Encyclopedia of Nursing Research

368 n OUTCOMe MeASUReS



Outcome measures are often used in outcomes. Outcome research in the past has
reference to Donabedian’s (1992) structure– strongly relied on observational research
O process–outcome paradigm, the predominant often using large-scale databases. Because of
quality model in health care. Donabedian its close relationship to quality and quality
defines outcomes as “states or conditions improvement, a stronger focus on the imple-
of individuals or populations attributed mentation of quality improvement initiatives
or attributable to antecedent healthcare” has developed in recent years with stronger
(p. 356). Donabedian’s framework of health focus on interventional designs.
care quality, which integrates measures of Outcome measures are indicators of a
structures, processes, and outcome, has been change of patient health status, important
instrumental for the development of outcome to patients, health care organizations, and
research and quality measurement. These policy makers. Currently, outcome data are
informational domains are not considered as compiled from a wide range of sources such
attributes of health care quality but deliver as clinical, administrative, and survey data,
evidence to make inference about the quality which too often puts redundant, if not con-
provided. Here structures refer to physical flicting, data collection burdens on health
and organizational properties (e.g., staffing), care providers. Lack of alignment of measure
whereas processes describe the treatment of specifications makes it difficult to compare
and interventions done for patients. Finally, analytic results from data sets using different
outcomes describe what is accomplished for specifications. The development of interoper-
the patient (Donabedian, 1992). Depending on able electronic medical records will reduce
the aim of the quality assessment, outcomes redundant data collection efforts and pro-
can be classified in seven different groups: mote faster reporting of outcomes to health
clinical, physiological-biochemical, physical, care providers.
psychological (mental), social and psycho-
social, integrative outcomes, and evaluative Michael Simon

P














or health context include pain in infants, the
Pain critically ill, the cognitively impaired, and at
the end of life.
The undertreatment of pain has been
Pain is a symptom, defined as an “unpleasant well documented for the past 37 years (Marks
sensory and emotional experience associated & Sachar, 1973). Barriers to the effective
with actual or potential damage or described treatment of pain include clinicians’ lack of
in terms of such damage; pain is always sub- knowledge of pain management principles,
jective” (International Association for the clinician and patient attitudes toward pain
Study of Pain, 1979, p. 250). Pain is a common and drugs, and overly restrictive laws and
component of illness and is the most common regulations regarding use of controlled sub-
reason that people seek medical attention. stances. The undermanagement of pain has
Nurses assess patients for pain and in collab- been particularly pronounced in children, in
oration with the patient and the physician; the elderly, and in those who cannot speak.
they endeavor to reduce or relieve pain and Pain relief in palliative care and at the end
to minimize the risk for long-term adverse of life is receiving increased attention around
effects of unrelieved pain. People experience the world.
pain in different ways and only those who Pain management includes pharmaco-
are experiencing pain know what it is really logical, cognitive-behavioral, physical, radia-
like. Communication of that pain to caregiv- tion, anesthetic, neurosurgical, and surgical
ers is dependent on the verbal abilities of the techniques. Analgesics administered orally
patient; those who are very young and those or intravenously are needed for moderate to
who are cognitively impaired are at risk for severe pain, and cognitive-behavioral tech-
being misunderstood by the caregiver. niques such as relaxation, music, and distrac-
Pain generally is classified into two tion can increase the relief. More complex
types: acute and chronic. However, there pain may require evaluation and treatment
are many different types and causes of pain. by a multispecialty pain management team.
There is acute pain after surgery and injury The successful management of pain gener-
and during labor, sickle cell crisis, and health ally depends on a careful assessment of the
care procedures. Acute pain subsides as heal- pain, patient education for pain management,
ing takes place. Acute pain has a predictable appropriate pharmacological and nonphar-
end and is of brief duration, usually less than macological intervention, reassessment to
3 to 6 months. Chronic pain is said to be that determine the effectiveness of interventions
which lasts longer. Chronic pain can occur in used, and reintervention until satisfactory
any system and can be recurrent or constant. relief is obtained (Good & Moore, 1996).
Cancer pain is from the enlarging tumor, its Pharmacological management of pain
metastases, or its treatment and can increase usually is treated by three types of drug:
in intensity and extent as the disease pro- (a) aspirin, acetaminophen, and nonsteroi-
gresses. “Breakthrough pain” are acute per- dal anti-inflammatory drugs; (b) opioids;
iodic increases in chronic cancer pain. The and (c) adjuvant analgesics. Nonsteroidal
types of pain that are classified by the age anti-inflammatory drugs decrease the levels

370 n PAIN



of inflammatory mediators generated at the nerves. Neuroablation techniques surgically
site of tissue injury, thus blocking painful interrupt the nerve and the transmission of
P stimuli. They are useful in the management painful impulses.
of mild pain and may be used in combina- The gate control theory published by
tion with opioids for moderate to severe Melzack and Wall (1965) provided a theoret-
pain. Opioids are morphine-like compounds ical basis for explaining how pain, transmit-
that produce pain relief by binding to opiate ted as electrical signals from the periphery
receptors. They are used with moderate and to the brain, can be influenced by cognitive,
severe pain. Patient-controlled analgesia is affective, and physiological factors. Theories
the use of equipment that is set to prescribed of pain have evolved in recent years to the
parameters to administer opioids intrave- idea of a mind–body unity that Melzack
nously, subcutaneously, orally, or epidurally. (1996) calls a neuromatrix. An active brain is
Adjuvant drugs are used to increase the effi- part of a whole person who has been shaped
cacy of opioids and to treat other symptoms by genetics and learning to respond to nox-
that exacerbate pain. ious stimuli in individually characteristic
Physical modalities for pain management patterns. Recent studies of the role of genet-
include use of heat and cold, counterstimula- ics, endorphins, and immune factors and
tion such as transcutaneous electrical nerve imaging studies of the thalamus, anterior
stimulation, and acupuncture. Cognitive cingulate, limbic system, and cortex sup-
techniques are focused on perception and port a holistic theory that goes beyond the
thought and are designed to influence inter- mechanics of transmission of noxious mes-
pretation of events and bodily sensations. sages. An appreciation of the mind–body
Providing information about pain and its experience of pain provides a basis for multi-
management, helping patients think dif- disciplinary research and practice, multicul-
ferently about pain, and distraction strate- tural responses, and multimodal strategies
gies are examples of cognitive techniques. for managing pain. Middle-range nursing
Behavioral techniques are directed at helping descriptive theories of pain have focused on
patients develop coping skills to modify their the whole person and prescriptive theories of
reactions to pain. Cognitive–behavioral tech- pain management have focused on prescrip-
niques commonly used by nurses and other tions for relief.
clinicians include relaxation, music, imagery, In recent years, various agencies and
distraction, and reframing. Psychotherapy, organizations have published guidelines for
social support, and hypnosis also have been the management of pain. These have included
used successfully in pain management. guidelines published the American Pain
Other management techniques may be Society: on analgesic use and pain in cancer,
used when the use of drugs is not adequate arthritis, sickle cell disease, fibromyalgia, low
to manage pain. The choice of techniques back pain. In addition, there are American
depends on the cause of the pain and these Pain Society guidelines for the use of chronic
therapies may be either temporary or per- opioid therapy in chronic noncancer pain.
manent. Radiation therapy is used to relieve The Joint Commission for Accreditation of
metastatic pain and symptoms from local Healthcare Agencies includes policies and
extension of primary disease. Nerve blocks procedures for pain management in their
are the injection of a local anesthetic into a standards. Pain relief is a patient’s right, but
spinal space or peripheral nerve destruc- there is greater consensus regarding man-
tion. Surgical procedures are used to remove agement of acute and cancer pain than for
sources of pain, such as debulking a tumor chronic nonmalignant pain.
that is pressing on abdominal organs or
removing bone spurs that are compressing Marion Good

PAllIATIve CARe n 371



• offers a support system to help the fam-
Palliative Care ily cope during the patient’s illness and in
their own bereavement; P
• uses a team approach to address the needs
The goal of palliative care is to prevent of patients and their families, including
and relieve suffering and to support the bereavement counseling, if indicated;
best possible quality of life for patients • will enhance quality of life and may also
and their families, regardless of the stage positively influence the course of ill-
of the disease or the need for other ther- ness; and
apies (National Consensus Project [NCP] • is applicable early in the course of ill-
for Quality Palliative Care, 2009). Palliative ness, in conjunction with other therapies
care expands traditional disease-focused that are intended to prolong life, such as
medical treatments to include the goals of chemotherapy or radiation therapy, and
enhancing quality of life for patient and includes those investigations needed to
family, optimizing function, helping with better understand and manage distressing
decision making, and providing opportu- clinical complications.
nities for personal growth. An Institute of
Medicine (IOM) report on end-of-life care At the turn of the twentieth century,
has called for models of care that implement Americans died from diseases such as yel-
palliative care concurrently with disease- low fever, small pox, diphtheria, and chol-
focused care earlier in the course of disease, era. Death was often rapid with little time
patient-focused care, and self-management to say goodbye to loved ones. In 1900, life
(IOM, 1997). expectancy was less than 50 years of age
The NCP for Quality Palliative Care for men and women, whereas in the year
(2009) recognized that multidimensional 2000, the median age of death was 77 years
support of patients and their loved ones old. Currently, Americans are struggling
is essential to quality palliative care. The to develop a health care system that is both
leading palliative care organizations and cost-effective and can ensure a “good life”
professionals involved in the creation and a “good death.”
of this document recognized the impor- Two landmark studies from the
tance of integrating palliative care as part 1990s, specifically, the Study to Understand
of the continuum of care. These reports Prognosis and Preferences for Outcomes and
support inclusion of palliative care as Risks of Treatments (SUPPORT Principal
a mechanism to meet patient and fam- Investigators, 1995) and the IOM’s (1997)
ily needs and their ability to take care of report Approaching Death: Improving Care at
their health. the End of Life, provide evidence of the need
Palliative care to improve the care of the dying in America.
The fear of experiencing a “bad death”
• provides relief from pain and other dis- seemed warranted by the conclusions of a
tressing symptoms; 5-year study of the end-of-life care received
• affirms life and regards dying as a normal by 9,000 dying hospitalized patients. The
process; Study to Understand Prognosis and Preferences
• intends neither to hasten nor postpone for Outcomes and Risks of Treatments
death; (SUPPORT Principal Investigators, 1995)
• integrates the psychological and spiritual was designed both to increase understand-
aspects of patient care; ing of hospitalized dying and to devise
• offers a support system to help patients an intervention to promote more humane
live as actively as possible until death; care of dying patients. The SUPPORT data

372 n PAllIATIve CARe



confirmed the high reports of pain among Saunders, a nurse who later became a social
dying patients (more than 50%), the clini- worker and physician, is credited with open-
P cians’ lack of training in pain manage- ing Saint Christopher’s Hospice in london
ment, and the institutional limitations on where she championed the need for a multi-
the delivery of pain-control interventions. disciplinary approach and around-the-clock
In addition, the SUPPORT data confirmed administration of opioids when caring for
that patients’ end-of-life treatment prefer- dying patients. Her approach to care focused
ences, whether written or verbally commu- on comfort, skilled nursing, family counsel-
nicated to nurses or family members, were ing, physical therapy, and addressing spiri-
often ignored by physicians or were other- tual needs. These fundamental elements of
wise ineffective in furthering the autono- care characterize quality palliative care. The
mous choices made by patients (SUPPORT hospice model serves as the gold standard for
Principal Investigators, 1995). offering the best end-of-life care to patients
In palliative care, death is also viewed and their families; palliative care found its
as an outcome measure for improving end- roots in the hospice movement. The World
of-life care. The IOM’s (1997) report provided Health Organization (2002) defines palliative
some conceptual benchmarks from which care as an approach that improves the qual-
quality outcome indicators can be developed. ity of life of patients and families who face
A “good death” was defined as one free from life-threatening illness by providing pain
avoidable stress and suffering for patients and symptom relief, spiritual and psychoso-
and families and caregivers, in general accord cial support to from diagnosis to the end of
with patients’ and families’ wishes, and rea- life, and bereavement.
sonably consistent with clinical, cultural, and Newer models of palliative care address
ethical standards. In contrast, a “bad death” both disease-specific therapies as well as
was one in which there was needless suffer- supportive-comfort therapies that pro-
ing, disregard for patients’ or family’s wishes mote the optimal function and well-being
or values, and a sense among participants or of patients and their family caregivers. The
observers that the norms of decency had been Canadian Palliative Care Association’s (1995)
offended. This is the challenge of nurses and model documented how palliative care needs
all health professionals in the twenty-first intensify at the end of life. The core issues of
century. palliation, comfort, and function are salient
Two reports that followed, Improving throughout the course of disease. A palliative
Palliative Care for Cancer (IOM, 2002a) and care model recognizes the need to address
When Children Die: Improving Palliative and End symptom distress, physical impairments,
of-Life Care for Children and Their Families (IOM, and psychosocial disturbance even during
2002b), continued the argument that medical the period of aggressive primary therapy
and other support for people with fatal or with goals of cure or the prolongation of life
potentially fatal conditions often fall short of (NCP for Quality Palliative Care, 2009).
what is reasonable, if not simply attainable. Definitions of palliative care have
The IOM report highlighted the inadequacy evolved based on the work of the NCP for
of current knowledge to guide the practice of palliative care (NCP for Quality Palliative
clinicians in end-of-life care and the need for Care, 2009). Palliative care and hospice pro-
support from policy makers. grams have grown in the United States in
The hospice concept originated in the response to a population living with chronic,
Middle Ages when pilgrims traveling to the debilitating, and life-threatening illness and
Holy land found their minds and bodies to clinician interest in effective approaches to
restored when they stopped at way stations providing care. In 2004, five major palliative
attended by religious orders. Dame Cicely care organizations led an NCP for Quality

PAllIATIve CARe n 373



Palliative Care (2004, 2009) to improve the and syndromes regardless of their underly-
quality of palliative care in the United ing condition. To decrease patient and fam-
States. efforts resulted in “Clinical Practice ily suffering at the end of life and improve P
Guidelines for Quality Palliative Care.” symptom control, in-hospital programs are
The guidelines were organized into eight adopting a palliative care model that offers
domains of care and aim to promote qual- comprehensive care for seriously ill patients
ity and reduce variation in new and existing and their families.
programs, to develop and encourage conti- Technologies that sustain life by artifi-
nuity of care across settings, and to facilitate cial means have increased our ability to pro-
collaborative partnerships among palliative long life, yet they have raised many moral,
care programs, community hospices, and ethical, and legal dilemmas for Americans.
other health care settings. Fundamental pro- Some bioethicists contend that the real
cesses that cross all domains include assess- political struggles of the twentieth century
ment, information sharing, decision making, have not been over legal rights, but over con-
care planning, and care delivery. Developers trol in the “way” individuals live their lives.
incorporated established standards of care Supreme Court rulings regarding the right
from Australia, New Zealand, Canadian, the to abortion, to die or cause death, to make
Children’s Hospital International, and the family decisions, to live, to control one’s
National Hospice and Palliative Care orga- own body, to health care, to refuse hydra-
nizations. Studies will be needed to evalu- tion, and to self-determination are examples
ate the usefulness of the guidelines to foster of health care issues brought forth in the last
access to care; continuity across settings, few decades (Annas, 1993, 1995; Matzo &
such as home, residential, hospital, and hos- Hijjazi, 2008).
pice; development of national benchmarks views toward death and dying in
for care; uniform definitions that assure American culture continue to change at a
reliable quality care and encourage perfor- relatively consistent pace as evidence is com-
mance measurement; and quality improve- piled documenting the need to improve the
ment initiatives for palliative care services. care of the dying and their families. This
Factors that have contributed to the pal- challenge to nurses and nurse educators is a
liative care movement in the United States formidable one in the decades ahead. Nurses
include the growing aging population, the leading the field need advanced education in
assisted suicide debate, the reduced patient palliative care. All nurses need to know when
autonomy, and the inappropriate end-of-life the services of an interdisciplinary specialist-
care (i.e., overtreatment of medical conditions level palliative care team are indicated and
and undertreatment of pain and depression). how to access them. They need to be aware of
Quality outcomes of good palliative care evidence-based clinical practice guidelines
ensure that patients’ values and decisions in palliative care and how to implement and
are respected; comfort is a priority; psycho- evaluate them to achieve desirable patient
social, spiritual, and practical needs will be and family outcomes.
addressed; and opportunities will be encour- Nurses are an essential voice in these
aged for growth and completion of unfin- discussions in their roles as patient and fam-
ished business (NCP for Quality Palliative ily advocates, clinicians, leaders, health care
Care, 2009). policy makers, educators, and as research-
Research results indicate that there is ers. education in the legal, moral, and ethi-
an overwhelming need for improved symp- cal principles and decision-making models
tom management at the end of life for both are essential for nurses to have an impact in
adults and children. Patients at the end-of- determining the quality of care offered to
life experience many of the same symptoms individuals at the end of life and empowering

