because
all three symptoms were significantly overes- of the increased need for tasks, then the con-
timated by caregivers (p = .000). This overesti- text has had little effect on the type of care-
mation is the basis upon which hospice nurses giving. The authors note the importance of
base their clinical decisions. The authors note time spent “being with” patients, not only in
that this study has implications for the educa- “doing for” patients.
tion of hospice family caregivers. The time devoted solely to tasks raises
perceptions of the intensity of symptoms the question of whether death anxiety is a
by nurses might be expected to be closer to significant factor in hospice nurses. payne,
those of their patients than was true for family Dean, and Kalus (1998) examined death anx-
caregivers. In a study by rhodes, McDaniel, iety in hospice and emergency nurses and
and Matthews (1998), 53 hospice patients, with found that the latter had higher death anx-
a mean age of 69 years, were queried about iety and less support from their peers and
their symptom experience with the Adapted supervisors. In another study, support was
Symptom Distress Scale Form 2. The nurses also deemed to be significant for hospice
were also questioned about their patients’ nurses if they were not engaging in block-
symptom experience. like the informal care- ing behaviors when confronted with the
givers, the nurses in this study overestimated emotions of patients (Booth, Maguire, Behir,
the symptom intensity of their patients. The Butterworth, & Hillier, 1996). Death anxiety
authors note that this is congruent with some can be reduced for student nurses through
other findings of overestimation but con- educational experiences, as Mallory (2003)
flicted with findings of underestimation, par- demonstrated.
ticularly with regard to perceptions of pain. research demonstrating the interest
Indeed, McMillan (1996) demonstrated that and need for advanced education for hos-
pain was still not well managed in cancer pice nurses had the additional benefit of pro-
patients. The importance of the instrument viding information to nurses interested in
as a reliable means of assessing symptoms hospice as a career (Wright, 2001). Although
resulted in the incorporation of the Adapted education and professional development
Symptom Distress Scale Form 2 into the clin- have always been considered important for
ical practice of the nurses. hospice nurses as for all nurses, Metcalfe,
QOl is an important concept in health pumphrey, and clifford (2010) argue that
care. Hill (2002) examined both the measure- hospice nurses need education on genetics
ment of QOl and how it might be improved so as to be able to address the implications
in hospice patients. This study, like that by of various genetic disorders. In particular,
rhodes et al. (1998) underscored the impor- the authors stress the need for such educa-
tance of nurses understanding how the tion if nurses are to be aware of the psycho-
patient assessed aspects of QOl. Hill indi- social implications for families and patients
cated that this knowledge was a guide to the afflicted with such diseases. Their research
reflective practice of the nurse and assured entailed responding to a questionnaire, and
clinically significant improvements of care although the response rate was low (29%), the
for the patient. sample size of 328 provided a useful sample
In an exploration of the context for care, size for exploring issues of the importance
rasmussen and Sandman (1998) investi- and confidence to address various genetic
gated how patients in an oncology unit and disorders. The development of knowledge in

HyperTeNSION n 245



genetics poses new opportunities in the pro- illness. “Special” patients were found to
vision of hospice care. be related to support of personhood of all
The bottom-line question for patients patients, although the “special patients” were H
and families is whether hospice has a posi- perceived to receive no preferential treat-
tive impact on QOl. Using the Hospice care ment. In fact, “special” patients were found
performance Inventory, yeung, French, and to have a positive impact on the caregivers.
leung (1999) identified six issues in which As noted, much hospice research has
patient expectations and effectiveness of care examined the impact of hospice on costs, an
were not congruent. Maximization of self- early concern of government officials when the
care and mobility were the two issues with development of a hospice benefit was being
the greatest discrepancy. patients preferred to considered. The coming of age of hospice is
do their own self-care rather than have it done indicated by the focus on enhancing hospice
to them. Another patient priority included access and focusing on the quality of remain-
dispelling fear of death which, given that this ing life of hospice patients and their informal
was investigated with a chinese population caregivers as well as the quality of the care
where it is considered a forbidden topic of con- received. research is crucial to assuring that
versation, is a challenge. Other patient priori- hospice care is all that it purports to be.
ties identified included gaining enough sleep,
willingness to listen and give reassurances, Inge B. Corless
and providing a satisfying diet. Interestingly,
pain relief was not a high priority for patients.
Not only does an approach such as this mea-
sure the discrepancy between patient expec- Hypertension
tations and effectiveness of care, it also has
the potential to evaluate the impact of hospice
care for patients. Hypertension (HTN), also known as high
A concern that enrollment in hospice can blood pressure (Bp), is the most com-
be equated to giving up was not substanti- mon risk factor for cardiovascular disease.
ated in a study by Keyser, reed, lowery, Approximately 74.5 million or one third of
and Sundborg (2010). They conducted a ret- U.S. adults have HTN and another quarter
rospective review of medical records from have pre-HTN, placing them at risk of devel-
2002 to 2008 and concluded that there was oping HTN (lloyd-Jones et al., 2010). Despite
no detrimental effect of hospice on survival improvements since the 1980s in awareness,
of patients with gynecological malignancies treatment, and control of HTN in the United
who accepted and those who declined hos- States, a new diagnosis of HTN shortens an
pice following a recommendation by their individual’s life expectancy an average of 5
provider. Indeed, those with recurrent dis- years because of potential target organ dam-
ease who followed the recommendation for age throughout the cardiovascular system,
hospice care had a longer survival (17 vs. 9 including the heart, the brain, the kidneys,
months). and the eyes (Franco, peeters, Bonneux, & de,
Another example of research that exam- 2005). HTN is anticipated to cost the United
ined the impact of hospice care was that by States a total of $76.6 billion in 2010 (lloyd-
Kabel and roberts (2003), who examined Jones et al., 2010). Globally, 26% of individu-
how the philosophy of hospice providers als are estimated to have HTN, and rates are
influences their perceptions of patient per- rising in many developing countries, result-
sonhood. Specifically, this qualitative study ing in a burgeoning global health problem
examined how hospice staff at two hospice (Kearney et al., 2005).
facilities in northwest england approached current guidelines from the Seventh
“normalizing” the symptoms of terminal report of the Joint National committee

246 n HyperTeNSION



on prevention, Detection, evaluation, and the United States, improvements since 1988
Treatment of High Blood pressure (JNc 7) in awareness (81% vs. 69%), treatment (73%
H define HTN as two or more Bp readings of vs. 54%), and control (50% vs. 27%) of HTN
systolic Bp ≥140 mmHg or diastolic Bp ≥90 have helped to recently attain the Healthy
mmHg (chobanian et al., 2003). pre-HTN, People 2010 goal of 50% control of HTN (egan,
defined as systolic Bp ≥120 mmHg or diastolic Zhao, & Axon, 2010). Despite the improve-
Bp ≥80 mmHg, increases the risk (up to twice ments in HTN control over the last decade,
the risk) of developing HTN (chobanian dramatic disparities in the prevalence and
et al., 2003). HTN is classified as either pri- control of HTN exist in certain subpopula-
mary HTN (formerly called essential HTN) or tions (Institute of Medicine, 2003). For exam-
secondary HTN. The cause of primary HTN, ple, Blacks have higher rates of HTN, (40% vs.
which accounts for 95% of cases, remains 27 and 25% in Whites and Hispanics, respec-
in question, but it is known to be correlated tively; Glover, Greenlund, Ayala, & croft,
with obesity, increasing age, diabetes, alco- 2005), higher average Bp, and more frequent
hol consumption, and salt intake (carretero target organ damage than other racial groups
& Oparil, 2000). Secondary HTN accounts for (lloyd-Jones et al., 2010). Mexican Americans
the rest of the cases and results from identifi- have disproportionately poor rates of HTN
able disorders, such as chronic renal disease, control when compared with other groups
renovascular disease, primary aldosteron- (17% vs. 30% in both Blacks and Whites)
ism, or sleep apnea, and may resolve with despite comparable prevalence (Glover et al.,
appropriate treatment of the underlying con- 2005). Socioeconomic status is consistently
dition (chobanian et al., 2003). inversely related to HTN prevalence, regard-
HTN is a major risk factor for cardiovas- less of race or ethnicity (Kaplan & Keil, 1993;
cular disease, independent of other risk fac- Mensah, Mokdad, Ford, Greenlund, & croft,
tors, although it is related to other metabolic 2005). Finally, geographic disparities in
risk factors. Metabolic syndrome, which is HTN control may contribute to higher rates
increasing in prevalence, comprises a con- of stroke in the Southeastern United States
stellation of risk factors, including HTN, than in other regions (Howard et al., 2006).
abdominal obesity, dyslipidemia and insulin These disparities are most likely the prod-
resistance (chobanian et al., 2003). Although uct of complex social, financial, and political
causal origins are not well understood, met- processes that result in barriers to effective
abolic syndrome itself is a risk factor for the health care and barriers to adoption of low-
development of HTN, and the presence of risk lifestyles (cooper et al., 2000; Institute
HTN alongside metabolic syndrome poses of Medicine, 2003). Unfortunately, despite
increased cardiovascular risk. Similar under- recent attention to health disparities, dispar-
lying modifiable lifestyle risk factors have ities in HTN in the United States have either
been identified for both the metabolic syn- persisted or worsened in the past three
drome and HTN. physical inactivity, diets decades, continuing to place an undue bur-
high in fats and refined carbohydrates, and den of cardiovascular risk on certain sub-
obesity are each associated with both HTN groups of the population (cooper et al., 2000;
and the metabolic syndrome. lifestyle modi- Mensah et al., 2005).
fications of these risk factors and smoking The current approach to HTN treat-
cessation is a central to management of both ment relies on adherence to treatment
disorders (Grundy et al., 2005). algorithms, such as the recommendations
Because HTN cannot be cured in the of JNc 7, within an organized health care
vast majority of cases, actions to increase system that provides regular assessments
awareness, treatment and control of HTN and reviews of care (Glynn, Murphy,
are critical to avert target organ damage. In Smith, Schroeder, & Fahey, 2010). The JNc

