Encyclopedia of Nursing Research

268 n JoB SATISFACTIoN



Developers of some dimension-specific tools other unit-level database indicators (e.g.,
report techniques for calculating a composite nursing care hours per patient day, nurs-
J measure. For example, Lake (2002) describes ing staffing mix, pressure ulcers, patient
averaging the subscale scores for a PES-NWI falls, and patient satisfaction) as part of the
total score. Composite scores derived from American Nurses Association Safety and
dimension-specific instruments should be Quality initiative. Boyle, Miller, Gajewski,
distinguished from estimates of global job Hart, and Dunton (2006) reported further
satisfaction. examination of the unit level properties of
Researchers choose measures of job satis- the NDNQI-adapted IWS. Individual-, unit-,
faction based on the aims of the study. Global and organization-level psychometric prop-
job satisfaction tools are most often used to erties have been reported for the PES-NWI
predict important employee outcomes such (Gajewski, Boyle, Miller, obserhelman, &
as turnover or patient outcomes such as mor- Dunton, 2009; Lake, 2002). Although job sat-
tality. Dimension-specific scales are used to isfaction has most frequently been examined
examine different strengths and weaknesses at the individual or organization level, sig-
of organizations and to assess the effective- nificant differences between acute care unit
ness of targeted interventions. types have been found (Boyle et al., 2006).
Important conceptual and measurement These differences highlight the need to care-
issues complicate the study of nursing job fully consider the most appropriate level in
satisfaction. It is unclear whether job satis- all study designs.
faction and dissatisfaction are opposite ends The important effect of cultural values
of a single continuum or two separate con- on nursing job satisfaction is not well under-
structs. Although job satisfaction currently stood. Recently, progress has been made
is reported most often in the literature, the in validating instruments for nurses in an
terms satisfaction and dissatisfaction are increasing number of countries, advancing
used inconsistently and sometimes inter- our understanding of the job satisfaction in
changeably. A more recent concern is the pos- the international nursing community. The
sibility that positive and negative affectivity, migration of nurses in response to the evolv-
which are mood-dispositional personality ing global nursing shortage brings new mea-
traits, contaminates effects of determinants surement challenges in destination countries.
(e.g., autonomy, stress, burnout) on strain- In addition, the effects of changes in social
related variables such as job satisfaction. In a values and orientation to work over time and
meta-analysis of affective underpinnings of across age groups are not well understood.
job perceptions, Thoresen, Kaplan, Barskky, Researchers also must consider modifica-
Warren, and de Chermont (2003) found that tions in nursing job satisfaction theory and
both positive and negative affect uniquely measurement required by the profound
contributed to the prediction of job satisfac- changes occurring in health care facilities,
tion, organizational commitment, emotional particularly in the role of technology as well
exhaustion, and personal accomplishment. as in organizational structure and manage-
The multilevel nature common in job ment (Tovey & Adams, 1999).
satisfaction research requires alignment of Researchers (Blegen, 1993; Irvine &
conceptual and measurement levels of stud- Evans, 1995) conducting meta-analyses
ies. Most job satisfaction instruments were of accumulated nursing job satisfaction
developed and validated for individuals. research have found that autonomy, stress,
Taunton et al. (2004) adapted the IWS for commitment to the organization, and intent
use in the National Database of Nursing to stay in the job demonstrate the strongest,
®
Quality Indicators (NDNQI ). The adapta- most consistent correlations with job sat-
tion aligned NDNQI-adapted IWS data with isfaction; autonomy and stress usually are

JoHNSoN’S BEHAvIoRAL SySTEM MoDEL n 269



antecedents of job satisfaction, whereas com- over time in health care organizations and in
mitment and intent to stay are outcomes. social values effecting employment.
other variables with more moderate corre- J
lations are communication with supervisor, Peggy A. Miller
recognition, routinization, communication Diane K. Boyle
with peers, fairness, and locus of control.
In general, variables measuring job charac-
teristics (e.g., routinization, autonomy) and
work environment (e.g., leadership, stress) JohnSon’S behavioral
have stronger relationships than economic
(e.g., pay, opportunity elsewhere) or indi- SyStem model
vidual difference (e.g., age, experience, orga-
nizational tenure) variables. More recently,
researchers of the organizational context for Johnson’s behavioral system model is a nurs-
nursing have found higher nurse-to-patient ing conceptual model developed in response
ratios are associated with lower job satis- to a need to clarify nursing’s social mission
faction and higher emotional exhaustion as directed to the care of human beings and
well as higher patient risk-adjusted mortality identify the nature of the body of knowledge
and failure to rescue (Aiken, Clarke, Sloane, needed to attain the goal of nursing. Within
Sochalski, & Silber, 2002). the model, seven behavioral subsystems
A high priority for current and future carry out specialized functions needed to
research is examining the relationship maintain the integrity of the whole behav-
between nurses’ job satisfaction and out- ioral system and to manage its relationship
comes of care, such as quality of care, patient to the environment. Behavioral actions asso-
satisfaction, adverse events (e.g., falls, pres- ciated with each subsystem are motivated
sure ulcers, failure to rescue, and hospital- by a particular drive and reflect the person’s
acquired infections), mortality, and the like. predisposition to act in certain ways as well
These relationships need to be studied not as all of the choices for actions that are avail-
only with RNs in acute care settings, but in able to the person.
the community, home care, and long-term The function of the attachment or affilia-
care facilities with all members of the nurs- tive subsystem is the security needed for sur-
ing workforce. Exploring the potential con- vival as well as social inclusion, intimacy,
tribution of nurse job satisfaction in research and formation and maintenance of social
testing interventions for improving patient bonds. The function of the dependency subsys-
care and outcomes is imperative. tem is the succoring behavior that calls for a
Several issues surrounding nursing job response of nurturance as well as approval,
satisfaction need more elucidation. First, the attention or recognition, and physical assis-
issue of whether job satisfaction and dissat- tance. The ingestive subsystem is concerned
isfaction are separate constructs warrants with the function of appetite satisfaction in
further attention, as nurses’ satisfaction and terms of when, how, what, how much, and
dissatisfaction may associate differently with under what conditions the person eats, all of
outcomes of care. Second, the degree to which which is governed by social and psychologi-
nurses’ positive and negative affectivity con- cal considerations as well as biologic require-
found relationships between job satisfaction ments for food and fluids. The eliminative
and variables such as autonomy, job stress, subsystem is concerned with the function
burnout, and emotional exhaustion is not of elimination in terms of when, how, and
clear. Last, the effect of diverse cultural val- under what conditions the person eliminates
ues needs further study, as well as changes wastes. The functions of the sexual subsystem

270 n JoHNSoN’S BEHAvIoRAL SySTEM MoDEL



are procreation and gratification with regard collaboration with multidisciplinary team
to behaviors dependent on the person’s bio- members. The model of the attending nurse
J logic sex and gender role identity, including has spread nationally (Fulton, 2008) and
but not limited to courting and mating. The internationally (Assad & de oliveira viana,
function of the aggressive subsystem is protec- 2005) and has been incorporated into a sep-
tion and preservation of self and society. The arate model of nursing care delivery associ-
function of the achievement subsystem is mas- ated with Watson’s Theory of Human Caring
tery or control of some aspect of self or envi- (Watson & Foster, 2003).
ronment, with regard to intellectual, physical, Research based on the model describes
creative, mechanical, and social skills as well disorders that arise in connection with ill-
as the skills needed to take care of children, ness. The ultimate purpose of behavioral sys-
partner, and home. tem model–based research is to determine
Nurse administrators at the University the effects on behavioral system balance and
of California–Los Angeles Neuropsychiatric stability of nursing actions, including pro-
Institute and Hospital developed and imple- vision of protection, nurturance, and stim-
mented the behavioral system model–guided ulation; temporary imposition of external
role of the “attending nurse” (Dee & Poster, regulatory or control mechanisms; and fos-
1995; Moreau, Poster, & Niemela, 1993; tering changes in the person’s behavioral set,
Niemela, Poster, & Moreau, 1992). The attend- choices, and actions. Those actions are specif-
ing nurse is regarded as a comprehensive ically directed toward “fostering of efficient
clinical case manager, with responsibilities and effective behavioral functioning in the
encompassing direct patient care; delega- patient to prevent illness and during and fol-
tion and monitoring of selected aspects of lowing illness” (Johnson, 1980, p. 207).
nursing care; provision of leadership, con-
sultation, and guidance to nursing staff; and Jacqueline Fawcett

K















Kangaroo Care Relevant theoretical paradigms include
(SKin-to-SKin ContaCt) mutual caregiving and self-regulation
(Anderson, 1977, 1989, 1999) and stress reduc-
tion (programming, inappropriate stress res-
ponsivity, and allostatic load; McEwen, 1998),
Most nurses working in an intensive care all physiological/developmental and life span
nursery have witnessed parents expressing in nature, and Fitzpatrick’s Rhythm Model,
intense need to hold their ill preterm infants. Levine’s Energy Principles, Nightingale’s
A relatively new way to address this need Model, Orem’s Self-Care Model, Rogers’
is kangaroo care (KC), a term derived from Energy Fields, and Roy’s Adaptation Model
its similarity to the way marsupials mother (Fitzpatrick & Whall, 1996).
their immature young. During KC, mothers KC has five categories, based primar-
simply hold their diaper-clad infant under- ily on how soon KC begins (Anderson,
neath their clothing, skin to skin (chest to 1995). Late KC, still most common in the
chest) and upright; if needed for warmth, a United States, begins when infants are sta-
cap and a blanket across the infant’s back ble in room air and approaching discharge.
may be added. In complete KC mothers allow Intermediate KC begins after the early inten-
self-regulatory breastfeeding. sive care phase; usually oxygen is needed
KC represents a blend of technology and some apnea and bradycardia occur. Also
and natural care. The method (also known included are infants who are stabilized with
as skin-to-skin contact) began in Bogotá, mechanical ventilation and infants who,
Colombia, is widespread in Scandinavia and although too weak to nurse, are placed at
Africa, and is proliferating elsewhere. In the breast during gavage feedings, a method
developing countries, the method is called that facilitates lactation. Early KC is for eas-
kangaroo mother care because mothers are ily stabilized infants and begins as soon as
usually the central figure responsible for stabilization occurs, usually during the first
continuous care and almost exclusive breast- week and perhaps even the first day after
feeding. Nyqvist et al. (2010a, 2010b) recom- birth. Very early KC begins in the deliv-
mends naming this continuous kangaroo ery or recovery room 15 to 60 minutes after
mother care and using the term intermit- birth. With birth KC, infants are returned to
tent kangaroo mother care for what usually their mothers immediately after birth. The
occurs in developed countries. rationale for these last two categories is that
Full-term infants also are vulnera- the mother can help to stabilize her infant
ble during the physiologically demanding (Bergman, Linley, & Fawcus, 2004).
intrauterine–extrauterine transition after Numerous important variations of KC
birth and therefore benefit from KC (Moore, have been reported as separate case stud-
Anderson, & Bergman, 2007). A Cochrane ies, mostly in MCN: The American Journal of
review protocol of KC for preterm and low– Maternal Child Nursing. Examples are twins
birth weight infants in the NICU has just and adolescent parents, triplets, an intubated
been submitted (Moore, Bergman, Anderson, preterm infant, full-term infants having
Rojas, & Chiu, 2010). breastfeeding difficulties, a near-term infant

272 n KANgAROO CARE (SKIN-TO-SKIN CONTACT)



with gastric reflux, adoptive parents, and a the funded trial, late preterm infants (32 36
–
mother who felt depressed during early post- weeks) began KC by 30 minutes after birth,
K partum (Anderson, Dombrowski, & Swinth, continued 84% of the time, had remarkable
2001). Other journals that frequently publish behavioral organization, began breastfeeding
KC articles include Acta Paediatrica, Journal of exclusively by 2 hours, and were breastfeed-
Obstetric, Gynecologic, and Neonatal Nursing, ing competently by 24 hours. Importantly,
Neonatal Network, and Journal of Neonatal two infants developed respiratory distress
Nursing. (grunting) before KC began, but this disap-
KC is safe and has health benefits based peared quickly while the infants remained
on evidence (Nyqvist et al., 2010a, 2010b). In in KC and received warmed humidified oxy-
the United States, nurses have done most of gen via oxyhood; the warmth and humidity
this research. Findings included adequate are essential (Ludington-Hoe et al., 1999).
warmth, energy conservation, regular heart Randomized trials in developing countries,
rate and respirations, fourfold decrease in Europe, and Taiwan have also been done.
apnea, adequate oxygenation, more deep Although fully implemented in some
sleep and alert inactivity, less crying, less hospitals, use of KC generally remains scat-
cranial deformity, no increase in infections, tered. The method is not allowed in some
fewer days in incubators, greater weight hospitals and might not last in others because
gain, earlier discharge, and increased and of resistance from some hospital staff with
longer lactation and breastfeeding. Morelius, resultant variable support for parents. An ele-
Theodorsson, and Nelson (2005) found that gant model for introducing the method and
maternal salivary cortisol, which was high at effecting desired change and implementation
baseline, decreased during the initial KC ses- is described by Bell and Mcgrath (1996). KC
sion and decreased further across repeated benefits are surely dose related. Thus, paren-
sessions. KC was also analgesic for infants, tal burdens (e.g., transportation needs, time
provided mothers felt relaxed (gray, Watt, & required, fatigue, discomfort, concern about
Blass, 2000). Fathers also gave KC effectively, home-related responsibilities, stress, anxi-
as did grandparents, young siblings, and ety) warrant creative initiatives, including
selected important others. Parents feel more broad social services to facilitate relaxation
fulfilled, become deeply attached to their and extend caregiving to the mother’s home
infants, and feel confident about caring for (Anderson et al., 2003).
them even at home. Cost-effectiveness and Other trends in KC include increasingly
improved long-term outcomes are apparent rigorous research, federal funding, publica-
but not yet evidence-based. tion of detailed guidelines (e.g., World Health
The National Institute of Nursing Organization, 2003), conferences devoted to
Research has funded nurses to conduct at KC, increased networking (Ludington, 2010),
least six randomized trials with preterm KC routinely provided to more vulnerable
infants and KC interventions. Five trials have infants and to full-term infants and pro-
been conducted by Ludington: three were vided by selected family members or friends,
with infants in open-air cribs, in incuba- a new focus on late preterms (Raju, Higgin,
tors, and on mechanical ventilation, one on Stark, & Leveno, 2006), consumer awareness
sleep and brain development measured by of and desire for KC, and increased use of
electroencephalogram, and one on blunting KC to facilitate lactation and breastfeeding
of pain measured by heart rate variability especially for dyads having breastfeeding
(Ludington-Hoe, 2010; http://report.nih.gov). difficulties. The new realization that very
The sixth trial was with 32- to 36-week infants early KC can help stabilize some preterm
beginning KC on average 4.5 hours after birth infants and even prevent NICU admission
(e.g., Anderson et al., 2003). In a pilot trial for has increased interest in giving KC as soon

KINg’S CONCEPTUAL SySTEM AND THEORy OF gOAL ATTAINMENT n 273



as possible after birth, as often as possible and includes a sequence of goal-directed
thereafter, and for as long as possible each behaviors (King, 1981, p. 85). Organization
time. Nursing research is needed to test the is a system whose continuous activities are K
great potential that these various forms of conducted to achieve goals (King, p. 119).
KC have for quality care, stress reduction, As a grand level theory, King’s Conceptual
and mutual relaxation for the mother–infant System provides a distinct focus for the dis-
dyad and the family, improved outcomes, cipline, the process of nursing, and a frame-
parental satisfaction, and cost reduction. work for deriving middle-range theories.
The middle-range theory derived from
Gene Cranston Anderson the conceptual system was King’s Theory of
goal Attainment (King, 1981). This theory
is focused on nurse–client interactions that
lead to transactions and goal attainment.
King’S ConCeptual SyStem King developed a classification system of
and theory of goal behaviors in nurse–patient interactions that
lead to transactions and goal attainment. The
attainment key behaviors in the process of transactions
include mutual goal setting, exploration of
means to achieve goals, and agreement on
Introduced in 1981, Imogene King’s theory means to achieve goals. The theory of goal
focused on individuals as personal systems, attainment specifies the process of nurs-
two or more individuals as interpersonal sys- ing and emphasizes nursing outcomes.
tems, and organized boundary systems that Outcomes are defined as goals achieved and
regulate roles, behaviors, values, and roles as can be used to evaluate the effectiveness of
social systems. Concepts for understanding nursing care.
personal systems are perception, self, growth In the past 2 decades, there has been a
and development, body image, learning, considerable extension and application of
time, personal space, and coping. Concepts King’s Conceptual System and Theory of
important for understanding interpersonal goal Attainment (Frey & Sieloff, 1995). Also,
systems are interaction, communication, role middle-range theories are derived from the
stress/stressors, and transaction. Concepts conceptual system. In addition to King’s
useful for understanding social systems are theory of goal attainment, middle-range
organization, authority, power, status, and theories derived by others address family
decision making. Perception, interaction, (Doornbos, 2000; Wicks, 1995), health out-
and organization are comprehensive con- comes in children with chronic conditions
cepts for personal, interpersonal, and social (Frey, 1995), empathy (Alligood, 1995), and
systems, respectively. Perception is a process nursing department power (Sieloff, 2003).
of organizing, interpreting, and transform- Each theory represents an ongoing program
ing information from sense data and mem- of research.
ory (King, 1981, p. 24). Interaction is defined
as two or more persons in mutual presence Maureen A. Frey

L














discovering the essence of care for a partic-
Leininger’s Theory of ular culture and puts forth the theory of cul-
CuLTure Care DiversiTy ture care worldwide as necessary research
for epistemic knowledge for the profession
anD universaLiTy of nursing. The theory has three theoreti-
cal modes: cultural care preservation and/
or maintenance, cultural care accommoda-
The theory of Culture Care Diversity and tion and/or negotiation, and cultural care
Universality is derived from the disciplines repatterning or restructuring (Leininger,
of nursing and anthropology. Madeline 2006). The three modes were developed
Leininger conceptualized the theory in the based on Leininger’s experiences with using
mid 1950s as a way to bridge the gap between culture care knowledge to assist clients in
nursing care and culture (Leininger, 2006). several Western and non-Western cultures.
Leininger is credited with establishing trans- According to Leininger, the modes are care
cultural nursing and coining the term “cul- centered and use both emic (generic or folk
turally congruent care” (Leininger, 2006; care) and etic (professional care) knowledge.
McFarland, 2006). According to Leininger, Culture care diversity points to the differ-
culture care is the broadest holistic means ences in meanings, values, patterns, and
of knowing, explaining, interpreting, and lifeways that are related to assistive, sup-
predicting nursing care phenomena to guide portive, or enabling human care expressions,
nursing practice. Culturally congruent care within or between collectives while culture
is beneficial care and occurs only when the care universality points to the common, sim-
culture care values, expressions, or patterns ilar, or dominant uniform care meanings
of the client (individual, group, family, or (Leininger, 1995, 2006).
community) are known and used in appro- Leininger defines health as “a state of
priate and meaningful ways by the nurse well being that is culturally defined, valued,
(Leininger, 1995, 2002, 2006). and practiced, and which reflects the ability of
Leininger established the theory of cul- individuals (or groups) to perform their daily
ture care to account for and explain much role activities in culturally expressed, bene-
of the phenomena related to transcultural ficial, and patterned lifeways” (Leininger,
nursing. The purpose of the theory is to dis- 1991, p. 47). Care is described as being essen-
cover human care diversities and univer- tial to curing, healing, health, well-being,
salities, whereas the goal of the theory is to and survival. Care is also presented as the
improve and provide culturally congruent dominant and unifying feature of nursing
care (McFarland, 2006). The components of and one of the most important concepts of
the theory are depicted in the Sunrise Model. transcultural nursing (Leininger, 1985, 1995,
Although Leininger provides orientational 2006). Nursing is presented as a transcul-
definitions for the concepts in the model, she tural humanistic and scientific profession
discourages the use of operational defini- and discipline, whose central purpose is to
tions in the study of culture care (Leininger, serve human beings worldwide. The eth-
2006). Leininger supports exploring and nonursing research method was designed to