374 n PAReNTING ReSeARCH IN NURSING



patients to take an active role in achieving adults—has received relatively little attention
this outcome. (McBride & Shore, 2001). There has also been
P limited research on the parenting experience
Marianne Matzo of adults with chronic or acute illnesses.
Designs for this body of parenting
research vary and include qualitative stud-
ies, descriptive and correlational designs,
Parenting researCh and interventions with parents. like other
areas of nursing research, commonly used
in nursing data collection methods include qualitative
interviews and self-report questionnaires
of parents and, to a lesser degree, children.
Parenting is as a process that involves a com- In addition, videotaped and direct observa-
plex set of responsibilities, including being tions of interactions of parents with children,
present for the child; caregiving, teaching, primarily infants or preschool children, are
protecting, and encouraging the child; and frequently used (Pridham et al., 2010). These
advocating on behalf of the child. These observations are scored using standard-
responsibilities evolve over time as the child ized assessments such as Kathryn Barnard’s
and parent mature and change in response NCAST scales (currently referred to as
to environmental contexts and any special Parent–Child Interaction Scales) or investiga-
needs of the child. tor-developed ratings or coding scales.
Parenting is a major focus of nursing Parenting during the transition to par-
and an identifiable group of nurse research- enthood has probably received the most
ers who study parents and parenting has attention from nurse researchers (lutz et al.,
emerged (Anderson, Riesch, Pridham, lutz, & 2009; Pridham et al., 2010). Areas of research
Becker, 2010; Beeber & Miles, 2003; Holditch- include maternal identity and competence,
Davis & Black, 2003; lutz, Anderson, Riesch, adjustments to parenting a newborn infant,
Pridham, & Becker, 2009; McBride & Shore, parent–infant interactions, and the effects of
2001; Miles, 2003, 2005; Pridham, lutz, stressors such as older maternal age, infertil-
Anderson, Riesch, & Becker, 2010; Riesch, ity, or a high-risk pregnancy. Fathers are
Anderson, Pridham, lutz, & Becker, 2010; beginning to be studied. Researchers have
Webster-Stratton & Reid, 2010). like parent- also studied the development of the paren-
ing researchers from other disciplines, nurse tal identity during pregnancy, maternal–fetal
researchers agree that parenting plays a crit- attachment, emotional tasks of pregnancy,
ical role in child development. The substan- and postpartum depression.
tive focus of nursing research on parenting A related area of research focuses
is varied and includes parenting during the on parenting high-risk infants, including
transition to parenthood, parenting of high- infants who are premature, technologi-
risk infants, parental responses to children’s cally dependent, prenatally exposed to
acute and chronic illnesses, parenting of substances, multiple births, or tempera-
healthy children and adolescents, and prob- mentally difficult (lutz et al., 2009; Pridham
lematic parenting including parenting chil- et al., 2010). Researchers have explored the
dren with behavioral problems. However, emotional distress and sources of stress of
with the exception of studies on the effects parents during the infant’s neonatal inten-
of parenting infants and children with sive care hospitalization (Holditch-Davis &
health problems on parental health, mental Black, 2003; Miles, 2005). Of particular con-
health, distress, and bereavement, the other cern is the impact of parental distress and
side of parenting—its effects on the lives of parent–infant separation on subsequent

PAReNTING ReSeARCH IN NURSING n 375



parent–child interactions and attachment. adolescent, and young adult child (Riesch
Parental influences on development of et al., 2010). Much of this research has looked
high-risk infants have also been identified at parental perceptions of the child or paren- P
through longitudinal studies. Recently, tal effects on child outcomes, such as obesity
nurse researchers have tested a number of or substance abuse, rather than parenting per
intervention studies for this population, se. However, discipline as an aspect of par-
including support programs in the inten- enting has received attention. This research
sive care unit and home visiting programs has examined the effects of maternal employ-
(Pridham et al., 2010). ment, maternal depression, supports for par-
Another focus of nursing research has enting, and issues involved in parenting by
been on parents of acute and chronically grandparents, parenting after divorce or
ill children (Anderson et al., 2010). Studies during period of partner conflict, parenting
on the experiences of parents of acutely ill during maternal chronic illness, or parent-
children have explored parental emotional ing after the death of a spouse. In addition,
responses, participation in care, and stress nurse researchers have begun to study eth-
during hospitalization (Youngblut, 1998). nic differences in parenting. However, only
Several interventions aimed at reducing very limited research has examined parent-
stress and supporting parenting have been ing with siblings.
conducted. Studies of parents of children Problematic parenting has been another
with chronic illnesses or developmental dis- focus of nursing research. Recently, research-
abilities have focused largely on the impact ers have begun to explore the effect of child
of the child’s diagnosis, stressors associated behavioral and psychiatric conditions, such
with treatments and repeated hospitaliza- as attention deficit disorder, conduct dis-
tions, and parental management of the ill- order, autism spectrum disorder, and schizo-
ness (Miles, 2003). A small but important phrenia, on parents and parenting. Studies
body of descriptive research about parents’ have also examined the impact of maternal
relationships with nurses and other health mental health problems or substance abuse
care providers demonstrates the power- on parenting and parents who are abusive
ful role nurses have in affecting parental to their children. Another important aspect
responses and maintaining the parental role, of problematic parenting has focused on
especially during acute illnesses. Studies of parenting by low-income parents (Beeber &
parents of ill children have largely been lim- Miles, 2003), but the area receiving the most
ited to descriptive, cross-sectional studies attention from nurse researchers has been
done with small convenience samples from adolescent parenting. Although a number
in one institution. Intervention studies are of intervention studies have been conducted
increasingly being tested, but very few lon- to improve parenting in these at-risk groups
gitudinal studies, even within the period of (Kearney, York, & Deatrick, 2000), many of
hospitalization, have been conducted. More the interventions were atheoretical. More
research is needed to explore the influence theoretically based intervention studies
of parenting on health and developmental aimed at improving parenting and remov-
outcomes in ill children and on the nature ing situational or environmental obstacles
of the interaction of health care providers to positive parenting are needed. Two major
and parents and how to strengthen those multidisciplinary teams, with nurses as pri-
interactions. mary investigators, have conducted research
Nurse researchers have also studied par- on designed parenting intervention for high-
enting of normal, healthy children. Preschool risk parenting situations: The Incredible
children have been studied the most, with Years (Webster-Stratton & Reid, 2010) and
less attention to parenting the school-aged, a home visiting program for low-income

376 n PARSe’S HUMANBeCOMING SCHOOl OF THOUGHT



mothers with long-term follow-up of the out- from around the world, there is still a need
comes (Kitzman et al., 2010). for research that examines parenting from
P The theoretical models used as frame- a cultural perspective. Nursing researchers
works for nursing research on parenting are need to go beyond comparing ethnic groups
as diverse as the substantive foci. Researchers and move toward understanding what is
interested in the transition to parenthood effective and adaptive for parents from vary-
often build on the concepts put forth by ing ethnic backgrounds and different cul-
Reva Rubin based on role attainment the- tures. likewise, nurse researchers need to
ory from sociology and adapted by Ramona conduct more longitudinal studies that study
Mercer and lorraine Walker. Another parenting as a process that unfolds over time
commonly used framework is ecological and focus as much attention on parenting
systems theory, influenced by the work of strengths as on parenting deficits.
Uri Bronfenbrenner, Jay Belsky, and Arnold
Sameroff, and based on psychology. Within Diane Holditch-Davis
nursing, Kathryn Barnard’s theory follows in Margaret Shandor Miles
this tradition. Recently, these theories have
been combined into the developmental sci-
ence perspective, which is beginning to be
used in nursing research on parenting (Miles Parse’s humanbeComing
& Holditch-Davis, 2003).
Other theories used in parenting sChool of thought
research by nurses include attachment, cog-
nitive, and stress theories. Attachment the-
ory with has its origins in ethology and is Humanbecoming school of thought (Parse,
influenced by the work of John Bowlby and 1992, 1995) was first titled Man–Living–
Mary Ainsworth. This framework is widely Health: A Theory of Nursing (Parse, 1981). In
used in infancy and preschool parenting 1998, Parse published The Human Becoming
research. Cognitively based theories of par- School of Thought: A Perspective for Nurses and
enting, such as that developed by Karen Other Health Professionals. Also, her theory
Pridham, are used in studies of mothering has evolved into a humanbecoming school of
during the prenatal and postpartum periods. thought (HST) that views the uniqueness of
Finally, models that build on various stress humans as unitary beings in mutual process
and coping models, such as Margaret Miles’ with a multidimensional universe.
Preterm Parental Distress Model, have been Parse (1998) draws from Roger’s Science
used in studies of the impact of acute illness of Unitary Human Beings and the writings
on parents. on existential phenomenology when she
Despite this theoretical diversity, much defines the person as being in a process of
of the nursing research conducted in the continuous becoming within the human-
area of parenting remains atheoretical and becoming school of thought. each person
descriptive. Therefore, the findings in this cocreates reality in mutual process with the
area of research are fragmented, and often environment. Quality of life is a central con-
nurse researchers are not building a coher- cept within the HST. The goal of nursing is
ent science on parenting. The major gaps in quality of life in Parse’s theory, thus demon-
the parenting literature in nursing include a strating the importance of this concept with
need for more information about fathering the theory.
and on parenting of adolescents and young Humanbecoming is viewed as (1) “freely
adults. Although there is an increasing num- choosing personal meaning with situation,
ber of parenting studies published by nurses living with value priorities,” (2) “configuring

PARTICIPANT OBSeRvATION n 377



rhythmical patterns of relating with huma- teaching–learning model is made up of
nuniverse,” and (3) “cotranscending illimit- essences, paradoxes, and processes. The
ably with emerging possibles” (Parse, 1998, essences are semantic coherence, synergistic P
p. 29). each of these assumptions is linked to a patterning, and aesthetic innovating (Parse,
principle about humanbecoming. These three 2004). The paradoxes are rational–intuiting,
principles constitute the theoretical structure. clarifying–obscuring, waring–woofing, ebb-
Principle 1 states, “structuring meaning mul- ing–flowing, considering–composing, and
tidimensionally is cocreating reality through beholding–refining (Parse, 2004). The pro-
the languaging of valuing and imaging” cesses are living with ambiguity, appreciating
(Parse, 1998, p. 35). The major conceptual pro- the mystery, potentiating integrity, weaving
cesses of this principle are imagining, valu- multidimensionally, honoring wisdom, and
ing, and languaging (Parse, 1998). Principle witnessing unfolding (Parse, 2004).
2 is that “co-creating rhythmical patterns of
relating is living the paradoxical unity of Updated by Mary T. Quinn Griffin
revealing-concealing, enabling- limiting, and
connecting- separating” (Parse, 1998, p. 42).
Principle 3 states, “cotranscending with the
possibles is powering unique ways of origi- PartiCiPant observation
nating in the process of transforming” (Parse,
1998, p. 46). The key conceptual processes
for this principle are powering, originat- Participant observation is an approach to
ing, and transforming (Parse, 1998). In 2007, data collection that is most often associated
Parse provided clarification of wording in with naturalistic or qualitative inquiry, and it
the HST. She wished to make clear the notion involves the researcher as a participant in the
of indivisibility by creating homecoming as scene or observation that is being studied.
one word, and humanuniverse as all one word The primary purpose is to gain an insider’s,
(Parse, 2007). She added four postulates, or emic, view of an event, a setting, or a gen-
illimitability, paradox, freedom, and mystery, eral situation. The researcher focuses on the
which are woven into the three principles context of the scene along with the ways that
(Parse, 2007). individuals are behaving. examples might
Parse (2007) has developed a specific include making and participating in obser-
research methodology based on phenomeno- vations in a busy emergency room, observ-
logical hermeneutic methods. It is a qualita- ing the ways in which people carry out rites
tive method that focuses on universal human of passage, or participating in a special feast
experiences described by research partici- or occasion. The researcher attempts to make
pants. There are three phases involved in this sense of the situation by interpreting per-
research, dialogical engagement (researcher- sonal experiences and observations and talk-
participant), extraction synthesis (dwelling ing with individuals who are present, while
with the data), and heuristic interpretation simultaneously being fully involved in all of
(Parse, 2007). The foci of knowledge devel- the experiences that occur in that setting. In
opment for the discipline within this type of this way, participant observation enables the
research are the universal lived experiences researcher to gain a view of a society but also
of individuals, such as hope, joy-sorrow, serves as a way to validate verbal informa-
grieving, and persevering. tion that was provided by members of a soci-
Parse (2004) continues to expand her ety or group being studied. Another way in
theoretical perspectives with the intro- which participant observation may be used
duction of the humanbecoming teaching– in research is with populations in which
learning processes. The human becoming there is limited communication, such as very

378 n PARTICIPANT OBSeRvATION



small children, the mentally impaired, or varies greatly, from full disclosure to no dis-
elderly stroke survivors. The challenge for closure, and is often based on the research-
P the researcher is to combine the activities of er’s estimation of how scientific truth can
observation and participation so that under- best be obtained.
standing is achieved while maintaining an The amount of time the researcher
objective distance. spends in observation and the scope or focus
To carry out participant observation, of the observation also depend on the pur-
the researcher needs to decide on (a) the pose and intent of the research. In some cases,
role of the observer, (b) the degree to which the participant observation experiences are
the role is known to others, (c) the degree carried out for the length and duration of
to which the purpose is known to others, the research. In other research studies, par-
(d) the amount of time that will be spent in ticipant observation may occur at only one
conducting the observation, and (e) the scope point during the study. For example, some-
of the observational focus. There is a contin- times a researcher may choose to enter the
uum along which the role of the observer field and become a participant observer
may be involved that ranges from involve- prior to conducting interviews. This gives
ment of the researcher in all aspects of the the researcher time to learn about a commu-
observational experience to only partial or nity, group of people, or situation and then to
minimal involvement. The researcher bases use this knowledge to develop questions for
this determination on the research question subsequent interviews. In addition, the focus
and the nature of the research. For example, and intent of the observations may vary from
a researcher who assists in a homeless shelter making general observations of the entire
may wish to be involved in all aspects of the situation, context, or event to very focused
daily routine; another researcher may wish observations. For example, a focused obser-
only to conduct observations in a busy emer- vation might include personal interactions or
gency room for which the routine is more a specific nursing or caring behavior.
complex. On the other hand, an invitation One major concern in using participant
to participate in a special ceremony or ritual observation is the degree to which subjects
may involve only partial participation. may become sensitized to the researcher’s
The degree to which the observer’s presence and may not behave as they nor-
role and the purpose of the observation are mally would if the researcher were not pre-
known to others also is related to the intent sent. The issue of subject sensitization can be
of the research. In some cases, the role of the addressed by increasing the duration of time
researcher will be known to all, and in others the researcher spends in the observational
it may not. If the purpose of the study is to experience. A longer time spent in observing
know and understand a particular ritual or can also enhance and strengthen the research-
religious ceremony, for example, the role of er’s credibility as well as any theoretical and
the researcher may be known to all involved empirical generalizations that are made.
in the situation. In other cases, the role of the In summary, participant observation is
researcher may be minimized, as in situa- a commonly used approach to data collec-
tions in which the informants may not fully tion that is used in naturalistic or qualitative
understand the researcher’s participation: research. It is an approach that allows the
observing children on a playground or in a researcher to gain an insider’s perspective
children’s unit in a hospital. However, ethical on a social situation or event and can per-
and moral issues arise when the nature and mit the researcher to be totally or minimally
role of the researcher are not made known involved.
to all of the individuals being observed. The
extent to which individuals are informed Kathleen Huttlinger