HyperTeNSION n 247



Table 3
Strategies to promote HTN control
H
Actions
Actions by Patients
engage in essential prevention and treatment behaviors
Decide to control risk factors
Negotiate goals with provider
Develop skills for adopting and maintaining recommended behaviors
Monitor progress toward goals with home blood pressure monitoring
resolve problems that block achievement of goals
patients must communicate with providers about prevention and treatment services
Actions by Providers
providers must foster effective communication with patients
• Provide clear, direct messages about importance of a behavior or therapy
• Include patients in decisions about prevention and treatment goals and related strategies
• Incorporate behavioral strategies into counselling
providers must document and respond to patient’s progress toward goals
• Create an evidence-based practice
• Assess patient’s compliance at each visit
• Develop a reminder system to ensure identification and follow-up of patient status
provide evidence-based treatment to goal, using JNc 7 guidelines
Actions by Health Care Organizations
Develop an environment that supports prevention and treatment interventions
provide tracking and reporting systems
provide education and training for providers
provide adequate reimbursement for allocation of time for all health care professionals
Adopt systems to incorporate innovations rapidly and efficiently into medical practice
Adopt policies and practices that address disparities in HTN
Adapted with permission from Dennison, c. r., Houston Miller, N., & cunningham, S. (2010).
Hypertension. In S.Woods, e. Froelicher, S. U. Motzer, & e. Bridges (eds.), Cardiac nursing, (6th
ed.). philadelphia, pA: Wolters Kluwer Health/lippincott Williams & Wilkins. Originally
taken from Miller, N. H., Hill, M. N. Kotke, T., et al (1997). The multilevel compliance challenge:
recommendations for a call to action. Circulation, 95, 1085–1090.





7 treatment algorithm for HTN highlights lifestyle and pharmacological manage-
the importance of lifestyle modification in ment strategies require actions by patients,
addressing HTN, followed by pharmacolog- health care providers, and health care orga-
ical treatment to goal based on established nizations within a multilevel framework of
guidelines (chobanian et al., 2003). lifestyle action, as outlined in Table 3. A team-based
modification that has been shown to lower approach to HTN management has been an
Bp includes weight loss, increased physical effective strategy in many settings and may
activity, and dietary modification such as improve both consistent delivery of preven-
sodium and alcohol reduction and adoption tive services and adherence to treatment
of the DASH diet (a diet low in fat and rich in algorithms (carter, rogers, Daly, Zheng, &
fruits, vegetables, and whole grains with low- James, 2009; Norby, Stroebel, & canzanello,
fat dairy products; chobanian et al., 2003). 2003; Walsh et al., 2006). Teams should include

248 n HyperTeNSION



the patient as a central figure and may also Future work will need to improve
include the nurse, health educator, commu- translation and dissemination of effective
H nity health worker, nutritionist, pharmacist, strategies into practice. This need is height-
and physician. Optimal management of ened all the more by the increasing burden
HTN requires collaboration between patients of HTN now in developing countries and
and providers, collaboration among team the anticipated increase in HTN in devel-
members, and effective intervention within oped countries with the rising obesity epi-
the health care organization (coordinating demic (Dennison et al., 2007). Because of
committee of the National High Blood this growing epidemic of obesity and meta-
pressure education program, 1984; Miller, bolic syndrome, nurses, other clinicians, and
Hill, Kottke, & Ockene, 1997). researchers should also anticipate increas-
Nurses have a key role in all aspects ing rates of HTN at younger ages. Greater
of a collaborative approach to HTN man- focus on prevention, including attention to
agement, from screening to identify unde- social and behavioral determinants of HTN,
tected HTN, to conducting research, to will improve our ability to respond to the
setting national policy. The role of the indi- growing global burden of HTN. Finally, tai-
vidual nurse depends on his or her prepara- loring interventions according to culture,
tion, work experience, and practice setting. language, social environment, and behav-
physician–nurse teams have been an effec- ioral constructs has the potential to improve
tive method of delivering HTN treatment the effectiveness of interventions and may
plans in many settings (canzanello, Jensen, help address health disparities in HTN.
Schwartz, Worra, & Klein, 2005; Dennison, In conclusion, HTN is a common and
peer, Steyn, levitt, & Hill, 2007; Dennison, major risk factor for cardiovascular disease.
post, et al., 2007; litaker et al., 2003). Within The prevalence is increasingly globally and
these settings, nurses provide any number is anticipated to rise in developed countries
of interventions, many of which have been as rates of obesity and metabolic syndrome
investigated by nurse researchers. In partic- rise. effective treatment of HTN includes
ular, nurses have a long history of delivering lifestyle modification and pharmacological
proven health education and health counsel- treatment. Although evidence-based algo-
ing interventions (Hill, 1989; Jones, 2008) and rithms for HTN prevention, detection, and
providing interventions aimed at treatment treatment have been widely promulgated
adherence (Hill, Miller, & De Geest; Kirscht, and HTN control rates have improved, the
Kirscht, & rosenstock, 1981; logan, Milne, rates remain suboptimal in subpopulations,
Achber, campbell, & Haynes, 1979), which is including Blacks, Hispanics, and those of
a key predictor of HTN control (chobanian low socioeconomic position. Achieving
et al., 2003). More recently, nurse practitioners further improvements in HTN control will
are increasingly taking the lead on managing require activated patients, providers, and
HTN in primary care settings, and a growing health care organizations. Nurses play a
body of evidence indicates they are effective key collaborative role in both research and
in this role (Glynn et al., 2010; laurant et al., practice.
2005). Nurses will continue to play a key role
in future research, dissemination, and imple- Cheryl R. Dennison Himmelfarb
mentation of effective interventions for HTN Laura J. Samuel
prevention and treatment. Martha N. Hill

I














migration and settlement—and in some
ImmIgrant Women cases, return migration—occur within fluid,
in-between spaces of transition and ongoing
social, cultural, economic, and identity adap-
Migration entails the movement of individu- tations and adjustments (Donnelly, 2006).
als and groups from one region or country The migration transition involves prepara-
to another with the intent of temporary or tion, the migratory act, complex processes
permanent settlement. Internal migration of settling in and adapting to the new envi-
within national borders often flows from ronment, and ensuing identity transforma-
rural to urban areas. Transnational migra- tions. In planned migration, the transition
tion is a global phenomenon with both begins with anticipation and preparation.
causes and consequences in social, cultural, Some women may engage in premigration
political, and health arenas (Messias, 2007). health practices (e.g., engaging in preventive
Women tend to leave their homes because of examinations or checkups, acquiring stocks
economic, political, environment, and social of prescription medications) either as part
difficulties and instability and often seek of formal migration procedures, to validate
family reunification, improved educational their personal health status, or as a strategy
and economic opportunities, with hopes and to avoid untoward future medical and den-
plans for a more stable and productive life tal expenses in the host country (Hilfinger
for themselves and their families. However, Messias, 2002). Migration tends to be an
the migratory passage and settlement expe- ongoing transition that has no set time span
riences often expose women to health risks, or universally applicable critical points or
increased social, physical, and emotional events (Messias, 2010). It is a transition that
vulnerabilities, and social marginalization. may be “reactivated” over time in conjunc-
In terms of health care access, immigrant tion with other situational, developmental,
women frequently encounter multiple bar- and health–illness transitions (e.g., job loss,
riers to appropriate and affordable services, pregnancy, personal or family illness, and
resources, and support. death of a family member).
In nursing, a transitions perspective Researchers also use other conceptual
is particularly appropriate for research on frameworks and theories to describe and
immigrant women’s health (Meleis, Sawyer, explain the health experiences and responses
Im, Messias, & Schumacher, 2000; Messias, of immigrants. These include selective
2010). For women—and those who migrate migration, opposing positions of the posi-
with them or whom they leave behind— tive or negative effect of migration on health,
migration is a complex social, cultural, eco- and the interactions of immigrant accultur-
nomic, and environmental transition that ation and health (Im & Yang, 2006; Messias
may involve significant changes, disrup- & Rubio, 2004). Selective migration (also
tions, and differences in a wide range of referred to as the healthy migrant effect)
human interactions and social networks posits that migrants tend to be healthy and
(Jones, Zhang, & Meleis, 2003; McGuire & resilient in the face of the potential health
Martin, 2007). For most immigrant women, hazards of migration. The healthy migrant