LeiNiNger’S Theory oF CULTUre CAre DiverSiTy AND UNiverSALiTy n 275



systematically explore the purpose, goal, and and valued by nurses and health profession-
tenets of the theory through a naturalistic and als worldwide. The Journal of Transcultural
predominantly emic open inquiry discovery Nursing, which was founded by Leininger L
approach (Leininger, 2006). ethnonursing in 1986, has been a major source for dissem-
focuses on the study of nursing care beliefs, ination of caring constructs, culture care
practices, and values, cognitively perceived information, and research findings from
and known by a particular culture through transcultural nurse researchers (Leininger,
their experiences, beliefs, and value systems. 2007).
over the past 40 years, Leininger’s the-
ory of culture care has become well known Sandra C. Garmon Bibb

M














• Plasticity of the hypothalamic–adrenal–
Maternal anxiety and pituitary axis through life, modifiable
Psychosocial adaPtation by the environment, to create hypervigi-
during norMal and lance to condition or kindle future stress
responses.
high-risk Pregnancy • Placental hormones (e.g., CRH).
Up-regulation of hormones by both mater-
nal and fetal cortisol correlate inversely
Pregnancy, with its joyful expectation, also with gestational length and parturition
is expected to be accompanied by some risk triggering.
to the life of the mother, baby, family, and • Neuroendocrine infection/inflammation
other children. The risks often extend on a of the maternal tract that occurs in 20%
continuum and are well documented from to 30% of PTB (McLean et al., 1995; Rich-
pregnancy throughout life; these elements Edwards & Grizzard, 2005; Teixteira,
are documented below by Rich-Edwards Fisk, & Glover, 2003; Warren, Patrick, &
and Grizzard (2005). The psychosocial and Goland, 1992).
psychophysical factors identified with high-
risk pregnancy and preterm birth (PTB) are Publications prepared by Behrman
thought to be interrelated in a host of ways: and Butler (2007) and review panels on the
prevention of PTB by the U.S. Office of the
• Psychosocial stressors: low income and Surgeon General and the Eunice Kennedy
education, lack of a partner, and minority Shriver National Institute of Child Health
status. Behavioral and physical factors may and Human Development (2008) made sev-
further complicate maternal risk status. eral novel recommendations for research
• “Weathering”: sharp age-related risk of on the assessment of PTB risk factors and
poor pregnancy outcomes in black high- personalized, specific interventions for pre-
risk mothers and those with low socioeco- vention. Many recommendations imply a
nomic factors and neighborhood poverty. significant nursing role in psychosocial nor-
• Chronic stress: long-term poverty, racism, mal and high-risk assessment and interven-
and lack of neighborhood safety so that tion. Emphasis is placed on assessment of
the reproductive axis may be vulnerable pregnancy-specific anxiety, and on assess-
to chronic stress. ment/intervention methods that focus on
• Maternal endocrine and immune systems family system methodologies that include
already predisposed to chronic stressors the father/partner, spouse, couple, and other
before conception, which may create vul- family members.
nerabilities to pregnancy complications Although the surgeons general’s con-
and preterm delivery. ference covered several pertinent topics,
• Neuroendocrine pathways between this entry focuses on those with particu-
chronic stress and PTB are exemplified by lar relevance to nursing practice, education,
the “weathering” hypothesis, altering neu- and research. Topics that appear to be
roendocrine mechanisms risks for PTB. of particular importance to nursing are

MATERNAL ANxIETy AND PSyCHOSOCIAL ADAPTATION n 277



(1) psychosocial and behavioral factors in Specific recommendations for increased
PTB, (2) professional education and training, nursing assessment and intervention to pre-
(3) communication and outreach, and (4) qual- vent material anxiety and psychosocial adap- M
ity of care and health services. Conference tion to parenting include the following:
recommendations affecting normal and PTB
are as follows: 1. Assessment and treatment of perinatal
depression and anxiety. High prenatal anxi-
• Identify needs in research, screening, and ety and depression was found among even
clinical care diverse samples. Goodman and Tyer-Viola
• Target African Americans as a priority for (2010) found 23% screened positive for anxiety
research services disorder and high depressive symptoms with
• Make research on the effects of race, rac- very low evidence of treatment. The signifi-
ism, and social injustice a priority cance of fetal programming with changes in
the fetal environment during sensitive devel-
The following are topics of concern in the opment that may cause both long-lasting life
near term: changes, and serious chronic disease is receiv-
ing increasing scientific attention (Schlotz
• Develop a panel to study preterm stress— & Phillips, 2009). Research shows that neo-
definition, conceptualization, measure- natal auditory-evoked responses are related
ment, and biological correlates of PTB to perinatal maternal anxiety, particularly
• Improve measurement of psychosocial in attention allocation (Harvison, Molfese,
and behavioral risk factors and promote Woodruff-Borden, & Weigel, 2009). Depressed
consistency of measures. Preferably use mothers are less responsive to their infants and
instruments with sufficient content to voices (Field, Diego, & Hernandez-Reif, 2009).
provide guidelines for informed psycho- Confirmed maternal anxiety from pregnancy
social interventions (Lederman and Weis, to 5 years postbirth was associated with chil-
(2009) dren experiencing attention problems from 5
• Collect and conduct data analyses to enable to 14 years (Clavarino et al., 2010). Also, high
high quality evaluation of intervention. midpregnancy anxiety was associated with
decreased gray matter density in children 6
Topics of concern in the midterm are: to 9 years old (Buss, Davis, Muftuler, Head,
& Sandman, 2010). Indications are emerg-
• Determine parameters that foster individ- ing that the early prenatal environment
ual decision making of health behaviors may have long life consequences for psy-
and develop interventions to foster the chological development and mental health,
decision-making process. including temperament, adult personality,
mental health, and negative personality con-
Long-term concerns are: sequences (Raikkonen & Pesonen, 2009). The
two- to threefold larger incidence of PTB for
• Shift from a risk-based to an assets-based African American women, the effects of rac-
approach to identify protective factors ism (Gavin, Chae, Mustillo, & Kiefe, 2009;
and alleviate stress factors for decreasing Nuru-Jeter et al., 2009), and the single-mother
stress associated with PTB. homes and/or parental conflict could further
• Develop study methods over the life span compound these negative high-risk PTB and
to obtain multideterminant causal mod- very low birth weight (VLBW) infant health
els: careers factors, measurement meth- disparities (Kramer & Hogue, 2009).
ods, interactions among data, and causal 2. Assessment of prenatal psychologi-
pathways. cal and psychosocial adaptation to pregnancy.

278 n MEASUREMENT AND SCALES



The largest general factor accounting for and other consequences of these decisions
pregnancy adaptation for men and women for the child and the family. The involvement
M (Durkin, Morse, & Buist, 2001) was psycho- of men in pregnancy is increasingly recog-
logical dysphoria (i.e., anxiety, anger, and nized as significant to pregnancy outcomes.
gender role stress). The remaining factors Researchers (Genesoni & Tallandini, 2009)
influenced adaptation of both partners but cited the significance of psychological reorga-
varied in gender proportions: individual nization of the self for men during pregnancy
relationship functioning, social support and self-image transformation, triadic rela-
from family and friends, and recalled qual- tionship development, and social environ-
ity of childhood family relationship, which mental influences. Partner relationship and
are supported by other research (Finger, environmental work-related challenges also
Hans, Bernstein, & Cox, 2009; Fonagy, Steele, are struggles for new families.
& Steele, 1991). These variables accounted Finally, the complex, challenging deci-
for 46.5% of the variance for prenatal psy- sion-making processes of families expecting
chosocial adaptation. The results underscore PTB or VLBW infants (Kavanaugh, Moro,
the need for assessment and interventions, Savage, Reyes, & Wydra, 2009) are addressed.
particularly for individual and for marital Parents and families need assistance in mak-
and parental relationship factors. Nurses ing decisions about life support and care
can address these needs through continuing after birth. Nurses have a significant role in
education workshops to advance their psy- assisting families with these challenges, and
chotherapy knowledge and skills to conduct by compassionately imparting information to
individual and couple relationship therapy. enable parents to make treatment decisions
Jallo, Bray, Padden, and Levin (2009) have that may have lifelong consequences for the
provided positive evidence of PTB birth out- health of all family members.
comes through nurse home visitation with a
37% reduction in PTB compared with women Regina Placzek Lederman
not receiving the program. The program
included dietary improvement, counseling
for family communication, and improved
patterns of prenatal care. Similar results are MeasureMent and scales
cited others (Goering, 2009). The significance
of nurse psychosocial and psychotherapy
contributions to PTB prevention deserves The focus of measurement is the quantifica-
substantial attention from health care deliv- tion of a characteristic or attribute of a per-
ery organization providers. son, object, or event. Measurement provides
3. Strengthening families. Research para- for a consistent and meaningful interpreta-
digms (Lu, 2010) suggest foci for optimization tion of the nature of an attribute when the
of health care across the life span, including same measurement process or instrument
social determinants, increased access to high is used. The results of measurement are
quality health care, and community preven- usually expressed in the form of numbers.
tion and wellness programs to strengthening Measurement is a systematic process that
families. uses rules to assign numbers to persons,
objects, or events, which represent the amount
Examining couple intentions for preg- or kind of a specified attribute (Pedhazur &
nancy and particularly their relationship has Schmelkin, 1991; Waltz, Strickland, & Lenz,
critical implications for father involvement and 2010). However, measurement also involves
maternal seeking of prenatal care (Hohmann- identifying and specifying common aspects
Marriott, 2009) as well as potential life health of attributes for meaningful interpretation

MEASUREMENT AND SCALES n 279



and categorization, using a common concep- unorderable categories. For example, catego-
tual perspective. Ambiguity, confusion, and rizing persons in a study as either female or
disagreement will surround the meaning of male is measurement on the nominal mea- M
any measurement when it is undefined. The surement scale.
measurement relevancy can be determined In ordinal-scale measurement, rules are
only when an explicit or implicit theory struc- used to assign rank order on a particular
tures the meaning of the phenomenon to be attribute that characterizes a person, object,
studied. “Theory not only determines what or event. Ordinal-scale measurement may be
attributes or aspects are measured but also regarded as the rank ordering of objects into
how they are to be measured” (Pedhazur & hierarchical quantitative categories accord-
Schmelkin, 1991, p. 16). Qualitative assess- ing to relative amounts of the attribute stud-
ments apply measurement principles by ied. The categorization of heart murmurs in
providing meaning and interpretation of grades from 1 through 6 is an example. In this
qualitative data through description and ordinal measure, a Grade 1 murmur is less
categorization of phenomena. Thus, mea- intense than a Grade 2, a Grade 2 less intense
surement may not result in scores per se but than a Grade 3, and so forth. The rankings in
may categorize phenomena into meaningful ordinal-level measurement merely mean that
and interpretable attributes. Therefore, mea- the ranking of 1 (for first) has ranked higher
surement is also basic to qualitative analysis than 2 (for second) and so on. Rankings do
(Strickland, 1993b). not imply that the categories are equally
Measurement is a crucial part of all nurs- spaced nor that the intervals between rank
ing settings. Nurses depend on measuring categories are equal.
instruments to determine the amount or kind Interval-scale measurement is a form
of attributes of patients and use the results of of continuous measurement and implies
measurements such as laboratory and physi- equal numerical distances between adjacent
cal examination results to determine patient scores that represent equal amounts with
needs and their plan of care. Nurse research- respect to the attribute that is the focus of
ers use a large array of physiological, clinical measurement. Therefore, numbers assigned
laboratory, observational, and questionnaire in interval-scale measurement represent an
measures to study phenomena of interest. attribute’s placement in one of a set of mutu-
Nurse educators depend on measurement ally exclusive, exhaustive categories that can
instruments and test scores to help determine be ordered and are equally spaced in terms of
a student’s mastery. Measurement is central the magnitude of the attribute under consid-
to all that nurses do. We cannot understand eration. However, the absolute amount of the
or “study well what we cannot measure well” attribute is not known for a particular object
(Strickland, 1993a, p. 4). because the zero point is arbitrary in an
The rules used for assigning numbers interval scale. The measurement of temper-
to objects to represent the amount or kind ature is a good example of an interval-level
of an attribute studied have been catego- measure because there is no true zero point.
rized as nominal, ordinal, interval, and ratio. For example, the zero point is different based
These types of measurement scales are com- on whether the Fahrenheit or Centigrade
mon in nursing. Measurements that result measurement approach is used, and one can-
in nominal-scale data place attributes into not say that an object with a temperature of
defined categories according to a specified 0°F or 0°C has no temperature at all. Ratio-
property. Numbers assigned to nominal- level measures provide the same informa-
level data have no hierarchical meaning but tion as interval-level measures; in addition,
represent an object’s membership in one of they have absolute zero points for which zero
a set of mutually exclusive, exhaustive, and actually represent absence of the attribute

280 n MEASUREMENT AND SCALES



under study. Volume, length, and weight are clinical settings of nurse researchers. Often
commonly measured by ratio scales. the instruments developed in other fields
M There is controversy about the level of were not sensitive to clinically relevant attri-
measurement scales and the type of statis- butes of concern to nurses in populations
tical procedures that may be appropriately such as children, frail patients, the elderly,
used for data analysis. There are researchers and the culturally diverse.
and statisticians who believe that only non- The movement in nursing to develop more
parametric statistical procedures can be used rigor in the use and development of measure-
for data analysis when data are nominal or ment instruments gained prominence in the
ordinal and that inferential statistics can be 1970s. In June 1974, a contract was awarded
properly applied only with interval and ratio to the Western Interstate Commission for
data. There is controversy about whether Higher Education by the Division of Nursing,
Likert scaling (which is often used in nurs- Bureau of Health Manpower, and Health
ing with measures of attitude or opinion) is Resources Administration to prepare a com-
in actuality ordinal-level measurement for pilation of nursing research instruments and
which only nonparametric statistics should other measuring devices for publication.
be used. Likert scaling involves having sub- With Doris Bloch as project officer, a two-
jects rank their responses to a set of items on volume compilation of instruments, titled
a range of numbers, such as “1” to represent Instruments for Measuring Nursing Practice and
lack of agreement to “5” to represent complete Other Health Care Variables, was published in
agreement. It has been the accepted practice 1978 (Ward & Lindeman, 1978). Priority was
for investigators to use scores generated with placed on compiling instruments dealing
Likert-type scales as interval-level data. with nursing practice and with patient vari-
Nurses have typically borrowed many ables rather than nurse variables. This was
measures from other disciplines. This reflects an important milestone for nursing mea-
the fact that nursing is a field that considers surement because it was the first effort that
the biological and psychosocial aspects of placed a large number of clinically focused
care and is based on knowledge generated instruments developed or used by nurses in
by many fields of inquiry. Therefore, many the public domain.
measures developed by other disciplines are During the late 1970s and early 1980s,
consistent with nurses’ measurement needs. nurse scientists began to focus their work on
However, the heavy dependence on borrow- developing measurement as an area of spe-
ing measures from other disciplines reflects cial emphasis in nursing. At the University of
the trend in the 1970s for nurses to pursue Arizona–Tucson, Ada Sue Hinshaw and Jan
doctoral education in related fields, such as Atwood focused their efforts on refining and
education, psychology, sociology, and phys- further developing instruments for clinical
iology. Nurses became familiar with mea- settings and for clinically focused research.
sures from other fields during their graduate The first postdoctoral program in nursing
studies and were encouraged to use them in instrumentation and measurement evolved
the nursing context. at the University of Arizona, and annual
By the mid-1970s, nurses became more national conferences on nursing measurement
cognizant of some of the limitations in bor- were offered. Ora Strickland and Caroyln
rowing certain measures and instruments Waltz at the University of Maryland at
from other disciplines. For example, it is not Baltimore focused on defining measurement
unusual for instruments developed to mea- principles and practices to build rigor in nurs-
sure psychosocial variables in other fields to ing research. Careful assessments of nursing
be cumbersome and inefficient for use in the research published in professional journals

MEASUREMENT AND SCALES n 281



revealed that nurse investigators were not on the specification of nursing interventions
giving adequate attention to reliability and to address the identified nursing diagnoses.
validity issues when selecting and develop- The NOC Study was particularly important M
ing instruments. Nurse investigators tended for the advancement of nursing measure-
to rely too heavily on paper-and-pencil self- ment because it took on the challenge of
report measures and did not give adequate developing measures that could empirically
attention to selecting biological measures as document outcomes of nursing care.
indicated by the conceptual frameworks of The nursing profession has developed
the studies (Strickland & Waltz, 1986). The nursing measurement to a great degree over
Maryland group published the first mea- the past four decades. Nurses have developed
surement textbook for nurses, Measurement in and tested instruments for use in a variety
Nursing Research (Waltz, Strickland, & Lenz of settings, created many new instruments,
1984), and implemented a measurement pro- and further developed measures designed in
ject funded by the Division of Nursing of the other disciplines for use in nursing. Although
Department of Health and Human Services. greater focus has been placed on assessing and
This project prepared more than 200 nurse reporting reliability, precision, accuracy, and
researchers to develop and test instruments validity of measures in clinical settings and
for use in nursing and resulted in the initi- nursing research, inadequate attention has
ation of a series of books, Measurement of focused on the metric qualities of laboratory
Nursing Outcomes, which compiled instru- physiological measures and on quality control
ments developed for the nursing context. procedures for the enhancement of clinical
In 1993, Ora Strickland initiated and measurements. There is still inadequate atten-
edited the Journal of Nursing Measurement tion given to “the specification of the concep-
with Ada Sue Hinshaw as coeditor. This tual base of measurement tools, and, a heavy
journal brought nursing measurement to a reliance on the use of self-report data, attitu-
new level of focus, responding to the need dinal and perceptual measures, and the use of
for continuing development and dissemina- questionnaires and rating scales” (Strickland,
tion of nursing measurement instruments DiIorio, Coverson, & Nelson, 2007). Measures
and providing an identifiable forum for the frequently have not been validated for or are
presentation and discussion of measurement not available for minority and low socioeco-
concerns in nursing. nomic populations, children, frail patients,
As nursing moved into the twenty-first and those with limited verbal communica-
century, the development of nursing mea- tion. Long and cumbersome instruments that
sures continued to evolve with a focus on are difficult for clinical populations to under-
documenting patient care outcomes through stand and complete validity remain an issue.
empirical assessment with well-designed The increasing number of immigrants in the
clinically validated outcome measures. general population has brought the need to
Under the leadership of Meridean Maas at validly translate and use existing instruments
the University of Iowa, the National Institute with a diverse population to the forefront
of Nursing Research funded the Nursing as nursing measurement issue. Nursing stud-
Outcome Classification (NOC) Study. NOC ies of families, communities, and organiza-
was implemented as a natural outgrowth tions and systems have been hampered by the
of the North American Nursing Diagnoses lack of effective measures to address group
Association’s movement, which emphasized and system variables from the nursing per-
the careful classification and documenta- spective (Strickland, 1995).
tion of nursing diagnoses, and the Nursing
Intervention Classification, which focused Ora Lea Strickland