PATIeNT CARe DelIveRY MODelS n 379



hierarchical structure of the Nightingale
Patient Care Delivery model. Within this context, each team is
composed of a mix of RNs, licensed practical P
moDels nurses (lPNs), and certified nursing assis-
tants (aides) responsible for a single group
of patients. The number of teams on a given
It could be stated without argument that the patient unit is obviously determined by the
first nursing care delivery model was initi- size of the unit. The onset of the advanced
ated by Florence Nightingale (c. 1859) during practice nurse, such as the clinical nurse spe-
the Crimean War. It was Nightingale who cialist and/or the nurse practitioner, has had
differentiated between the “head” nurse (she a major impact on professional practice in
who did the thinking, planning, and direct- the organizational setting, while giving
ing of patient care) and the “floor” nurse, new meaning to the concept of team nurs-
who in essence was the provider of that ing. Although the nurse practitioner is gen-
care (Nightingale, 1859). Thus, a hierarchi- erally thought of as providing primary care
cal model for the delivery of patient care that to a group of clients outside the hospital set-
prevailed for nearly a century in english and ting, many are employed within hospital-
American health care facilities was born. operated ambulatory care setting or within
In the early years following the turn of the hospital itself, many times providing
the twentieth century, professional nursing the initial physical assessments of patients
was dominated by private-duty nurses who required by regulating agencies such as the
were employed through a “registry.” These State Health Department and the Centers for
nurses cared for a single patient in the home Medicare and Medicaid Services. Primarily
or in the hospital (before the introduction of prepared at the Master’s level, these nurses
intensive care units). Oftentimes, the director in advanced practice roles serve as consul-
of the nursing school also was the director tants to the nursing staff; they fill roles such
of nursing in the hospital; nursing “pupils” as staff educator, researcher, administrator/
provided the care of patients “on the wards,” manager, and, in many instances, as master
and nursing faculty provided the supervision clinician.
of these students in their clinical rotations. Primary nursing in its truest form assigns
After the stock market crash of 1929, when a “caseload” to the professional nurse, who is
families could no longer afford private duty then responsible for each of his or her patients
nurses, hospitals began to staff the wards “around the clock,” as it were. It is the respon-
with graduate nurses (new graduates not yet sibility of the primary nurse to make clinical
licensed) utilizing the original Nightingale rounds and to prescribe appropriate nursing
hierarchical model. interventions depending on client diagno-
In an effort to recruit and retain profes- sis. In the case of a hospital admission, the
sional nurses, little by little, models such as primary nurse maintains responsibility for
team and primary nursing as well as all RN the client(s) from admission to discharge;
staffs began to evolve in health care settings in a community health or long-term care, or
and advanced practice roles such as the clinical home care setting, it is possible that the pri-
nurse specialist and the nurse practitioner— mary nurse maintains responsibility for the
which had an impact on the effective deliv- client over an extended period of time.
ery of clinical nursing services, regardless of An all RN staff is expensive but self-
the setting. These models were popular in explanatory. Within this model, professional
the second half of the twentieth century. nurses provide all dimensions of direct
Team nursing is undoubtedly one of patient care whereas ancillary personnel
the earliest models designed to replace the are responsible for those tasks not involved

380 n PATIeNT CONTRACTING



in direct patient care. With the tightening Theory on Human Caring. Other models in
of fiscal belts, cutbacks in Medicare and the acute care arena have elevated the regis-
P Medicaid reimbursement, organizational tered nurses role to a care coordinator over-
mergers, changes in organizational philoso- seeing the patient care of several patients
phy, and the like, except for limited instances whose direct care is being provided by nov-
one might conclude that the all RN staff has ice nurses, lPNs, or nursing assistants. A
largely become a phenomenon of the past. new role has been created from these models
In 2007, the Robert Wood Johnson of care coordinator called the clinical nurse
Foundation funded an original research leader who is a master’s prepared nurse who
project to identify and profile new mod- leads teams of caregivers. examples of the
els of care that could be widely replicated care coordinator models include the patient-
throughout the United States. In collabora- centered care, the primary care coordinator,
tion with Health Workforce Solutions llC the unit-based case manager model, and
and through a broad-based e-mail inquiry, the 12-bed hospital developed at the Baptist
a literature search, and Internet research, 60 Hospital of Miami.
new care delivery models were selected for The care transitions models are designed
in-depth research interviews. to bridge the continuum of care between
The group was narrowed through a acute care and home or outpatient services.
process of comparing the models to criteria This is a model that will meet the needs of
developed by a select group of chief nurs- the new health care reform initiatives. even
ing officers and executives, nurse manag- more critical to future health care models will
ers, and academics from a variety of nursing be the comprehensive care models developed
schools. Twenty-four models were further to focus on people lives from prevention
investigated and selected to be included in and wellness through the entire continuum
a white paper titled Innovative Care Delivery including social programs.
Models: Identifying New Models that Effectively To learn more about each of these mod-
Leverage Nurses, published in 2008 by the els, go to www.innovativecaremodels.com.
Health Works Solutions group. At the same
time, the Robert Woods Johnson Foundation M. Janice Nelson
created a Web site that contains the complete Connie A. Jastremski
profiles of each model described, including
a detailed description, impetus for its devel-
opment, results, consideration for implemen-
tation, and replication and selected tools Patient ContraCting
(http://www.innovativecaremodels.com).
The models are divided into three cate-
gories: acute care models, models that bridge Patient contracting is an intervention for
the continuum of care, and comprehensive promoting patient adherence in practice or
care models. Within the acute care models, research settings. Patient contracting pro-
there are components of earlier care deliv- vides an opportunity for patients to learn
ery models with a more comprehensive role to analyze their behavior relative to their
for the professional nurse. Some incorpo- environment and to select behavioral strate-
rate team nursing (medical–surgical unit gies that will promote learning, changing, or
team nursing, which is an RN–lPN team maintaining adherence behaviors (Boehm,
model; the model RN line model). The nurs- 1992). Patient contracting is relevant to nurs-
ing caring delivery model is a team-oriented ing practice and research because it can assist
primary nursing model for providing inpa- patients to adhere to treatment regimens,
tient and outpatient care based on Watson’s such as medication taking, meal planning,

PATIeNT CONTRACTING n 381



physical activity, and monitoring airflow and patient chooses the behavior and reinforcer
blood glucose levels. in the contract with direction by the nurse.
Research on the effectiveness of patient Patient contracting is based on the principle P
contracting in nursing has been reported for of positive reinforcement, which states that
a variety of behaviors across age groups, set- when a behavior is followed by a reinforc-
tings, and disorders. For example, patient ing consequence, there is an increased likeli-
contracting has been used to control levels of hood of the behavior being performed again
serum potassium (Steckel, 1974) and serum (Boehm, 1992).
phosphorus (laidlaw, Beeken, Whitney, & The nursing process provides the context
Reyes, 1999) in patients on dialysis, to pro- within which to develop the patient contract.
mote adherence to daily peak expiratory The nursing process provides the clinical
flow monitoring in children with asthma data that can be jointly used by nurses and
from pediatric practices (Burkhart, Rayens, patients to establish priorities for adherence
Oakley, Abshire, & Zhang, 2007), to pro- behaviors (Steckel, 1982). The adherence
mote adherence to self-monitoring of blood behavior is the ultimate complex behavior to
glucose in adolescents with diabetes treated be learned or changed. The adherence behav-
at a children’s hospital clinic (Wysocki, ior is broken down into successive approxi-
Green, & Huxtable, 1989), to achieve rehabil- mations or small steps. By performing small
itation goals in adolescents with tetraplegia steps of the behavior, the patient gradu-
who received multidisciplinary care in an ally achieves performance of the adherence
inpatient rehabilitation unit (Gorski, Slifer, behavior. Over a series of patient contracts,
Townsend, Kelly-Suttka, & Amari, 2005), the patient will specify a variety of behav-
to increase knowledge and consistency in iors, which include such behavioral strategies
use of contraceptive methods by sexually as self-monitoring, arranging and rearrang-
active college women from a student gyne- ing antecedent events, practicing small steps
cology clinic (van Dover, 1986), to improve of the adherence behavior, and arranging
self-foot-care behaviors and reduce serious positive consequences (Boehm, 1992). The
foot lesions in patients with type 2 diabetes first several patient contracts are usually for
in primary care (litzelman et al., 1993), to self-monitoring to identify the successive
increase knowledge, keep appointments, and approximations of the adherence behav-
reduce diastolic blood pressure in hyperten- ior and the antecedents and consequences
sive outpatients (Steckel & Swain, 1977; Swain of the behavior. In later patient contracts,
& Steckel, 1981), to and keep appointments, patients specify behavioral strategies related
lose weight, and reduce blood pressure to arranging antecedent events, practicing a
among outpatients with arthritis, diabetes, small step of the behavior, or arranging pos-
and hypertension (Steckel & Funnell, 1981). itive consequences. Self-monitoring is ongo-
Patient contracting did not reduce blood glu- ing throughout the behavior change process
cose and glycosylated hemoglobin in patients to provide data about the performance of the
with diabetes (Boehm, Schlenk, Raleigh, & small steps of the behavior and the effec-
Ronis, 1993; Morgan & littell, 1988; Steckel & tiveness of the new antecedents and positive
Funnell, 1981; Wysocki et al., 1989). consequences.
Patient contracting is the process in which The reinforcer in the contract is chosen
the nurse and the patient negotiate an indi- by the patient and provided by the nurse in
vidualized, written, and signed agreement return for evidence that the behavior was
that clearly specifies the behavior and identi- successfully performed, such as the self-
fies in advance the positive consequences to monitoring records. Reinforcers are unique
be given when the patient has successfully to patients. The availability of reinforcers
performed the behavior (Steckel, 1982). The varies greatly by the practice or research

382 n PATIeNT CONTRACTING



setting. For example, patients may request setting out athletic shoes at night may cue
more convenient appointments, magazines, walking the next morning.
P lottery tickets, etc. Tokens or points can be Behavioral analysis can identify the
collected and exchanged for a larger rein- multiple small steps that comprise the adher-
forcer (Boehm, 1992). ence behavior. When the small steps are
Behavioral analysis is the foundation identified, the behavioral strategy is to per-
of the patient contracting intervention. form a small step of the adherence behavior
Behavioral analysis is the process by which for a designated period of time. When that
the patient’s behavior is observed, recorded, small step is being successfully performed,
and analyzed to describe the successive the patient moves onto the next small step.
approximations of the adherence behav- eventually, patients gradually achieve per-
ior, the antecedent events that precede the formance of the adherence behavior (Steckel,
behavior, and the consequences that follow 1982). This behavioral strategy is effective
the behavior. The behavioral data used in the because patients are often overwhelmed by
analysis are obtained by the patient through expectations of a treatment regimen, which
self-monitoring (Boehm, 1992). can lead to nonadherence. For example, sed-
Behavioral analysis begins with the entary patients who are beginning a walking
patient self-monitoring the adherence behav- program might start by walking 5 minutes
ior. Increasing self-monitoring is done using five times per week. each week the walking
Smartphones or Internet Web sites. Self- goal is gradually increased until they achieve
monitoring provides baseline data that can their goal of accumulating 30 minutes of
be used to determine the effectiveness of the moderate intensity walking 5 days per week.
behavioral strategies implemented later in Positive reinforcement is the behavioral
the behavior change process. By using the strategy in which a positive consequence is
patient’s self-monitoring records, the nurse provided contingent upon performance of
can teach the patient to identify anteced- the desired behavior, which results in an
ent events that precede the behavior, small increase in performance of the behavior.
steps that comprise the behavior, and con- Behavioral analysis can identify positive
sequences that follow the behavior. On the consequences for behaviors and provide
basis of the behavioral analysis, behavioral ideas for new consequences (Boehm, 1992).
strategies are specified that will assist in the The behavioral strategy is to arrange posi-
behavior change. tive reinforcement to acquire or maintain a
An antecedent event precedes a behav- desired behavior. For example, adopting a
ior and prompts the behavior by identifying walking program will be strengthened if a
conditions under which a behavior will be positive consequence follows each walking
reinforced or not (Boehm, 1992). Much behav- goal that is met. Positive consequences can
ior is under the control of antecedent events. be pleasurable items and activities; social
When behavioral analysis demonstrates that reinforcement, such as praise; and cogni-
the behavior the patient chooses to decrease tive reinforcement, such as feelings of pride.
or eliminate is cued by an antecedent event, Conversely, eliminating positive reinforce-
the behavioral strategy is to rearrange, to ment can be used to decrease or extinguish
avoid, or to eliminate the antecedent event. an undesired behavior. For example, eating
For example, the patient may take a different with selected companions may eliminate
route home to avoid stopping at a fast food positive consequences for inappropriate food
restaurant after work. Conversely, when the item selections.
patient chooses to increase a behavior, the There are several directions for future
behavioral strategy is to arrange an anteced- research. First, the feasibility and cost-
ent event to cue the behavior. For example, effectiveness of changing single versus

PATIeNT eDUCATION n 383



multiple adherence behaviors by patient con- education and education in healthy lifestyle
tracting needs further study. Second, studies behaviors.
are needed to determine the frequency of con- Historically, patient education in the P
tact needed with subjects to produce progres- United States dates back to the mid-1800s with
sive changes in adherence interventions using some physicians willing to share information
patient contracting. Third, patient contracting regarding disease management and some
during the maintenance phase of adherence guarding this information to prevent ques-
interventions has not been studied. Fourth, tioning of treatment modalities by patients
whenever possible, studies should include (Bartlett, 1986). On the contrary, in europe
objective measures of adherence behaviors, during the mid-1800s, Florence Nightingale
such as electronic event monitors to assess (1859) was providing education to patients
medication adherence and accelerometers or as well as other nurses regarding hygiene,
pedometers to assess physical activity. nutrition, and aspects of health promotion.
Patient education has since evolved from this
Elizabeth A. Schlenk narrow focus to empowering patients to take
a lead in their health care and to changing
health policy to mandate that clinicians in
health care organizations provide and docu-
Patient eDuCation ment proof of adequate patient education in
self-management to receive reimbursement.
Private accreditation organizations, such
Patient education is a process of providing as The Joint Commission (2010), issue stan-
individuals and their families with health dards for patient disease self-management
information related to their medical con- education, and Federal agencies, such as
ditions or procedures, treatment options, the Centers for Medicare and Medicaid, tie
lifestyle behaviors, and health promotion reimbursement to and display the results of
(Centers for Disease Control and Prevention, patient education quality indicators by hos-
n.d.). This information is provided in a variety pital on a public Web site called “Hospital
of ways, including more traditional formats Compare” (U.S. Department of Health and
such as verbal instruction, demonstration Human Services, 2010). This health care pol-
and return-demonstration procedures, and icy attaches an economic incentive to hospi-
written materials, and more recently in elec- tals to provide for these quality controls, and
tronic formats through video, Internet, DvDs it encourages the public to choose hospitals
and CD-ROMs. Nurses are in a key role to with the best quality indicators.
provide health and disease self-management Patient education and self-care have
education to improve outcomes and quality theoretical underpinnings in the works of
of life for the patient, his or her family, and Henderson, Peplau, and Orem. According to
more globally, for the community at large to Henderson (1991), the nurse meets the needs
promote healthy lifestyles. The modern health of the patient during periods of dependency;
care environment has become increasingly however, the nurse must also identify the
complex and more challenging for patients learning needs of the patient and supply ade-
to navigate and understand medical termi- quate knowledge based on that assessment to
nology, technology, and care instructions enable the patient to take over his own care
(Sand-Jecklin, Murray, Summers, & Watson, and return to independence. Similarly, in
2010). As patient advocates, nurses are in the Peplau’s theory of interpersonal relations, the
position to assess patients’ current knowl- nurse is identified in the nurse–patient rela-
edge, learning needs, and readiness to learn tionship as a resource person, teacher, and
to provide effective disease self-management counselor to facilitate patient learning and

384 n PATIeNT eDUCATION



promote experiences leading to health promo- support and education to transition patients
tion (Reed, 2005). Central to Orem’s self-care to independence would fit. Other patient
P framework are nursing systems designed to education research aims to reduce hospital
assist the individual to continue to provide recidivism in chronic disease. In one study,
his or her own self care or care of dependent discharge nurses hired as part of the study
family members, thus reducing the length of worked with patients throughout their hospi-
time the individual requires health care ser- tal stay to coordinate appointments and post
vices (Fawcett, 2000). In all three of these the- discharge diagnostic testing, provide educa-
oretical works, patient education is central tion related to medications and medication
to patient self-management and health pro- reconciliation, and conduct patient education
moting behaviors. In contemporary nursing with written materials. In addition, a phar-
care, clinical or critical pathways that include macist made telephone calls to the patients
components of patient education assist in after discharge to reinforce medication edu-
mapping the education plan to progress the cation and the discharge plan, with a sub-
patient along the trajectory from illness to sequent reduction of 30% rehospitalization
wellness and return to the highest level of rate within 30 days of discharge for the study
independence possible. participants (Jack et al., 2009). Although this
Research aimed at the effects of patient study demonstrated a reduction in rehospi-
education has supported beneficial effects talization, it included an elaborate education
in many studies, particularly in chronic plan that may prove to be complicated and
disease self-management. In a systematic challenging to continue long range because
review of 35 meta-analyses, comprising 598 of limited staff time and patient census.
studies and approximately 61,000 patients Health literacy in patient education
for chronic conditions including diabetes, is an emerging topic of research. There is
asthma, COPD, hypertension, obesity, rheu- a strong correlation between literacy lev-
matology, and oncology, the majority of the els and patient knowledge of disease self-
studies, or 64%, demonstrated improvement management (Horner, Surratt, & Juliusson,
of patient outcomes because of therapeutic 2000). Complex written patient care instruc-
patient education (lagger, Pataky, & Golay, tions and medication schedules are difficult
2010). Another meta-analysis for chronic dis- for patients to comprehend. In addition, cli-
ease self-management programs for older nicians who provide verbal patient education
adults supported a beneficial effect on some using medical jargon may not be successful
physiologic outcomes, such as blood glucose in providing quality education to patients.
control and blood pressure reduction in dia- In this situation, patients may be too embar-
betes and hypertension; however, there was rassed to disclose that they do not under-
no evidence to support a beneficial effect stand the written or verbal instruction and
on weight loss among diabetic patients or thus be unable to comply with their treat-
improved physiologic functioning among ment regime. As health care and technology
patients with arthritis (Chodosh et al., 2005). used to treat patients become more complex,
In another study, the combination of qual- a future challenge will be conveying health
ity nursing care in a bariatric surgery prac- care information to patients in a manner that
tice along with effective patient education is easily understood by the layperson.
supported positive patient outcomes during There are many future opportunities and
the postoperative period for self-care, recov- challenges in providing patient education in
ery, and successful weight loss (Grindel & different formats to address varying learn-
Grindel, 2006). Although this study does not ing styles. An evolving method for patient
name a theoretical model, Henderson’s the- education delivery is interactive Web-based
ory of nursing in the provision of adequate education programs aimed at providing