250 n IMMIGRanT WoMen



effect explains, at least partially, the better the social and environmental transition to an
health status of recent immigrants compared egocentric culture may affect women’s health
I with native-born groups. The notion of the and health-promoting activities (Bathum &
positive effect of migration on health is based Baumann, 2007). Yet living in proximity with
on the premise that many migrants encoun- other immigrants does not necessarily cre-
ter better living conditions, upward social ate a sense of community. Community-based
mobility, improved economic status, and a research with recent Latina immigrants in
safer and healthier environment in the host a new settlement area of the Southeastern
country (evans, 1987). others have posited United States indicated that the de facto
a negative effect of migration on health, the concentrations of Latino immigrants in
result of inherently difficult, stressful, and apartment complexes or trailer parks are
even hazardous conditions of immigrant not necessarily accompanied by a sense of
life and exposure to communicable diseases, belonging and community (Barrington &
physical and emotional stress, and limited Messias 2010).
access to care (Trimble, 2003). Much of the Immigrant women share unique charac-
nursing research related to immigrant health teristics that require special gender-sensitive
has focused on the notion of acculturation. research and clinical efforts. They share the
However, there is considerable variation vulnerabilities and the marginalization of
in the definition and operationalization of minority women in general, and face addi-
acculturation as a research variable (Messias tional challenges related to cultural differ-
& Rubio, 2004). Critiques of existing theoreti- ences, language barriers, transportation, and
cal models of immigration and health include role overload. Immigrant women often find
ethnocentric bias, inadequate empirical sup- host country gender roles and expectations
port, and lack of applicability to diverse, het- are at odds with those of their home country
erogeneous immigrant populations (Hunt, (Remennick, 2004; Rodriguez, 2007). another
Schneider, & Comer, 2004). challenge is maintaining home country her-
nursing research with specific immi- itage while adopting the values and beliefs
grant groups, such as Lipson’s (1993) study necessary to integrate themselves and their
of afghan refugees, and McGuire’s (2001) families into the host culture (aroian et al.,
transnational investigation of indigenous 2009). although most studies of immigrant
immigrants from oaxaca, Mexico, have con- women focus on groups characterized by
tributed to furthering the understanding of evident gender inequality, there is some evi-
migration-related trauma, loss, and post- dence that even women from groups with
migration health care needs. Distance and less gender inequality experience more psy-
separation from family and community is a chological distress and have different sources
difficult aspect of transnational migration. of distress than their male counterparts
McGuire and Martin (2007) examined the (aroian, norris, & Chiang, 2003; aroian,
effect of global neoliberal economic mod- norris, Gonzalez de Chavez Fernandez, &
els on families and communities in rural averasturi, 2008). These variables influence
Mexico and the resulting accelerated migra- immigrant women’s health and health care,
tion of indigenous women to the United and many of the variables have not been
States. The fracturing of families resulted in adequately studied.
physical and emotional suffering and sad- a nursing perspective focusing on
ness among women separated from their immigrant women and their health includes
children, for whom they were making enor- research on gender and health, culturally
mous personal sacrifices. For women from influenced explanatory models of illness,
sociocentric cultures (e.g., Central and South transitions and health, and marginalization
america) who migrate to the United States, and health (aroian, 2001; Meleis, 1995; Meleis,

IMMIGRanT WoMen n 251



Lipson, Muecke, & Smith, 1998). Immigrant Several strategies have been developed
women’s multiple gender roles influence their to provide care for immigrant women. The
ability to access and receive quality care. most effective models are groups that focus I
They are expected not only to cook, do house- on women’s strengths, employ the use of cul-
work, care for children, and often to contrib- tural brokers, and are implemented using
ute income but also to act as family mediators feminist participatory models. Research
and culture brokers. In addition to their focused on limited english–proficient immi-
family responsibilities, immigrant women grants has highlighted the importance of
often are expected to take responsibility for qualified language interpretation and trans-
accessing and navigating host-country insti- lation services and the need for cultural bro-
tutions and bureaucracies (e.g., schools, social kering, orientation, and support programs to
services, health care systems). The ways facilitate the immigrants’ access to and nav-
in which immigrant women express their igation of the complex U.S. health care sys-
symptoms and the meanings they attach to tems (McDowell, Messias, & estrada, 2011).
health care encounters also contribute to their Future areas for scholarship include
health outcomes. The opportunity for immi- methods for defining populations, devel-
grant women to describe and explore their oping culturally competent research tools,
explanatory models of illness with health using appropriate theoretical frameworks,
care providers may contribute to improved and uncovering the critical markers in the
provider–patient relations and, ultimately, to transition process that render immigrants
improved health outcomes (Reizian & Meleis, more vulnerable. Immigrant women face
1987). Research with South asian women increasingly complex social and health prob-
in Canada indicated the ways in which lems. The impact of public policy changes in
essentialism, culturalism, and racialization the social welfare area and the institution
are manifested in health care interactions of health care reform could directly affect
(Johnson et al., 2004). There is a clear need for immigrant women and their families. What
ongoing educational and policy interventions is needed is a comprehensive immigra-
to address such othering practices to support tion reform focused on women. Immigrant
equitable health care for immigrants. women must be part of the dialogues about
Immigrant women tend to work and be such reforms. Their voices and presence in
employed in environments that contribute to policy dialogues must be sought, valued,
increased health risks. These include work- and included (Glasford & Huang, 2008). In
ing at home or in family businesses that pro- the United States, the increasing diversity of
vide limited protections or benefits. When the population and concurrent resurgence of
employed outside the home, immigrant nativism and backlash against immigrants
women often work in low-income jobs such is a concern for nurses and health care pro-
as work in poultry plants, garment shops, or viders. engaging immigrant communities
domestic work where they engage in repeti- in health initiatives, increasing the cultural
tive and awkward movements, are exposed and linguistic competence of nursing and
to risk of injury, and often have little or no health care personnel and systems, and
recourse to occupational health resources developing and testing culturally and lin-
(Burgel, Lashuay, Israel, & Harrison, 2004). guistically appropriate models of care are
Women who accompany male family mem- top priorities with the increasing diversity
bers may be concerned about their personal of populations.
immigration status and, therefore, because of
their insecurity and perceived vulnerability, Afaf Ibrahim Meleis
may be less likely to disclose or report batter- DeAnne K. Hilfinger Messias
ing, harassment, or abuse. Karen J. Aroian

252 n InFeCTIon ConTRoL



nowadays, 5% to 10% of patients admit-
InfectIon control ted to the hospital acquire a HCaI (Smyth
I et al., 2008; World Health organization, 2005).
HCaIs are a major challenge to the health
Infection control addresses the spread of services and to society in general because of
infections within health care settings (from the burden (economic, socioeconomic, mor-
patient to patient, patients to staff, staff to bidity, and mortality) placed on individu-
patients, or among staff), including pre- als, their families, and on the health services
vention (via hand hygiene/hand washing, (Cosgrove, 2006; Kilgore et al., 2008).
cleaning/disinfection/sterilization, vaccina- There is a wealth of evidence that under-
tion, and surveillance), monitoring/investi- pins the critical role that health care workers’
gation of demonstrated or suspected spread hands play in transmitting potentially path-
of infection within a particular health care ogenic microorganisms within the health
setting, and management (interruption of care environment and, in due course, to
outbreaks). acquisition of health care–asso- patients (World Health organization, 2005).
ciated infections (HCaIs) are perceived as a optimal hand hygiene is considered the cor-
significant challenge in terms of the risk to nerstone of preventing HCaIs (Pittet et al.,
patient safety as well as the economic burden 2006). Internationally, health care work-
placed on health services. additionally, there ers’ hand hygiene practices are guided by
is intense media and public interest on infec- evidence-based guidelines published by the
tion control, to the extent that prevention and World Health organization or the Centers
control of HCaIs is now a key focus of global for Disease Control (CDC; Boyce & Pittet,
health care policy. 2002; World Health organization., 2005). In
Controling infection is a problem Ireland, health care workers’ hand hygiene
because hospitals were established to pro- practices follow guidelines published as part
vide care for the sick. Pioneering individuals, of the Strategy for control of antimicrobial
such as Semmelweiss, nightingale, Lister, Resistance in Ireland (2005). The Strategy
and Koch, demonstrated that a direct rela- for control of antimicrobial Resistance in
tionship existed between the rate people Ireland guidelines closely resemble the CDC
acquired infection while in the hospital and guidelines. However, compliance is poor,
infection control practices within hospitals. internationally (akyol, 2007; Dedrick et al.,
advances in medical technology and treat- 2007; Rosenthal, Guzman, & Safdar, 2005)
ment means that more patients are now being and nationally (Creedon, 2005; Creedon
treated in hospitals and many are increas- et al., 2008), despite an enormous amount
ingly vulnerable to infections because of the being written on health care worker’s hand
greater severity of underlying illness, the use hygiene practices (Gould, Chudleigh, Drey, &
of invasive devices, and increased levels of Moralejo, 2007; Pittet et al., 2006).
immunosuppression. Pathogen resistance to The quality of care that patients’ receive
antimicrobial agents and hospital organiza- while being cared for in hospitals is the focus
tional factors, such as high bed occupancy of increased attention. In particular, control
and understaffing, have compounded the of infection is perceived as a fundamental
problem. The risk of acquiring an infection aspect of quality health care and is a cause
is dependant on the relationship between for concern for patients who access the health
microorganisms, patients, health care work- services. Findings from a recent european
ers, and the environment. It is not possible Commission survey (n = 26,663 individuals)
to prevent all HCaIs, but high standards of revealed that 71% of Irish respondents (n =
infection control can mimimize the risk of 976) felt that they are likely to contract a hos-
their occurrence. pital infection if admitted to an Irish hospital.