282 n MENOPAUSE



of factors associated with symptom severity
MenoPause during the menopausal transition, including
M biomarkers related to glucose metabolism; (5)
experiences of menopause among popula-
Menopause is the final menstrual period, said tions of women with special health problems;
to have occurred after a woman has not had (6) nonpharmacological approaches to symp-
menses for at least 1 year. Nurse researchers tom management; and (7) relationship of the
have developed an approach using a men- menopausal transition to healthy aging.
strual calendar to determine women’s pro- Holistic frameworks for understand-
gress through the menopausal transition ing women’s experience of menopause have
(Mitchell, Woods, & Mariella, 2000), which permeated nursing research contributions,
has been influential in stimulating a Staging in particular in studies focused on symp-
Reproductive Aging Workshop sponsored toms. Among the constructs that organize
by the National Institutes of Health. The investigation of symptoms during the men-
staging criteria have been subsequently opausal transition and early postmenopause
validated by a multi-investigator interna- are age and age-related factors, menopause-
tional collaborative in the ReSTAGE Study related factors including hormone levels and
(Harlow et al., 2007). For women who have patterns across the menopausal transition
had regular cycles, the time before the onset stages, perceived stress, social factors, health-
of persistent menstrual irregularity dur- related factors such as perceived health, and
ing midlife is labeled the late reproductive health-related behaviors and symptoms that
stage. The early menopausal transition stage co-occur. Reference to nursing and related
is defined as persistent irregularity of more theory about symptoms has enriched under-
than 6 days absolute difference between any standing of the menopausal transition
two consecutive menstrual cycles during the experiences (Lenz, Pugh, Milligan, Gift, &
calendar year, with no skipped periods, and Suppe, 1997). For example, results from anal-
late transition stage is defined as persistent yses using these frameworks reveal that per-
skipping of one or more menstrual periods ceived stress is not related directly to the
(having double the modal cycle length or menopausal transition or endocrine changes,
more for the calendar year). In the absence but perceived stress is related to experienc-
of a modal cycle length, a population-based ing more severe symptoms (Woods, Mitchell,
cycle length of 29 days was used. Persistence Percival, & Smith-DiJulio, 2009).
meant the event, irregular cycle or skipped Staging the menopausal transition
period, occurred one or more times in the has enabled investigators to determine the
subsequent 12 months. The time following sequence of events taking place as women
the final menses is postmenopause. progress through the early and late meno-
Nursing scholars have contributed to the pausal transition period and experience the
field of menopause research in many ways, early postmenopause. In the Seattle Midlife
including (1) development of holistic frame- Women’s Health Study, a longitudinal study
works for understanding women’s experi- of the natural history of the menopausal
ences of menopause; (2) understanding of the transition, use of the menopausal transition
normative experience of menopause, includ- staging system allowed identification of pre-
ing an approach to staging progress through dictable stages related to endocrine changes
the menopausal transition described above (follicle-stimulating hormone and estrogen)
and the chronology of symptom experiences and symptoms such as hot flashes, depressed
across the menopausal transition and post- mood, and nighttime awakening, which are
menopause; (3) comparative approaches to most severe during the late menopausal tran-
measurement of symptoms; (4) identification sition stage (Smith-DiJulio, Percival, Woods,

MENOPAUSE n 283



Tao, & Mitchell, 2007; Woods & Mitchell, focused on women with breast cancer or
2010; Woods et al., 2008). The chronology of other contraindications to estrogen use. This
symptoms has been tracked using health work is exemplified by Carpenter’s clinical M
diaries and repeated measures of symptoms trial demonstrating the efficacy of on paced
over the course of the menopausal transition respiration for reduction of hot flash bother
for as long as 20 years (Woods et al., 2007). and interference (Carpenter, Neal, Kimmick,
In addition, the staging system has been & Sotrniolo, 2007) as well as Cohen’s research
useful in discerning when changes in lipid on acupuncture for hot flashes (Cohen,
levels and metabolic markers related to Roussouw, & Carey, 2003).
healthy aging (Lee et al., 2009). Healthy aging is increasingly under-
Factors associated with symptom sever- stood in relation to a life span view of health.
ity span biological, behavioral, social, and cul- This perspective is beginning to permeate
tural. Biological hypotheses accounting for the understanding of menopause and its
hot flashes have addressed glucose metabo- effects on future health. Although most bio-
lism (Dormire & Bongiovanni, 2008; Dormire medical researchers have emphasized the
& Howharn, 2007), serotonin (Carpenter et al., consequences of menopause and hormone
2009), and gene polymorphisms influencing changes on osteoporosis, cardiovascular dis-
estrogen synthesis, metabolism, and recep- ease, diabetes, and more recently metabolic
tors (Woods et al., 2006). syndrome, nurse researchers have empha-
Menopause among special populations sized health promotion and prevention strat-
of women has attracted the interest of nurse egies that may also alleviate symptoms, such
scientists, as exemplified by Carpenter’s work as use of health education and cognitive-
focusing on women with breast cancer who behavioral therapy interventions.
experience induced menopause. This body of Although contributions to symptom
work has contributed not only to understand- management from nurse investigators are
ing utility of hot flash monitors to assess skin beginning to influence the field of menopause
temperature but also use of increasingly care, trials examining nonpharmacological
more sophisticated approaches to under- agents compared with standard care proto-
standing symptoms (Carpenter, Monaham, & cols are needed. Given the pressing need for
Azzouzz, 2004). Carpenter (2001) developed evidence to guide primary care interven-
the Hot Flash Daily Symptom Interference tions, new models of therapeutics should be
Scale to further understand the degree to tested in these settings. Tailoring therapies to
which hot flashes interfered with multiple women from diverse ethnic backgrounds will
dimensions of life, including work, social, require collaboration between investigators
leisure, sleep, mood, concentration, relation- trained to conduct clinical trials and those
ships, sexuality, and enjoyment as well as schooled in culturally appropriate strategies
asking women to describe the extent to which for the delivery of care. In addition, health
they were bothered by their symptoms. education about menopause delivered in pri-
Following publication of the results of mary care and community settings should be
the Women’s Health Initiative Trial, women examined for effects on women’s uncertainty
exhibited increased interest in nonhormonal about what to expect during the menopausal
therapies for symptoms related to meno- transition and postmenopause.
pause. Given the recommendation to women Although nursing research on symp-
who experienced breast cancer to avoid using tom clusters is commonplace in the oncology
hormone therapy, the field of nonpharmaco- specialty, identification of symptom clusters
logical approaches to managing menopause is just beginning in studies of menopause
symptoms has also been enriched by contri- (Cray Woods, & Mitchell, 2010). Growing
butions of nurse investigators whose work evidence that women experience clusters of

284 n MENTAL HEALTH IN PUBLIC SECTOR PRIMARy CARE



symptoms, not only hot flashes, during the Both economic barriers to care and health
menopausal transition and early postmeno- disparities—including inequalities in men-
M pause, warrants more careful examination tal health care related to race and ethnicity—
of both factors related to different symptom are key priorities for research on improving
clusters and differential treatment effects of health services (Institute of Medicine, 2003d;
pharmacological and nonpharmacological Primm et al., 2010; U.S. Department of Health
therapies on clusters of symptoms to enhance and Human Services, 2001). These issues cut
the precision of therapeutic effectiveness. across all areas of public health need, includ-
Involvement of several nurses as investiga- ing mental health services.
tors (Carpenter, Landis, Woods, Newton, and Also in the late 1970s, the primary care
La Croix) for the newly National Institutes setting became formally recognized as
of Health–funded Menopause Symptoms: the de facto mental health services system
Finding lasting Answers for Symptoms and in the United States (Regier, Goldberg, &
Health (MS-FLASH) multisite trials of thera- Taube, 1978). Of the minority of individuals
pies for menopause-related symptoms prom- who receive needed mental health services,
ises to yield opportunity to further these most receive their services in primary care
efforts. instead of the mental health specialty sec-
tor. Many people seen in primary care for
Diana Taylor medical problems have clinically signif-
Nancy Fugate Woods icant comorbid mental health conditions
(Miranda, Hohmann, Attkisson, & Larson,
1994), especially anxiety, depression, and
substance misuse disorders. People with
Mental health in Public severe forms of co-occurring disorders that
include severe mental illness and chronic
sector PriMary care physical illnesses have been found to die
up to 25 years earlier on average compared
with the general population, and this health
Primary care was first comprehensively disparity has increased over time in context
defined by the World Health Assembly in the of inadequate health care service models for
late 1970s following a seminal conference in this population (Morden, Mistler, Weeks, &
Alma-Ata in 1977 (World Health Assembly, Bartels, 2009). The burden of unmet mental
1978). Building upon the key aspects of Alma- health needs remains high for racial and eth-
Ata, the 1978 World Health Organization nic minorities compared with Whites (U.S.
definition of primary care emphasized its Department of Health and Human Services,
defining aspects as essential, first-level health 2001; U.S. Public Health Service Office of
care embedded in the community, avail- the Surgeon General, 1999). Although the
able to all, evidence based, socially accept- past decade has seen some improvements,
able, and affordable. In the United States, there continue to be significant barriers exist
this optimistic vision for high-quality pri- to accessing public sector health services,
mary care has been only partially achieved. including the affordability of care, social
Ongoing challenges to high-quality primary stigma associated with mental illness, and
care services are especially pronounced for fragmented care delivery systems acting as
public sector primary care. Public sector barriers to care when care is sought (U.S.
primary care services serve disproportion- Department of Health and Human Services,
ate of numbers health care users who have 2001; Villena & Chesla, 2010). These issues
limited ability to pay for health services and continue to be most pronounced for popu-
experience significant health disparities. lations which experience the greatest health

MENTAL HEALTH IN PUBLIC SECTOR PRIMARy CARE n 285



disparities, including those with severe Nurse researchers have the potential to
forms of co-occurring physical and men- make significant contributions to services
tal disorders (Committee on Crossing the and interventions research for a redesigned M
Quality Chasm, 2006; U.S. Department of primary care mental health services in two
Health and Human Services, 2001). specific areas. The first area concerns testing
A central goal of contemporary mental interventions and models of care with well-
health services research is to generate new documented effectiveness for common men-
knowledge directed to the transformation of tal health issues within the primary care and
mental health services to achieve high-qual- other community-based settings where peo-
ity, accessible, recovery-oriented care for all ple obtain health care services, but these are
(The President’s New Freedom Commission tailored in innovative ways to be acceptable
on Mental Health, 2003). In recent decades, for various high-need patients populations
tests of interventions for primary care men- and which can be shown to be both effec-
tal health care have evolved from primar- tive and cost-effective in nontraditional set-
ily efficacy assessments to effectiveness tings of care. Consistent with the literature
assessments, with the most recent empha- in medicine and other fields, the nursing
sis on research to foster implementation of literature on managing mental health issues
effective interventions and service delivery in primary care and community-based set-
models to alter usual care (Chambers, 2008; tings has grown over the past two decades.
Mental Health America, 2010). As primary However, there are still relatively few tests
care research continues to evolve to better of nursing interventions using advanced
address issues of health disparities and men- practice nurses (such as nurse practitioners
tal health care delivery models for primary and mental health clinical nurse specialists)
care settings, there are key opportunities for to manage mental health issues in “usual
nurse researchers in context of health care care” primary care and community-based
reform legislation. The Patient Protection and settings. This is especially so for public sec-
Affordable Care Act (HR 3590) will expand tor primary care with populations that are
health care coverage, including building the most underserved and which experience
infrastructure for colocated integrated physi- health disparities. Some recent examples
cal and mental health care delivered by com- of research with underserved populations
munity health teams (Hanrahan et al., 2003; include testing a nursing intervention for
National Alliance on Mental Illness, 2010; managing major depression in rural women
Sundarandam, 2009). The health care reforms (Hauenstein, 1996), participation of urban
also are projected to increase research that is nurse-managed center in a depression col-
focused on Medicare/Medicaid patients and laborative to improve care for depression
their service utilization, such as provider (Torrisi & McDanel, 2003), testing the effect
and treatment approaches, and optimized of a motivational group intervention on exer-
payment options. Mental health research cise self-efficacy and outcome expectations
is now situated within the top tiers of pri- for exercise in community-dwelling adults
orities for comparative effectiveness health with schizophrenia spectrum disorders
care research (Institute of Medicine, 2009a). (Beebe et al., 2010), and testing an in-home
Related reform legislation such as the Melanie intervention to reduce depressive symptoms
Blocker Stokes Postpartum Depression Act among Latina mothers of infants and tod-
(Section 2942) has direct relevance to pri- dlers enrolled in Early Head Start programs
mary care research in terms of interven- (Beeber et al., 2010). Within these types of
tions to reduce the rates of undiagnosed and nursing intervention studies, there is a well-
untreated postpartum depression (National matched opportunity to include aspects that
Alliance on Mental Illness, 2010). foster high-level recovery of people who

286 n MENTAL HEALTH SERVICES RESEARCH



are living with mental health conditions are most commonly managed in primary
(Camann, 2010). care and community-based settings.
M The second area of research opportunity
concerns evaluations of now rapidly evolv- Celia E. Wills
ing integrated health care roles for advanced Anna L.D. Villena
practice nursing, in which medical and men-
tal health skills are available in the same
geographic location and primary care pro-
vider (Delaney, 2009, 2010; National Panel for Mental health services
Psychiatric-Mental Health NP Competencies,
2003). Although integrated care models for research
management of physical and mental disor-
ders are not yet universally available, there is
a key role for advanced practice nurses who Mental health services research (MHSR)
effectively blend medical and mental health is a subset of health services research that
training and well positioned to manage the focuses mental disorders across the life span
holistic needs of the patients they see in pri- in diverse populations in terms of the organi-
mary care settings (Hogan & Shattell, 2007; zation and delivery of services, outcomes and
Manderscheid, Masi, Rossignol, & Masi, quality of care, clinical epidemiology, and
2007). This is an especially critical need for evidence-based practice dissemination and
populations in which there are complex co- implementation (National Institute of Mental
occurring physical and mental health dis- Health, 2010). The importance of MHSR to
orders that are associated with substantial inform improvements to public health ser-
morbidity, premature mortality, and dimin- vices has become increasing recognized in
ished quality of life (Weber, Cowan, Millikan, recent years, especially as mental disorders
& Niebuhr, 2009) and addresses the Institute are documented to be a leading and increas-
of Medicine recommendation to integrate ing cause of disability in the United States and
mental health and substance abuse care worldwide (U.S. Public Health Service Office
within primary care services (Committee of the Surgeon General, 1999; World Health
on Crossing the Quality Chasm: Adaptation Organization, 2008). MHSR generates new
to Mental Health and Addictive Disorders, knowledge directed to the transformation of
2006). There are some models of integrated mental health services to achieve high-qual-
nursing care for co-occurring disorders that ity, accessible, recovery-oriented care for all
have been developed and tested within the (The President’s New Freedom Commission
past decade. For example, Lyles et al. (2003) on Mental Health, 2003). In MHSR, the meth-
reported the results of an intervention that ods used to study general health services
used nurse practitioners trained to man- research are applied to examine a diverse
age the medical and mental health needs of range of topics such as reducing the morbid-
primary care patients with medically unex- ity and mortality of suicidality in at risk pop-
plained symptoms. McDevitt, Braun, Noyes, ulations, research on effective approaches to
Snyder, and Marion (2005) described the improving the dissemination and uptake of
evaluation of a nurse-managed integrated evidence-based practices, research on men-
primary and mental health care center for tal health care delivery in traditional and
persons with serious and persistent mental nontraditional service settings, economics
illness. These types of integrated roles need and financing of mental health services, and
additional research testing for various com- identification of innovations in mental health
binations of comorbid health conditions that service delivery models to address unmet

MENTAL HEALTH SERVICES RESEARCH n 287



mental health care needs (National Institute et al., 2003; Hanrahan, 2009) as well as lim-
of Mental Health, 2010). ited numbers of nurses with doctoral and
MHSR is interdisciplinary and inte- postdoctoral training in MHSR. The current M
grates the expertise of researchers in diverse supply of mental health services researchers
fields, including such as psychiatric-mental remains low in relation to present and pro-
health nursing, psychology, psychiatry, jected future needs. There remains a contin-
social work, anthropology, sociology, eco- uing need to increase the supply of nurses
nomics, biostatistics, health administration, with doctoral level training and funded
and public policy. Broad interdisciplinary research programs to improve the contribu-
research expertise is needed for the diverse tions of nursing to MHSR.
range of health services research topics that Results of MHSR appear in journals
require the integration of literature from publishing MHSR, such as the Archives of
multiple fields, construction of complex Psychiatric Nursing, Issues in Mental Health
research designs and data collection proto- Nursing, Journal of the American Psychiatric
cols, use of sophisticated approaches to data Nurses Association, Journal of Psychosocial
analysis, and designing effective approaches Nursing and Mental Health Services,
to dissemination and implementation of Administration and Policy in Mental Health
research results. Research funding for MHSR and Mental Health Services Research, and
is supported by multiple sources, includ- Psychiatric Services as well as many other
ing local, state, and federal. At the federal journals not specifically focused on mental
level, MHSR is especially supported by the health or health services research. A review
NIMH Division of Services and Intervention of literature from mental health nursing
Research. Most federally funded, academi- journals leads to a conclusion that qual-
cally based research centers for MHSR are led ity outcomes and mental health delivery
by nonnurse researchers. An exception is the systems are among mental health nursing
Southeastern Rural Mental Health Research research priorities (Pullen, Tuck, & Wallace,
Center at the University of Virginia, School 1999). Fifteen years ago, a review of nursing
of Nursing, which began in 1992 supported literature from 1989 to 1994 concluded that
by NIMH funding and continues its focus few psychiatric nursing studies were pub-
on unmet mental health needs among poor lished in major nursing journals and that
and minority populations in rural settings there was a lack of programmatic research
(Southeastern Rural Mental Health Research upon which to base rigorous evaluation
Center, 2008). of outcomes (Merwin & Mauck, 1995). An
Distinctions between interventions updated review of current nursing literature
(treatment) and services research are some- done for this chapter obtained results that
what indistinct. Interventions research remained consistent with these earlier con-
focuses on efficacy and effectiveness of dis- clusions. Relatively few nurse researchers
crete therapeutic interventions, whereas conduct MHSR. Some representative exam-
services research focuses on the organi- ples of MHSR conducted by nurse research-
zation and delivery of health care. Nurse ers over the past decade include research on
researchers have most often focused on test- outcomes and satisfaction of patients of psy-
ing mental health interventions research chiatric clinical nurse specialists (Baradell
as opposed to conducting broader service & Bordeaux, 2001), shortages of rural men-
systems research. MHSR programs led by tal health professionals (Merwin, Hinton,
nurses remain uncommon; in part, this scar- Dembling, & Stern, 2003), and identification
city reflects the small number of nurses spe- of mental health treatment disparities in
cializing in psychiatric nursing (Hanrahan rural minority groups based on analysis of