PATIeNT SAFeTY n 385



plain language instructions easily under- patient education information. Return dem-
stood by many populations. In addition, onstrations for procedures reinforce immedi-
these programs are often provided in vari- ate learning, assessing health literacy needs P
ous languages to address the ethnic mix of will determine whether written instructions
different populations. Web-based programs are appropriate, and a mix of verbal teaching,
provide a unique opportunity to allow for illustrations, and multimedia may further
just-in-time training for informed consent engage the patient and his or her caregiver.
before procedures, symptom management The nurse as patient educator is a critical role
and instructions for care after discharge that extends beyond the walls of an institu-
during hospital stays, and the availability to tion to the outside community and to advo-
retrieve the education programs for review cate for health policy that will improve the
at home for patients who have home com- care environment.
puters. With technology advances, this may
spread to other electronic formats such as Alyson Blanck
MP3 players and cell phones, allowing for
more flexibility in the delivery of patient
education for disease management as well
as health promotion topics for the general Patient safety
population. The Internet allows for more
access to health-related information, afford-
ing individuals the ability to easily research It has been more than a decade since the
symptoms and disease information before Institute of Medicine’s (IOM) seminal report,
seeking medical attention. The benefits when To Err Is Human, which spotlighted the prob-
used appropriately may yield a more edu- lem of patient safety and reported that tens
cated patient who may validate symptoms of thousands of Americans die each year as a
and seek medical attention. The challenge result of human error in the delivery of health
lies in Internet sites that may contain false care (IOM, 2000). In subsequent IOM reports,
or misleading information, which either pro- it was noted that care should be (1) safe, (2)
vide wrong or potentially harmful informa- effective, (3) patient centered, (4) timely,
tion or solicit money for “miracle” products (5) efficient, and (6) equitable (IOM, 2001).
that may not be approved by the FDA, may Additionally, the IOM noted that nursing is
not produce the advertised outcome, or may inseparably linked to patient safety, empha-
even be harmful. sizing that poor working conditions for
Patient education is paramount in assist- nurses and inadequate nurse staffing levels
ing patients to make informed decisions threaten patient safety and increase the risk
regarding their care, to establish healthy of error (IOM, 2004). However, despite some
lifestyle behaviors, and to learn disease impressive results by groups such as the
self- management during times of illness. Institute for Healthcare Improvement, patient
Depending on the learning style of the indi- safety remains a grave concern today.
vidual, there are various ways to provide Despite the slow pace of improvement,
patient education through verbal, writ- some of the lessons we have learned are
ten, illustrative, and multimedia venues to incredibly powerful. The first is the con-
enhance learning. With both health liter- cept of latent errors, which are defects in
acy and diverse ethnic mixes in population, the design and organization of the system.
careful attention is required to deliver infor- Furthermore, to improve patient safety, we
mation in a form that is easily understood. need to design systems that prevent adverse
In addition, it is paramount to determine outcomes resulting from errors and near
the level of understanding after providing misses. The implication is that we need to

386 n PATIeNT SAFeTY



standardize and simplify work systems and In a seminal study on leadership, trans-
improve communication to eliminate errors actional leaders were differentiated from the
P and near misses. more potent transformational leaders (Burns,
There has been much research, and 1978). Transactional leadership typifies most
experts at the National Quality Forum (2004) leader–follower relationships; it involves
reviewed the evidence and identified 30 a “you scratch my back, I’ll scratch yours”

evidence-based safe practices that all hos- exchange. In contrast, transformational lead-
pitals should follow (such as unit dosing, ership occurs when leaders engage with their

wrong-site protocols, deep venous thrombo- followers in jointly held goals. This leader-

sis prophylaxis). Implementing them seems ship approach is recommended because it

easy, but it is not. This has led to increased transforms all workers—both managers and

interest in evidence-based practice and dis- staff—in the pursuit of the higher collective
semination and implementation science. The purpose of patient safety and quality care.
latter refers investigating how best to trans- There is increasing consensus that the orga-
late what we know into everyday practices. nizational culture impacts patient safety and
Health care leaders and managers must the quality of care (Gershon, Stone, Bakken, &
strive to create nursing work environments larson, 2004). Important aspects of safety
that promote patient safety through use of evi- cultures include communication, nonhierar-
dence-based management strategies (Sackett, chical decision making, constrained improvi-
Rosenberg, Gray, Haynes, & Richardson, 1996). sation, training, and rewards and incentives
Most clinicians are now exposed to the idea of (Committee on the Work environment for
evidence-based practice, defined as the con- Nurses and Patient Safety, 2004).
scientious, explicit, and judicious integration For more than a decade, research has
of current best evidence to inform clinical documented a strong association between
deci sion making, in their educational cur- lower staffing levels and greater occurrence
ricula. Yet, use of evidence-based practice by of adverse events. Inadequate nurse staff-
nurses in their daily clinical practice is lim- ing has been associated with medication
ited (estabrooks, 1998; Forsman, Rudman, errors (Blegen & vaughn, 1998), patient falls
Gustavsson, ehrenberg, & Wallin, 2010; (Blegen & vaughn, 1998; Krauss et al., 2005;
Kovner, Brewer, Yingrengreung, & Fairchild, Unruh, 2003), spread of infection (Fridkin,

2010) and reflects the gap between research, Pear, Williamson, Galgiani, & Jarvis, 1996;
clinical practice, and quality improvement. Kovner, Jones, Zhan, Gergen, & Basu, 2002;
Organizational barriers such as lack of time Stone, Pogorzelska, Kunches, & Hirschhorn,
and lack of autonomy are viewed as the main 2008), increased mortality (Aiken, Clarke,

barriers to evidence-based nursing prac- Sloane, Sochalski, & Silber, 2002; estabrooks,
tice (Brown, Wickline, ecoff, & Glaser, 2009). Midodzi, Cummings, Ricker, & Giovannetti,
evidence-based management implies that 2005), and failure to rescue (Aiken et al., 2002;
managers, like clinical practitioners, search Needleman, Buerhaus, Mattke, Stewart, &
for, critically appraise, and apply empirical Zelevinsky, 2002). A meta-analysis of 28 stud-
evidence from management research in their ies (Kane, Shamliyan, Mueller, Duval, & Wilt,
practice. In doing so, managers send a clear 2007) that examined registered nurse (RN)
message that research and practice are strongly staffing and patient outcomes link found
connected and can structure work environ- significant association between RN staffing
ments that promote staff confidence and and lower odds of acute-care hospital-related
skill for incorporation of an evidence-based mortality and adverse events, including hos-
approach as the standard for nursing clinical pital acquired pneumonia, unplanned extu-
practice (Barnsteiner, Reeder, Palma, Preston, bation, respiratory failure, and cardiac arrest.
& Walton, 2010; Staffileno & Carlson, 2010). On the basis of the studies included in the

PATIeNT SATISFACTION n 387



meta-analysis, patient and hospital charac- data, information, knowledge, and wisdom
teristics, including hospitals’ commitment in nursing practice is critical in helping
to the quality of care, are likely contributors design better work environments. Nursing P
to the causal mechanism of the relationship informatics research and practice is needed
between RN staffing and patient outcomes. for efforts aimed at promoting patient safety
A line of research with a broader focus in health care organizations. To this end,
than staffing levels is the investigations nursing informatics researchers and practi-
involving Magnet hospitals (i.e., hospitals tioners can play an important role in improv-
that attract nurses, hence the term Magnet). ing access to information (Currie et al., 2003;
When Magnet hospitals were matched with Newhouse, 2006), developing automated sur-
control hospitals, controlling for case mix, veillance for real-time error detection and
Aiken, Smith, and lake (1994) observed a prevention (McCartney, 2006; Weir, Hoffman,
Medicare mortality rate that was lower by 4.6 Nebeker, & Hurdle, 2005), facilitating com-
per 1,000 discharges (95% confidence inter- munication among members of the health
val, 0.9–9.4). However, besides the attainment care team (Kuziemsky et al., 2009), and devel-
of Magnet status, specifics were not identi- oping clinical decision support (Anderson &
fied. Magnet hospitals are known for higher Willson, 2008; Bakken, Cimino, & Hripcsak,
nurse-to-patient ratios, lower staff turnover 2004). Although the components of an infor-
rates, and higher rates of nursing satisfaction. matics infrastructure are widely available to
More recently, investigators found that nurses develop informatics applications that pro-
working in Magnet hospitals were signifi- mote patient safety, today only 1.5% of U.S.
cantly less likely to report jobs that included hospitals have a “comprehensive electronic-
mandatory overtime (Trinkoff et al., 2010). records system” (Jha et al., 2009).
Furthermore, other researchers have found Organizational and individual commit-
the use of overtime to be adversely related to ment to improving patient safety requires
patient safety (Stone et al., 2007). effective leadership and proactive interven-
Nurses are in the position of being “at tions. Patient safety improvements need
the sharp end” of health care interventions to draw from qualitative and quantitative
by being the patient’s advocate, providing research describing work processes and
care that may result in an error, or witness- responsibilities, methods to improve perfor-
ing the error(s) of other clinicians. Accidents, mance respecting human limitations, and
errors, and adverse outcomes result from a designs of patient safety supportive commu-
chain of events involving human decisions nication and team approaches to health care
and actions associated with active failures delivery.
and latent failures. Many of these failures are
associated with individual performance that Patricia W. Stone
is impaired by stress, distractions/interrup- Arlene Smaldone
tions, and fatigue. Robert Lucero
Information technology was identi-
fied by the IOM Committee on Quality of
Health Care in America as critical in design-
ing a health system that produces care that Patient satisfaCtion
is safe, effective, patient centered, timely,
efficient, and equitable (IOM, 2001). Nursing
informatics defined by the American Nurses Patient satisfaction is a compelling topic in
Association (2008) as the integration of nurs- the current health care environment when
ing science, computer science, and informa- cost, financial viability of organizations,
tion science to manage and communicate quality, and empowerment of consumers are

388 n PATIeNT SATISFACTION



major considerations. Patient satisfaction is patients 27 questions about their recent hos-
defined as the degree to which the patient’s pital stay 48 hours to 6 weeks after discharge.
P desired goals and expectations are achieved The survey contains 18 core questions and
(Fitzpatrick and Hopkins, 1983; Mahon, eight aspects of the patients’ hospital experi-
1996). eriksen (1995) defined patient satisfac- ences such as communication with doctors,
tion with nursing care as “the patient’s sub- communication with nurses, responsiveness
jective evaluation of the cognitive-emotional of hospital staff, pain management, commu-
response that results from the interaction nication about medicines, discharge informa-
between the patient’s expectations of nursing tion, cleanliness of the hospital environment,
care and their perception of the actual nurse and quietness of the hospital environment.
behaviors/characteristics” (p. 71). Studies The survey also includes four screener ques-
indicate that nursing care is a key determi- tions and five demographic items, which are
nant in overall patient satisfaction in the used for adjusting the mix of patients across
hospital setting (Abramowitz, Cote, & Berry, hospitals and for analytical purposes. The
1987; Beck & larrabee, 1996; Greeneich, 1993; survey can be administered by mail, tele-
Jacox, Bausell, & Mahrenholz, 1997). phone, mail with telephone follow-up, or
Donabedian (1988) proposed a frame- active interactive voice recognition. Hospitals
work in evaluating the quality of health care. can use the HCAHPS survey alone or include
The quality of health care is viewed from additional questions to the core HCAHPS
the perspectives of structure, process, and items. Hospitals are required to survey
outcome. Patient satisfaction is considered patients monthly (HCAHPS, 2010).
an important quality indicator (Wagner & The American Nurses Association imple-
Bear, 2009) and outcome of care (Press, 2006; mented the Nursing Care Report Card for
Woodring et al., 2004). Acute Care that includes nursing-sensitive
The importance of patient satisfaction quality indicators such as patient satisfac-
as a quality indicator has been mandated by tion with overall care, nursing care, educa-
regulatory and accreditation bodies in nurs- tion, and pain management (Moore, lynn,
ing and in health care. Health care organiza- McMillen, & evans, 1999; Woodring et al.,
tions such as the Joint Commission and the 2004). The Magnet Recognition Program iden-
National Committee on Quality Assurance tified 14 forces of magnetism over 5 years ago,
require measurement and monitoring of which focused more on structure and pro-
patient satisfaction (Joint Commission, 2010). cess (American Nurses Credentialing Center,
The Patient Protection and Affordable Care 2008). In 2007, a new model focusing on out-
Act of 2010 have provisions to ensure the comes was developed. In the new model, four
delivery of quality care, quality measure- categories were identified. These categories
ment, data collection, and public reporting. It were patient outcomes, empirical quality
includes the Hospital Consumer Assessment outcomes, nurse organization, and consumer
of Healthcare Providers and Systems outcomes. Patient overall satisfaction and
(HCAHPS, 2010) among the measures to be patient satisfaction with nursing care, edu-
used to calculate value-based incentive pay- cational information, and pain management
ments beginning October 2012. were patient outcome indicators (American
The HCAHPS survey developed and Nurses Credentialing Center, 2008).
tested by the Centers for Medicare and Research on patient satisfaction with
Medicaid Services in partnership with the nursing care included the development of
Agency for Healthcare Research and Quality patient satisfaction models and the develop-
is the first national, standardized, publicly ment, refinement, and use of patient satisfac-
reported survey of the patients’ perspectives tion instruments. Few studies were done on
of hospital care. The HCAHPS survey asks patient satisfaction before the 1970s. Abdellah

PATIeNT SATISFACTION n 389



and levine (1957) interviewed patients to namely, technical/professional, educational
identify satisfying and unsatisfying events relationship, and trusting relationship. The
during hospitalization. An instrument was PSS served as a basis for the development P
developed on the basis of these patient- of other instruments (Hinshaw & Atwood,
identified events. Seven dimensions were 1982; la Monica, Oberst, Madea, & Wolf, 1986;
identified, indicating satisfaction with care, Munro, Jacobsen, & Brooten, 1994).
rest and relaxation, dietary needs, elimina- Patient satisfaction instruments were
tion, personal hygiene and supportive care, developed or refined to make the instru-
reaction to therapy, and contact with nurses. ment less cumbersome, to measure a spe-
Tagliacozzo (1965) found that patients were cific nursing behavior, to measure patient
sensitive to the personality and attitudes satisfaction in a specific setting or language,
inferred from nurse behavior. Ware, Davies- and to measure patient satisfaction to dif-
Avery, and Stewart (1978) reviewed 111 stud- ferent health care providers. larson and
ies over a 25-year period. They developed a Ferketich (1993) developed the CARe/SAT,
taxonomy of patient satisfaction that initially a 29-item instrument that measures patient
included the art of care, technical quality satisfaction with regard to nurses’ caring
of care, accessibility/convenience, finances, behavior. Marsh (2003) compared patient
physical environment, availability, efficacy, satisfaction with health care providers from
and continuity. After years of further study, different disciplines working in the same
these dimensions were refined to six dimen- clinical setting using the Patient Satisfaction
sions. These dimensions are nursing and with Health Care Provider Scale. eriksen
daily care, hospital environment and ancil- (2003) revised the Patient Satisfaction with
lary staff, medical care, information, admis- Nursing Care instrument into the Revised
sions, and discharge and billing (Ware & Patient Satisfaction with Nursing Care. The
Berwick, 1990). purpose of the revision was to develop a reli-
More patient satisfaction studies were able and valid measure that was simpler to
done with the advent of the quality and out- use. eriksen and Witter (2003) translated the
comes movement in the 1980s and the 1990s. Revised Patient Satisfaction with Nursing
However, few models of patient satisfaction Care instrument in Spanish in response to
were developed. linder-Pelz (1982) devel- answers written in Spanish in the english
oped a model of patient satisfaction which version of the instrument and the rising
postulated that patient’s expectations of care, number of Hispanics living in the United
health care values, sense of entitlement, and States. Measurement of patient satisfac-
interpersonal comparisons of care were ante- tion was generally limited to english liter-
cedents of positive evaluations of care. When ate participants. Appropriately, Centers for
tested, only 8% of the variance in patient Medicare and Medicaid Services proactively
satisfaction was explained. Greeneich (1993) developed the HCAHPS survey in english,
proposed a model describing characteristics Spanish, Chinese, Russian, and vietnamese
of the nurse, patient, and organization that (HCAHPS, 2010).
influence patient satisfaction. This model has Major challenges in the research of
not been tested. Comley and Beard (1998) pro- patient satisfaction with nursing care are
posed a theory of patient satisfaction derived related to its conceptualization and mea-
from job satisfaction models. This model has surement. Models of patient satisfaction that
not been tested in a prospective study. reflect the structure, process, and outcomes
Risser (1975) created the Risser Patient of nursing care need to be developed and
Satisfaction Scale (PSS), an instrument to empirically tested. Majority of patient satis-
measure patient satisfaction. The PSS con- faction instruments are not based on theo-
sisted of 25 questions and three subscales, retical models (laschinger & Almost, 2003).