InFeCTIon ConTRoL n 253



This represented the fifth highest rate of con- studies only consider two opportunities for
cern expressed by participants across the hand hygiene, that is, before and after patient
27 member states. Greeks scored the risk of contact (Rosenthal et al., 2005; Swoboda et al., I
acquiring a HCaI highest at 81% and austria 2007), whereas others base their indications
lowest at 18% (european Commission, 2010) for hand hygiene on published sets of hand
The provision of quality patient care hygiene guidelines, for example, the CDC
is not simply about exhorting individu- incorporating nine different opportunities
als within hospital settings to change their (Larson, Quiros, Giblin, & Lin, 2007) or five
own practices; the environment in which sequential steps (Pittet et al., 2006). Methods
health care workers’ work in must be consid- of quantifying hand hygiene compliance dif-
ered as well (Buetow & Roland, 1999; West, fer, for example, self-reported, direct obser-
2001). The importance of considering the vation, or proxy measurement, that is, the
environment that health care workers’ prac- use of hand hygiene agent (Boyce, 2008).
tice in was emphasized in a seminal report Seminal publications on the most prom-
by the Institute of Medicine in the United ising ways to address health care workers’
States in 2004. Serious concerns were raised noncompliance with hand hygiene guide-
about health care workers’ work environ- lines focus on the importance of addressing
ments, particularly nurses, and their impact personal variables that may influence behav-
on patient outcomes. The authors noted that ior (Gould, Moralejo, & Drey, 2007; naikoba &
typical nursing work environments are char- Hayward, 2001; Pittet, 2004). a variety of
acterized by many serious threats to patient perspectives have been used to examine
safety (Page, 2004) and suggested that these hand hygiene behavior and how it can be
threats may be caused by organizational promoted. The World Health organization
management practices, work design issues, (2009, pp. 87–88) emphasizes the role of edu-
and organizational culture. cation, motivation, cues to action, patient
The report First Do No Harm concluded empowerment, and the need for structural
that it is not acceptable for patients to be and philosophical change to health care sys-
harmed by the health care system that is tems. Some authors highlight the possible
supposed to offer healing and comfort. one effect of hospital organizational features on
of the report’s main conclusions is that the health care workers’ hand hygiene behavior
majority of adverse patient outcomes result and resultant acquisition of HCaIs (Larson,
from faulty systems, processes, and condi- Cloonan, Sugrue, & Parides, M, 2000; Pittet,
tions that lead people to make mistakes or 2000; Whitby, Slater, Tong, & Johnson, 2008).
engage in suboptimal practices, that is, it is others focus on the role of social cognitive
not a “bad apple” problem. The impact of models, such as the health belief model,
health care workers’ work environment on health locus of control, protection motiva-
health care workers hand hygiene behavior tion theory, theory of planned behavior,
is a poorly studied area. and the self-efficacy model (World Health
Hand hygiene research varies enor- organization, 2009). additionally, the-
mously in terms of methods and interventions. oretical perspectives such as PReCeDe
Some studies focus on a particular occupa- (Creedon, 2005) and the importance of role
tional group only (Gould & Chamberlain, modeling (Lankford et al., 2003) deserve
1997; Rosenthal, McCormick, Guzman, mentioning.
Villamayor, & orellano, 2003; Van de Mortel & none of the theoretical approaches have
Heyman, 1995), whereas others include all yet made a cogent contribution to provid-
health care workers’ involved in patient care ing an answer to understanding why health
(Creedon, 2005; Swoboda, earsing, Strauss, care hand hygiene behavior is clearly a prob-
Lane, & Lipsett, 2007; Trick et al., 2007). Some lem and it is telling that the World Health

254 n InSTITUTIonaL ReVIeW BoaRD anD InFoRMeD ConSenT



organization (2009) concludes that “the positively identifying with, and actively par-
inability over two decades to motivate health ticipating in the intervention, but many lack
I care workers compliance with hand cleans- empirical data to support the conclusions
ing suggests that modifying hand hygiene made (Lankford et al., 2003; Larson et al., 2000;
behavior is a complex task.” Pittet, 2000; Whitby et al., 2008).
Despite the lack of empirical evidence, nursing research extending Kanter’s
it is reasonable to suggest that a relation- (1977) theory found that a supportive work
ship may exist between health care work- environment is directly related to work effec-
ers perceptions, their work environment, tiveness, job satisfaction, and organizational
hand hygiene behavior, and infection rates. commitment (Laschinger & Havens, 1997;
To date, variations in infection rates and Laschinger, almost, & Tuer-Hodes, 2003).
health care workers’ hand hygiene practices a supportive work environment is also
in similar type hospitals are unexplained. inversely associated with patient outcomes,
Furthermore, health care workers hand such as mortality (aiken, Clarke, Sloane,
hygiene practices remain persistently low Lake, & Cheney, 2008; aiken & Lake, 1994;
despite national campaigns such as the Say Rafferty et al., 2007), patient falls, medication
No to Infections campaign in Ireland and the errors (Laschinger & Leiter, 2006), patient sat-
Clean Your Hands Campaign in the United isfaction (Donahue, Piazza, Griffin, Dykes, &
Kingdom. a possible explanation may be Fitzpatrick, 2008), length of stay (needleman,
that these campaigns were directed entirely Buerhaus, Mattke, Stewart, & Zelevinsky,
at the individual health care worker without 2002), and improved hemodialysis perfor-
making any attempt to focus on addressing mance (Harwood et al., 2007).
hospital organizational factors that impact Given the continuing level of interest
on health care workers work environment. that exists in improving health care work-
The possible impact that hospital orga- ers’ hand hygiene practices and the lack of
nizational features may have on health care any study, with the exception of Larson et al.
workers’ hand hygiene behavior and resul- (2000), explicitly and empirically investigat-
tant acquisition of HCaIs has merited some ing the association between hand hygiene
discussion (Larson et al., 2000; Pittet, 2000; and hospital organizational characteristics,
Whitby et al., 2008). From a theoretical per- it may be timely to further explore the effect
spective, organizational behavioral theory that hospital organizational characteristics
focuses on the association between participa- and health care workers’ perceptions of a
tion in an organization and achieving orga- supportive work environment have on health
nizational goals (Kanter, 1977). achieving care workers’ hand hygiene behavior and
organizational goals within a hospital setting ultimately rates of HCaIs.
may easily be related to a reduction of HCaIs.
Kanter’s (1977) theory of organizational Sile A. Creedon
behavior concludes that the behavior exhib-
ited by an individual working in an organiza-
tion is shaped by their perceptions of support
within the work environment. It is plausible InstItutIonal revIeW Board
to suggest that health care workers’ percep-
tions of support within the work environment and Informed consent
influences their compliance with guidelines
such as hand hygiene guidelines. There is evi-
dence that interventions overtly supported by In 1974, the Department of Health and Human
hospital organizational features (e.g., hospi- Services required that all research involving
tal management) lead to health care workers human subjects should have an institutional

InSTITUTIonaL ReVIeW BoaRD anD InFoRMeD ConSenT n 255



review. The Institutional Review Board research subjects to no apparent risks, then
(IRB) procedures are part of the regulations the research activities are exempt from IRB
for the Protection of Human Subjects of review. In Table 4, a list of research activities I
Biomedical Research (Title 45, Code of Federal exempt from review is displayed.
Regulations [CFR] 46, Subpart a). This code
was revised and expanded in 1978, 1983, (2) Expedited review (45, CFR 46.110). This type
1991, 2001, and 2009. In 1991, these guidelines of review is undertaken when the reviewers
were adopted, as a common core of regula- ascertain that the research will have only a
tions governing human subjects’ research, by minimal risk to research subjects. Under
all federal agencies and departments. These 46.303 of the code, minimal risk is defined as
core regulations (45, CFR 46) became known “the probability and magnitude of physical or
as the common rule, because the regulations psychological harm that is normally encoun-
were common to federal entities conducting tered in the daily lives, or in the routine med-
research on human subjects. ical, dental, or psychological examination of
each IRB should have a minimum of five healthy persons” (45, CFR 46.303).
members with varying backgrounds and also, expedited review may be con-
diversity to ensure adequate review of the ducted when there are minor changes in
research usually conducted at the institution previously approved research protocols.
(45, CFR 46.107). Members must be qualified expedited reviews may be conducted by the
with pertinent experience and expertise to IRB chairperson or by one or two experi-
ensure the protection of research subjects. enced reviewers designated by the chairper-
The diversity of the members, including son from the IRB members. These reviewers
race, gender, and ethnicity, is another consid- may exercise all of the authorities of the IRB,
eration in the makeup of the IRB. IRBs that except that the reviewers may not disap-
are regularly reviewing research protocols prove the research. a complete review of the
involving vulnerable populations, such as research protocol is necessary prior to disap-
children, prisoners, and pregnant women, proval of the research.
should consider having IRB members expe-
rienced with these vulnerable subjects (3) Complete review (45, CFR 108; 45, CFR
involved in the review. IRBs must have male 46.109). all studies with greater than min-
and female members coming from more than imal risks must have a complete review
one profession. one member of the IRB must by the IRB. The IRB must ensure that spe-
be from the scientific area, one from a non- cific requirements are met to approve the
scientific area, and at least one not affiliated research. These requirements include
with the institution. When additional exper- ensuring that the risks to research subjects
tise is required for a particular review, the are minimized and are reasonable in rela-
IRB may invite additional individuals to par- tion to the anticipated benefits. Informed
ticipate in the review. These individuals are consent must be obtained and documented.
nonvoting. a data-monitoring plan to ensure research
There are three levels of IRB review: subject’s safety and adequate protections
(1) exempt from review, (2) expedited review, to ensure the privacy and confidentiality
and (3) complete review. The IRB chairper- of subjects and data are in place. Complete
son or IRB decide on the type of review review is conducted at IRB meetings with
warranted for individual studies. the majority of the IRB members present,
including at least one whose primary con-
(1) Exempt from review (45, CFR 46.101b). cern is nonscientific. The majority of the IRB
When human subjects are involved in spe- members must approve the research for it to
cific categories of research exposing the be approved.