288 n MENTAL STATUS MEASUREMENT



the Medical Expenditure Panel Survey data by the mere fact of aging they are at risk
(Petterson, Williams, Hauenstein, Rovnyak, for developing Alzheimer’s disease, could
M & Merwin, 2009). have undetected mild cognitive impair-
An emerging and significant area of ment (MCI), or cognitive deficits secondary
MHSR that nurse researchers have begun to to other disease processes. The Mini-Mental
address is the integrated mental and phys- State Examination (MMSE; Folstein, Folstein,
ical health care for persons with severe co- & McHugh, 1975) is a brief clinical assess-
occurring mental and physical disorders. ment appropriate for use in a variety of set-
Traditionally, research in this area has been tings for cognitive screening of older adults.
conducted by other types of health care Up to 75% of cases of dementia or probable
researchers such as psychiatrists, psycholo- dementia are not identified by primary care
gists, social workers and physicians, and often physicians, most likely because of the brief
not in community health care settings. There time available for an office visit (Holsinger,
are some nursing research programs within Deveau, Boustani, & Williams, 2010). A 5- to
academic centers, such as the University 10-minute baseline assessment of cognitive
of Illinois–Chicago Nursing Integrated status using the MMSE would allow for early
Health Care (IHC) Center that researches diagnosis of neurodegenerative disorders
best practices for systems of integrated care such as Alzheimer’s disease, identification of
(McDevitt, Braun, Noyes, Snyder, & Marion, cognitive impairment secondary to a stroke
2005; University of Illinois–Chicago College or diseases such as Parkinson disease, or
of Nursing, 2010). Internationally, some nurse detection of cognitive impairment caused by
researcher teams have partnered with com- medication side effects.
munity health centers to study the impact of The MMSE was constructed more than
integrated care (Smith & Ross, 2007). These 35 years ago to conduct serial cognitive test-
nursing community collaborative initiatives ing of patients on a neurogeriatric ward. The
show promise for improving health care ser- MMSE has been translated into more than
vices for people with severe co-occurring 50 languages (Dean, Feldman, & Morton,
mental and physical disorders and are a pri- 2009), is the most widely used cognitive
ority for continued nursing research. assessment scale (Holsinger et al., 2010),
and was cited by 7000 articles in the OVID
Celia E. Wills Medline database from 1986 to August 2010.
Anna L.D. Villena The MMSE was developed to be a brief and
easy to administer clinical evaluation tool.
Scores range from all correct (30) to no cor-
rect (0) responses. Scores of 26–29 indicate
Mental status questionable dementia, 21–25 mild demen-
MeasureMent: Mini-Mental tia, 11–20 moderate, and 0–10 severe demen-
tia (Perneczky et al., 2006).
state exaMination Six categories of cognitive tasks com-
prise the MMSE: (1) orientation determined
by responses to five questions each about
Recognizing cognitive impairment is impor- time and place (10 points); (2) registration
tant for establishing patients’ capacity to assessed by ability to learn the names of
make (or not) independent health care deci- three unrelated objects (3 points); (3) atten-
sions to be active participants in their care tion and calculation tested by either per-
and for providing individualized qual- forming serial sevens or spelling the word
ity care. It is especially important to know “world” backwards (5 points); (4) recall
the cognitive status of older adults because evaluated by naming the three objects

MENTAL STATUS MEASUREMENT n 289



previously learned (3 points); (5) language was supported by convergent and discrimi-
assessed by six items of naming two nant validity comparing hypothesized sim-
objects, repeating a statement, following a ilarities/differences between scores from M
three-stage verbal command, reading and three groups of normal, demented, and
following a written command, and writing depressed subjects with and without cogni-
a sentence spontaneously (8 points); and tive symptoms.
(6) visual–spatial capacity by copying two The MMSE is the most studied of all cog-
intersecting pentagons (1 point). nitive tests (Holsinger et al., 2010). Additional
To administer the MMSE, a one-page cognitive tests have been developed and com-
sheet with items/instructions and space for pared with the MMSE across conditions, and
writing scores is used. The MMSE is not a those empirical data have supported the sensi-
timed test but usually takes 5 to 10 minutes. tivity and specificity of the MMSE as a cogni-
The tester asks the patient to respond to each tive screening scale. Sensitivity, the percentage
item and records individual scores. Item of people who test positive (number of true
scores are summed to provide the final score positives divided by the number of true posi-
and a calculator is not needed. The MMSE is a tives plus the number of false negatives), has
copyrighted scale, and the Mini-Mental LLC ranged from 71% to 92% (Boustani et al., 2003).
of Massachusetts offers forms, guides, and Specificity, the percentage of people who test
software through Psychological Assessment negative (number of true-negatives divided by
Resources of Florida for approximately $1 the number of true-negatives plus the num-
per test (Powsner & Powsner, 2005). ber of false-positives) has ranged from 56%
Before conducting an MMSE assessment, to 96% (Boustani et al., 2003). Therefore, the
the nurse or other tester should make the MMSE is expected to correctly identify per-
patient comfortable and establish rapport. sons with mild to moderate cognitive impair-
During the testing, praising success and not ment approximately 80% of the time and not
pressing on items the patient finds difficult to incorrectly identify persons as having mild
should enhance cooperation. The testing sit- to moderate cognitive impairment when they
uation may be embarrassing for patients who do not approximately 75% of the time.
are aware that they are “missing” some items Variables other than cognitive status,
and the nurse needs to protect the self-esteem most notably age and education, may influ-
of such patients while preserving the integ- ence test scores (Butler, Ashford, & Snowdon,
rity of the testing procedures. As with any 1996). Older persons and those with low
scale, the degree to which the MMSE is reli- education may score slightly lower yet
able and valid is critical. The tester needs to have higher cognitive capacity so there are
follow the administration procedures exactly MMSE test norms based on these variables
and clinicians/researchers need to interpret (Crum, Anthony, Bassett, & Folstein, 1993).
the meaning of scores properly. Modifications have been made for culturally
Psychometric assessment of the MMSE and linguistically appropriate MMSE ver-
has been conducted. Reliability and validity sions (Folstein, 1998). An increased risk of
estimates of the MMSE were satisfactory for false-positives has been found when using
a screening tool (Folstein et al., 1975). Initial the MMSE with the culturally deaf popu-
reliability, accuracy by measuring consis- lation (Dean et al., 2009). Scores need to be
tency in the items and different raters, was interpreted differently for persons with
adequate for interrater agreement and retest visual or auditory deficits that preclude use
stability when two samples of patients and of certain items that require sight or hearing
several test administrators were compared. or impact test performance.
Validity, the degree to which the MMSE mea- After 35 years of use, an MMSE score of
sures the construct of cognitive impairment, 23 points or less is generally considered to be

290 n MENTORING



preliminary evidence of cognitive impairment or the Saint Louis Mental Status Examination
and grounds for further evaluation (Cockrell & (Tariq, Tumosa, Chibnall, Perry, & Morley,
M Folstein, 1988). When patients score approxi- 2006), be used.
mately 27 on the MMSE, scores of items test- In the research arena, the MMSE is
ing long-term memory should be checked used both as an enrollment criterion (cut
because failing only those items could be the score) and to characterize subjects’ cogni-
first signal of MCI (Pasqualetti et al., 2002). tive capacity. Because the MMSE is used in
MMSE scores should be considered with so many studies, it is almost incumbent on
other assessment data and neuropsycho- researchers to include the MMSE to provide
logical test to inform diagnoses and make consumers of research with a benchmark
treatment decisions, for example, a test for of cognitive capacity for comparing results
executive function (Kennedy & Smyth, 2008), across studies. For instance, the Cochrane
because that is not measured by the MMSE. Group conducted systematic reviews of sta-
There are specific clinical instances tins and dementia. In prevention trials, cog-
when the MMSE is not recommended for nition was measured at different times and
use at all, should be used as an adjunct with different scales, precluding their com-
with other assessments, or substituted bination in a meta-analysis (McGuinness,
with an assessment that is not copyrighted. Craig, Bullock, & Passmore, 2009). Treatment
The MMSE is not appropriate for assessing studies provided MMSE change scores from
delirium, and the Confusion Assessment baseline, thus allowing comparisons across
Method is recommended (Inouye et al., 1990). studies (McGuinness et al., 2010).
The MMSE has a “bottom” effect, meaning The MMSE remains a reasonable screen-
that once “0” is scored, the MMSE does not ing instrument for assessing and communi-
have the capacity to further quantify cogni- cating mild-moderate cognitive impairment
tive differences that exist between patients and for characterizing research subjects.
who score “0.” Another scale, as the Bedford Reliability checks need to be in place and
Alzheimer Nursing Subscale (BANS; Volicer, testers should periodically be observed for
Hurley, Lathi, & Kowall, 1994), allows addi- accuracy. Testing needs of special popula-
tional discrimination for persons who “bot- tions should be addressed and validated
tom” on the MMSE. The National Institutes test norms should be used. We agree with
of Health Stroke Scale and the MMSE both Holsinger et al. (2010) that clinicians should
detected severe cognitive impairment after consider one primary tool that is population
a stroke (Cumming, Blomstrand, Bernhardt, appropriate and add others for special situa-
& Linden, 2010). The Montreal Cognitive tions as needed.
Assessment (Nasreddine et al., 2005) is sug-
gested to detect MCI or dementia in persons Ann C. Hurley
with Parkinson disease, with the caveat that Ladislov Volicer
a positive screen using either the MMSE or Ellen K. Mahoney

the Montreal Cognitive Assessment requires
additional assessment because of suboptimal

specificity at the recommended screening
cutoff point (Hoops et al., 2009). Overcoming Mentoring

the copyright (and thus cost) issue of the
MMSE has been addressed (Smith, 2010) with
suggestions that no-cost scales, for example, Mentor relationships are being recognized as
the Modified Mini-Mental State Examination an essential component in the career devel-
(3MS) (Teng & Chui, 1987) that has been found opment of every professional nurse. The
to detect dementia (Bland & Newman, 2001) value of these developmental and support

MENTORING n 291



relationships for people in life and work has collegiality, and affirmation” (Vance & Olson,
been documented through anecdotal and 1998). This contemporary definition is more
research studies (Allen, Eby, Poteet, Lentz, & inclusive and diverse, with no restrictions M
Lima, 2004; Ensher & Murphy, 2005; Kram, of gender, age, education, experience, edu-
1988; Noe, Greenberger, & Wang, 2002; cation, and racial-ethnic background. This
Wanberg, Welsh, & Hezlett, 2003; Zey, 1984). mentoring can be an expert-to-novice model
In particular, the complexity of a nursing or peer-to-peer model in which mentors can
career requires a substantial mentoring net- include colleagues, bosses, teachers, friends,
work to develop expertise and safe perfor- and families. The mentor relationship should
mance, to ensure professional and personal be characterized by reciprocity, as all partici-
success and satisfaction, and to promote lead- pants can both give and receive the benefits
ership development (Benner, 1984; Benner, of mentoring. “This relationship can be an
Tanner, & Chesla, 1996; Chandler, 1992; expansive resource of growth, empower-
Johnson, Cohen, & Hull, 1994). For exam- ment, and opportunity for both mentors and
ple, the presence of mentor relationships proteges” (Vance, 2011).
was identified as an important factor in the Although nurses have undoubtedly
socialization and development of expertise mentored each other since the beginning
in critical care nurses (Pyles & Stern, 1983). of modern-day nursing, the phenomenon
Mentor collegial partnerships are necessary throughout the profession is relatively new.
for students and professional nurse to learn The first documented study of mentor rela-
and refine the nursing discipline as they pro- tionships in the nursing profession was
vide clinical care, learn and teach, perform conducted by Vance (1977, 1982) with a pop-
research and scholarship, and lead the pro- ulation of nationally identified “nurse influ-
fession (Grossman, 2007; Fawcett, 2002; Olson entials.” Until that time, the word “mentor”
& Vance, 1993, 1998; Stewart & Kreuger, 1996; was not widely acknowledged in the nursing
Vance, 1997; Vance & Olson, 1998). literature, nursing research, clinical work-
The word “mentor” was introduced place, nursing programs, and professional
in the literature thousands of years ago in associations. Nurses, who are predominantly
Homer’s (1967) The Odyssey. According to this women, along with women in every field did
legend, Mentor in the disguise of Athena, the not historically experience the advantages of
Goddess of Wisdom, was appointed to serve being part of mentor networks until relatively
as guardian, teacher, advocate, and adviser to recent. Traditional mentoring was viewed as
the son of King Odysseus while he was fight- a male phenomenon in the older professions
ing the Trojan War for 10 years. Mentoring and in the business world (Collins, 1983;
has traditionally been defined as a teaching Jeruchim & Shapiro, 1992).
and support relationship between an older, Two types of support are provided in
wiser, more experienced person who guides a mentoring relationships: expert and peer-
younger and/or less experienced person (i.e., collegial. The expert mentor is someone with
protégé) during an extended period of time advanced education, knowledge, and expe-
(Johnson & Ridley, 2004). This is an expert- rience who provides assistance to protégés
to-novice model of mentoring, in which the through (1) career-focused activities (i.e.,
mentor was usually male and at least 8 to 10 guidance, coaching, networking, teaching,
years older than the protégé. More recently, feedback, and role modeling) and (2) psycho-
the mentor connection in nursing has been social activities (i.e., support, advocacy, inspi-
described as a “developmental, empower- ration, empowering, and counseling). The
ing, nurturing relationship extending over peer mentor is a colleague who can provide
time, in which mutual sharing, learning, and similar types of mentoring assistance and is
growth occur in an atmosphere of respect, a more equalitarian relationship because of

292 n MENTORING



similarity of age, experience, and education. studies in nursing education that demon-
Both expert and peer-collegial mentors are strated mentorship as being a key process in
M important as they offer different perspec- facilitating academic success and retention,
tives and assistance. Having several different scholarly productivity, clinical excellence,
types of mentors at different career stages is and leadership development. Increasingly,
recommended for the complexity of the nurs- nursing education programs are establishing
ing career. formal mentor programs among students,
All levels of nurses may benefit from faculty, and alumni to foster learning, schol-
both individual and collective mentoring. arship, and development of academic careers.
Individual mentoring occurs when men- Ongoing studies continue to document the
tors and protégés choose each other through value of mentoring for nursing students and
mutual attraction, common interests and faculty.
goals, and mutual admiration and trust. This Formal mentoring programs within clin-
relationship can be expert to novice as well ical environments contribute to a supportive
as peer to peer. Collective mentoring occurs professional practice environment and are
in a formalized program in which mentors particularly valuable for the novice nurse. The
and protégés are “matched” or “assigned” to mentored novice nurse is socialized into the
each other to accommodate special goals and professional role and supported in the devel-
needs. Formal mentor programs are often opment of clinical competence, safe patient
part of orientation programs for novices or care, self-confidence, work satisfaction, and
newly hired nurses in clinical settings, in professional commitment (Barton, Gowdy, &
schools of nursing for students and/or fac- Hawthorne, 2005; Pelico, Brewer, & Kovner,
ulty, and as special programs for members 2009; Roberts, Jones, & Lynn, 2004). Nelson,
of professional or specialty nursing associa- Godfrey, and Purdy (2004) found that novice
tions. Establishing a culture of mentoring in nurses in mentor programs gained skills in
organizations and professions unleashes the nursing process, gained critical think-
human potential, talent, and achievement ing skills, and had a greater understanding
and provides multiple benefits to the indi- of the organizational culture. For experi-
vidual, the workplace, and the profession enced nurses, mentoring provides ongoing
(Vance, 2011). support, clinical development and expertise,
The positive outcomes of mentoring in expanded career opportunities, and lead-
educational settings, clinical workplace, pro- ership development (Johnson et al., 1994;
fessional associations, and scholarship and Reeves, 2004; Schoessler & Farish, 2007; Vance
research activities are being documented in & Larson, 2002). One study found that rela-
extensive anecdotal and research-based lit- tionships with peers, mentors, and patients
erature. The necessity and value of mentor were directly instrumental in nurses’ ability
connections for the leadership development to perform at higher levels of expertise and
of nurses throughout the entire career spec- leadership (Roche, Morsi, & Chandler, 2009).
trum is becoming well established in the Recruitment and retention in the clinical
profession. workplace are also enhanced through for-
The educational milieu is a prime site for mal mentor programs and the establishment
mentorship. Mentoring is a relational phe- of a mentoring culture (Butler & Felts, 2006;
nomenon and is therefore a natural compo- Funderburk, 2008; Greene & Puetzer, 2002;
nent of teaching and learning. Students at Olson et al., 2001; Vance, 2007). Mentorship
all levels, junior and senior faculty, and aca- is also closely linked to the establishment of
demic administrators benefit from mentor- respectful collegial and mentor relationships
ing relationships. Olson and Vance (1998) and that empower and support nurses’ clinical
Vance and Olson (1998) reviewed research excellence (Laschinger, Finegan, & Wilk, 2009;

META-ANALySIS n 293



Thomas & Burk, 2009). The presence of dis- contributes to excellence and leadership in
ruptive behaviors in the clinical workplace, the profession. Research recommendations
including intimidation, lateral violence, and include study of peer mentoring outcomes, M
workplace incivility, has been widely docu- identification of different forms of mentor-
mented. These behaviors have been linked to ing to meet specific learning needs, outcome
various factors such as medical and nursing measures related to research and scholarly
errors, communication problems, high cost of productivity through mentoring, qualitative
care, and job dissatisfaction. The American and phenomenological methods of mentor-
Nurses Association (2004) has adopted a ing dyads, and mentoring outcomes for the
Leadership Standard, which states that nurses novice nurse.
should teach others to succeed by mentoring
and other strategies. Connie Vance
Numerous professional nursing associa-
tions have assumed leadership in promoting
mentor connections among their members
for networking, information, education, Meta-analysis
and leadership training. Special interest
and general professional and clinical spe-
cialty associations are providing both infor- Meta-analysis is a quantitative approach that
mal and formal mentoring opportunities for permits the synthesis and integration of results
their members. They are reporting anecdotal from multiple individual studies focused on a
reports of mentoring and networking ben- specific research question. A meta-analysis is
efits in their publications and Web sites. a rigorous alternative to the traditional nar-
Mentoring is a vital component of nurs- rative review of the literature. It involves the
ing scholarship and research activities application of the research process to a col-
(Byrne, Kangas, & Warren, 1996; Fawcett lection of studies in a specific area. The indi-
& McCorkle, 1998; Olson & Connelly, 1995; vidual studies are considered the sample. The
Rempusheski, 1992). One study reported findings from each study are transformed into
that the most productive (i.e., eight or more a common statistic called an effect size. An
research articles in a 3-year period) faculty effect size is a measure of the magnitude of the
members were more likely to have coau- experimental effect on outcome variables.
thored papers with mentors while in grad- Once the results from each study have
uate school (Megel, Langston, & Cresswell, been converted to a common metric, these
1988). Mentoring for scholarship and research findings can be pooled together and synthe-
is occurring through university research sized. The most common effect size indica-
programs, regional nursing research associ- tor is r, which is the Pearson product moment
ations, private foundations, and the National correlation. Another effect size indicator
Institute of Nursing Research. is the d index. Cohen’s d is the difference
In conclusion, an explosion of research between the means of the experimental and
studies and anecdotal reports in nursing control groups divided by the standard devi-
over the past 20 years is providing impor- ation. Cohen (1988) has provided guidelines
tant knowledge about the positive mentor- for interpreting the magnitude of both the r
ing outcomes for the nursing profession. and d effect size indicators. For the r index,
Through ongoing investigation, mentoring Cohen has defined small, medium, and large
has been identified as an essential human effect sizes as .10, .30, and .50 or more, respec-
and professional developmental relationship tively. For the d indicator, an effect size of .2
that empowers and develops students, nov- is considered small, .5 is medium, and .8 or
ice and experienced nurses, and leaders and more is large.