390 n PeDIATRIC PRIMARY CARe



This can be explained by the lack of theoreti- 25 years, primary care has changed to include
cal models of patient satisfaction. pediatric nurse associates who are now
P One issue related to measurement of called pediatric nurse practitioners (PNPs).
patient satisfaction with nursing care is the PNPs were the first nurse practitioners; they
lack of psychometrically tested, valid, and are advanced practice nurses who are edu-
reliable instruments (lynn & McMillen, 2004; cated to provide primary care services to
Urden, 2003; Woodring et al., 2004; Yellen, children. Dr. Henry K. Silver and Dr. loretta
2003). A second issue is the lack of consid- Ford started the PNP program in Colorado
eration for demographic factors such as age, in 1964. Although the role has remained
educational level, and ethnic and cultural much the same from its inception, one major
background in the development of instru- change is the level of education required.
ments. A third issue is the development of Originally, it was a 4-month continuing edu-
instrument from the perspective of the pro- cation program and now it is a 2-year educa-
vider and not the patient (lynn & McMillen, tional program culminating with a master’s
2004). Finally, issues related to methodology, degree. National certification is required in
survey design, administration techniques, some states to allow PNPs to practice. There
and timing are of concern (Urden, 2003). are two certifying organizations for PNPs: the
These issues need to be addressed. American Nurses Credentialing Center and
An issue not directly related to concep- the Pediatric Nursing Certification Board.
tualization and measurement of patient satis- Currently, there are differences in health
faction is the lack of inclusion of nurses in the care outcomes between minority and majority
development of instruments and the exclu- ethnic groups. Children in minority groups
sion of nurse-sensitive indicators in hospital are at much greater risk for poor health care
quality reports (Yellen, 2003). There is a high factors, and there is a lack of culturally com-
correlation between patient satisfaction with petent health care providers. Hispanic and
nursing care and satisfaction with overall care Black children are more likely to be uninsured
(Beck & larrabee, 1996; Jacox et al., 1997). For and receive lower quality primary care than
this reason, nurses need to be active partici- White children (Flores & the Committee on
pants in quality reporting and in the develop- Pediatric Research, 2010). In 1998, President
ment of patient satisfaction instruments. Clinton presented the Initiative to eliminate
In summary, patient satisfaction is a crit- Racial and ethnic Disparities in Health. This
ical outcome indicator. It impacts both the proposal seeks to eliminate disparities by the
quality and financial aspects of health care year 2010 and focuses on the same goals and
organizations. Nurses are major contribu- outcomes as Health People 2010: infant mor-
tors to the level of patient satisfaction. These tality, child and adult immunizations, HIv/
contributions need to be measured and AIDS, diabetes, cardiovascular disease and
recognized. stroke, and cancer screening and manage-
ment. Access to health care and quality of
Cecilia D. Alvarez health care are also part of the focus.
Childhood immunizations, particularly
in children less than 2 years of age, con-
tinue to be a major health concern in primary
PeDiatriC Primary Care care. Health People 2010 and the President’s
Childhood Immunization Initiative man-
dated a goal of 90% immunizations for chil-
Pediatric primary care has existed for a long dren younger than 2 years by the year 2000.
time and has been provided by family prac- In 1992, only 55% of children under the age
tice physicians and pediatricians. In the last of 2 years had received an adequate number

PeDIATRIC PRIMARY CARe n 391



of immunizations. By 1994, the rate had risen such as family stresses, socioeconomic sta-
to 73%, and now it is above the 90% goal. tus, and family life were found not to be sig-
Although these are excellent numbers, there nificant predictors. P
still remain pockets primarily in large cities Faulkner (2002) studied 18 mothers
where immunizations rates are much lower. of preschool children enrolled in a nutri-
Data from the CDC National Immunization tion clinic for mothers and children in
Survey suggest that minority children, pri- low-income households. Mothers were ques-
marily African American and Hispanic, chil- tioned in a 1-hour focus group as to how
dren living below the poverty level, children they defined overweight, how they thought
of teen mothers, children in large families, their children became overweight, and what
children of parents who lack education, fam- barriers existed in preventing and man-
ilies with transportation problems, and chil- aging obesity. Interestingly, the mothers
dren of mothers who lack social support have described their children as strong or solid
lower rates of receiving immunizations by and did not think that standardized growth
age 2 years than the national average. charts reflected a healthy weight. As long
Obesity is another health issue commonly as children were active, the mothers did not
seen in primary care. It is a complex issue consider them overweight but if they were
and not fully understood. The number of lazy or lay around then they were consid-
obese children has increased substantially ered overweight. The mothers thought that
in the last 20 years, putting them at risk for heredity and the environment determined
serious health problems as adults including the child’s weight. In their attempts to man-
cardiovascular disease and stroke, diabetes, age their children’s weight, the mothers had
hypertension, arthritis, and psychological lots of difficulty. Food was used as a reward
problems. Obesity during infancy and child- by some, others did not want to deny their
hood increases the risk of obesity in adoles- children food, and with others, family mem-
cence and adulthood. Children with a body bers did not want the mother restricting the
mass index equal to or more than the 95th child’s diet. Mothers also thought that their
percentile are more likely to become obese own obesity affected their management of
adults. Obesity is considered to be multifac- their child’s weight.
torial with both genetic and environmental Prevention of obesity and development
components. Family lifestyle, stress, socio- of effective programs for those who are over-
economic status, and maternal characteristics weight are critical to reversing the devastat-
are some of the environmental components. ing long term effects. Unfortunately, there
Sowan and Stember (2000) studied infants are not many effective programs available
until 15 months of age to identify parental for children. Dietary management, increas-
characteristics and to see whether obesity ing physical activity, and parental behavior
was linked to any of these characteristics. management are critical ingredients in any
Age of the mother at the time of the infant’s program. Primary care providers need to
birth was predictive of obesity in the infant include appropriate eating patterns, types
at 10 months of age. The chances of obesity of foods, and amounts when talking with
increased in the infant with every 5 years parents during well-child visits. Parents
of age increase in the mother. For every 25 have a crucial role in how children’s eating
pound increase in the mother’s usual weight, habits develop and how that affects their
the chances of the infant being obese at 7 overall health and psychological well-being.
months of age increased. Maternal smoking Providers also need to discuss the amount of
increased the chances of infant obesity at 1 physical activity children receive. Children
and 7 months of age. The usual stressors one should receive 60 minutes of physical activity
might think could cause childhood obesity per day, but where a family lives influences

392 n PeNDeR’S HeAlTH PROMOTION MODel



where and how parents are able to ensure Practice, is currently in the sixth edition
children receive this. Providers need to be (Pender, Murdaugh, & Parsons, 2010).
P aware of safe community resources to guide The 10 major theoretical propositions of
families. the revised HPM collectively state that indi-
Anderson and Whitaker (2010) studied vidual characteristics and beliefs will influ-
preschool-aged children exposed to three ence the person’s level of commitment and
household routines of eating the evening likelihood of demonstrating the desired
meal as a family, getting enough nighttime health promotion behavior. These interre-
sleep and having limited screen time. These lated variables are represented in Pender’s
children had a 40% lower incidence of obesity revised HPM conceptual map (1996); related
than those who did not have these routines. variables are clustered and separated into
It is imperative that adequate and appro- three main categories: individual character-
priate health services are available to chil- istics and experiences, behavior-specific cog-
dren and families to help ensure positive nitions and affect, and behavioral outcome
outcomes. A variety of health care providers, (Pender, Murdaugh, & Parsons, 2002).
including nurse practitioners with knowl- The antecedents to action are the indi-
edge of the needs of children, is essential for vidual characteristics and experiences, which
changes to occur. include variables that have been determined
by past experiences, genetics, or biopsycho-
Virginia Richardson social influence. These variables can influ-
ence behaviors, beliefs, and outcomes. The
most substantial part of the model is com-
posed of variables based on beliefs and out-
PenDer’s health side influences that are fused together under
the heading “Behavior Specific Cognitions
Promotion moDel and Affect.” This category includes proposi-
tions that people will be more successful if
they anticipate benefit, perceive self-efficacy,
Pender’s Health Promotion Model (HPM) and have a positive affect toward the health
is a middle-range theory that explains and promotion goal. The expectations of signif-
predicts how the complex interaction among icant others (family, peers, and health care
perceptual and environmental factors influ- providers), the external environment, and
ences health-related choices. Pender focused the competing demands (distractions) and
the model on high-level wellness and health preferences can influence attainment of the
promotion. The model has been used inter- health promotion behavior. Both of these
nationally as the basis for nursing research, groupings are related to the last cluster of
practice, and education. variables termed the behavioral outcome. The
Since her first published model in 1982, desired outcome is the health promotion
Pender has made two major revisions to her behavior, which is influenced by compet-
model resulting in a 1987 version and a 1996 ing demands and making a commitment to
version. The revised version has shown to be changing behavior. The level of commitment
a better predictor of health-related behav- to a plan of action both influences the out-
ior change in nursing research, such as pre- come and may predict the ability to main-
dicting physical activity in adolescents and tain the desired health promotion behavior
predicting the use of hearing protection in change over time (Pender et al., 2002).
construction workers (Ronis, Hond, & lusk, Pender’s HPM has been used in research,
2006; Wu & Pender, 2005). The text based on clinical practice, and nursing education.
Pender’s HPM, Health Promotion in Nursing Hundreds of published nursing articles have

PePlAU’S THeOReTICAl MODel n 393



used the model as a theoretical framework. and clinical practice. Pender’s model also
Research based on the HPM covers a vari- addresses the barriers to action that are
ety of clinical applications such as the use important areas to focus nursing interven- P
of hearing protection, smoking cessation, tion. lastly, Pender has taken a truly holistic
exercise, sexual behaviors and contraceptive approach, considering sociocultural, psycho-
use, dietary goals and cholesterol levels, logical, and biological variables. The content
use of seat belts, job strain/absenteeism/ of the HPM model is consistent with con-
productivity, stress reduction, cancer risk temporary beliefs that health promotion is
reduction, accessing prenatal care, avoiding a national and international priority and a
secondhand smoke, and diabetes preven- cost-effective alternative to sick care.
tion. Pender states that she primarily uses
the model to study exercise behaviors in ado- Caryn A. Sheehan
lescents and young adults (Pender, 2001b).
Nursing implications derived from the HPM
research offer specific nursing interventions
that can be readily used in clinical practice. PePlau’s theoretiCal moDel
Information about how to promote healthy
choices and lasting behavior modification
is valuable to both health care professionals Hildegard Peplau (1909–1999) formulated
and the public. Pender has also published an her theoretical ideas about the therapeu-
article specifically outlining health promo- tic interpersonal process of nursing in the
tion recommendations for BSN, MSN, and 1940s and published them in the now-classic
PhD nursing curricula (Pender, Barkauskas, 1952 book, Interpersonal Relations in Nursing.
Hayman, Rice, & Anderson, 1992). The foundation of Peplau’s work was inter-
The HPM offers a high degree of gen- personal relationships with patients as the
eralizability to many diverse groups of peo- significant context in which nurses facili-
ple. Pender has consulted internationally in tate patients’ well-being. Peplau’s theoretical
such countries as Japan, Korea, Dominican model can be categorized as a middle-range
Republic, Jamaica, england, New Zealand, theory. The theory has a specific focus on the
and Mexico (Pender, 2001a, Biographical characteristics and process of the therapeu-
sketch). The HPM is available in several lan- tic relationship as a nursing method to help
guages including english, Spanish, Japanese, manage anxiety and foster healthy develop-
and Korean translations (Pender, 2001a). ment. Through the therapeutic relationship,
Research based on the model has tested both the patient develops resources for healthy
males and females at all ages from preschool behaviors by actively participating with the
children to older adults. Research partici- nurse in a developmental process of change.
pants have been from a variety of settings Through the therapeutic relationship, the
including inpatient, outpatient, primary care, nurse uses a complex set of knowledge and
and community dwellings. Most importantly, skills (interpersonal competencies, investiga-
the research based on the HPM has not been tive skill, and theoretical knowledge) along
limited to healthy subjects. Some popula- with patient strengths and characteristics to
tions that have been studied have included assist the patient in using energy provided
people diagnosed with CAD, HIv, asthma, by the anxiety to identify and grow from a
cancer, hypertension, cognitive disorders, problematic situation (O’Toole & Welt, 1989;
and chronic disease. Reed, 2005). The nurse–patient relation-
Strengths of the HPM include its use of ship is fundamental to providing nursing
concepts that are logical and basic, its gen- care and derives from the human need for
eralizability, and its usefulness in research connectedness that is still relevant in the

394 n PeT THeRAPY



twenty-first century (Peplau, 1997). Through interpersonal relationship process in psychi-
this interpersonal relationship, nurses assess atric mental-health nursing care. Peden (1998)
P and assist people (a) to achieve healthy levels and her colleagues (e.g., Peden, Hall, Rayens,
of anxiety intrapersonally and (b) to facilitate & Beebe, 2001) have conducted several stud-
healthy pattern integrations interpersonally, ies on depression in college-age women in
with the overall goal of fostering well-being, which they found Peplau’s theory on phases
health, and development. of the relationship to be significant in the
The structure of the interpersonal rela- timing of their depression intervention.
tionship was originally described in terms Research has generated policy implica-
of four phases: orientation, identification, tions. The studies by McNaughton (2005)
exploitation, and resolution (Peplau, 1952). of pregnant women at risk and by Beeber
Forchuk (1991b), with the support of Peplau, et al. (2010) of latina mothers with depres-
clarified the structure as consisting of three sive symptoms had policy implications for
main phases: orientation, working (which increasing the standard number of visits to
incorporated identification and exploita- better facilitate positive mental and physi-
tion), and resolution. In a 1997 publication, cal health outcomes of the therapeutic rela-
Peplau endorsed this three-phase view and tionship. Although much of the research has
explained that the phases were overlap- focused on psychiatric and mental health set-
ping, each having unique characteristics. tings, increasingly researchers are studying
Throughout these phases, the nurse func- applications of the theory in other contexts
tions cooperatively with the patient in the (Nyström, 2007). Peplau’s theoretical ideas
nursing roles of stranger, resource person, continue to be significant in contemporary
counselor, leader, surrogate, and teacher. The nursing for their relevance not only in psy-
nurse’s range of focus includes the patient chiatric mental-health nursing practice but
in relationship with the family, other health also in practice anywhere a nurse–patient
care providers, and community (Peplau, relationship exists.
1952, 1997).
Peplau was explicit in promoting Pamela G. Reed
research-based theory. Research based on Nelma B. C. Shearer
Peplau’s theoretical model has addressed
topics related to both nurse behaviors and
patient health conditions. Nurse-focused
topics include: (a) the practices of psychiatric Pet theraPy
mental-health nurses, (b) the family systems
nursing, and (c) the nature of the nurse–
patient relationship in reference to roles and Using animals as an adjunct to treatment has
role changes over the trajectory of a mental been practiced by a variety of professionals
illness, boundary issues in pediatric nursing, including registered nurses, nurse practitio-
and concepts such as therapeutic intimacy. ners, physicians, physical and occupational
Patient-focused research has addressed therapists, social workers, psychologists,
health conditions including depression, psy- and licensed counselors (Delta Society, 2005;
chosis, sexual abuse, Alzheimer’s disease, Kruger & Serpell, 2006).
and multiple sclerosis. A particularly nota- Nursing, with its broad biopsychosocial
ble Peplau-based researcher is Forchuk (e.g., framework for disease management, makes
Forchuk, 1994; Forchuk et al., 1998; Forchuk, it an optimal venue for animal-assisted
Jewell, Tweedell, & Steinnagel, 2003), who, therapy practice. As clinicians, nurses are
along with colleagues, has conducted a pro- amenable to using nontraditional practices
gram of research into applications of the in an effort to heal and provide comfort for