256 n InSTITUTIonaL ReVIeW BoaRD anD InFoRMeD ConSenT



Table 4
Research activities exempt From IRB Review (45, CFR 46.101b)
I
(1) Research conducted in established or commonly accepted educational settings, involving normal educational
practices, such as (i) research on regular and special education instructional strategies, or (ii) research on
the effectiveness of or the comparison among instructional techniques, curricula, or classroom management
methods.
(2) Research involving the use of educational tests (cognitive, diagnostic, aptitude, or achievement), survey
procedures, interview procedures or observation of public behavior, unless: (i) information obtained is recorded
in such a manner that human subjects can be identified, directly or through identifiers linked to the subjects; and
(ii) any disclosure of the human subjects’ responses outside the research could reasonably place the subjects at
risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, or reputation.
(3) Research involving the use of educational tests (cognitive, diagnostic, aptitude, ad achievement), survey
procedures, interview procedures, or observation of public behavior that is not exempt under paragraph (b2) of
this section, if: (i) the human subjects are elected or appointed public officials or candidates for public office; or
(ii) federal statute(s) require(s) without exception that the confidentiality of the personally identifiable
information will be maintained throughout the research and thereafter.
(4) Research involving the collection or study of existing data, documents, records, pathological specimens, or
diagnostic specimens, if these sources are publicly available or if the information is recorded by the investigator
in such a manner that subjects cannot be identified, directly or through identifiers linked to the subjects.
(5) Research and demonstration projects which are conducted by or subject to the approval of department or agency
heads, and which are designed to study, evaluate, or otherwise examine: (i) Public benefit or service programs,
(ii) procedures for obtaining benefits or services under those programs, (iii) possible changes in or alternatives to
those programs or procedures, or (iv) possible changes in methods or levels of payment for benefits or services
under those programs.
(6) Taste and food quality evaluation and consumer acceptance studies, (i) if wholesome foods without additives are
consumed or (ii) if a food is consumed that contains a food ingredient at or below the level and for a use found
to be safe, or agricultural chemical or environmental contaminant at or below the level found to be safe, by the
Food and Drug administration or approved by the environmental Protection agency or the Food Safety and
Inspection Service of the U.S. Department of agriculture.

From U.S. Department of Health and Human Services (2009, January 15). Protection of human subjects. Code of Federal
Regulations, Title 45, Part 46. Retrieved from http://www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.htm#46.101


Under federal guidelines, the IRB can review to subjects and involves no procedures for
and has the power to approve, disapprove, which written consent is normally required
or require modifications for all research cov- outside of the research context.
ered by Title 45, CFR 46.109 (IRB Review of The IRB gives investigators and the insti-
Research). The IRB requires that the infor- tution, in writing, its decision to approve, dis-
mation given to research subjects as part of approve, or of modifications required prior to
the informed consent is provided accord- IRB approval of the research. When the IRB
ing to Title 45, CFR 46.116. also, the IRB can disapproves a research study other reasons
require that additional information be given for the decision are provided and the inves-
to research subjects if such information will tigator is given an opportunity to respond to
add to the protection of the subjects. The IRB the decision.
requires documentation of the informed con- The IRB has the authority to conduct
sent. a waiver of written consent can be given continuing reviews of the research once it is
if the consent form is the only record linking approved. The frequency of these reviews is
the subject and the research, and the principal determined by the degree of risk to the sub-
risk would be potential harm resulting from jects, but it should not be less than yearly.
a breach of confidentiality. also, a waiver of also, the IRB has the power to observe or
written consent may be given if the research have a third party observe the consent pro-
presents no more than minimal risk of harm cess of any approved research study.

InSTRUMenT TRanSLaTIon n 257



The consent form must contain a state- many nurse scientists need expertise in
ment that the study is research along with the instrument translation prior to conducting
purposes of the research, the expected length cross-cultural research. I
of participation, and details of the procedure Instrument translation is defined as a
(elements of a consent form; 45, CFR 46.116). process of adapting an instrument devel-
There is a description of the foreseeable risks oped in one language (source language; SL)
and expected benefits, and details of alter- into another language (target language; TL)
nate procedures are given if appropriate. with sensitivity to the culture being stud-
Information related to confidentiality of the ied (Geisinger, 1994). The aim of translation
data, as well as details of compensation in is not merely to achieve literal or syntactic
the event of injuries, are provided. The con- equivalence, but to maintain the original
sent form also contains information related meanings (denotation and connotation) of
to voluntary participation, and withdrawal the instrument items or questions (Tang &
from the study without penalty. Contact Dixon, 2002). Therefore, an instrument
information for answers to any questions is translation is not a simple word-for-word
also contained on the form. translation process. Rather, it is a multistep
The written consent form must be process involving rigorous and scientific
approved by the IRB. Prior to participation procedures.
in the research study, the subject or the sub- Many researchers (Jones, Lee, Philips,
ject’s legal representative will sign the con- Zhang, & Jaceldo, 2001; McDermott &
sent form. The information on the consent Palchanes, 1994; Tang & Dixon, 2002;
form can be read to the subject or the sub- Willgerodt, Kataoka-Yahiro, Kim, & Ceria,
ject’s legal representative. also, they must be 2005; Yu, Lee, & Woo, 2004) recommended
given sufficient time to read the consent form and used Brislin’s (1970, 1980, 1986) transla-
before they sign it. a copy of the consent tion method as the most reliable method for
form is given to the signee (documentation of developing an equivalent translated instru-
informed consent; 45, CFR 46.117). ment. This method includes the following
five steps: (1) forward (one way) translation—
Mary T. Quinn Griffin translation of the original instrument, the
SL version, into a TL version by a bilingual
person; (2) review of the TL version by a
monolingual reviewer of the TL for wordings
Instrument translatIon that are ambiguous or difficult to understand;
(3) backward translation (back-translation)—
the reviewed TL version (step 2) is translated
With the growing cross-cultural and interna- back into the source language (BT) version by
tional collaboration in nursing research, and another bilingual person, who is “blinded” to
with the emphasis on identifying differences the SL version; (4) comparison of the original
and similarities among people’s ethnic- and SL and BT versions, as well as the TL version,
culture-related health status outcomes, the for linguistic congruence through identifica-
need for culturally sensitive instruments has tion and correction of discrepancies; and (5)
also increased. Yet, being able to systemati- a pretest of the TL versions on monolingual
cally account for health-related perceptions individuals and/or the SL and TL version on
and health behaviors is strongly associated bilingual individuals, to ensure the linguis-
with the majority of well-established mea- tic equivalence and cultural relevancy of
surements developed in english that are tar- the translated instrument. When translation
geted for the Western culture, particularly errors that lead to differences in meaning are
for people in the United States. Consequently, identified, these steps need to be repeated so

258 n InSTRUMenT TRanSLaTIon



that a maximum equivalence between the SL serve as bilingual translators and personally
and TL versions is achieved. develop a translated instrument. However,
I one of the major issues related to even if back-translation is employed, the per-
instrument translation is that there has son conducting the research is unlikely to
been no consensus on standard guide- be blinded to the original instrument, and
lines for the processes and evaluation of its therefore, may be biased toward the culture
quality (Maneesriwongul & Dixon, 2004). of the SL. as a result, the approach of having
Historically, nursing has shifted from quali- the researchers themselves serving as bilin-
tative methods to applying multiple methods gual translators calls into question the trans-
of qualitative and quantitative approaches, lation quality and the validity of the study
including the use of instruments to under- findings (Jones & Kay, 1992).
stand and compare health phenomena In addition, the recruitment of sufficient
among different cultures and groups of peo- bilingual subjects for pretesting on the target
ple (Meleis, 1996). However, with a lack of population may not be easy (Jones, 1986; Tang
standard guidelines, the quality of instru- & Dixon, 2002; Yu et al., 2004). Willgerodt
ment translation processes and how these et al. (2005) also points out that researchers
processes are implemented varies widely often underestimate the time needed to trans-
among published cross-cultural nursing late instruments. Because the translation pro-
research (Maneesriwongul & Dixon, 2004; cesses involves numerous discussions and
Willgerodt et al., 2005). To address this issue, iterations in each of multiple steps, it can be
Maneesriwongul and Dixon (2004) systemat- time-consuming and costly. Therefore, ade-
ically examined published nursing literature quate time and budget must be built into a
and classified instrument translation pro- research plan. If sufficient numbers of trans-
cesses into six hierarchical categories with lators, experts (reviewers), and/or bilingual
an analysis of strengths and weaknesses of subjects cannot be recruited, or time and/or
the approaches: (1) forward-only translation budget is severely restricted, the rigor of the
(without pretest), (2) forward translation with instrument translation process will be dimin-
monolingual test, (3) back-translation only ished (Maneesriwongul & Dixon, 2004).
(without pretest), (4) back-translation with Major issues from theoretical and
monolingual test, (5) back-translation with research perspectives are related to the
bilingual test, and (6) back-translation establishment of equivalence (validity) in
with both monolingual and bilingual tests. a translated instrument. Literal translation
Unfortunately, nurse researchers compromises not only the language congru-
encounter socioeconomic and contemporary ence, but also the content/conceptual valid-
practice issues that may render these rig- ity of the translated instrument. For example,
orous, and possibly expensive, approaches bilingual translators tended to follow the
to instrument translation as unfeasible. It grammatical structure (word sequence)
may be challenging to locate more than one and/or nuances of the SL and the transla-
experienced bilingual translator and experts tion is likely to be literal (word-for-word
(reviewers) who are knowledgeable in the translation), which can result in awkward
purpose and intent of the instrument, as syntax and incomprehensible sentences in
well as familiar with the everyday use of the the TL version (Hilton & Strutkowski, 2002;
language in the target society (Wang, Lee, & Maneesriwongul & Dixon, 2004; Willgerodt
Fetzer, 2006). on the contrary, as increasing et al., 2005). as recommended by Brislin
number of nurses from non–english-speak- (1986), the TL version should be reviewed by
ing countries receive advanced educations in one or more individuals who do not have any
the United States or other english-speaking familiarity with the original version, so that
countries, the researchers themselves may such grammatical errors can be identified.