294 n MIDDLE-RANGE THEORIES



Approaches are available to examine and nursing. Since then, meta-analyses have been
reduce bias from operating within a meta- conducted and published in a wide variety
M analysis. Some ways that biased conclusions of areas, such as patient outcomes of nurse
can occur in a meta-analysis are effects of practitioners and nurse midwives, job satis-
a bias toward publishing positive but not faction and turnover among nurses, relation-
negative results, giving each study an equal ship between postpartum depression and
weight in the meta-analysis despite the fact maternal–infant interaction, effects of educa-
they differ in sample size or quality, inclusion tional interventions in diabetes care, quality
of multiple tests of a hypothesis from an indi- of life in cardiac patients, and nonnutritive
vidual study, and not ensuring an acceptable sucking in preterm infants.
level of agreement or reliability among raters The outcome of this quantitative
in coding the study characteristics. approach for reviewing the literature has
It can be argued that not all studies syn- tremendous potential for a practice-based
thesized in a meta-analysis should be given discipline such as nursing. Meta-analysis of
equal weight. Some studies may be poorly the abundance of research being conducted
designed and have small unrepresentative can benefit nursing practice. Not only will
samples, whereas other studies use random- the use of meta-analysis further knowledge
ized control group designs with large sample development in the discipline of nursing, but
sizes. To remedy this problem, studies can be it also can help nurses in the clinical setting
evaluated and assigned a quality score. The to decide whether to apply research findings
meta-analysis can then be calculated with to their practice based on the size of the dif-
studies weighted by their quality scores. ference an intervention makes. Meta-analysis
A source of nonindependence in a meta- can resolve issues in nursing where there are
analysis can result from using multiple multiple studies with conflicting findings. In
hypothesis tests based on multiple variable addition, meta-analysis highlights gaps in
measurements obtained from a single study nursing research for future studies.
(Strube & Hartman, 1983). One suggested
remedy when selecting findings obtained Cheryl Tatano Beck
from multiple measures of the hypothesis
tests located within a single study is to col-
lapse the various findings into a single, global
hypothesis test. Middle-range theories
One assumption that should be met
before specific studies are quantitatively
combined in one meta-analysis is that each Middle-range theories are described by
study provides sample estimates of the effect Merton (1968, p. 9) as those that “lie between
sizes that are representative of the popula- the minor but necessary working hypoth-
tion effect size. Homogeneity tests can be eses that evolve in abundance during day-
calculated to identify any outlier studies. If to-day research and the all-inclusive sys-
outliers are identified, they can be removed. tematic efforts to develop unified theory.”
Meta-analysis first appeared in the nurs- He goes on to say that the principal ideas of
ing literature in 1982, when O’Flynn published middle-range theories are relatively simple.
her article describing meta-analysis in the Simple here means rudimentary, straightfor-
“Methodology Corner” of Nursing Research. ward ideas that stem from the focus of the
A meta-analysis of the effects of psychoedu- discipline. Thus, middle-range theory is a
cational interventions on length of postsur- basic, usable structure of ideas, less abstract
gical hospital stay (Devine & Cook, 1983) was than grand theory and more abstract than
the first meta-study analysis published in empirical generalizations or microrange

MIDDLE-RANGE THEORIES n 295



theory. Middle-range theory is a set of related for viewing the world. With the particulate-
ideas that are focused on a limited dimen- deterministic lens, processes are causal in
sion of the reality of nursing. These theories nature with antecedents and consequences. M
are composed of concepts and suggested With the interactive-integrative lens, pro-
relationships among the concepts that can be cesses are relational with rich contexts that
depicted in a model. Middle-range theories contribute to understanding. With the uni-
are developed and grown at the intersection tary-transformative lens, processes are pat-
of practice and research to provide guidance terns unfolding over time. The majority of
for everyday practice and scholarly research middle-range theories in nursing are concep-
rooted in the discipline of nursing. Typically, tualized through the interactive-integrative
middle-range theories are conceptualized lens, whereas a smaller number are concep-
and referred to by a topical focus such as story tualized through the unitary-transformative
theory (Liehr & Smith, 2008b), uncertainty lens and even fewer through the particulate-
theory (Mishel & Clayton, 2008), or theory deterministic lens. For instance, in the Smith
of symptom management (Humphreys, Lee, and Liehr (2008) book, the editors include
Carrieri-Kohlman et al., 2008). nine middle-range theories designated as
More than three decades ago, Ada Jacox consistent with the interactive-integrative
(1974) addressed middle-range theory in lens (uncertainty, community empower-
a classic paper on theory construction in ment, symptom management, unpleasant
nursing. Since then, there has been ongoing symptoms, self-efficacy, family stress and
attention to middle-range theory, and it is adaptation, cultural marginality, caregiving
increasingly recognized for its potential as dynamics, and moral reckoning) and three
a foundation guiding practice and research. consistent with the unitary-transformative
Smith and Liehr (2008b) report 27 new mid- lens (meaning, self-transcendence, and
dle-range theories for a 7-year period begin- story). Although there are no middle-range
ning in 2000. There are two current books theories conceptualized through the particu-
dedicated to middle-range theory (Smith & late-deterministic lens included in the book,
Liehr, 2008; Peterson & Bredow, 2008), and it is possible to create such a theory, but it
Parker and Smith include a large section on would tend toward a microrange rather than
middle-range theories for practice in their a middle-range level.
2010 book. Considerable evidence documents the
Although theory has always been fore- use of middle-range theory to guide research.
front in PhD nursing education, the recent A few middle-range theories have associ-
development of the doctor of nursing prac- ated measurement tools, such as Mishel’s
tice degree as well as the push by the nation’s Uncertainty in Illness Scale (Mishel, 2008) and
hospitals to achieve Magnet designation has Reed’s Self-Transcendence Scale (Reed, 2008).
created a niche for middle-range theory as a Availability of measurement tools that corre-
guide for nursing practice and corresponding spond with the theory facilitates use of the
research. Liehr and Smith (2008a) propose a theory in research. One of the middle-range
10-step process for scholars wishing to trans- theories, the story theory, has an inquiry
late practice ideas into structures for research method that is consistent with the concepts
that can culminate in middle-range theory. of the theory (Liehr & Smith, 2008a).
Middle-range theory is developed within Since Merton introduced middle-range
a paradigmatic perspective. For instance, theory in academic circles more than 40 years
Newman, Sime, and Corcoran-Perry (1991) ago, there has been an escalation in the devel-
proposed the particulate-deterministic, opment of middle-range theories for nursing.
interactive-integrative, and unitary-transfor- However, it is essential that nursing scholars
mative paradigms. Each paradigm is a lens persist in testing these theories to maintain

296 n MILD COGNITIVE IMPAIRMENT



a vibrant middle-range theory base guiding define a commonly observed clinical condi-
the discipline of nursing. Simply proposing a tion characterized by the presence of mild
M middle-range theory without ongoing testing cognitive deficits that preceded dementia
renders the theory of little use to the disci- and that might therefore be useful in predict-
pline. Therefore, it is imperative that existing ing dementia (Molinuevo, Valls-Pedret, &
middle-range theories be used, tested, and Rami, 2010). The term MCI was originated by
refined and that findings from these endeav- Flicker, Ferris, and Reisberg (1991) to describe
ors be published. individuals who exhibited cognitive diffi-
There continues to be a need for relevant culties at or about stage three on the Global
discipline-specific theories developed at the Deterioration Scale (Reisberg, Ferris, de Leon,
middle-range level of discourse. Population & Cook, 1982) but who did not meet the clini-
or disease-specific theories are not at the cal criteria for a diagnosis of dementia. In the
middle range. A nursing theory framed at late 1990s, Petersen et al. (1999) proposed a set
the middle-range level of discourse can be of criteria for the MCI concept. These were
applied across populations and with persons that (1) the individual themselves reported
in differing complex health circumstances. memory problems, preferably corroborated
Nurse educators are challenged to inte- by an informant; (2) their general cognition
grate middle-range theories into curricula was essentially normal; (3) their activities
so that students become familiar with these of daily living functioning was essentially
theories as structures that guide practice normal; (4) objectively, any memory impair-
and research. If educators accept this chal- ment was commensurate with their age and
lenge, building nursing knowledge would educational level; (5) and they did not have
shift from an esoteric endeavor to frontline dementia. However, a significant proportion
activity for nursing practice. Likewise, nurs- of MCI patients were subsequently found to
ing scholars have a responsibility to niche exhibit deteriorations in other areas of cog-
research into appropriate nursing theories, nition leading a team of researchers at the
thus contributing to the substantive body of Mayo Clinic to revise the criteria of Petersen
nursing knowledge. et al. They therefore proposed a set of sub-
types to classify a wider range of people
Patricia Liehr with cognitive impairment (Petersen et al.,
Mary Jane Smith 2001). The amnesic subtype of MCI equates
with the general criteria for MCI outlined
by Petersen et al. (1999). This subtype is
most likely to convert to Alzheimer’s dis-
Mild cognitive iMPairMent ease (AD) (Molinuevo et al., 2010). Amnesic
multidomain MCI involves memory impair-
ment with slight alterations in other areas
Mild Cognitive Impairment (MCI) is a term of cognition, whereas isolated nonamnesic
used to describe individuals who lie some- MCI describes individuals whose memory is
where between normal aging and dementia intact but who have impairment in one aspect
in regard to their cognitive ability (Dubois of their cognitive domain. Hence, there are
& Albert, 2004). As far back as the early many variants of nonamnesic MCI depend-
nineteenth century, Pritchard (1837, cited ing on which aspect of cognition is involved,
in Gauthier et al., 2006) described the early and it is thought that each will progress to
stages of dementia as the impairment of different clinical entities (Molinuevo et al.,
recent memories with intactness of distant 2010). Finally, multidomain nonamnesic MCI
memories. Then, in the latter part of the describes individuals who have deficits in
twentieth century, researchers sought to two areas of cognition but whose memory

MILD COGNITIVE IMPAIRMENT n 297



remains intact. It is thought that this type Both genetic and nongenetic factors,
of MCI may be a prodrome of Lewy Body such as APOE e4 alleles, depression, social
dementia (Petersen & Morris, 2005). isolation, chronic kidney disease, thyroid M
To date, no Diagnostic and Statistical dysfunction, testosterone deficiency, estro-
Manual of Mental Disorders, fourth edition, or gen levels, and vitamins B 12 and D, have been
International Statistical Classification of Diseases, implicated in the etiology of MCI (Etgen,
10th revision, international diagnostic crite- Bickel & Förstl, 2010; Gauthier et al., 2006);
ria have been established for MCI (Dierckx, however, so far no definitive links have been
Engelborghs, De Raedt, De Deyn, & Ponjaert- established. One certainty is that age is the
Kristofferson, 2007), and there is much dis- most significant risk factor, and cardiovas-
agreement in the literature about the status cular risks such as hypertension and dia-
of the MCI concept; however, most authori- betes are also thought to play a prominent
ties recommend that a diagnosis is reached role (Molinuevo et al., 2010). Although some
through a process of clinical judgment, promising work is underway into the use of
usually based on the Mayo clinic criteria biomarkers in AD, work of this nature in the
(Chertkow et al., 2007; Petersen, 2004). Others MCI context is in its infancy (Prabhavalkar &
suggest that this may be augmented by the Chintamaneni, 2010).
use of standard cognitive functional assess- A number of studies have been con-
ments (Prabhavalkar & Chintamaneni, 2010). ducted into the effectiveness of a variety of
Petersen (2004) proposes that most people pharmacological and nonpharmacological
with MCI fall 1.5 standard deviations below therapies in both the prevention of the con-
norms on memory tests, and hence these tests version of MCI to dementia and the improve-
may be used in the objective assessment of ment of cognitive functioning in persons
MCI. However, many of the assessments that with MCI. Clearly, such a discovery would
are used in AD may not be valid or sensitive have significant social and economic benefits.
enough to detect MCI (Raschetti, Albanese, In a recent review, Chertkow et al. (2008) con-
Vanacore, & Maggini, 2007); hence, in the cluded that only leisure activities, treatment
last decade, a number of more MCI-specific of sleep disorders, cognitive stimulation,
instruments such as the Montreal Cognitive physical activity, opportunities for social
Assessment (Petersen, 2004) and the DemTect interaction, and control of vascular risk fac-
(Kalbe et al., 2004) have emerged. tors can be recommended at this time. They
Data from prevalence studies vary con- found insufficient evidence to recommend
siderably for MCI chiefly because of dif- any of the drugs reviewed (cholinesterase
ferences in definition and classification. inhibitors [ChEIs], estrogen therapy, vitamin
Gauthier et al. (2006) report that prevalence E, nonsteroidal anti-inflammatory drugs,
in population-based epidemiological studies and ginkgo biloba). Similarly, a review by
ranges from 3% to 19% in those over the age Massoud et al. (2007) recommended a gen-
of 65 but that this increases significantly with eral healthy lifestyle combined with close
age. Other research has focused on the rate monitoring and treatment of vascular disor-
of progression of MCI to dementia; however, ders and, in addition, gave some support for
again, results have varied considerably. One vitamin B 6 , vitamin B 12 , folate supplements,
recent meta-analysis concluded that although omega fatty acids, and antioxidants. Other
the annual conversion rate from MCI to work has indicated that the ChEI galan-
dementia was approximately 5% to 10%, a tamine is associated with increased mortal-
majority of individuals will not progress to ity in MCI patients (Loy & Schneider, 2006).
dementia even after a 10-year follow-up, and Accordingly, ChEIs are not currently recom-
some individuals will revert from MCI back mended in the treatment of MCI (Chertkow
to normal (Mitchell & Shiri-Feshki, 2009). et al., 2008; Massoud et al., 2007).

298 n MILD COGNITIVE IMPAIRMENT



To date, MCI research has been predom- activities such as driving or using power
inantly biomedical and epidemiological, and tools (yueh-Feng et al., 2007). Problems with
M this is understandable given the relative new- executive functioning such as difficulties
ness of the concept and the ongoing effort to operating household appliances, declin-
attain diagnostic clarity and to better under- ing cooking skills, difficulties managing
stand its pathophysiology. Some nursing finances, and decline in home repair and
research has been conducted; however, much maintenance skills have also been reported
of which has focused on MCI caregivers. Key (Chirileanu et al., 2008). Although cognitive
studies have explored caregiver burden and symptoms have been the key features of
psychiatric morbidity in spouses (Garand, MCI, recent research has demonstrated that
Dew, Eazor, DeKosky, & Reynolds, 2005), like AD, people with MCI may also exhibit
depressed mood among informal caregivers behavioral symptoms. Garand et al. (2005,
(yueh-Feng, 2007), and marital quality among 2007), for example, found “repeatedly asking
couples where one person has MCI (Garand the same question,” “trouble remembering
et al., 2007). Future research endeavors might recent events,” “losing or misplacing things,”
continue to examine the etiology and preva- “forgetting what day it is,” and “talking little
lence of the various subtypes as well as the or not at all” to be common and to be among
continued identification of possible biomark- the most stressful symptoms for family
ers. Work on validating screening instru- caregivers. Lopez, Becker, and Sweet (2005)
ments and neuropsychological scales specific reported disruptive and psychotic behaviors
to MCI is also needed as is further clarity that are more usually found in established
on the various risk factors and in particular, dementia such as agitation, aggression, delu-
the manner in which these factors interact sions and hallucinations, and disorders of
(Prabhavalkar & Chintamaneni, 2010). From mood such as depression and apathy among
a nursing perspective, although further work some individuals with MCI. The presence
is required on the implications of MCI for of behavioral and psychological signs such
informal caregivers, this work might also as these generally indicate a high likelihood
extend to examinations of the effectiveness of of progression to overt dementia (Huang &
nursing interventions such as those based on Cummins, 2004).
the Progressively Lowered Stress Threshold MCI is associated with significant mor-
Model (Hall & Buckwalter, 1987); the Need- bidity and economic loss as well as distress
Driven Dementia-Compromised Behavior to individuals, families, and society (yeuh-
Model (Algase et al., 1996), or the Enriched Feng et al., 2007). Although some evidence
Model of Dementia (Kitwood, 1997), for suggests that the economic costs of MCI in
example, as these have been found helpful in primary care are not significantly different
the AD context. Clearly, nursing research also from those of individuals without cogni-
needs to focus on the person with MCI them- tive deficits (Luppa et al., 2008), many cases
selves. Considerations of the effects of MCI of MCI will progress to dementia. It is well
on patient coping, social support, depression, established that dementia is a costly illness.
grief, and anxiety, for example, would be use- Noneconomic costs to the individual include
ful at this time, as would work on behavioral anxiety and depression associated with prog-
symptoms associated with MCI. nostic uncertainty; performance difficulties
Patient problems are many and varied at work before diagnosis, which may lead
and depend on the MCI subtype, the exis- to retirement earlier than might have been
tence of comorbidities, and the degree of cog- expected; loss of intimacy, relationships, and
nitive impairment. Some people with MCI roles as the condition progresses; and loss
lack insight into the extent of their functional of dignity and personhood. Implications
deficits and hence may engage in unsafe for spouses and family are similar and also

MORAL DISTRESS n 299



include the burden and mental health impact for nursing involvement, particularly in the
of caring for someone with increasing depen- areas of health promotion and in the provi-
dency (Garand et al., 2005). Significant losses sion of evidence-based interventions for both M
also accrue to society, chief among which is care recipient and caregiver alike.
the loss of productivity if the person has to
take early retirement, and in time, the addi- Mark P. Tyrrell
tional economic burdens of caring for some- Geraldine McCarthy
one with progressive cognitive impairment
(yeuh-Feng et al., 2007). These and other
hidden costs of MCI need to be explored
and also need to be targeted with evidence- Moral distress
based interventions to diminish the adverse
social and economic consequences of MCI
(Molinuevo et al., 2010). Moral distress occurs when a person is aware
Given that people with MCI generally of a moral problem, acknowledges moral
continue to function with a good degree responsibility, and makes a moral judgment
of independence, they usually live and are about the correct action yet is constrained
cared for at home. Nursing practice there- from the self-determined morally correct
fore primarily involves supportive interven- action. Moral distress is not a response to
tions such as the provision of education and a violation of what is unquestionably right
information; maximizing independent liv- but rather a violation of what the individual
ing; assisting clients and family members in judges to be right. Moral distress has been
planning for the future, in particular the for- studied in a number of settings and with
mulation of advance directives and nominat- several professions. It is acknowledged as a
ing enduring powers of attorney; monitoring serious problem, and researchers are begin-
and intervening in the physical and mental ning to identify implications for education,
health status of both the person with MCI research, and practice.
and their family caregivers; monitoring MCI Ethicists define an ethical or moral
progression; promoting health, in particular dilemma as a moral problem for which
nutritional and vascular health; running sup- two or more solutions carry equal weight,
port groups for both care recipient and care- thus making decisions very difficult. In the
giver; and in collaboration with other health early 1980s, ethicist Andrew Jameton (1984)
professionals, the provision of cognitive stim- asked a group of nurses to relate their per-
ulation, physical, and other evidence-based sonal stories of moral dilemmas. The nurses
therapies (Hodson & Keady, 2008). in Jameton’s study did not identify “dilem-
MCI represents a transition state mas” according to the common definition
between normal aging and dementia. but consistently described situations with
Although the proposed diagnostic criteria compelling moral problems for which the
are still too broad and experts have thus far morally correct action was clear, yet each
failed to agree on a definition, clinical evi- felt constrained from following personal
dence has shown that many patients with convictions (Jameton, 1993). Jameton con-
MCI will progress to some form of dementia. cluded that nurses were compelled to tell
Accordingly, early diagnosis and interven- these stories because of their profound suf-
tion in MCI would seem prudent as this may fering and their belief about importance of
delay the onset of dementia. The advantages the situations. Identifying this new category
of this are apparent. Currently, despite the of moral problem, Jameton wrote, “Moral dis-
disagreements in the literature about the sta- tress arises when one knows the right thing
tus of MCI, there appears to be great scope to do, but institutional constraints make it