PeT THeRAPY n 395



their patients. In addition, nursing research human services professional that uses ani-
focuses on understanding the symptoms of mals to achieve specified goals and objec-
acute and chronic illness, finding ways to pre- tives through measured progress. Also used P
vent or delay chronicity of physical or emo- are AAA, which are more commonly used
tional illness and finding overall approaches in hospitals through infrequent pet visits.
to achieve and maintain good physical and The difference lies in the absence of prede-
emotional health. In other words, nurses termined treatment goals and inconsistent
understand the interconnectedness between practice.
emotional, mental, and physical health and Dogs are most frequently used in AAT/
through alternative modalities can reduce or AAA because of their general social nature,
ameliorate stressors, allowing the body to do trainability, and size; however, horses are
what it was designed to do—heal. used extensively in a variety of remedial
Nursing’s unique role in both the psy- fields. Horses are categorized and certified
chological and the physiological dimensions by the Delta Society, but overall jurisdiction
of disease and stress places it in an ideal resides within the North American Riding
position to examine and use the role of com- for the Handicapped Association, its sub-
panion animals in clinical interventions. section the equine-Facilitated Mental Health
Practitioners of animal-assisted therapy or Association, and its affiliate partner the
animal-assisted activities are often involved American Hippotherapy Association (AHA).
in pet visitation and animal-facilitated ther- equine-facilitated psychotherapy is facilitated
apy programs in hospitals, nursing homes, by a credentialed health professional work-
hospice, assisted living centers, and more ing with a credentialed equine professional.
(Spence & Kaiser, 2002). Research has dem- Hippotherapy, which is often incorrectly
onstrated that animal-assisted interventions used synonymously with equine-facilitated
and therapies have been highly effective psychotherapy, uses neurodevelopmental
among young hospital patients, troubled ado- treatment and sensory integration based on
lescents, individuals with acute or chronic the movement of the horse to improve bal-
illnesses, dementia, Alzheimer’s disease and ance, coordination, fine motor skills, posture,
elderly residents living in long-term care improving articulation, and increasing cog-
facilities. nitive skills (Kruger & Serpell, 2006).
Despite the long history of using thera- Historically, AAT and AAA are believed
peutic animals, the custom of animal-assisted to have been practiced as early as the ninth
therapy is still being defined today. literature century in Gheel, Belgium, with handicapped
searches reveal dozens of definitions of ani- persons (Serpell, 2000). Other research has
mal-assisted therapy and at least 12 different documented the use of AAT and AAA in the
terms for the same practice including pet late 1790s in York, england, where rabbits
therapy, pet psychotherapy, pet-facilitated and chickens were used as complementary
therapy, pet-mediated therapy, and so forth. modalities to therapy with the mentally ill to
The most commonly used terminol- teach self-control without the use of restraints
ogy is animal-assisted therapy (AAT) and or harsh medicines (Arkow, 1987; Salotto,
animal-assisted activities (AAA). The Delta 2001). During the 1830s, mental institutions
Society, one of the largest organizations in Britain used animals on the grounds to
in the country responsible for certifying create a more pleasant environment (Serpell,
therapy animals (Kruger & Serpell, 2006), 2000). even Florence Nightingale used small
provides definitions that are cited consis- animals in her care of wounded soldiers dur-
tently throughout the AAT and the AAA ing the Crimean War. In her Notes on Nursing,
literature. The Delta Society defines AAT as she posited that a “small pet is often an excel-
a goal-directed intervention by a health or lent companion for the sick, especially for the

396 n PeT THeRAPY



chronic cases” (Nightingale, 1969; Serpell, family member, and a confidant (Beck &
2006). In 1962, child psychiatrist Boris Hatcher, 2003). For individuals with a human
P levinson used his own dog, Jingles, to help social support deficit, pets can moderate an
him connect with hard-to-reach children and intimacy with other humans. For the elderly
adolescents. He published his findings “The who live alone, animals play a positive role
Dog as the Co-therapist” in the journal of in the improvement of life satisfaction, sense
Mental Hygiene (levinson, 1962). of purpose, and feelings of personal safety
In 1988, at the National Institutes of compared with non–pet owners (Beck &
Health Technology Assessment Workshop Hatcher, 2003).
on the Health Benefits of Pets, major evi- In using dogs therapeutically, even one
dence was reported indicating that pet own- session of 30 minutes per week has been
ers had an increase in 1-year survival rates demonstrated to be clinically significant in
after being discharged from a coronary care reducing feelings of loneliness per patient
unit (Beck & Hatcher, 2003; Morrison, 2007), self-reports. Other measured benefits include
demonstrating that pet ownership is a sig- decreased blood pressure and heart rate as
nificant social predictor of 1-year survival well as an increased peripheral skin temper-
for post coronary patients studied. Ten years ature (McCabe, Baun, Speich, & Sangeeta,
later, in a clinical trial ancillary study to the 2002). Patients with Alzheimer’s disease who
Coronary Arrhythmia Suppression Trial by have an attachment to a companion animal
the National Institutes of Health, research- have fewer mood disorders and fewer epi-
ers reported that pet owners had slightly sodes of anxiety and aggression compared
lower systolic blood pressures, plasma with those without a loved pet (McCabe
cholesterol, and triglyceride values than et al., 2002).
non–pet owners (Beck & Hatcher, 2003). From a physical health perspective,
Combined, the study purports that because individuals with companion animals have
of pet ownership’s influence of psychosocial a lower frequency of primary care visits
risk factors, having a loved pet reduces the (Siegel, 1990). Stressful life situations con-
incidence of cardiovascular disease (Beck & tribute to higher physician visitation rates
Hatcher, 2003). because of the stressors interconnectedness
Benefits of AAT/AAA have demon- with psychological distresses. The more
strated both physical and fiscal outcomes. stressors experienced, the greater attention
employing the use of animals has been paid and significance attributed to physi-
shown to be a cost effective intervention ological symptoms, thus more trips to the
in a variety of health care settings through family physician. Individuals encountering
shorter hospital stays, reduction in need for meaningful interactions with animals saw
medication and an increase in food con- improved moods and faster recovery times
sumption resulting in a decrease in need (Coakley & Mahoney, 2009).
for supplements. A study conducted in New Feelings of loneliness and isolation are
York, Missouri, and Texas showed that in common in residential facilities—whether in
nursing homes where animals and plants are prisons, youth detention centers, hospitals,
an integral part of the environment, medica- nursing homes, or assisted living. The physi-
tion costs dropped from an average of $3.80 cal separation from loved ones (through spou-
per patient per day to just $1.18 per patient sal loss, loss of home) often triggers the onset
per day (Geisler, 2004). of loneliness and the need for social relation-
Animals also provide the necessary ships (Banks & Banks, 2002; Geisler, 2004).
social support as well as increase the fre- Residents in nursing homes who received
quency of this type of support to individu- regular pet visits had lower scores for loneli-
als who consider their pet to be a friend, a ness than those with a low level or no contact

PeT THeRAPY n 397



(Banks & Banks, 2002). Animal-assisted ther- Whether it is because of the bond with
apies distract patients from pain perception a nonjudgmental being or finding a sense of
and often provide comforting thoughts of purpose or a connection to nature, almost P
home (Coakley & Mahoney, 2009). Rather any animal can have a therapeutic impact.
than feeling lonely, the dogs made them feel Using animals other than dogs might be
connected and cared for and provided them more acceptable in certain settings, such as
with a sense of purpose. fish tanks used to improve morale and eating
It is attachment to another being that habits. Research by edwards and Beck (2002)
is associated with greater physical health. has found that the presence of fish in a nurs-
Pets provide companionship and feelings ing home dining room provided a positive
of security and of being loved (Siegel, 1990). influence for Alzheimer’s patients as resi-
Further research has found a decrease in dents sat at the table longer and consumed
anxiety, systolic pulmonary pressure, and more calories, which meant a weight gain
epinephrine and norepinephrine levels of 1.65 pounds and less need for nutritional
(Coakley & Mahoney, 2009) in individuals supplements; patients felt it provided a nice
with pets. distraction during prolonged hospital stay
Alzheimer’s disease provides spe- and felt less anxiety, depression, and hostil-
cific challenges for caregivers that require ity typically seen in patients awaiting a heart
alternative interventions. These challenges transplant.
include agitation, aggression, delusions, hal- Pets in nursing homes encourage an
lucinations, sleep problems, wandering, and increase in the level of social interaction
vocalizations. Agitation affects more than between people. Increase in social and ver-
90% of the residents, which inhibits opti- bal interaction provides a valuable adjunct to
mal health care (Richeson, 2003). This con- other therapy (Geisler, 2004). Residents can
cern continues to escalate as the Alzheimer’s experience themselves as nurturer and care-
Association predicts that by 2050, there will giver rather than the recipient (Geisler, 2004).
be 14 million people affected by Alzheimer’s At the other end of the life span, ani-
disease. mal-assisted interventions have been suc-
For individuals with Alzheimer’s dis- cessful in working with chronically ill
ease, sensory-based techniques have been children. Companion animals have been
used successfully to promote independence, found to provide companionship and tactile
to decrease medications and need for phys- comfort, to decrease stress, and to facilitate
ical restraint, and to improve the quality of social interaction as well as decrease car-
life (McCabe et al., 2002). Settings that are diovascular reactivity to stress. Companion
secure and comforting, featuring a myriad of animals serve as playmate, confidante, and
sensory stimuli, are most effective for these friend who provide unconditional love, a
residents. The success of using companion direct source of social support (Spence &
animals stem from those factors. McCabe Kaiser, 2002). The bond children have with
et al. (2002) posited that when a dog was pre- companion animals has been positively
sent on the unit from morning to evening, related to improved self-esteem, social com-
results showed the resident to be less vio- petence, and socioemotional functioning.
lent, have fewer conflicts, need less medica- Pets as social facilitators based on findings
tion, and have more acceptable behavior as that animals make a person more socially
well as decreased agitation and improved attractive and provide a topic for conversa-
socialization during sundown hours, very tion could be important for chronically ill
similar to the aforementioned study at the children who may feel different and whose
institution where the residents cared for the social life maybe interrupted (Spence &
injured bird. Kaiser, 2002).

398 n PeT THeRAPY



AAT is not theory specific; therefore, countless articles that provide heartwarm-
a variety of theories can be used. Common ing anecdotes, but because most of the work
P theories cited and often supported in AAT is done by individuals outside the academic
include but are not limited to attachment world, resources to conduct such extensive
theory, attention egens, Rogerian theory, research are not sufficient (Beck & Hatcher,
biophilia hypothesis, learning theory, social 2003).
mediation theory, object relations theory, and Most of the studies that have been con-
cognitive theories. Table 5 gives a brief over- ducted were nonexperimental, and although
view of theories that have been used in AAT samples were large enough, most were
literature. nonprobability, nongeneralizable samples
Although the use of animal-assisted (Wilson & Barker, 2003).
interventions dates back hundreds of years, Isolating variables to show the animal
the amount of empirical evidence support- as the catalyst for change is often difficult.
ing its effectiveness is minimal. There are Beck and Hatcher (2003) wrote that there are

Table 5
Overview of Theories Used in AAT literature
John Bowlby’s attachment Sable (1995) Attachment theory contends that infants develop a unique and
theory continuous attachment to a caregiver. As they grow, they need
a combination of relationships from attachments built with
other individuals. Pets can be used as surrogate relationships.
“Humans have an innate, biologically based need for social
interaction—behaviors such as following, smiling toward,
holding and touching are evident in reciprocal relationships
between child and attachment figure” (Kruger & Serpell, 2006).
Attention egens Odendaal (2000) Humans have a basic need for attention. The bond between human
and animal correlates to the animals’ need for attention and
sociable behavior. When animals fulfill this need for attention,
success is measured.
Rogerian theory Coakley and Mahoney Stress interferes with recovery; thus, energy fields are dynamic
(2009) and reciprocal—changes in one can change the other. Carl
Rogers describes living matter as energy fields. energy fields
include body, mind, emotions, and environment. When an
animal is introduced into the patient’s energy field, the person
experiences change.
e. O. Wilson’s biophilia Kruger and Serpell Developed by e.O. Wilson in 1984, the biophilia hypothesis
hypothesis (2006) maintains that humans possess a genetically based propensity
to attend to and to be attracted by other living organisms or
“an innate tendency to focus on life and lifelike processes”
(Kruger & Serpell, 2006).
Bandura’s learning Brickel (1982) learning theory states that an activity that is pleasurable will
theory be self-reinforcing and more likely to occur in the future—
unpleasant or anxiety-provoking activities may result in
avoidance or withdrawal of the behavior. Animals introduced in
a therapeutic context may serve as a buffer and divert attention
from an anxiety generating stimulus that the patient faces
(Brickel, 1982).
Cognitive and social Kruger and Serpell Cognitive and social cognitive theories are continuous
cognitive theories (2006) reciprocal relationships among a person’s cognitions, behavior,
and environment (i.e., if I think I’m a bad person, I will behave
like a bad person and will therefore be treated like a bad per-
son by those around me)—the goal of therapy is to bring about
positive changes in person’s self-perception and hence their
behavior.

PHeNOMeNOlOGY n 399



inconsistencies within the literature, and as which refers to the inseparable connected-
a result, the magnitude of the health benefits ness of human beings to the world. Subject
may be over or underestimated, begging the and object are united in being-in-the-world. P
question as to whether the populations that One cannot describe either the subjective or
benefit would faire just as well enjoying other objective world but only the world as expe-
living environments like gardening or walk- rienced by the subject. The observer is not
ing in green spaces, and so forth. even rig- separate from the observed. One can know
orous experimental designs used in natural what one experiences only by attending to
settings are subject to intervening variables perceptions and meanings that awaken con-
that are outside of the researchers’ control scious awareness. Phenomenologists hold
(Wilson & Barker, 2003). Other considerations that human existence is meaningful only in
include sample selection within specific the sense that persons are always conscious
populations (i.e., patients with Alzheimer’s of something. Meaning emerges from the
disease), which makes randomization mean- relationship between the person and the
ingless (Wilson & Barker, 2003) and is not world as the person gives meaning to expe-
always accurate in generalizing groups from riences. Phenomenology focuses on lived
one facility to another. experience, that is, human involvement in
With that being said, Beck and Hatcher the world.
(2003) concluded that the available data do In phenomenology, the process of
suggest that animals play a significant role in recovering our original awareness is called
benefiting the lives of humans, and despite reduction. Through phenomenological
the deluge of anecdotal evidence and rela- reduction, one refrains from preconceived
tively fragile empirical data, the field of AAT notions and judgments. The layers of mean-
continues to be vibrant and alive in a vari- ing provided by a researcher’s knowledge
ety of clinical and nonclinical settings. In an and interpretation are preserved by being
effort to make the practice more mainstream temporarily set aside—that is, bracketing.
and accepted throughout the various disci- Through phenomenological reduction, the
plines, current practitioners conducting evi- world of everyday experience becomes
dence-based research are needed to provide accessible.
well-designed research studies to further edmund Husserl is considered the father
scientifically demonstrate the efficacy that so of phenomenology. His is a descriptive phe-
many have experienced while using animal- nomenology. He was interested in the episte-
assisted interventions. mological question, How do we know about
man? The goal of his phenomenology is the
Amy R. Johnson description of the lived world. Husserl’s
student, Martin Heidegger, took phenom-
enology in a different direction and was
more interested in the ontological question,
Phenomenology What is being? The goal of his phenomenol-
ogy, called hermeneutic phenomenology,
was understanding. This understanding is
Phenomenology refers to both a philosoph- achieved through interpretation. Heidegger
ical movement and a research method. The argued that it was not possible to bracket
philosophical underpinnings of phenom- one’s being-in-the-world.
enology are first summarized to provide a The phenomenological philosophies of
backdrop for what this methodology aims Husserl and Heidegger have different meth-
to accomplish. One of the philosophical odological implications for nurse research-
tenets of phenomenology is intentionality, ers. Husserlian phenomenology focuses

400 n PHIlOSOPHY OF NURSING



on the analysis of the subject and object as offers the following definitions. Metaphysics
the object appears through consciousness. is the study of the ultimate nature of reality
P Bracketing is essential in this descriptive and of being. epistemology is the study of the
phenomenology. In Heideggerian phenom- scope and nature of knowledge and of the
enology, bracketing is not used because this justification of knowledge claims. ethics is
phenomenology views people as being-in- the study of the moral life. History of philos-
the-world. This notion of being-in-the-world ophy is the study of major philosophers and
allows researchers to bring their experiences of major movements in philosophy. logic is
and understanding of the phenomenon the study of sound principles and methods
under study to the research. of reasoning in determining valid arguments
As a research method, phenomenology from invalid ones.
is inductive and descriptive. Phenomenology Philosophy’s method of inquiry is called
provides a closer fit conceptually with clin- philosophical inquiry; it involves subject-
ical nursing and with the kinds of research ing philosophical perspectives to critical
questions that emerge from clinical practice examination to determine their soundness
than does quantitative research. The goal of through appeals to reason (Iannone, 2001).
phenomenological research is to describe the These appeals typically include (a) criti-
meaning of human experience. In its focus cal analysis, reflection, and interpretation;
on meaning, phenomenology differs from (b) conceptual, linguistic, and ethical analy-
other types of research, which may, for exam- sis; (c) logical and dialectical argumentation;
ple, focus on statistical relationships among and (d) historical analysis. Although philos-
variables. Phenomenology tries to discover ophy has its own body of knowledge and
meanings as persons live them in their every- distinctive method of inquiry, it relates to
day world. It is the study of essences, that is, other disciplines through subfields such as
the grasp of the very nature of something. philosophy of science, philosophy of art, and
essence makes a thing what it is; without it, philosophy of medicine. Philosophy of nurs-
the thing would not be what it is. The phe- ing is another subfield.
nomenological approach is most appropriate Before defining philosophy of nursing,
when little is known about a phenomenon the following questions need addressing:
or when a fresh look at a phenomenon is What is the history of philosophy of nurs-
indicated. ing? Why is it important? What are its major
issues?
Cheryl Tatano Beck Philosophy of nursing has existed since
Florence Nightingale (1859/1946) identified
the nature of nursing in Notes on Nursing:
What It Is, and What It Is Not. Since then, sub-
PhilosoPhy of nursing stantive nursing philosophical research has
been conducted; conferences and institutes
have been held; and books and journals on
Generically defined, philosophy is love of philosophy of nursing have been published.
wisdom. Specifically, philosophy is a disci- An example is Nursing Philosophy, which was
plined method of inquiry involving critical first published in July 2000. Between 2000 and
examination and comprehensive study of October 2009, 205 original articles were pub-
the universe—its reality (metaphysics), its lished in this journal by 225 different authors
knowledge (epistemology), its morality (eth- (Sellman, 2009). These articles focused on all
ics), its history (history of philosophy), and its major aspects of nursing philosophy: nursing
method of argumentation (logic). Audi (2006) metaphysics, nursing epistemology, nursing