InSTRUMenTaTIon n 259



also, some contents and words repre- In summary, instrument translation is a
senting a particular construct (concept) are multistep process of adapting an instrument
difficult to translate into another language developed in one language (SL) into another I
when no comparable concept or word exists language (TL) with sensitivity to the culture
in the TL or when the use of a concept is being studied. Without the established equiv-
slightly different between cultures (Hilton & alence, cross-cultural comparisons using the
Skrutkowski, 2002; Yu et al., 2004). In addition, translated instruments should not be made
a word in the SL may have several meanings because differences found may be due to
in different contexts, thus rendering several translation errors rather than the true dif-
possible translations in the TL. Consequently, ference among cultures. There is a need for
the translators need to focus on the whole nursing to build the consensus on standard
meaning (both denotation and connotation) of guidelines for the processes and evaluation
a sentence, rather than the literal translation, of instrument translation and equivalence.
so that the translated sentence in the TL accu- all studies involving instrument transla-
rately reflects the original intent and specific tion should provide detailed information in
concepts in the instrument (Capitulo, Cornelio, reports to demonstrate that the translation
& Lenz, 2001; Willgerodt et al., 2005). process and testing of equivalence were the-
Without the established equivalence, the oretically and methodologically valid and
research findings are considered inconclusive adequate.
because the difference may be due to trans-
lation errors rather than the true difference Chiemi Kochinda
among groups or cultures (Goulet, Polomeno,
Laizner, Marcil, & Lang, 2003; Jones et al.,
2001). Yet, most published literature on cross-
cultural research fails to provide detailed InstrumentatIon
information on processes and criteria used
to evaluate the equivalence of translated
instruments with the original instruments Instrumentation is a broad term for the activ-
(Tang & Dixon, 2002). Specifically, the fol- ities involved in developing, testing, and
lowing information is essential to determine revising measures of concepts important
the equivalence of the translated instrument to nursing. The term is typically applied to
(Maneesriwongul & Dixon, 2004; Wang, Lee, these processes that relate to psychosocial or
& Fetzer, 2006; Willgerodt et al., 2005): (1) the self-report measures of attitudes and behav-
methods of translation (forward only or both iors. However, instrumentation also refers to
forward and back-translation), (2) the qualifi- the validating of measures for physiological
cation of translators and experts (reviewers), parameters or laboratory devices. The goal
(3) the approach used to examine the equiva- of instrumentation is to produce quantita-
lence (validity) of translation, (4) the process tive values that reduce measurement error
and the results on pretesting of the instru- through consistency, accuracy, and sensi-
ment with monolingual and/or bilingual tivity of the procedure, tool, or survey. For
subjects, (5) the information on psychometric self-report instruments, consistency is analo-
properties, and (6) the criteria used. Without gous to reliability, and accuracy is analogous
this information, it is difficult to fully under- to validity. With laboratory instruments,
stand how translation procedures were validity is also used to describe the accu-
implemented or adapted to maintain the sci- racy of the measures, but precision refers to
entific rigor of instruments and studies while the instrument’s consistency in measure-
being culturally sensitive to the populations ment. Sensitivity is directly applicable to
of interest. both types of measurement and refers to the

260 n InSTRUMenTaTIon



instrument’s ability to finely discriminate in measureable. Item generation involves deci-
individual differences and changes in the sions about concept dimensionality and scal-
I concept under study. Reduction of measure- ing methodology.
ment error is achieved by assuring that as When the phenomenon of interest is a
much response variability as possible is due highly abstract concept, the theoretical def-
to the subject’s relationship to the concept inition will include a number of conceptual
under study rather than to inconsistent or aspects that require measurement. Less
systematic extraneous factors. abstract concepts can often be indexed with
The term psychometrics refers to the test- items that tap only one or more finite aspects.
ing of self-report measures and to the sta- For each aspect of the concept, items must be
tistics that are utilized in that examination. developed in a manner that assures homo-
Self-report measures generally fall into the geneity within that conceptual dimension.
categories of norm-referenced and criterion- Thus, the instrument may have to be multi-
referenced. With norm-referenced instru- dimensional or unidimensional, depending
ments, the goal is to obtain a spread of scores on the concept of interest. Typically, multidi-
across a wide range for the purpose of dis- mensional concepts will be measured with
criminating between subjects. Criterion- instruments that have a subscale that relates
referenced measures are constructed for the to each dimension.
purpose of determining whether a subject Decisions about scaling involve whether
has or has not achieved a predetermined set the model is meant to scale stimuli or people.
of target behaviors. Steps in instrumenta- Methods used for scaling stimuli are paired
tion for these two categories differ: however, comparisons, constant stimuli, successive
the majority of attitudinal and behavioral categories, and psychophysical methods.
measures applicable to nursing are norm- Common approaches to scaling people are
referenced, and their construction and test- cumulative (e.g., Guttman-type), differential
ing is emphasized. (e.g., Thurstone-like), and summated (e.g.,
Instrumentation for self-report measures Likert-type) instruments. nunally (1978) pro-
involves three general phases: development, vided an excellent overview of these scaling
testing, and revision. Instrument develop- procedures. other decisions in item-gener-
ment involves concept clarification, develop- ation include factors involved with instru-
ing a theoretical definition, operationalizing ment formatting. These factors relate to levels
the concept, and generating items. Concept of measurement, scaling responses, and the
clarification commonly is done through appearance of the scale to the respondent.
concept analysis, synthesis, or derivation. Instrument testing for self-report mea-
Concept analysis involves a careful review sures involves two aspects. Initially, the con-
of literature with attention to consistencies tent of the instrument is examined to assure
and inconsistencies in the use of the concept. its relationship to the theoretical definition
Concept synthesis uses clinical observa- of the concept. The procedures include esti-
tions to explore the phenomenon of interest. mates of whether the concept has been suf-
Concept derivation consists of moving a con- ficiently indexed by the instrument’s items
cept from one field or discipline to another. and whether the format is clear and promotes
after the concept to be measured is clarified, response consistency. evaluation of the link
a theoretical definition is formulated that between the concept and items is primarily
delineates the dimensions of the concept to performed by a panel of content and instru-
be measured based on the result of concept ment experts. once it is determined that the
clarification. operationalization is the pro- concept is adequately indexed, a second phase
cess of moving to a variable that is isomor- of testing involves the use of the instrument
phic with the theoretical definition and is with a sample from the target population.

InTeRnaTIonaL CLaSSIFICaTIon FoR nURSInG PRaCTICe n 261



This testing results in a quantitative exam- data can be reused for many purposes,
ination of reliability and validity measures including communication, clinical decision-
(see “reliability” and “validity”). support, knowledge generation, and policy I
Instrument revision for self-report mea- making. The International Classification
sures includes a critical examination of test- for nursing Practice (ICnP®), a program of
ing results and individual items. options for the International Council of nurses (ICn),
items are (a) inclusion as is, (b) alteration to is a standardized terminology designed to
clarify or meet theory, and (c) elimination. represent nursing diagnoses, interventions,
once the instrument has been revised, it and outcomes. To represent nursing prac-
must be tested again with another sample tice worldwide, the ICnP needs to be broad
from the target population. enough to capture the domain of nursing
Instrumentation for laboratory measures practice globally and sensitive enough to
involves similar phases of development and represent the diversity of nursing practice
testing. However, the development phase across countries and cultures. To be specific,
typically focuses on the establishment of pro- the ICnP must be:
cedures for use of the device. Testing evalu-
ates the precision, accuracy, and sensitivity of • broad enough to serve the multiple pur-
the device, given the procedures established. poses required by different countries;
examinations of precision must include cal- • simple enough to be seen by the ordinary
ibration of the device and evaluation for practitioner of nursing as a meaningful
inconsistency in readings, given repetitive description of practice and a useful means
use. assessment for accuracy includes not of structuring practice;
only the meeting of established standards, • consistent with clearly defined conceptual
but appraisal of appropriate theoretical spec- frameworks but not dependent on a par-
ification of measurements to the concept of ticular theoretical framework or model of
interest. The sensitivity of the device is very nursing;
related to the accuracy but requires testing • based on a central core to which additions
the device measurements in known change can be made through a continuing process
states or across a spectrum of different lev- of development and refinement;
els. Revisions of procedures may be needed • sensitive to cultural variability;
when the results of testing do not meet estab- • reflective of the common value system of
lished standards for precision and accuracy. nursing across the world as expressed in
the ICn Code for nurses; and
Joyce A. Verran • usable in a complementary or inte-
Paula M. Meek grated way with the family of classifica-
tions developed within the World Health
organization, the core of which is the
International Classification of Diseases (ICn,
2009).
InternatIonal
classIfIcatIon for nursIng ICn, a federation of 135 national nurses
associations, has provided an infrastructure
PractIce to enhance the development of an ICnP.
acknowledging that there was no interna-
tional terminology to describe nursing’s con-
Use of standardized terminologies can sup- tribution to health, the ICn approved the
port the electronic capture of clinical data resolution that launched the ICnP project
by nurses at the point of care delivery. These in 1989. The ICnP Program has facilitated