300 n MORAL DISTRESS



nearly impossible to pursue the right course lead to moral distress. Moral distress, in turn,
of action” (Jameton, 1984, p. 6). Further refin- causes nurses to leave the workforce, thus cre-
M ing the concept, Jameton (1993) added that in ating a self-perpetuating downward spiral.
cases of moral distress, nurses participate in Moral distress occurs in high stress situ-
the action that they have judged to be mor- ations or with vulnerable patients. Areas that
ally wrong. On the basis of Jameton’s work, engender high overall stress levels, such as
Judith Wilkinson, a nurse, defined moral critical care or other areas with very vulner-
distress as “the psychological disequilib- able patients, harbor a greater proportion of
rium and negative feeling state experienced moral problems (Corley, 1995; Fenton, 1988;
when a person makes a moral decision but Forchuk, 1991a; Hefferman & Heilig, 1999;
does not follow through by performing the Kelly, 1998; Krishnasamy & Plant, 1998;
moral behavior indicated by that decision” Liaschenko, 1995; Millette, 1994; Perkin,
(Wilkinson, 1987–1988, p. 16). Further refin- young, Freier, Allen, & Orr, 1997; Powell,
ing the definitions or offering examples for 1998; Redman & Fry, 2000; Rushton, 2006;
clarification, nearly every subsequent source Solomon et al., 1993; Sundin-Huard & Fahy,
relies on either Jameton’s or Wilkinson’s defi- 1999). In the studies listed above and others,
nitions of moral distress. moral distress has been documented in the
Reports of the number of nurses who following specific situations: prolonging the
experience moral distress vary. Redman suffering of dying patients through the use
and Fry (2000) report that at least one third of aggressive/heroic measures; performing
of nurses in their study (n = 470) experienced unnecessary tests and treatments; lying to
moral distress (2000). Nearly 50% of nurses in patients or failing to involve nurses, patients,
another study (n = 760) report that they had or family in decisions; and incompetent or
acted against their consciences in providing inadequate treatment by a physician.
care to the terminally ill (Solomon et al., 1993). Institutional setting also contributes to
Possibly heralding the present nursing short- moral distress. Health care institutions, par-
age, Wilkinson’s, Millette’s, and Nathaniel’s ticularly hospitals, are high tech and fast
studies indicate that 45% (n = 24), 50% (n = 24), paced, patients are older and sicker, and
and 43% (n = 21) of nurses in their respective reimbursement is problematic. Many nurses
samples left their units or nursing altogether view themselves as powerless within this
because of morally troubling situations. type of hierarchical system (Corley, Elswick,
Loss of nurses from the workforce is Gorman, & Clor, 2001; Davies et al., 1996;
an indirect but strong patient care threat Krishnasamy, 1999; Liaschenko, 1995; Perkin
that may perpetuate moral distress. In 2001, et al., 1997; Sundin-Huard & Fahy, 1999;
nurses reported poor working conditions Wilkinson, 1987–1988). They perceive little
such as inadequate staffing, heavy work- support from nursing and hospital admin-
loads, increased use of overtime, and lack of istration. Nurses may experience moral dis-
sufficient support staff (General Accounting tress as a result of being socialized to follow
Office, 2001). In 2005, Buerhaus et al. (2005) orders, having experienced futility of past
reported that more than 75% of registered actions, and having a fear of losing a job.
nurses believe the nursing shortage dimin- Other organizational factors contributing to
ishes the quality of their work life and the nurses’ moral distress include their views
quality of patient care. Nearly all nurses sur- concerning the quality of nursing and medi-
veyed predicted that the continuing nursing cal care, the organizational ethics resources,
shortage will increase stress on nurses (98%), the nurses’ satisfaction with the practice
lower patient care quality (93%), and cause environment, and the law and/or lawsuits.
nurses to leave the profession (93%) (Buerhaus Relationships with physicians are the
et al., 2005). Thus, the nursing shortage may most frequently mentioned institutional

MORAL DISTRESS n 301



constraints. Nurses experience moral distress cultural pressures or by rationalizing, deny-
as a result of physicians and nurses having ing, or trivializing or distancing themselves
different moral orientations, different deci- from moral problems (Deady & McCarthy, M
sion-making perspectives, and adversarial 2010). In addition, evidence suggests that
physician–nurse relationship (Corley, 1995; prolonged or repeated moral distress leads
Davies et al., 1996; Liaschenko, 1995; Oberle to loss of nurses’ moral integrity (Kelly, 1998;
& Hughes, 2001; Powell, 1998; Sundin-Huard Rushton, 1995; Wilkinson, 1987–1988).
& Fahy, 1999; Wilkinson, 1987–1988). Moral distress sometimes causes cause
Moral distress results in unfavorable unpleasant physical and affective prob-
outcomes for both nurses and patients. It can lems. Physical reactions include weeping
lead to physical and psychological problems, (Anderson, 1990; Fenton, 1988), sweating,
sometimes for many years (Anderson, 1990; palpitations, headaches, diarrhea, and sleep
Davies et al., 1996; Fenton, 1988; Kelly, 1998; disturbances (Anderson, 1990; Nathaniel,
Krishnasamy, 1999; Nathaniel, 2006; Perkin 2006; Wilkinson, 1987–1988). Affective reac-
et al., 1997; Wilkinson, 1987–1988). Among tions include anger, frustration, depression,
participants in one study, every respondent shame, embarrassment, grief, sadness, and a
described some detrimental effect of moral sense of ineffectiveness (Austin et al., 2008).
distress (Elpern, Covert, & Kleinpell, 2005). The early studies of moral distress
Some nurses lose their capacity for caring, focused on nurses, but within the last decade,
avoid patient contact, and fail to give good moral distress has been identified as a prob-
physical care because of moral distress lem for a variety of disciplines around the
(Corley, 1995; Hefferman & Heilig, 1999; globe. Researchers from Canada, Norway,
Kelly, 1998; Millette, 1994; Nathaniel, 2006; Spain, Ireland, Portugal, Sweden, Uganda,
Redman & Fry, 2000; Wilkinson, 1987–1988). Jordan, China, Chile, and Israel have dem-
Individuals may cope with moral distress in onstrated the presence of moral distress
a variety of ways including avoiding patient among physicians, podiatrists, psycholo-
interaction, acting in secret, working fewer gists, psychiatrists, childbirth educators,
hours, leaving the unit in search of better con- nurse anesthetists, respiratory care prac-
ditions, or dropping out of nursing altogether titioners, pharmacists, physical therapists,
(Austin, Kagan, Rankel, & Bergum, 2008; dental hygienists, health systems managers,
Kelly, 1998). Austin, Bergum, and Goldberg and rehabilitation professionals (Eizenberg,
(2003) suggest that some nurses have stopped Desivilya, & Hirschfeld, 2009; Krishnasamy &
listening to the call of their patients, having Plant, 1998; Losa Iglesias, Becerro de Bengoa
chosen to avoid engagement. Vallejo, & Salvadores Fuentes, 2010; Mitton,
The psychosocial consequences of moral Peacock, Storch, Smith, & Cornelissen, 2010;
distress include blaming others, excusing Mrayyan & Hamaideh, 2009; Mukherjee,
their own actions, self-criticism, self-blame Brashler, Savage, & Kirschner, 2009; O’Ryan,
(Kelly, 1998), anger, sarcasm, guilt, remorse 2010; Radzvin, 2008; Schwenzer & Wang,
(Fenton, 1988; Wilkinson, 1987–1988), frustra- 2006; Sporrong, Höglund, & Arnetz, 2006;
tion, sadness, withdrawal, avoidance behav- Sporrong, Höglund, Hansson, Westerholm,
ior, powerlessness, dispiritedness (Austin & Arnetz, 2005).
et al., 2003), burnout (Davies et al., 1996), Moral distress remains a relatively
betrayal of personal values, sense of insecu- immature concept. It has been studied from
rity, self-doubt, unease (Deady & McCarthy, a number of theoretical perspectives and
2010), low self-worth (Krishnasamy, 1999), methods. Because of the nature of moral dis-
and effects on spirituality (Elpern et al., tress, most nurse researchers have chosen to
2005). Nurses may also choose to desensitize use qualitative methods including grounded
themselves by adapting or acquiescing to theory, ethnography, phenomenology, survey

302 n MORAL RECKONING



research, case study, and qualitative descrip- examines a more inclusive process surround-
tive analysis. Others have begun to develop ing moral distress.
M and refine quantitative means of measuring Moral reckoning is a process that occurs
moral distress and some have used mixed when nurses experience moral distress.
methods (Corley et al., 2001; Eizenberg et al., Ethicists define an ethical or moral dilemma
2009; Morris & Dracup, 2008; Raines, 2000; as a moral problem for which two or more
Sporrong et al., 2006). solutions carry equal weight, thus making
Moral distress is a pervasive problem decisions very difficult. In the early 1980s,
that may lead to a number of consequences. ethicist Andrew Jameton (1984) discovered
Causing harm to nurses, diminishing the a new type of moral problem, undefined in
quality of patient care, and contributing to previous ethics literature. He uncovered this
the nursing shortage, moral distress is a prob- problem when he asked a group of nurses to
lem that requires continued study. Strategies relate their personal stories of moral dilem-
to prevent moral distress and mitigate its mas. The nurses responses did not meet the
effects are imperative and interdisciplinary definition of “dilemma,” in which there are
cooperation is needed to further understand two solutions to a moral problem, each with
its causes and effects. equal moral weight. Rather, the nurses con-
sistently described situations in which the
Alvita Nathaniel morally correct solution was clear, yet each
felt constrained from following personal con-
victions (Jameton, 1993). Identifying this new
category of moral problem, Jameton (1984)
Moral reckoning wrote, “Moral distress arises when one knows
the right thing to do, but institutional con-
straints make it nearly impossible to pursue
The Grounded Theory of Moral Reckoning the right course of action” (p. 6). Subsequently,
in Nursing identifies a lengthy and painful Jameton (1993) stipulated that nurses who
process—before, during, and after the acute experience moral distress believe that they
phase of moral distress. Moral distress occurs participated in the action that they judged to
when a person is aware of a moral problem, be morally wrong. On the basis of Jameton’s
acknowledges moral responsibility, and original study, many nurse researchers have
makes a moral judgment about the correct studied moral distress. Findings from these,
action yet is constrained from the self-deter- mostly qualitative, studies consistently
mined morally correct action (Jameton, 1984, reinforce Jameton’s original findings. The
1992; Nathaniel, 2006; Wilkinson, 1987–1988). grounded theory of moral reckoning takes
Moral distress is not a response to a violation a conceptual perspective on a larger process
of what is unquestionably right but rather a that includes and surrounds moral distress.
violation of what the individual judges to be Moral reckoning includes a critical junc-
right. Moral distress has been studied in a ture in nurses’ lives and explains a process
number of settings and with several profes- that includes motivation and conflict, resolu-
sions. Moral distress is acknowledged as a tion, and reflection (Nathaniel, 2006). Moral
serious problem and researchers are begin- reckoning is a three-stage process that offers
ning to identify implications for education, important implications for nursing prac-
research, and practice, but few have exam- tice, education, and administration. Distinct
ined the process over time—what are the stages include the stage of ease, the stage of
conditions previous to the events that lead resolution, and the stage of reflection.
to moral distress and what are its long-term During the stage of ease, nurses are moti-
consequences? The theory of moral reckoning vated by core beliefs and values to uphold

MORAL RECKONING n 303



congruent professional and institutional nurses recall occurred early in their careers.
norms. They are comfortable: They have tech- The stage of reflection raises questions about
nical skills and are feeling satisfied to prac- prior judgments, particular acts, and the M
tice within the boundaries of self, profession, essential self. The properties of the stage of
and institution. They know what is expected reflection include remembering, telling the
of them and experience a sense of flow and story, examining conflicts, and living with
at-homeness. The stage of ease continues as consequences. These properties are interre-
long as the nurse is fulfilled with the work of lated and seem to occur in every instance of
nursing and comfortable with the integration moral reckoning.
of core beliefs and professional and institu- Sampling, investigation, and analy-
tional norms. For some, though, a morally sis of moral reckoning followed the classic
troubling event will challenge the integration grounded theory method as described by
of core beliefs with professional and institu- Glaser and Strauss (1967) and subsequently
tional norms. Nurses find themselves in sit- by Glaser (1965, 1978, 1998, 2001). The classic
uational binds that herald a critical juncture grounded theory allowed the investigator to
in their professional lives. A situational bind discover theoretically complete explanations
interrupts the stage of ease and places the of moral reckoning and to maintain a consis-
nurse in turmoil when core beliefs and other tent philosophical stance.
claims conflict. Situational binds force nurses Glaser and Strauss (1967) were said to
to make difficult decisions and give rise to have broken new ground in 1967 when they
critical junctures in their lives. Binds involve described this new inductive method which
serious and complex conflicts within indi- “discovers” theoretically complete expla-
viduals and tacit or overt conflicts between nations about particular phenomena, but
nurses and others—all having moral/ethical they did not explicate the method’s philo-
overtones. Inner dialogue leads the nurse to sophical stance. In an attempt to clarify the
make critical decisions—choosing one value grounded theory method, many scholars
or belief over another. Types of situational have published opinions about grounded
binds include (a) conflicts between core val- theory’s ontological position. Because Glaser
ues and professional or institutional norms, and Strauss rarely discussed ontology, pub-
(b) moral disagreement in the face of power lished speculations lead to a confusion of
imbalance, and (c) workplace deficiencies. conflicting labels including realist, construc-
These binds lead to consequences for nurses tivist, critical realist, objectivist, relativist,
and patients. interactionist, positivist, postpositivist, and
Situational binds constitute crises of others. Many claim that the philosophi-
intolerable internal conflict. The move to set cal foundation is symbolic interactionism.
things right signifies the beginning of the Although the originators of the method did
stage of resolution. For most, this stage is a not delve into its foundations, inferences
critical juncture that alters professional tra- from Glaser’s (1978, 1998, 2001) writings clar-
jectory. There are two foundational choices ify the method’s ontological position. Glaser
in the stage of resolution: making a stand recognizes that (1) there is an objective real-
or giving up. These choices are not mutu- ity that can be observed; (2) inasmuch as it
ally exclusive. In fact, many nurses give up is possible, the investigator gathers data
initially, regroup, and make a stand. Others from the perspective of the research partici-
make an unsuccessful stand and later give pant; and (3) grounded theory sheds light on
up. Moving from the stage of resolution, latent patterns. Although neither Glaser and
nurses reflect as they reckon their behav- Strauss’s original description of grounded
ior and actions. The stage of reflection may theory nor Glaser’s subsequent development
last a lifetime. In most cases, the incidents identify it’s philosophical foundations, their

304 n MOTHER–INFANT/TODDLER RELATIONSHIPS



published references to objective reality, par- traits that affect the individual’s behavioral
ticipant perspective, and latent patterns are reactions to environmental stimuli (De Pauw
M consistent with the American pragmatist & Mervielde, 2010). Temperamental qual-
philosophical foundation. Therefore, it is ities, such as high-intensity reactions, low
from this perspective that the moral reckon- adaptability to change, or shyness, influ-
ing has been studied. ence children’s abilities to regulate emotions
Moral reckoning explains the process in stressful situations, relate to others, and
that surrounds moral distress, a pervasive adjust to changes in daily routines. Similar
problem that may lead to a number of long- temperamental qualities in the mother are
lasting consequences. Because moral dis- likely to affect her ability to adjust her par-
tress causes harm to nurses, diminishes the enting behaviors to accommodate an unpre-
quality of patient care, and contributes to dictable infant or a defiant 2-year-old (Gross
the nursing shortage, the larger process of & Conrad, 1995; Karreman, de Hass, van
moral reckoning requires continued study. Tuijl, van Aken, & Dekovi, 2010). A poor fit
Strategies to prevent moral distress and mit- between parent and infant/toddler tempera-
igate the long-lasting effects that occur as mental styles has been associated with more
nurses reckon their role in the distressing sit- child behavior problems and increases in
uation are imperative. Further research, now physiological indices of stress (Bridgett et al.,
in process, includes expanding the investi- 2009; Bugental, Olster, & Martorell, 2003).
gation to better understanding the causes However, temperament can be moderated
and consequences of moral reckoning and by the social environment of the mother and
to compare the process among nursing and child (Barry, Kochanska, & Philibert, 2008;
other disciplines. Karreman, de Hass, van Aken, & Dekovic,
2009). Children with a “difficult” temper-
Alvita Nathaniel ament who are reared by mothers who are
responsive and positive in their parenting
techniques are less likely to have behavior
problems when compared with similar chil-
Mother–infant/toddler dren reared in dysfunctional family systems
(Karreman et al., 2009).
relationshiPs Recently researchers have studied the
expression of genes to identify physiologi-
cal mechanisms affecting parents’ sensitiv-
The study of mother–infant/toddler rela- ity to an infant or toddler’s behavioral cues.
tionships centers on knowledge related to Studies suggest that patterns in the genetic
the health and development of the mother– expression of neurotransmitters, chemical
child dyad from birth to 3 years. This focus messengers in the brain, may increase or
of inquiry is necessarily large because the decrease social sensitivity depending on the
mother–child system is an open one, respon- expressed genetic allele and the social envi-
sive to genetic, biological, environmental, ronment of the family (Way & Taylor, 2010).
cognitive, and psychological influences Biological factors can also influence the
(National Research Council and Institute child’s developmental trajectory, making par-
of Medicine, 2000, 2009; National Scientific enting more stressful and altering the quality
Council on the Developing Child, 2004). of the mother–infant/toddler relationship.
The mother–infant/toddler relationship For example, low-birth-weight infants with
is influenced by genetic and constitutional neonatal medical complications are at greater
factors such as the child’s temperament. risk for later developmental difficulties
Temperament is an inborn constellation of (Aarnoudse-Moens, Weisglas-Kuperus, van

MOTHER–INFANT/TODDLER RELATIONSHIPS n 305



Goudoever, & Oosterlaan, 2009; Boyce, Smith, Maternal stress, low social support, marital
& Casto, 1999). Research has found that when discord, and maternal depression have been
compared with normal birth weight peers, viewed as important factors placing young M
low-birth-weight children have greater diffi- children at risk for poor developmental
culty in sustaining attention, are at risk for outcomes (Gao, Paterson, Abbott, Carter, &
poorer academic performance, have more Iusitini, 2007; Gross, Sambrook, & Fogg, 1999;
problems regulating their emotions, and are Petterson & Albers, 2001; Perry & Fantuzzo,
more likely to have internalizing behavioral 2010). Recently, researchers have shifted the
difficulties (Aarnoudse-Moens et al., 2009). focus away from unidirectional to bidirec-
Even in the absence of medical complica- tional effects. For example, depressed moth-
tions, mothers of low-birth-weight infants ers who are sad, preoccupied, and irritable
tend to experience greater stress and care- may be unable to attend to their infant’s needs
giver burden than mothers of normal birth or to deal calmly and effectively with their
weight infants (May & Hu, 2000; Singer, toddler’s demands for attention. However, it
Ethridge, & Aldana, 2007). Such early biolog- is also possible that behaviorally demanding
ical risk can have significant effects on the children cause mothers to feel ineffective,
quality of the mother–infant/toddler rela- fatigued, and ultimately depressed. The clin-
tionship. Caregiver burden has been shown ical implications of viewing problems in the
to decrease maternal quality of life which in mother–infant/toddler relationship as bidi-
turn increases parenting stress. High levels rectional is that effective nursing interven-
of parenting stress can negatively impact the tions should focus on the mother–child dyad
parent–child relationship and reciprocally or the family unit rather than on the mother
affect the child’s quality of life (Lee, Hwang, or child alone (National Research Council
Chen, & Chien, 2009). and Institute of Medicine, 2009).
The relationship between parenting envi- In the past 10 years, greater attention
ronment and the mother–infant/toddler rela- has been placed on the role of race/ethnic-
tionship has been extensively studied, although ity in the development of the mother–infant/
the theory underlying cause-and-effect rela- toddler relationship. Demographic trends
tionships remains poorly understood. For toward greater multiculturalism and expec-
example, there are many hypotheses to account tations for researchers to understand how
for the significant associations found between parenting processes may differ across racial/
parenting in low-income environments and ethnic groups have led to more thought-
poorer outcomes in very young children ful examinations of parenting processes
(Blair et al., 2008; Duncan & Brooks-Gunn, among families of color (Coll et al., 1998;
1997; Mistry, Vandewater, Huston, & McLloyd, McLloyd, Cauce, Takeuchi, & Wilson, 2000).
2002; Shonkoff, Boyce, McEwen, 2009). As a Different family structures and childrear-
result, interventions for promoting healthy ing values will affect how parents socialize
parent–child relationships among low-income their infants and toddlers. Although all chil-
families simultaneously target many environ- dren thrive under the care of a loving and
mental risk factors (e.g., support, psychological responsive parent, research has shown that
guidance, education, nutrition, and facilitat- there is no single way that love and atten-
ing access to community-based services). The tion need to be expressed. Indeed, research
complexity of the parenting environment and has shown that some parenting strategies
understanding how social contexts in early life that negatively affect behavioral outcomes in
affect young children and parents has been an European American children appear to have
important area of study. no such affect on African American chil-
The psychological health of the mother dren (Berlin et al., 2009; Dodge, McLoyd, &
and child has received much attention. Lansford, 2005).