PHIlOSOPHY OF NURSING n 401



ethics, history of nursing philosophy, and of answers are discussed. The questions
nursing methods of philosophical inquiry. raised guide the inquiry, and data collection
These articles, along with past and current and analysis occur together. Data analysis P
scholarship on nursing philosophy, comprise focuses on words and is often collaborative
the core and expanding knowledge base of and cyclical (i.e., answers generate questions,
philosophy of nursing. This knowledge base questions generate analysis, analysis gener-
has helped nurses to identify central phil- ates questions). Thus, the ultimate investiga-
osophical concerns of nursing, the nature tive method in nursing philosophical inquiry
of and boundaries for nursing, and the val- is the critically engaged and reflective mind;
ues and beliefs of nurses. Yet, major issues it searches for nursing philosophical insights
remain. examples of these issues include the through reasoning and through ways of
following: (a) How does one determine the knowing. The expression of this critically
good in quality of life when the good is defined engaged and reflective mind is the written
differently? (b) How does one resolve com- word.
peting stances on the nature of being and of In addition to the preceding philosoph-
doing in nursing practice? (c) How does one ical inquiry research method, Burns and
identify the moral aims of nursing in a plu- Grove (2009, chap. 4) also identify three cat-
ralistic society? egories of philosophical inquiry research.
Philosophy of nursing is a disciplined These categories, with their primary meth-
method of inquiry involving critical examina- ods of inquiry, include the following:
tion and comprehensive study of the human
health nursing experience—its reality (nurs- 1. Foundational inquiry. This category of
ing metaphysics), its knowledge (nursing philosophical inquiry research focuses on
epistemology), its morality (nursing ethics), analysis of the philosophical bases, struc-
its history (history of nursing philosophy), ture, and values of a science; its primary
and its ways of reasoning and of knowing. methods of inquiry are exploration and
Nursing’s disciplined method of inquiry is logical analysis. Two examples of foun-
called nursing philosophical inquiry; it involves dational philosophical inquiry research
subjecting nursing philosophical perspec- include Mackey’s (2009) Towards an
tives to critical examination to determine Ontological Theory of Wellness: A Discussion
their soundness through appeals to reason of Conceptual Foundations and Implications for
and through appeals to ways of knowing. Nursing and Green’s (2009) A Comprehensive
These appeals typically include (a) critical Theory of the Human Person from Philosophy
analysis, reflection, and interpretation; (b) and Nursing.
conceptual, linguistic, and ethical analysis; 2. Philosophical analysis inquiry. This cat-
(c) nursing historical analysis; (d) nursing egory of philosophical inquiry research
process analysis; (e) personal processes of focuses on examination of meaning and
knowing; (f) artistic processes of knowing; on building theories of meaning; its pri-
and (g) intuitive processes of knowing. mary methods of inquiry are linguistic
Philosophy is the basis of science and analysis and concept analysis. Two exam-
of research and directs the methods within ples of philosophical analysis inquiry
them. The qualitative research method research include Hage and lorensen’s
of nursing philosophical inquiry is simi- (2005) A Philosophical Analysis of the
lar to other qualitative research methods: Concept Empowerment: The Fundament of an
literature is broadly examined; conceptual Education-Programme to the Frail Elderly and
meanings are explored; questions are raised; Harper’s (2006) Ethical Multiculturalism: An
answers are suggested; and ramifications Evolutionary Concept Analysis.

402 n PHYSICAl ReSTRAINTS



3. ethical inquiry. This category of philo- rails, some types of furniture, and audible
sophical inquiry research focuses on an alarm systems are also considered restraints
P analysis of the moral life and on an analy- when used to limit movement. Although this
sis of ethical problems; its primary meth- entry focuses mainly on physical restraints,
ods of inquiry are critique and debate it is important to keep in mind that these
based on ethical theories, principles, and devices are often used in conjunction with
virtue ethics. Two examples of ethical psychopharmacological drugs. When given
inquiry research include Begley’s (2008) for the purposes of discipline or convenience
Guilty but Good: Defending Voluntary Active and not required to treat specific medical or
Euthanasia from a Virtue Perspective and psychiatric conditions, such drugs are con-
Holland’s (2010) Scepticism about the Virtue sidered chemical restraints.
Ethics Approach to Nursing Ethics. The prevalence of physical restraints in
nonpsychiatric settings, estimated in 1989 to
In sum, foundational inquiry, philosoph- affect 500,000 elderly persons daily in hospi-
ical analysis inquiry, and ethical inquiry, tals and nursing homes (evans & Strumpf,
when focused on nursing philosophical phe- 1989), led many to conclude that a restraint
nomena, constitute the three categories of crisis existed. High prevalence in the United
nursing philosophical inquiry research in States sharply contrasted with reported
qualitative nursing research. Philosophical lesser use in Western europe. The historical
nursing knowledge is often derived from antecedents for these differences appeared
the research method of nursing philosoph- related to American beliefs that were embed-
ical inquiry. Future directions for nursing ded by the end of the nineteenth century:
philosophical inquiry and for philosophy of that restraint use was therapeutically sound,
nursing include (a) increased commitment necessary to control troublesome behavior,
by nurses to conduct nursing philosophi- and protective against tragic accidents and
cal inquiry research, (b) clarification of the injuries.
multiple processes of inquiry that constitute For nearly 100 years, those beliefs were
philosophical inquiry in nursing, (c) analy- largely unchallenged; debate concerning the
sis and synthesis of the existing literature on efficacy of physical restraint was limited, and
nursing philosophical inquiry and on phi- interventions for preventing and responding
losophy of nursing with the goal of building to “unsafe” or “troublesome” behaviors were
a cohesive body of philosophy of nursing rarely considered. Over a 20-year period,
knowledge, and (d) application of the out- the efforts of advocacy groups and com-
comes of nursing philosophical inquiry to mitted clinicians, changes in nursing home
nursing practice. regulations and standards for accreditation
of hospitals, warnings from the Food and
Mary Cipriano Silva Drug Administration, media exposés, and
research demonstrating successful restraint
reduction have forced a complete reexamina-
tion of their use (Castle & Mor, 1998; evans &
PhysiCal restraints Strumpf, 2010). Although average prevalence
has now declined in U.S. nursing homes to
approximately 3% and acute-care medical
A physical restraint is any device or object units are often restraint free, restraint use
attached to or adjacent to a person’s body that and the problems associated with it remain
cannot be removed easily and restricts free- a global concern. Witness the upsurge since
dom of movement. Bilateral full-length side 2000 of published research on prevalence,

PHYSICAl ReSTRAINTS n 403



perceptions, and outcomes of restraint, orig- injuries or hiring more staff (evans et al., 1997;
inating primarily from europe, Asia, the Pellfolk, Gustafson, Bucht, & Karlsson, 2010).
Middle east, and Australia, which reflect U.S. Data show that caring for nursing home resi- P
studies from the early 1990s. dents without restraints is less costly than
Physical restraints are applied in hospi- caring for those who are restrained (Phillips,
tals and nursing homes primarily for three Hawes, & Fries, 1993).
reasons: fall risk, treatment interference, Too often, hospitals and nursing homes
and behavioral symptoms. To date, no scien- lack personnel with specialized expertise in
tific basis of support demonstrates the effi- aging or with the requisite skills for assess-
cacy of restraints in safeguarding patients ing and treating clinical problems specific
from injury, protecting treatment devices, to older adults. Studies provide promis-
or alleviating behavioral symptoms such ing evidence that a model of care using
as “wandering,” agitation, or aggression. advanced practice nurses specializing in
Several studies, in fact, suggest relationships geriatrics can reduce restraint use in nurs-
between physical restraints and falls, serious ing homes and hospitals through staff edu-
injuries, increased behavioral symptoms, cation and consultation (evans et al., 1997;
or worsened cognitive function (Capezuti, Sullivan-Marx, Strumpf, evans, Capezuti,
Strumpf, evans, Grisso, & Maislin, 1998; & Maislin, 2003).
Castle & engberg, 2009). Continued use of physical restraints is
Nevertheless, health care profession- paradoxical in view of mounting knowledge
als and other caregivers perceive few alter- about their considerable ability to do harm.
natives to restraint use in some situations, Physical restraints are known to reduce func-
especially in critical care (Minnick, Mion, tional capacity and exert physical and psy-
Johnson, Catrambone & leipzig, 2007). chological effects (Castle & engberg, 2009;
Misplaced fears about legal liability, lack of evans & Strumpf, 1989; Saarnio & Isola, 2009).
interdisciplinary discussions about deci- Furthermore, restraint use can lead to acci-
sions to restrain, and staff perceptions about dental death by asphyxiation (Miles & Irvine,
patients’ behavior also influence restraint 1992). Persons who are likely to be restrained
practices. Insufficient staffing levels and are usually those of advanced age who are
outdated models of care assignments have physically and cognitively frail, prone to
long been regarded as obstacles to minimal injury and confusion, and experiencing inva-
use of physical restraints. Hospital studies sive treatments. The evidence is compelling
offer indirect support for this conclusion by that prolonged physical restraint further
demonstrating that night shifts and week- contributes to frailty, dysfunction, and poor
end day shifts are the most frequent times quality of life.
when restraints are used (Bourbonniere, Restraint-free care can be accomplished
Strumpf, evans, & Maislin, 2003; Whitman, through implementing a range of alternative
Davidson, Sereika, & Rudy, 2001). Prevalence approaches to assessment, prevention, and
studies that demonstrate wide variation in responding to the behaviors routinely lead-
restraint use across facilities in one system ing to restraint. For such approaches to take
strongly suggest that organizational culture hold, however, changes in fundamental phi-
and norms play an important role (Meyer, losophy, culture, and attitudes within insti-
Kopke, Haastert, & Mühlhauser, 2008). tutions and among caregivers must occur. In
Several reports of restraint reduction in nurs- settings where restraints have been reduced,
ing homes and two clinical trials show that there is strong emphasis on individualized,
prevalence of physical restraints can be sig- person-centered care; normal risk taking;
nificantly reduced without increasing serious rehabilitation and choice; interprofessional

404 n PHYSIOlOGY



team practice; environmental features that the feasibility of achieving the same changes
support independent, safe functioning; in hospitals, where a disproportionately high
P involvement of family and community; and incidence of iatrogenesis occurs, much of
administrative and caregiver sanction and it exacerbated by immobilization from the
support for change. The presence of profes- use of physical restraints and adverse reac-
sional expertise, particularly expert nurses tions to psychoactive drugs. The resulting
and physicians with education and skill in complications—especially delirium, pres-
geriatrics, is crucial for sustained cultural sure ulcers, infections, and fall-related seri-
change. ous injuries—add dramatically to the cost of
Although legislation and other forms care, increased lengths of stay, and further
of external regulation or control do not in loss of function.
and of themselves change beliefs or entirely Although professional organizations in
alter entrenched practice, the Nursing Home nursing and medicine have endorsed non-
Reform Act, part of the Omnibus Budget use of physical restraints and appropriate
Reconciliation Act of 1987 (enacted in 1990), use of psychoactive drugs as the standard
helped to raise standards in nursing homes of care in all health care settings, the debate
(Castle & Mor, 1998). The Food and Drug surrounding physical restraint use in hospi-
Administration, in response to the known tals continues unabated (Jones et al., 2007).
risks of physical restraints and reports of Clinicians caring for specialty populations,
restraint-related deaths, mandates that all such as those found in critical care, trauma,
devices carry a warning label concerning and neurology, are urged to identify, test,
potential hazards. implement, and disseminate evidence-based
Following a decade of emphasis on interventions that reduce reliance on physical
restraint reduction/elimination in nursing restraints. A standard of least restrictive care
homes, clinicians, researchers, and regu- challenges professionals to use comprehen-
lators began to focus attention on these sive assessment to make sense of individual
practices in acute-care settings. As with behavioral symptoms and to employ a range
nursing homes, the Joint Commission on of interventions that enhance physical, psy-
Accreditation of Healthcare Organizations chological, and social function, as well as to
and the Centers for Medicare and Medicaid acknowledge, affirm, and protect the unique-
Services define restraint use as both phys- ness and dignity of each older person under
ical and chemical. Standards mandate that their care.
restraints be used only to improve well-
being in cases where less restrictive mea- Lois K. Evans
sures have failed to protect the patient or Meg Bourbonniere
others from harm. In addition, continual Neville E. Strumpf
individualized assessment and reevalua-
tion of the patient by clinicians and consul-
tation with the patient’s own provider must
occur with restraint use. Direct care staff
must also be trained in proper and safe use Physiology
of restraining devices.
Current approaches to restraint reduc-
tion vary along a continuum from promotion Physiology is the study of the function
of restraint-free care to an attitude of toler- of living organisms. Human physiology
ance for restraint use under certain circum- encompasses function at the molecular,
stances. Successful reduction of physical and cellular, tissue, organ, and system levels.
chemical restraints in nursing homes suggests Physiological investigations usually seek to

PHYSIOlOGY n 405



explain how the human body maintains or Understanding the physiology of health
restores homeostasis. As principle and coin- and disease has the potential to affect the
vestigators, nurses are engaged in physiolog- economics of health care, particularly in P
ical research to discover biological processes managing complications from acute ill-
that support and restore function across the ness and preventing or slowing progres-
life span. sion of dysfunction from chronic illness.
Physiological research is linked to the Aggregated physiological data can be use-
metaparadigm of nursing through the con- ful in identifying groups who may respond
cepts of person and health (Meleis, 2007). to specific interventions. To illustrate, many
Although some might argue that a physiolog- nurse researchers have contributed to man-
ical approach to understanding human health agement of hypertension and diabetes.
is reductionist, physiology provides impor- Preventing and managing complications
tant understanding about components, path- from these two common, chronic, and poten-
ways, and processes of homeostasis, building tially debilitating conditions has the poten-
knowledge about the relationships between tial to significantly impact the economics of
health and human experiences. Humans use health care.
physiological mechanisms to maintain and The explosion of information about
restore health. Holism implies that all aspects molecular influences in physiology since
of human experience— physiological, psycho- completion of the genome project has pro-
social, spiritual, behavioral, and environmen- vided new insights into homeostasis at
tal—are valuable and interactive. the microscopic level. Nurses need to
Nurses commonly deal with the physi- access and use this information in educa-
ological needs of patients and this aspect of tion, research, and practice (www.nursing-
nursing care is accepted by society (Meleis, world.org/MainMenuCategories/ethics
2007). A physiological perspective is con- Standards/Genetics_1/essentialNursing
nected directly and consistently with nurs- CompetenciesandCurriculaGuidelinesfor
ing education and practice (Ignatavicius & GeneticsandGenomics.aspx; Competencies
Workman, 2009; McCance, Huether, Brashers, and Curricula Guidelines established by
& Rote, 2010). Since its establishment as a Consesnsus Panel, 2009). To illustrate, tests
unique institute at the National Institutes to identify infecting organisms using poly-
of Health, the National Institute of Nursing merase chain reactions or protein-based
Research has championed physiological assays provide results in less than 24 hours
research under initiatives to explore and com pared with 48 to 72 hours for traditional
build biobehavioral knowledge for practice microbiology culture techniques. Appre-
(Rudy & Grady, 2005). Further, articles about ciating the biological science that devel-
physiological research are used by nurses oped these diagnostic strategies contributes
as well as other disciplines (Burns, Yucha, to effective test selection and interpreta-
& Wiss, 2004). Knowledge from investiga- tion by bedside and advanced practice
tions into physiological phenomena is val- nurses.
ued by agencies that fund nursing research, Physiologic nursing research embraces
professional nursing societies, and the indi- multi- and interdisciplinary research. Resea-
viduals that receive nursing care. The prepa- rch in a collaborative research team envi-
ration and support of nurses who engage in ronment is recognized as beneficial across a
physiological inquiry continues to be some- variety of disciplines (Kher, 2010). Identifying
what controversial as does the acceptance of and testing biomarkers for rapid diagno-
researchers who engage in laboratory and sis and evaluation of interventions appears
basic science that is not directly linked to to be a trend among funding organiza-
nursing practice. tions. early diagnosis and targeted, effective