262 n InTeRnaTIonaL CLaSSIFICaTIon FoR nURSInG PRaCTICe



the work of many nurses around the world, Centers. There are currently 10 accredited
resulting in the expansion of ICnP from a centers with defined organizational struc-
I set of nursing concept (alpha, beta and beta ture across the world. additionally, there is a
2 versions) to a logic-based nursing termi- major emphasis on worldwide participation
nology or ontology (ICnP 1.0, 1.1, and 2 ver- of nurses and additional partners (such as
sions). In other words, based on the concern informatics experts, researchers, and indus-
that the terminology was increasing in size try) in the development of the ICnP. Many
and complexity, a formal mechanism to orga- individual nurses and researchers, thus have
nize and maintain ICnP using Web ontology contributed to the ongoing development, test-
Language was adopted from version 1.0. ing and evaluation of ICnP. a major priority
Using Web ontology Language, which is for ICn is to encourage translations of ICnP.
underpinned by description logic, helped Translations can expand opportunities for
determine subsumption relations among nurses to participate in research and devel-
concepts and organizing ICnP in a machine- opment in their own language. Recently,
interpretable format for automated reasoning ICnP was recognized as a related member
(Hardiker & Coenen, 2007). a new version of of the World Health organization Family
ICnP will be released every 2 years in con- of International Classifications, and ICn
junction with the ICn Conference. ICn plans joined the International Health Terminology
to launch the release of the ICnP Version 3 in Standards Development organization in
2011, at the ICn Congress in Malta. an agreement to harmonize the ICnP and
ICn’s commitment to the ICnP contin- Systematized nomenclature of Medicine
ues to be strengthened. The objectives and Clinical Terms.
plans of the ICnP Program are identified ICnP research projects contribute to
and reviewed annually and organized into ongoing development and include (a) con-
three activity clusters; (a) research and devel- cept validation studies, (b) computer-based
opment, (b) maintenance and operations, and information system demonstration projects,
(c) dissemination and education (ICn, 2009). (c) evaluation studies, (d) subset development
Research and development projects are initi- projects, and (e) cross-mapping projects.
ated by ICn and by nurse and other experts evaluation studies include the degree of ICnP
worldwide. Terminology maintenance and content coverage given a specialty area and
operations is, for the most part, a set of pro- the extent to which ICnP meets terminology
cesses internal to ICn. Dissemination and requirements defined by the International
education encompass internal and exter- organization for Standardization.
nal strategies and are directed at audiences To facilitate the use of ICnP in practice,
worldwide. all the activities are intended clinically relevant subsets of ICnP nursing
to support the vision of ICn as an integral diagnoses, interventions, and outcomes are
part of the global information infrastructure being developed (Coenen & Kim, 2010). For
informing health care practice and policy to example, ICn released an ICnP subset for
improve patient care worldwide. Palliative nursing Care. In addition, a new
For the success of the ICnP Program, part- Internet site, ICNP C-Space, was launched to
nerships are a priority for the ICnP Program. facilitate collaborative work in ICnP devel-
ICn already has a strong infrastructure, opment and evaluation, along with facilitat-
including collaborative relationships with ing the dissemination of ICnP.
the member national nurses’ associations and The vision of ICnP is to have nursing
other established nursing, health care, and data readily available and used in health
governmental organizations. a new ICn ini- care systems worldwide. In addition to pro-
tiative to facilitate collaboration is the estab- moting comparable nursing data, the ICnP is
lishment of ICn Research and Development intended to facilitate a comparison of nursing

InTeRnaTIonaL nURSInG ReSeaRCH n 263



data with data from other health disciplines. experiences to studies that produce evidence
It is important to understand, thus, that the for best models of care that reflect and tran-
ICnP will always be dynamic. Just as nurs- scend countries (Mcauliffe & Cohen, 2005). I
ing science and technology evolve, the ter- To add to these definitions, global nurs-
minology that represents nursing practice ing research represents comparative research
must evolve. In addition, the ICnP must on nursing phenomena and on nursing issues
continue to meet international criteria set conducted in more than one country. This
by standards organizations and to work in includes research that is conducted cross-
harmony with other informatics and termi- nationally to examine issues of global inter-
nology initiatives. The ongoing development est to nurses and to test and develop theories.
and dissemination of the ICnP continue to The research is usually conducted by a nurse
be complementary to efforts already under- who resides in one country and studies phe-
way in nursing, building on and supporting nomena in another country. The purpose is
the existing work in nursing classifications. to compare the findings with the results of
similar research obtained in other countries.
Tae Youn Kim Such research provides opportunities to clar-
Amy Coenen ify scientific values, explore assumptions,
and develop shared frameworks.
Global research in nursing is growing
with the increased opportunities for travel,
InternatIonal nursIng networking, and collaboration. The increas-
ing abilities of nurses to study abroad, to
research attend international conferences, to visit
international institutions, and to commu-
nicate through electronic mail systems,
Driving international research through enhance comparative and collaborative
coherent frameworks and grounding it in research projects. International scholarship
research and experiences will help advance has focused on the use of U.S. nursing the-
knowledge in the discipline of nursing. It ories and the evaluation and testing of their
is important to note that the concept inter- utilities and appropriateness to the different
national, as in international education, nursing cultures. There are many descriptive
research, exchanges, and health, have been and analytical dialogues related to theory in
substituted in most contemporary literature the international literature. These dialogues
into the concept of global. Global health is have resulted in scholarly publications
differentiated from international health and related to the introduction and analysis of
public health by geographical research, level U.S. theories in many countries.
of cooperation, access to health, range of dis- Human resources analyses and investi-
ciplines, and the nature of the focus on indi- gations led to several international projects.
viduals and populations (Koplan et al., 2009). Questions related to the image and status
With global health transcending national of nursing, shortage of nurses, and distribu-
boundaries, requiring global cooperation, tions of nurses in urban and rural settings
embracing populations, and preventive care were examined. The results were compared
within equity and interdisciplinarity mod- and contrasted among and between coun-
els. Having a clear conceptual definition for tries and regions. There is general agreement
global health and using social justice theo- among researchers in many countries on
ries as frameworks (Kleinman, 2010) could the perception of nursing and the difficulty
help direct global research and exchanges in recruitment of students and retention of
in nursing from narratives about personal nurses in the workforce.

264 n InTeRPeRSonaL CoMMUnICaTIon



There are commonalities in nurses’ rea- identified to enhance international collabo-
sons for leaving their countries and seeking ration and provide nurses with shared goals.
I employment in other countries or regions. one important framework for global
nurses emigrate to seek better job opportu- nursing research are the eight United
nities, to secure a better future for their chil- nations Millennium Development Goals to
dren, to improve their skills, and to complete be achieved by 2015 (United nations, 2000).
their graduate education. according to the Institute of Medicine’s
other research areas that received the report on the U.S. Commitment to Global
attention of global nurses were the car- Health (Institute of Medicine, 2009) there are
ing practices of nurses and the relationship areas for action that warrant careful review in
between nurses’ cultural heritage and lan- directing nursing scholarship. These include
guage and patients’ cultural heritage and scaling-up interventions to achieve health
their primary language of communication. gains, addressing health problems endemic
There is beginning evidence that nurses of to the global poor, investing in developing
multicultural heritage who speak more than the capacity of global partners, and devel-
one language tend to provide more culturally oping models for engaging in respectful
competent care. Research focused on nurs- partnerships.
ing theories tends to draw on communities
of scholars from different countries. Afaf Ibrahim Meleis
other areas of comparative and collab-
orative research were focused on women’s
health and quality of life. Questions about
women’s health were considered within InterPersonal
a sociopolitical context, with attention to communIcatIon:
health and health care in the overall develop-
ment of women through better options, more nurse–PatIent
education, and higher status. other research
examples were in ethical and clinical decision
making, pain management, and the manage- Interpersonal communication refers to a
ment of the care of the elderly. function of language and is one of the most
Future international research requires important skill sets in nursing practice. It
the development of culturally competent is what nurses’ use with both spoken and
methods, analysis of ethical issues in con- written words in the formation and main-
ducting collaborative international research, tenance of the therapeutic relationship with
development of guidelines for international patients. It is central to the work of a profes-
collaboration, and a framework for deci- sion whose service outcomes depend on the
sions related to data ownership, author- skillful blending of interpersonal and clini-
ship, and culturally sensitive rules for data cal expertise, as effective delivery of health
dissemination. care depends to a great extent on the quality
The International Council of nursing, of communication between health care pro-
in collaboration with the U.S. Institute for viders and their patients. Interpersonal com-
nursing Research, developed a list of pri- munication encompasses both verbal and
orities for international research, which nonverbal aspects of the interaction within
addressed the urgency for preparing the context of the therapeutic relationship.
researchers internationally and providing Interpersonal communication is distinct
international strategies to support nursing from therapeutic communication, and the
research. a future direction for priorities two terms should not be used interchange-
in substantive research questions has to be ably because they are not synonymous.