306 n MUSIC THERAPy



Finally, maternal cognitions affect how parent training programs (e.g., Centers for
mothers interpret and respond to their chil- Disease Control and Prevention, 2009b; Gross
M dren’s behavior. For example, a mother’s et al., 2009), designed to teach parents skills
belief that using corporal punishment with that promote positive parenting and reduce
her defiant 2-year-old may be based on a behavioral risk in young children.
series of cognitions related to her values
about child defiance and physical punish- Deborah Gross
ment, cultural expectations, perceived envi- Shelly Eisbach
ronmental dangers, how she was raised, and
her knowledge of alternative discipline strat-
egies (Garvey, Gross, Delaney, & Fogg, 2000;
Goodnow & Collins, 1990; Stack, Serbin, Music theraPy
Enns, Ruttle, & Barrieau, 2010). Socialization
behaviors such as the mother’s ability to reg-
ulate her own emotional reactions will affect Music therapy is the use of music for the pur-
the child’s ability to self regulate. In essence, pose of improving physiological and psy-
mothers are the social role model for their chological health and well-being. For music
child and can positively or negatively influ- to be therapeutic, there must be an interac-
ence the child’s behavior through day to day tion between the music and the person who
experiences. Research has shown that this desires a health outcome from the music
behavior transcends generations with grand- (Meyer, 1956). This implies that there are
mothers influencing the parenting behaviors individual, age, culture, and situation-related
of mothers who in turn affect their child’s differences in choice and effect. The saying
emotional reactivity and future parenting that music is a universal language gives the
behavior (Stack et al., 2010). false impression that everyone appreciates
Although many investigators have and is helped by the same music. Although
understandably narrowed their research to all cultures of the world use music in some
one or two conceptual areas of inquiry, the form and derive meaning from it, different
dyad is dynamically affected by all of these cultures and different generations are accus-
influences. That is, mothers identify parent- tomed to listening to widely divergent kinds
ing goals and devise child-rearing strategies of music. There may be large differences in
that are consistent with their temperaments, volume, pitch, rhythm, tempo, harmony, dis-
biology, child-rearing environments, cogni- harmony, words, and meaning (Cross, 2003).
tions, and psychological capacities (Gross, In addition, there is variation within age and
1996). Likewise, children’s responses to par- cultural groups (Good, Picot, Salem, Picot, &
ents are similarly tied to these same factors. Lane, 2000).
Future research should refine how these Music therapy may be provided by a reg-
influences transact within the parent–child istered music therapist who has been taught
relationship so that research methods can be to use music in many therapeutic ways.
clarified and cost-effective nursing interven- However, any member of the health care team
tions disseminated to populations in need. may suggest to patients that soft music can
To date, a number of intervention strat- be helpful for stress, pain, and mood and can
egies for improving mother–infant/toddler use stimulating music to encourage sociali-
relationships have been validated. Among zation, expression, and exercise. Nurses can
the most well researched are home visiting assess musical preferences, offer a choice of
programs (e.g., Olds et al., 2007), in which selections, and encourage patient involve-
parents receive a range of services designed ment in the music with the goal of achieving
to improve maternal and infant health and specific health outcomes.

MUSIC THERAPy n 307



Throughout history, music has been meanings, and self-insight. In addition, stud-
used for a variety of therapeutic purposes ies have shown that music reduces pain and
by primitive people to ward off evil spirits, anxiety, reduces muscle tension, raises levels M
to prevent or cure illnesses, to relieve depres- of beta-endorphins, and lowers adrenocor-
sion, to modify emotions, and to achieve ticotropic stress hormones. Music has been
inner harmony. Early cultures had little found to improve the immune system, sali-
means to treat disease, so music and spir- vary cortisol, postoperative and cancer pain,
ituality were used to provide comfort and sleep, nausea and vomiting of chemotherapy,
help people cope. During the Renaissance, mood during stem cell transplantation, pain
physicians became interested in the thera- of osteoarthritis, and cardiac anxiety and
peutic value of music and incorporated it in autonomic balance. It has also been effective
their training and practice. From the seven- for acute and chronic pain and during stress-
teenth century onward, physicians studied ful or painful procedures (e.g., injections,
the effect of music on physiology and psy- gastrointestinal endoscopy, and lumbar
chology and debated whether to focus on punctures). Music has been generally found
the type of music that was effective versus to reduce anxiety before, during, and after
the type of person who responds positively surgery, during burn debridement, in chroni-
to music. Florence Nightingale used music cally ill patients, and after myocardial infarc-
with injured soldiers in the Crimea. She had tion. It has been studied for circumcision
recreation areas where recovering men could pain in infants, for injection pain in children
go to listen to singing or playing of musical and adults, for disturbances in psychiatric,
instruments. demented, and agitated patients, in the criti-
At the beginning of the twentieth cen- cally ill, in dyslexic children, in postanesthe-
tury, the first laboratory studies of the phys- sia patients, in the emergency department,
iological effects of music were conducted on and in those who are comatose or dying.
animals and humans. These experiments Lullabies have shown beneficial effects on
demonstrated changes in vital signs and preterm infants. A double-blind study of
body secretions in response to various types music during surgery showed effects on
of music. They are rejected by most investiga- recovery. In mice, music reduced stress and
tors today because of the poor quality of mea- metastasis and improved immune factors.
surement, analysis, and control. In the 1930s, Music has been categorized into stimu-
music began to be used in patients’ hospital lative and sedative types. Stimulative music
rooms, in surgery before general anesthesia, has strong rhythms, volume, dissonance,
and during local anesthesia. Music was used and disconnected notes, whereas sedative
in obstetrics and gynecology to reduce the music has a sustained melody without strong
side effects of inhalation anesthetics. rhythmic or percussive elements. Stimulative
Nursing reviews of research on the music enhances bodily action and stimu-
effect of music on health outcomes can be lates skeletal muscles, emotions, and sub-
found in chapters by Good (1996), Guzzetta cortical reactions in humans. Sedative music
(1988, 1997), Standley and Hanser (1995), results in physical sedation and responses
and Snyder and Chlan (1999). The American of an intellectual and contemplative nature
Music Therapy Association and two journals, (Gaston, 1951). Precategorization by the
the Journal of Music Therapy and the Music nurse, however, does not consider the kind of
Therapy Perspectives, are excellent resources. subject response. Other ways of categorizing
Music can transport patients’ thoughts to are slow and fast music, or by type of music
a new place, give them new perspectives, lift or instrument.
their mood, provide comfort, familiarity and To choose music that is therapeutic,
pleasure to patients, and stimulate memories, the nurse should consider the nature of

308 n MUSIC THERAPy



the music, the patient preferences, and the or type of music, their inability to turn it off
health state. Nurses can assess patients’ when desired, cochlear implants, and cultur-
M sex, cultural background, musical prefer- ally incongruent music. In addition, those
ences, music training, participation in music, with hearing loss may or may not find that lis-
degree of auditory discrepancy, time avail- tening to music is beneficial. Future research
able, and, most of all, degree of liking for the in music may include studies that determine
music under consideration. Variations in the the kinds of music that are effective for health
nature of the health state determine whether outcomes in countries around the world and
music will be used to cheer, encourage, between cultures in each country. More work
soothe, relax, distract the mind, stimulate on comparing symptomatic response with
exercise, or evoke emotions of joy, triumph, physiological response is needed to gener-
resolve, or peace. Studies have indicated that ate theories of conditions in which music is
different kinds of music result in positive effective, how it affects body processes, and
or negative feelings and differences in sero- what effect it has on recovery, immune func-
tonin. Music is economical for patient use. tion, and health.
Tapes, compact discs, and players are rela- Music brings an air of normalcy, enter-
tively inexpensive, and a small library can tainment, pleasure, and escape into a world
be maintained on any nursing unit. Music where illness is often the enemy and both
piped into patients’ rooms also may be patients and caregivers are fighting back.
available. Nurses can suggest that patients Music is an integral part of most people’s
and their families bring in favorite music normal lives and should not be forgotten
from home that is likely to invoke healthy when they go to hospitals and other health
responses. They can refer patients to a music care facilities. With the increased reliance on
therapist if one is available. technology in health care today, music can
There are some contraindications and add a humanistic touch. Beyond the human-
considerations when using music for patients. istic value of music is the therapeutic value
Contraindications include hypersensitivity to in reducing stress, pain, anxiety, and depres-
sound, tone deafness, musicogenic epilepsy, sion and promoting movement, socialization,
and inability to recognize music in some and sleep.
stroke patients. Nurses should consider any
patient dislike for any particular selection Marion Good

N














representing structured meaning. Narratives
Narrative aNalysis are structured about a story plot or plots
illustrated by characters (actors) and events.
Narratives as stories are characterized by
Narrative analysis is a specific analytic a sense of internal chronology (either tem-
approach in the more general field of narra- poral or thematic) and connectedness that
tive research or narrative inquiry. Narrative brings about coherence and sense making.
analysis is defined as an analytic process Narratives differ from discourse in that nar-
involving structuring, interpretation, and ratives contain descriptions of chronologi-
recontextualization applied to human stories cally articulated events along with sketches
constructed by narrators who are situated in of characters within the stories.
specific personal and social contexts of their As narratives are human linguistic prod-
lives. Narrative analysis does not refer to ucts, their constructions are closely tied to
one specific analytic technique or strategy as “storytelling,” that is, the processes involved
there is a variety of ways stories are analyzed in producing them. In narrative analysis, sto-
and interpreted, which are sometimes sug- rytelling is often the object of analysis, along
gested for consolidation in application for an with narratives themselves.
in-depth understanding of the work of nar- The heterogeneity of narratives, the rep-
ratives and narratives themselves (Mishler, resentative disciplinary plurality, and the
1986, 1995; Riessman, 1993, 2001). Narrative varieties in narrative theories have been
analysis has a grounding in many different evidenced in various approaches and ori-
disciplines and is being applied in various entations in narrative analysis. There are
research traditions: literary studies, linguis- at least three diverse orientations within
tics, anthropology, psychology, sociology, narrative analysis: (a) structural orientation,
theology, history, and practice disciplines (b) storytelling orientation, and (c) interpre-
such as nursing, medicine, occupational tive orientation (for other ways of catego-
therapy, and social work. Narrative analysis rizing narrative analysis, see Mishler, 1995;
has been gaining popularity among nurse Polkinghorne, 1988; Riessman, 1993).
researchers during the past two decades as Structural orientation can be identified
one approach to study human experiences of with structuralists such as Barthes (1975)
both clients and nurses, especially from the and sociolinguists such as Labov (1972) and
perspective of interpretivism. Gee (1991). In this orientation, narratives are
All sorts of oral and written represen- thought to be organized about a specific set
tations are considered narratives—fables, of structural units that bring about coher-
folktales, short stories, case histories, exem- ence and connectivity in the narratives.
plars, news reports, personal stories, his- Attention to narrative structures is analyti-
toriography, and interview data. Although cally juxtaposed to such aspects as functions
there are controversies, the term narrative in that different structural units perform, sense
narrative analysis refers to a story that con- making in story, and narrativity. Narrative
tains two or more sequentially ordered units, analysis in the structuralist tradition within
with a beginning, middle, and ending, and literary studies and linguistics focuses on

310 n NARRATIve ANALySIS



structural–functional connections, as in considered as the processing of nonlinguis-
Propp’s (1968) morphology in relation to tic ideas, events, and actions into a series of
N internal patterning and narrative genre and connected and coherent representation of
in Genette’s (1988) three specific aspects of a meanings.
story’s temporal articulation (i.e., order, fre- On the other hand, narrative analysis
quency, and duration). in the sociological version within the eth-
Sociolinguists within this orientation nomethodological tradition is concerned
attend to “natural” or “situated” narratives, with the interactive process of narrative
which are constructions produced in spe- making. Conversational narratives are of
cific situations of social life. Labov (1972) prime interest. The listener is an active part
and Labov and Waletzky (2003) identified six of storytelling as an interactive participant
structural units for fully formed narratives: in the making of a story. From an anthropo-
abstract, orientation, complicating action, logical perspective, storytelling is viewed as
evaluation, resolution, and coda. These bounded by cultural conditions and cultural
structural units are related to two functions categories. Narrative analysis in this orienta-
in narrative: the referential function and the tion carries out an analysis of narrative texts
evaluative function. Gee (1991), on the other in terms of form and content, along with an
hand, identified structural properties of nar- analysis of the flow of storytelling, with the
rative as poetic structures of lines, stanzas, or assumption that the nature of narrative text
strophes, which organize meaning construc- is integrally connected to the processes of
tions in telling a story. The structural orienta- construction.
tion is primarily an examination of structural Narratives in the interpretive orientation
elements of story in relation to the narrative’s are chronological in a double sense: chro-
form, function, and meaning. nology in terms of temporal serialization of
In storytelling, narratives are viewed events and chronology in terms of tempo-
not simply as products that can be taken out rality of story itself. Ricoeur (1984) specified
of the context of narrating but as process- episodic and configurational dimensions as
oriented constructions that are enmeshed the temporal dialectics that integrate plots
with linguistic materialization of cognition in narrative. Hence, narratives are stories
and memory, interactive structuring between of individuals etched within the commu-
the teller and listener, and contextually and nal stories of the time and context. Narrative
culturally constrained shaping of experi- analysis thus involves interpretation of rep-
ences and ideas. From this standpoint, narra- resentation posed within the contexts in
tive analysis is closely aligned with discourse which the story is shaped and the storytell-
analysis, as in ethnography of communica- ing occurs, reflecting on the worldviews that
tion in anthropology and ethnomethodology provide a larger contextual understanding.
in sociology. In this sense, the interpretive orientation
Narrative analysis in this orientation is is more concerned with meaning of narra-
differentiated into two schools: linguistic/ tives than with either the structure or the
cognitive and sociocultural. The linguistic/ process.
cognitive version focuses on how narratives Riessman (1993) offered five levels of rep-
are materialized in language from ideas and resentation in the research process of narra-
experiences. This construction is viewed to tive analysis: attending, telling, transcribing,
be accomplished by applying communica- analyzing, and reading. Interpretation occurs
tive and interactive functions of language at the levels of transcribing and analyzing by
and through scripting and schematizing of the researcher, whereas the level of reading
yet unorganized information into connected implies additional interpretation that occurs
storytelling. In this version, storytelling is in the readers of research reports. Riessman

NATIONAL INSTITuTe OF NuRSING ReSeARCH n 311



favored the use of poetic structures as the understanding of human experiences that
mode of structuring narratives as interpre- are fundamental to nursing practice.
tive; however, the use of any specific struc- N
turing model is less critical for the analysis Hesook Suzie Kim
than is interpretation.
Within the interpretive orientation in
narrative analysis, critical narrative analy-
sis has emerged within the last decade NatioNal iNstitute of
(Holstein & Gubrium, 2000). Critical narra-
tive analysis is aligned with critical philos- NursiNg research
ophy and is based on the assumptions that
knowledge is ideologically, historically, and
culturally embedded (Gergen, 1994), and The National Institute of Nursing Research
language use and meanings in language (NINR) is one of 27 institutes and centers
are socially constructed entrenched with that comprise the National Institutes of
power (Foucault, 1972). Critical narrative Health (NIH). The NIH is one of 12 operating
analysis, therefore, focuses on critiquing divisions of the u.S. Department of Health
how patterns of power and social practices and Human Services. Headquartered in
shape and construct narratives as well as Bethesda, Maryland, the NIH is the nation’s
storytelling (emerson & Frosh, 2004). medical research agency—making impor-
Although there are distinct differences tant medical discoveries that improve health
among these orientations, there are many and save lives. Thanks in large part to NIH-
hybrid forms of narrative analysis used in funded research, Americans today are liv-
actual research practice. Hybrid forms often ing longer and healthier. Life expectancy in
combine analysis of process or meaning with the united States has jumped from 47 years
structural analysis. In nursing research, nar- in 1900 to 77 years today, and disability in
rative analysis has been applied with various people older than 65 years has dropped
orientations and in different hybrid forms. dramatically in the past three decades. In
The literature in nursing reveals some con- recent years, nationwide rates of new diag-
fusion in the use of narrative analysis as a noses and deaths from all cancers combined
research method, such as in (a) using it inap- have fallen significantly. More than 80% of
propriately instead of discourse analysis, (b) the NIH’s budget goes to more than 300,000
applying to research with textual data but research personnel at over 3,000 universities
without focus on stories, or (c) using in com- and research institutions. In addition, about
bination with techniques within grounded 6,000 scientists work in NIH’s own labora-
theory, phenomenological analysis, or eth- tories, most of which are on the NIH main
nography without either theoretical or meth- campus. The campus is also home to the NIH
odological justification. Although many Clinical Center, the largest hospital in the
scholars including Mishler (1995) suggested world totally dedicated to clinical research.
for each individual researcher in narrative In the fall of 2010, NINR commemo-
research to design and apply a set of specific rated the 25th anniversary of its establish-
strategies for narrative analysis, there is a ment at the NIH. Originally designated as
need for a rigor in specifying one’s theoretical the National Center for Nursing Research by
and methodological commitments regarding Public Law 99–158 in 1986, it attained insti-
narratives and narrative knowledge in such tute status through the NIH Revitalization
methodological formulation. Research of Act of 1993. Its budget of $16 million in 1986
narrative accounts of clients and nurses, as has grown to $145 million in 2010. The origi-
well as their interactions, can produce deep nal staff of 9 members has increased to nearly

312 n NATIONAL INSTITuTe OF NuRSING ReSeARCH



100 people, including scientists, administra- home- and community-based use; and devel-
tors, and support staff. oping future research and clinical workforce
N NINR supports clinical and basic at a time of increased demand across numer-
research to build the scientific foundation for ous sectors of the health care system.
clinical practice, prevent disease and disabil- A fundamental part of NINR’s mission is
ity, manage and eliminate symptoms caused developing the next generation of scientists.
by illness, and enhance end-of-life and pallia- The percentage of NINR’s budget allocated
tive care. NINR’s research portfolio is greater to training is nearly twice the NIH average.
than 90% clinically focused. Although NINR under its training programs, NINR sup-
does support basic research, which has his- ports graduate and postgraduate research
torically comprised a large proportion of fellowships and career development awards,
the NIH research portfolio, the institute has including awards to trainees from underrep-
always been a leader at NIH, and across the resented and disadvantaged backgrounds.
broader biomedical community, in clinical Many NINR-trained scientists will also serve
research and research translation. as faculty in schools of nursing, responsible
Over the past 25 years, NINR-supported for educating future nurses that are vital to
scientists have addressed clinical and policy improving patient health and the effective-
deficiencies across the health and health care ness of the nation’s health care.
spectrum, improving—often transforming— NINR supports a number of special-
practice guidelines and public policies on the ized training programs designed to pro-
basis of their research findings. NINR grant- mote career advancement and provide the
ees have led the way in bringing person- next generation of scientists with the skills
centered, point-of-care translational research necessary to address today’s most press-
to the forefront of the health sciences by ing issues. For example, the NINR Summer
investigating all dimensions of health includ- Genetics Institute is an intensive summer
ing fundamental issues of quality of care and training program that provides graduate
quality of life in disparate settings from the students and faculty with a foundation in
neonatal intensive care unit (NICu) to nurs- molecular genetics to enhance their research
ing homes; preventative interventions and and clinical practice. Along with supporting
symptom management in acute critical care numerous other predoctoral and postdoc-
settings and in the realm of chronic disease; toral research opportunities, NINR also par-
and health promotion for individuals, fam- ticipates in the NIH Graduate Partnerships
ilies, and communities across the life span Program, a doctoral fellowship training pro-
and across generations. gram that coordinates training and funding
NINR’s focus on science that spans the for doctoral students attending schools of
full disease spectrum and all stages of life nursing with established NINR-supported
enables the institute to explore and address training programs. Another program, the
some of the most important challenges K22 Career Transition Award, funds post-
affecting the health of the American people. doctoral research in two phases: an intramu-
These issues include improving management ral phase at NIH and an extramural phase
of chronic illness, including in persons with to aid the transition to tenure-track research
comorbid conditions; developing new strate- and faculty positions. In addition, the BNC
gies for preventive health that are culturally Fellowship, supported by the Bravewell
relevant at a time of increasing ethnic, racial, Collaborative, NINR, and the NIH Clinical
and cultural diversity and in the face of per- Center, trains individuals on how to address
sistent health disparities; enhancing the key issues in integrative health research.
ability to translate emerging patient manage- In NINR’s role as the lead NIH institute
ment technologies into clinical practice and for end-of-life research, an area of increasing

NeuMAN SySTeMS MODeL n 313



importance in public policy, the institute relevant to the application. Scored applica-
seeks to apply interdisciplinary biological, tions then undergo a second stage of review
behavioral, and social science strategies to by the National Advisory Council for Nursing N
advance understanding of the challenges Research. upon completion of the required
of a life-threatening illness, improve pal- reviews, final funding decisions are made
liative care, and enhance quality of life for by NINR based on the Initial Review score,
dying patients and their informal caregivers. advisory council recommendations, portfolio
In 2009, NINR established the NINR Office analysis, and fiscal considerations. This peer
of Research on end-of-Life Science and review system ensures that all applications to
Palliative Care, Investigator Training, and NINR receive full and fair consideration and
education to coordinate research efforts in that NINR supports only the best science.
these critical areas of science. Individuals who are interested in sub-
The first NINR director, Dr. Ada Sue mitting applications for grants to conduct
Hinshaw, who held the position from 1987 research in areas of interest to the insti-
to 1994, is widely recognized for her contri- tute are encouraged to visit www.ninr.nih.
butions to teaching, nursing research, and gov to learn more about research opportu-
academic administration. under her lead- nities and proposed areas of investigation
ership, the institute was established as an before embarking on the application process.
active participant within the federal research General questions regarding the NINR may
community and achieved national recogni- be addressed to Office of Science Policy and
tion for nursing research. Information, NINR, NIH, Building 31, Room
The current director, Dr. Patricia A. 5B10, 31 Center Drive, MSC 2178, Bethesda,
Grady, an internationally recognized stroke MD 20892-2178; telephone: (301) 496-0207;
researcher, was appointed in 1995 following email: [email protected].
positions as deputy director and acting direc-
tor of the National Institute of Neurological Patricia A. Grady
Disorders and Stroke. Dr. Grady has
authored or coauthored numerous articles
and papers on hypertension, cerebrovascular
permeability, vascular stress, and cerebral NeumaN systems model
edema. She is an editorial board member of
the major stroke journals. Dr. Grady lectures
and speaks on a wide range of topics, includ- The Neuman Systems Model (NSM) pro-
ing future directions in nursing research, vides a broad, comprehensive, systems
developments in the neurological sciences, approach as a framework for the profession
and federal research opportunities. In addi- of nursing to organize care, educate future
tion to her numerous honors for her scientific providers, and conduct research. The model
accomplishments, Dr. Grady is a past recip- offers a holistic approach, a wellness orienta-
ient of the NIH Merit Award and received tion, client perception, and motivation with
the Public Health Service Superior Service a systems perspective of variable interac-
Award for her exceptional leadership. tion with the environment (Neuman, 2001,
Applications received by NINR, and p. 12). Two components form the foundation
across all of NIH, are evaluated for funding of the model: exploring the client’s response
through a two-stage peer review process. to stressors and identifying the nurse’s pre-
In the first stage, applications assigned to ventive interventions that assist the client
NINR are reviewed and scored for scientific in responding to these stressors. The ulti-
merit by an Initial Review Group, a panel mate goal of nursing is to assist the client in
that consists of experts in fields of research achieving the goals of an optimum state of

314 n NeuROBeHAvIORAL DeveLOPMeNT



wellness. Primary components of the NSM system (CNS) achieves maturity in form and
include stressors, lines of defense and resis- function. Neurodevelopment also depends
N tance, levels of prevention, the five client on the environment since CNS development
systems variables (basic structure, interven- occurs through an “experience expectant”
tions, internal and external environment, process in which normal species-typical
and reconstitution; Neuman, 2001). The experiences enable the CNS to make the
nurse is an intervener who uses three lev- structural and functional changes neces-
els of prevention (primary, secondary, and sary for the next stages of development
tertiary) to achieve the goal of reducing the (Greenough, Black, & Wallace, 1987). In order
client’s encounter with stressors and mitigat- to balance the needs of the present develop-
ing the impact of the stressor. The client or mental stage and the anticipated needs of
client system may be an individual, group, subsequent stages, this process is somewhat
family, and community and is composed plastic (Oppenheim, 1981). When an infant is
of five interrelated variables (physiological, placed in an atypical environment, such as
psychological, sociocultural, developmental, a neonatal intensive care unit, ontogenetic
and spiritual). Health, according to Neuman adaptation is affected. Although the infant
(2001), is equated with living energy, deter- may initially adapt successfully, changes in
mined by the degree of harmony among the trajectory of the infant’s neurobehavioral
the five client variables and basic structure developmental may be maladaptive at older
factors, on a continuum from wellness to ages. The effects of this disturbance vary
illness. The degree of wellness is deter- depending on the timing and severity of
mined by the amount of energy required environmental stresses, individual genetic
to retain, attain, or maintain system stabil- background, the interaction of genetic back-
ity (Neuman, 2001, p. 12). An integrative ground and prenatal history, adaptations
review of NSM-based research conducted made to uterine stresses, and specific neu-
by Fawcett and Giangrande (2001) found 200 rological insults. Infants probably develop
research reports with an analysis focused normally when neural plasticity—the pro-
on general information, scientific merit, cess by which the brain develops new con-
and the NSM. Gigliotti and Fawcett (2001) nections after neural damage—compensates
reviewed 212 research reports and identified for abnormalities due to any atypical onto-
different instruments explicitly linked to the genetic adaptation and neurological insults.
NSM—sometimes more than once and for Infants exhibit abnormal neurobehavioral
different purposes. To enhance and facilitate development when neural plasticity is not
future research related to the NSM, Neuman able to compensate or when compensatory
and Fawcett (2001) have established a set of processes result in structural or functional
guidelines for NSM-based research. changes that are maladaptive at later ages.
The Synactive Model of Neonatal
Patricia Hinton Walker Behavioral Organization provides a frame-
work for exploring the concept of neurobe-
havioral development. Als (1986) and Als,
Neurobehavioral Duffy, and McAnulty (1996) have proposed
a dynamic model for assessing infant behav-
developmeNt ioral organization. They suggested that the
behavioral organization displayed by an
infant is a reflection of the infant’s central
Neurobehavioral development may be nervous system integrity, defined as the
viewed as a genetically determined pro- potential for the brain to develop normally.
cess by which the primitive central nervous The infants’ behaviors reflect subsystems of

NeuROBeHAvIORAL DeveLOPMeNT n 315



functioning, which include the autonomic, primary expression of brain functioning
motor, state, attentional or interactive, and and the critical route for communication
regulatory systems. The autonomic system with adults. Investigation of these behaviors N
controls physiologic functions that are basic and their central mechanisms is essential
for survival such as respiration and heart for nursing in understanding of the needs
rate. The motor system involves muscle tone, of infants and in planning interventions to
infant movements, and posture. State organi- improve their neurodevelopmental status.
zation encompasses clarity of states and the The idea of evaluating the vitality and
pattern of transition from one state to another. central nervous system integrity of a neonate
The attentional or interactional system can be by assessing sucking is not new. Nutritive
observed only in the alert state and is indica- sucking is initiated in utero and continues to
tive of an infant’s ability to respond to visual develop in an organized pattern in the early
and auditory stimulation. An infant’s regula- weeks after birth. It involves the integration
tory system reflects the presence and success of multiple sensory and motor central ner-
of an infant’s efforts to achieve and maintain vous system function (Wolff, 1968). Sucking
a balance of these other subsystems. behaviors are thought to be an excellent
Another framework used is the perspec- barometer of central nervous system orga-
tive of developmental science, a multidisci- nization. They can be quantified in detailed
plinary field that brings together researchers analysis and are disturbed to various degrees
and theorists from psychology, biology, nurs- by neurologic problems.
ing, and other disciplines (Cairns, 1996; Miles The work of Medoff-Cooper and col-
& Holditch-Davis, 2003). In this perspective, leagues (Medoff-Cooper, Bilker, & Kaplan,
infants are viewed as developing in a contin- 2001; Medoff-Cooper, McGrath, & Shults,
uously ongoing, reciprocal process of inter- 2002; Medoff-Cooper, McGrath, & Biler, 2000)
action with the environment. Infants and demonstrated that changes in the pattern of
their environments form a complex system, nutritive sucking behaviors can be described
consisting of elements that are themselves as a function of gestational age in healthy
systems, such as the mother and child, inter- preterm and full-term infants. They reported
acting together so that the total system shows that sucking patterns change systematically
less variability than that of the individual ele- with increasing postmenstrual and gesta-
ments. Moreover, plasticity is assumed to be tional age, with a strong correlation between
inherent in the infants, their families, and the increasing maturation and more organized
environment. Infants are active participants sucking patterns (Medoff-Cooper et al., 2002).
in their families and the greater environ- When comparing sucking behaviors at term
ment, constantly changing them at the same of 213 extremely early born infants (gesta-
time that the physical and social environment tional age ≤29 weeks), more mature preterm
is influencing the infant. Interactions, rather infants (30–32 weeks gestational age), and
than causation, are the focus of this perspec- newly born term infants, sucking behaviors
tive. No action of one element can be said to were noted to be a function of gestational age
cause the action of another because interac- at birth and the interaction of maturation and
tions between elements are simultaneous experience. extremely early born preterm
and bidirectional. The interactions affect- infants demonstrated less competent feeding
ing development of infants are too complex behaviors than either more mature preterm
to ever be totally identified, and infants can infants or newly born full-term infants.
achieve the same developmental outcomes Lau, Smith, and Schandler (2003) also
through different processes. found that with increasing postmenstrual age
Newborn behavior, which includes suck- (PMA), preterm infants demonstrated signif-
ing and sleeping and waking, is the infant’s icant improvement in feeding performance.

316 n NeuROBeHAvIORAL DeveLOPMeNT



They reported a significant relationship was neonatal morbidity of developmental
between average bolus size and sucking pres- outcome at 6 months of age. At 12 months of
N sures and sucking frequency. The ability to age, organized feeding patterns at 40 weeks
tolerate, as well as adapt to, increasing bolus PMA was significantly correlated with both
size serves as an indicator of maturation in Mental Developmental and Psychomotor
feeding behaviors. Developmental Index (Medoff-Cooper et al.,
Gewolb, Bosma, Reynolds, and vice 2009). Mizuno and ueda (2005) found sig-
(2003) used increasing rhythmic stability as nificant correlation between feeding assess-
the index of maturation of sucking or feed- ment and neurodevelopmental outcome at
ing behaviors. In their comparison of healthy 18 months. The sensitivity and specificity of
preterm infants and preterm infants with feeding assessment were higher than those
bronchopulmonary dysplasia, an increase in of ultrasound assessment. In summary,
stability of rhythm and uniformity of wave- nutritive sucking, a noninvasive and easily
form morphology was correlated with feed- measured behavior, appears to be an excel-
ing efficiency and increasing PMA in healthy lent index of neurodevelopment in preterm
preterm infants. This relationship was not infants.
found to be true in the bronchopulmonary Sleeping and waking states are clusters
dysplasia cohort. They hypothesized that that of behaviors that tend to occur together and
the poor feeding efficiency may be related to represent the infant’s level of arousal, respon-
decreased respiratory reserves or to nonspe- sivity to external stimulation, and central
cific neurologic impairment. nervous system activation. Three states have
Mizuno and ueda (2005) assessed the been identified in adults: wakefulness, non-
feeding behavior of preterm infants by mea- ReM sleep, and ReM sleep. In infants, it is
suring sucking pressure, frequency, duration, also possible to identify states within wak-
and efficiency, as well as the coordination of ing and states that are transitional between
swallowing and respiration. The sucking waking and sleeping. Infant sleep states are
efficiency significantly increased between 34 usually designated as active and quiet sleep
and 36 weeks after conception and exceeded because the electrophysiological patterns
7 ml/min at 35 weeks. There were significant associated with sleep in infants are different
increases in sucking pressure and frequency than those in adults.
and in duration between 33 and 36 weeks. Because of newborn infants’ neurologi-
Swallowing patterns demonstrated matu- cal immaturity, eeG and behavioral scoring
rational changes as well, which occurred of states in preterm and full-term infants
mostly during pauses in respiration at 32 and provide quite similar results. Sleeping and
33 weeks and then at the end of inspiration waking states in infants can be validly scored
after 35 weeks. either by using eeG or by directly observing
The potential link between nutritive infant behaviors. Four standardized systems
sucking and future developmental prob- for scoring behavioral observations of sleep–
lems has been identified throughout the wake states are currently being used by nurse
feeding literature. One early study by Burns researchers: the 6-state system developed
et al. (1987) showed that infants with sig- by T. Berry Brazelton, the 10-state system of
nificant intraventricular hemorrhage were evelyn Thoman (1990), the 12-state system
delayed in their ability to achieve a nutritive from Heideliese Als’s (2003) Assessment of
suck reflex. At week 40, only 75% of the 110 Preterm Infant’s Behavior, and the Anderson
infants demonstrated mature nutritive suck- Behavioral State Scale developed by Gene
ing patterns. Medoff-Cooper and Gennaro Anderson (Holditch-Davis & Blackburn,
(1996) reported that sucking organization or 2007). These systems define states in very
rhythmicity was a far better predictor than similar ways and are probably equally useful

NeWMAN’S THeORy OF HeALTH n 317



for clinical purposes. However, the Brazelton Sleep–wake patterns can also be used
system is the most limited for research as it to predict developmental outcome (ednick
can only be used with infants between 36 et al., 2009). Measures of sleep–wake states N
and 44 weeks PMA, and Thoman’s is the during the preterm predict Bayley scores
most flexible as it has been used with 27-week during the first year. Developmental changes
PMA preterm infants through 1-year-olds. and stability in the amounts of specific sleep
Sleeping and waking states have wide- behaviors during the preterm period and
spread physiological effects. The functioning the first year are related to developmental
of cardiovascular, respiratory, neurological, and health outcomes in the second and third
endocrine, and gastrointestinal systems dif- year. eeG sleep measures in preterm infants
fers in different states. Sleeping and waking have been related to developmental outcome
also affect the infant’s ability to respond to at up to 8 years (Holditch-Davis & Blackburn,
stimulation. Thus, infant responses to nurses 2007). For example, Arditi-Babchuk, Feldman,
and parents depend to a great deal on the and eidelman (2009) found that rapid eye
state the infant is in when the stimulation movement activity at 32–36 weeks PMA was
is begun. Timing routine interventions to related to Bayley scores at 6 months. Infants
occur when the infant is most responsive is who showed more rapid active sleep devel-
an important aspect of current systems of opment in the preterm period had higher
individualized nursing care. average cognitive skills and better language
Studies have indicated that sleep and and fine motor abilities at 3 years than those
waking patterns are closely related to neu- of other preterm infants (Holditch-Davis,
rological status (Halpern, MacLean, & Belyea, & edwards, 2005). In summary, sleep-
Baumeister, 1995). State patterns of infants ing and waking patterns appear to provide
with neurological insults differ markedly an excellent index of neurodevelopmental
from those of healthy infants. Abnormal status in preterm and full-term infants that
neonatal eeG patterns are associated with can be scored either behaviorally or by eeG.
severe neurological abnormalities and
major neurodevelopmental sequelae dur- Barbara Medoff-Cooper
ing childhood. Also, preterm infants with Diane Holditch-Davis
severe medical illnesses exhibit patterns of
sleep–wake states that differ from those of
healthier preterms, although most of these
differences disappear when infants recover NewmaN’s theory of health
(Holditch-Davis & Blackburn, 2007). Sleep
and wakefulness may be directly related to
brain development. For example, because Margaret Newman’s contributions to nurs-
ReM sleep is less common in adults than ing science and practice span 35 years of sus-
non-ReM sleep but active sleep is more tained scholarship on her theory of health
common than quiet sleep in infants, active as expanding consciousness. Her theory is a
sleep has been hypothesized to be necessary grand theory, focusing on a unitary-transfor-
for brain development (Roffwarg, Muzio, mative paradigm for nursing and on research
& Dement, 1966). Also, eeG changes over as praxis.
age in sleep architecture, increasing spec- Newman’s (1979) conceptual framework
tral energies, and greater spectral eeG of health was introduced in her book Theory
coherence probably indicate maturational Development in Nursing. This framework was
changes in the brain, including synaptogen- expanded and refined in two editions of
esis, evolution of neurotransmitter pools, Health as Expanding Consciousness (Newman,
and myelination. 1986, 1994) and in Transforming Presence