InTeRPeRSonaL CoMMUnICaTIon n 265



Interpersonal communication is a form of to interpersonal communications. Further
communication and therapeutic communica- emphasis on systematically studying the
tions is a subtype of interpersonal commu- interactive process, ascertaining the content I
nication. Interpersonal communication skills of the communication, and deciding whether
are the basic foundation and underpinnings or not what is being communicated is assist-
for therapeutic communication outcomes. ing in the nursing situation was encouraged
Ideally, interpersonal communication is born (Travelbee, 1971).
between the nurse and the patient, from the Interpersonal communication in health
nurses’ conscious application of an interper- care is often complex—influenced by per-
sonal model of practice. Therapeutic commu- sonal characteristics and interaction styles
nication is then the aggregate result from the of nurses, patients, or patient companions
entire process. as well as contextual factors. The majority
Interpersonal communication is the pri- of research on provider–patient communi-
mary means by which patients learn about cation has occurred over the past 30 years.
their particular health problems, appro- The focus of this research has been on com-
priate prevention and treatment strategies, munication styles and strategies that occur
and the roles both nurses and patients play within the provider–patient relationship.
in achieving health outcomes. Within the Physicians’ verbal communication has been
nurse–patient relationship, interpersonal studied far longer and more frequently than
communication should primarily be con- that of any other type of health care provider.
cerned with the development, for the patient, Researchers have largely ignored the role of
of a clear and adequate conception of the nonphysician providers and have excluded
experience of the illness (Peplau, 1991). them from communication analysis. Much of
Discussion of the parameters of inter- what is known from this research is limited
personal communication in nursing care to what is said by White male primary-care
can be found as far back as 1858. Florence physicians during initial acute-care visits
nightingale had published Notes on Nursing (Roter, 2003).
and pointed out in the section “Chattering although nurse–patient communication
Hopes and advices,” that much damage has been examined during this time period
can be done by what is said to a sick patient. and provided a basis on which to describe
Giving false hopes and discussing personal the types of communication styles used by
matters that are anxiety-producing is not nurses in practice, most of the current com-
helpful in restoring the patient to health munication research remains exploratory
(nightingale, 1992). Heightened focus on the and descriptive, and appears to be driven by
importance of interpersonal communications validating assessment tools and coaching on
in the nurse–patient relationship occurred technique rather than application of interper-
during the 1950s with the work of nurse the- sonal theories. Problems, such as how to deal
orist, Hildegard Peplau, who introduced an with interpersonal communicating barriers
interpersonal model to guide nursing prac- in ventilated patients, again resulted in a
tice. What was said, how it was said, and why description of barriers and strategies for deal-
it was said, became the focus of many stu- ing with them but failed to integrate inter-
dent nurses’ process recordings in conversa- personal theories into the remedy (Laakso,
tions with patients. Joyce Travelbee, another Hartelius, & Idvall, 2009). Interpersonal com-
theorist, furthered the importance of inter- munication practices of student undergradu-
personal communication in 1971 with the ate nurses and student graduate nurses have
publication of Interpersonal Aspects of Nursing. also been studied but again this was not tied
The importance of “relatedness” to the cli- to an interpersonal nursing model of prac-
ent and their situation was integrally linked tice (Klakovich & Dela Cruz, 2006). Teaching

266 n InTeRPeRSonaL CoMMUnICaTIon



strategies for improving nursing student’s of a nursing theory (Sampaio, aquino, de
interpersonal communication skills were also araujo, & Galvao, 2008).
I explored without any reference to interper- More explicit research connecting nurses
sonal models of practice as a guiding factor and how nurses choose to respond to patients
(Jones, 2007). Interpersonal communications from a social processing and an interpersonal
problems in the emergency room have also nursing model (orlando) have been investi-
been studied. The relationship to interper- gated (Sheldon & ellington, 2008).
sonal models of practice was inferred but not The application of interpersonal com-
explicitly correlated (Kelly, 2005). munication as structured within a nursing
The importance of this correlation has theoretical paradigm is an important area
been previously documented. In her obser- for future research because the concepts of
vation of nurse–patient interactions, Peplau interpersonal communication and thera-
discovered that nurses who practiced from peutic relationships are inherently linked.
an interpersonal model reported that as Interpersonal communication and Peplau’s
they attended to what they were feeling dur- model is currently being explored as applied
ing the evolution of the relationship, they to cyber-nursing and has been found to still
become aware of empathic observations that be relevant (Hrabe, 2005).
drove the interpersonal conversation into Discoveries in knowledge about the
important areas that the patient may not presumed mechanisms behind the effects
have even noticed or talked about (o’Toole & of communication will occur only when
Welt, 1989). theory-driven questions and hypotheses are
Between 2005 and 2010, approximately systematically asked and tested. In addition
139 research articles appeared in a litera- to being studied as a process, communica-
ture review of therapeutic communications tion may serve as an outcome, a predictor, a
in nursing (CInaHL, 2010). Few (~3.5%) are mediator of a process, or a moderator of rela-
devoted to interpersonal communication as tionships among other variables. When these
being driven by the theoretical structure of issues begin to be addressed, the profession
the interpersonal relationship specifically. will be better able to determine how the find-
Within the small percentage studying this ings on nurse–patient communication and
correlate was the navigation of orem’s self- interpersonal relations research can be used
care theory and the relevance of using inter- to affect the clinical and educational aspects
personal communication to facilitate the of nursing.
process in ostomy patients. although not
an interpersonal theory per se, it neverthe- Marjorie Thomas Lawson
less tied interpersonal prompts to concepts Updated by Jeffrey Schwab Jones

J















In early studies of organizations, work-
Job SatiSfaction ers’ liking or disliking their jobs usually was
labeled morale. Midway through the twenti-
eth century, researchers began to develop both
Job satisfaction is the degree to which general and dimension-specific measures
individuals like their jobs. It has been stud- of satisfaction and dissatisfaction. General
ied extensively from multiple perspectives, or global measures estimate an individual’s
including economics, psychology, nurs- overall feelings about the job. In dimension-
ing, sociology, and organization science. specific measures, subconstructs distinguish
Researchers have studied job satisfaction as satisfaction about specific facets of the job,
a dependent variable in assessing the impact such as the work or task, pay and benefits,
of organizational changes or as an inter- administration, and, for nurses, dimensions
vening variable with multistaged models of such as professional status, nurse–physician
employee turnover, retention, or absentee- relationships, and quality of care.
ism. More recently nurses’ job satisfaction is Global job satisfaction is measured by
being examined, along with variables such items that directly ask about the job over-
as nurse staffing, autonomy, empowerment, all, either in single items or in multiple item
safety climate, and burnout, as part of the scales. Scales measuring global job satis-
work context that affects patient care out- faction are often developed from subsets of
comes such as patient satisfaction, length of the Brayfield and Rothe (1951) instrument.
stay, adverse events, mortality, and costs. Dimension-specific tools measuring nursing
Job satisfaction is a complex construct job satisfaction include similar components.
with multiple conceptual influences. Among The McCloskey–Mueller Satisfaction Scale
the most important influences are Maslow’s (Mueller & McCloskey, 1990) includes extrin-
(1954) Hierarchy of Needs and Hertzberg, sic rewards (salary, vacation, and benefits),
Mausner, and Bynderman’s (1959) Motivator- scheduling, balance of family and work,
Hygiene Theory. As a complex construct, job coworkers, interaction opportunities, pro-
satisfaction has both perceptual and attitudi- fessional opportunities, praise and recog-
nal components, both an evaluation of how nition, and work control and responsibility.
well a job meets one’s needs and an affective The Index of Work Satisfaction (IWS; Stamps,
orientation to the job (Tovey & Adams, 1999). 1997) includes task, interaction, decision
As a perceptual construct, job satisfaction making, autonomy, professional status, and
reflects an evaluation of the extent to which pay. The nurse job satisfaction instrument
the job meets one’s expectations and needs, endorsed by the National Quality Forum, the
ranging from physiological and safety needs Practice Environment Scale of the Nursing
to self-actualizing career development. As Work Index (PES-NWI) (Lake, 2002), includes
a general attitudinal construct, job satisfac- nurse participation in hospital affairs; nurs-
tion reflects a positive affective orientation ing foundations for quality of care; nurse
toward work and the organization, whereas manager ability, leadership, and support
job dissatisfaction reflects a negative affec- of nurses; staffing and resource adequacy;
tive orientation. and collegial nurse–physician relations.