406 n PHYSIOlOGY



interventions that cross disciplines can mit- inflammation relationships (Thompson &
igate suffering, prevent complications and voss, 2009; Winkelman, 2010). Technology
P save lives. Physiological homeostasis is com- and funding trends support the use of
plex and the incorporation of many perspec- biomarkers in national research initia-
tives in health care has the greatest potential tives (www.researchamerica.org/uploads/
to develop comprehensive care. healthdollar08.pdf; Frazier, Sparks, Sanner,
Incorporated into a wide range of both & Henderson, 2008). The use of biomarkers
grand and middle range theories, physiologi- will likely expand with the development of
cal investigations build understanding about biobanks or other large repositories of genetic
human responses to health and disease. Some material (Williams, Schepp, McGrathe, &
models of nursing that explicitly use physio- Mitchell, 2010).
logical concepts in the theoretical framework leaders in clinical research have
include the Neuman Health Systems Model investigated physiology related to cardiac
(e.g., bodily structure and internal func- monitoring (Drew et al., 2010), neonatal
tion are assessed and supported; Neuman development (Brown, 2009; lyon et al., 2010),
& Fawcett, 2002, pp. 16 and 17); the Human gender (Heitkemper, landis, & Woods,
Response to Illness Model (e.g., the interac- 2010), mood (Woods & Mitchell, 2005), and
tion of physiological processes with psycho- caregiving (Berg & Woods, 2009; Douglas,
social factors; Mitchell, Gallucci, & Fought, Daly, Kelley, O’Toole, & Montenegro, 2005).
1991); The Roy Adaptation Model (e.g., These topics have helped develop insight
physiological regulator systems are used to into homeostasis across the life span and
promote adaptation; Meleis, 2007, p. 293), the the interaction between physiology and
Orem Self-Care (e.g., meeting biologic needs human experiences in health and disease.
is a goal of nursing care; edwards, 2000), and Clinical research is also linking physiology
Johnson’s Behavioral Systems (e.g., nursing with patient safety, such as identifying vital
intervenes to reduce stress to the ingestive, signs or heart rate variability with patient
eliminative, and sexual subsystems for recov- risk for adverse events and applying lessons
ery/goal achievement; Meleis, 2007, pp. 280 learned to nursing education (Rathbun &
and 281). Midlevel theories that incorporate Ruth-Sahd, 2009).
physiology into nursing research and practice exemplars of translational physiological
include acute pain management (Good, 1998) research are investigations into the identifi-
and biobehavioral approaches to stress man- cation and management of chronic, debili-
agement (Kang, Rice, Park, Turner-Henson, tating disease. Nurses have been leaders and
& Downs, 2010). collaborators in funding projects related to
Physiologic research in nursing acute and chronic pain. Other exemplars of
embraces basic, clinical, and translational translational research are illustrated with
science. For example, nurse researchers are investigations using physiological factors to
using an animal model to investigate chro- prevent pressure ulcers, to promote urinary
nobiolological contributions to chronic crit- continence, and to manage fatigue. A large
ical illness (Hanneman, McKay, Costas, & body of nursing research has contributed to
Rosenstrauch, 2005; McCarley, Hanneman, the assessment of pain in nonverbal patients
Padhye, & Smolensky, 2007). Other nurse and evaluated of the effects of nonpharma-
researchers use basic research techniques cological management of acute and chronic
to determine genetic and proteomic asso- pain (Page, Fennelly, littleton-Kearney,
ciations with transplant rejections (Cashion & Ben-eliyahu, 2008; National Institute of
et al., 2010; Driscoll et al., 2006), tobacco Nursing Research, 2010).
cessation (Ahijevych, 2009; Ashford et al., Physiology is incorporated into nursing
2010), and psychoimmunology, stress, and research, education, and practice. emerging

PIlOT STUDY n 407



trends in physiological nursing research collection. Pilot work can be used to develop,
include the use of molecular biomarkers to test, or to refine a study protocol, including
and cellular models. Genomic science holds the treatment or intervention to be used in an P
great promise for identifying restoration of experimental or quasi-experimental study.
health. The complexity and interactive pro- Sufficient pilot work is necessary to support
cesses of physiology are ideally suited to the efficacy of an intervention prior to pro-
multidisciplinary research teams. Biobanks posal submission for a large-scale interven-
will provide new and unique opportu- tion study. During a pilot study, extraneous
nities for physiological nursing research. variables that had not been considered in the
Physiologic research continues to build design may become apparent, and methods
nursing science and, ultimately, improve to control for them can be introduced when
nursing care. the larger study is designed.
Pilot work also allows the development
Chris Winkelman or refinement of data collection instruments,
including questionnaires and equipment. The
performance of instruments with a particu-
lar sample under specific conditions also can
Pilot stuDy be evaluated in the pilot project. When col-
lecting quantitative data, the reliability and
validity of instruments and the ease of oper-
A pilot study is a smaller version of a pro- ation and administration can be evaluated
posed or planned study that is conducted to prior to data collection in a large-scale study.
refine the methodology for a larger study. A This is an important step whether the data
pilot study uses subjects, settings, and meth- collection instruments are interview sched-
ods of data collection and data analysis simi- ules, questionnaires, computers databases,
lar to those of a larger study. or equipment to gather biophysical data. For
It is recommended that all large-scale example, during pilot work, questionnaires
studies have either pilot work or other pre- can be evaluated for clarity of instructions,
liminary work as evidence of feasibility of the wording of questions, reading level, and time
project and to demonstrate the competence required for completion. For qualitative stud-
of the investigator with the area of study. ies, pilot work may be important for gaining
Feasibility issues that might be addressed in a experience in interacting with the sample
pilot study include the availability of subjects and with aspects of data collection, coding,
and estimating the time required for recruit- and analysis.
ment of subjects, the conduct of the investi- The results of a pilot study are likely to
gation, and the cost of the study. Particularly be significant for the larger proposed study. If
when planning studies with populations that the pilot study is of sufficient size, estimates
may not be easily available or accessible, a about the relationships between variables
pilot study is an opportunity to develop or and of effect sizes can be made. This is essen-
refine sampling methods and to evaluate the tial not only for statistical power analysis but
representativeness of a sample. for a better understanding of the phenom-
Preliminary work in the form of a pilot ena under study. Pilot studies often provide
study provides an opportunity to identify important insights into the problem being
problems with many aspects of study design. investigated and may lead to reconceptual-
One important design issue that can be eval- ization of the problem or refinement of the
uated during the pilot work is determining research questions.
the number of data collection points and
the optimal time between phases of data Carol M. Musil

408 n POPUlATION HeAlTH



these authors concluded that population
PoPulation health health is concerned with both the defini-
P tion and measurement of health outcomes
and the roles of determinants. Kindig and
The term population health is fairly new. Stoddart (2003) defined population health
Although the current emphasis on improving as the health outcomes of a group, includ-
health outcomes, eliminating health dispari- ing the distribution of the outcomes within
ties, and reducing health care costs ampli- the group, and argued that the field of pop-
fies the importance of population health, a ulation health included health outcomes,
single accepted definition has yet to emerge. patterns of determinants of health and
Furthermore, the debate about whether interventions, and policies that link out-
population health refers to a “concept of comes with determinants. In 1998, Young
health” or “the study of determinants of published a book titled Population Health
health” is unresolved (Hartley, 2004; Kindig, Concepts and Methods. Now in its second
2007; Kindig & Stoddart, 2003; Mechanic, edition, this textbook provides a compre-
2007; Raphael & Bryant, 2002). Nevertheless, hensive overview of factors that influence
the origin of the concept of population health health along with the identification of basic
can be traced back to a historic eighteenth- methods for assessing population health.
century debate over the relationship between Young (2004) defined population health as a
economic growth and human health (Szreter, “conceptual framework for thinking about
2003). expectedly, across the years, the health why some people are healthier than oth-
of populations has been inextrinsically ers and the policy development, research
linked to concepts of both epidemiology and agenda, and resource allocation that flow
economics. from this” (p. 4). Young (2004) lays out a tra-
In an article titled “Producing Health, jectory for population health studies based
Consuming Health Care,” evans and on description, explanation, prediction, and
Stoddart (1990) merged concepts and prin- control. Specifically, Young (2004) supports
ciples from economics and epidemiology that the state of the health of a population
to support that health is determined by should be first described to identify prev-
multiple factors. In a book titled Purchasing alent health problems. Once problems are
Population Health: Paying for Results, Kindig identified, explanations should be sought in
(1997) defined population health as “the relation to “why the state of health is what it
aggregate health outcome of health adjusted is” and “why certain problems occur” (p. 6).
life expectancy (quantity and quality) of Then, according to Young, results of studies
a group of individuals, in an economic of disease patterns and their determinants
framework that balances the relative mar- should be used to predict health effects and
ginal returns from multiple determinants strategies for risk avoidance. In the end,
of health” (p. 47). Kindig’s definition pro- knowledge from these population health
posed a unit of measure for population studies can be translated into health policy
health and underscored a relationship to prevent disease and promote health.
between economics and health. In an arti- In the study of determinants of pop-
cle titled “What Is Population Health?” ulation health, population is defined
Kindig and Stoddart (2003) attempted to demographically, politically, and/or geo-
distinguish population health from public graphically. Health is most often defined
health, health promotion, and social epi- as “a state of complete physical, mental and
demiology. Following a critique of existing social well-being and not merely the absence
definitions and understandings of popula- of disease or infirmity” (World Health
tion health dating back to the early 1990s, Organization, 1948, p. 100), and determinants

POPUlATION HeAlTH n 409



are defined as factors (events, characteristics) improve population health. Built on consen-
that affect health (Department of Health and sus and rooted in an operational framework,
Human Services, 2000; evans & Stoddart, these leading health indicators are identified P
1990; Kindig, 2007). “A clear conceptual as (1) physical activity, (2) overweight and
framework for the selection and use of indi- obesity, (3) tobacco use, (4) substance use,
cators may help point to the dimensions of (5) responsible sexual behavior, (6) mental
population health of import, and lead to health, (7) injury and violence, (8) environ-
more balanced discussions about what indi- mental quality, (9) immunization, and (10)
cators should be targeted . . . to impact pop- access to care.
ulation health” (etches, Frank, Di Ruggiero, In Canada, the document titled “The
& Manuel, 2006, p. 44). Ideal indicators are Population Health Template: Key elements
as follows: built on consensus, based on a and Actions that Define a Population Health
conceptual framework, valid, sensitive, spe- Approach” consolidates current understand-
cific, feasible, reliable, sustainable, under- ings of population health and outlines pro-
standable, timely, comparable, and flexible cedures and processes for implementing a
(etches et al., 2006). population health approach. In the Health
evans and Stoddart (1990) proposed a Canada (2001) template, population health
framework for the study of determinants of is defined as “the health of a population as
population health, incorporating this pre- measured by health status indicators and as
mise of ideal indicators and depicting the influenced by social, economic, and physi-
complex casual relationships between health cal environments, personal health practices,
and function, disease, well-being, health care, individual capacity and coping skills, human
individual behavior and biology, social envi- biology, early childhood development, and
ronment, physical environment, and genetic health services” (p. 2). Addressing the notion
environment. Purposed to promote under- that population health is both a concept of
standing of the determinants of population health and the study of determinants of
health and the discussion and formulation health, the population health template is a
of policy, the evans and Stoddart framework framework in which eight key elements of
has been foundational to shaping national a population health approach are identified:
health goals. In the United States, Healthy (1) focusing on the health of populations,
People 2010 outlines a systematic approach (2) addressing the determinants of health and
for improving the health of the nation based their interactions, (3) basing decisions on evi-
on two broad goals, increasing the quality dence, (4) increasing upstream investments,
and years of healthy life, and eliminating (5) applying multiple strategies, (6) collab-
health disparities (Department of Health and orating across sectors and levels, (7) using
Human Services, 2000). Incorporating both mechanisms for public involvement, and
ideal indicators and determinants of health (8) demonstrating accountability for health
into a plan for population health improve- outcomes (Health Canada, 2001).
ment, Healthy People 2010 underscores the Population health is focused on
necessity of monitoring and evaluating deter- improving the health status of populations,
minants (biology, behavior, social and phys- enhancing health care quality and access,
ical environment, policies and interventions, and decreasing costs. A population health
and access to quality care) in understanding approach targets entire populations; inter-
a population’s health status. leading health venes with families, communities, systems,
indicators are identified to facilitate under- and individuals; recognizes and emphasizes
standing of the importance of health promo- multiple determinants of health; incorpo-
tion and disease prevention and encourage rates primary, secondary, and tertiary pre-
participation in developing strategies to vention; and includes ongoing assessment,

410 n POPUlATIONS AND AGGReGATeS



monitoring, and improvement. Population facts about a sample drawn from that pop-
health research can be used to describe, to ulation or universe” (p. 89). In statistics, pop-
P explain, to predict, and to control. Keys for ulation characteristics are called parameters
effective study of the determinants of health and are denoted by Greek letters, and sample
include a conceptual framework and health characteristics, called statistics, are denoted
indicators that are valid, sensitive, specific, by Roman letters. According to Blalock, in
feasible, reliable, sustainable, understandable, inductive statistics “it is the population,
timely, comparable, and flexible. These keys rather than any particular sample, in which
are essential to accomplishing the ultimate we are really interested.” As a matter of con-
goal of population health research, which venience, a sample is selected but the goal is
is to translate knowledge gained from the “practically always to make inferences about
results of population health studies into pol- various population parameters on the basis
icy that can be used to prevent disease and of known, but intrinsically unimportant sam-
promote health. ple statistics” (p. 90). The underlying founda-
tion for making inferences from samples to
Sandra C. Garmon Bibb the population is the mathematical theory of
probability.
Within the health field, particularly in
public health and the disciplines of epidemi-
PoPulations anD ology and biostatistics, and the nursing spe-
cialization of public health nursing, the term
aggregates population usually refers to biological enti-
ties such as people, animals, or microorgan-
isms that hold characteristics in common.
The term population has come into the lan- Population has a very prominent position
guage of nursing by way of public health spe- in epidemiology. In discussing the classical
cialists and statisticians. It has importance understanding of epidemiology, J. N. Morris
because of its meaning to both researchers (1964) referred to it as “the study of the health
and practitioners. In a very broad sense, the and disease of populations” (p. 4). More
term population refers to a collection of enti- recently, Mausner and Kramer (1985) defined
ties that have one or more characteristics in epidemiology as “the study of the distribu-
common. The characteristic may be defined tion and determinants of diseases and inju-
in many ways, in terms of place, time, or a ries in human populations” (p. 1).
personal characteristic. According to Kendall Historically, public health specialists
and Buckland (1960), “in statistical usage the such as health officers focused on popula-
term ‘population’ is applied to any infinite tions and subpopulations as the target for
collection of individuals. It has displaced planning, service programming, and evalu-
the older term ‘universe’ … it is practically ation efforts. Although public health nurses
synonymous with ‘aggregate’ and does provided clinical services in public health
not necessarily refer to a collection of liv- programs directed to target populations such
ing organisms” (p. 223). The conception of as children younger than 6 years or prenatal
a population is basic to an understanding clients, their predominant focus was clini-
of inductive or inferential statistics. Stated cal, at the level of the patient or the family.
succinctly by Blalock (1960), “the purpose The idea of taking a population approach to
of statistical generalizations is to say some- the practice of public health nursing began
thing about various characteristics of the to appear in public health nursing discus-
populations studied on the basis of known sions and literature in the 1970s. In a 1977

POPUlATIONS AND AGGReGATeS n 411



paper, Williams pointed out the conceptual The conceptual shift from a focus on
and sematic muddle that surrounded what individual patients, the thrust in the clinical
was then referred to as either community preparation of nurses, to a focus on popula- P
health nursing or public health nursing, tions, which is the concern of public health,
terms which were used interchangeably. can be difficult. The basic idea in popula-
Williams suggested that community and tion-focused practice, the essence of public
public health nursing were defined primar- health practice, is that problems are defined
ily in terms of where care was provided and at the population level using a variety of
that the majority of the efforts of nurses assessment strategies and solutions (inter-
who were identified as public health nurses ventions) such as policy development and/
or community health nurses were actually or the implementation of particular services
individualistic in focus, directed to specific or programs for a defined population or sub-
individuals or families. Williams recom- population as opposed to diagnoses or inter-
mended that to increase effectiveness, public ventions at the level of the individual client
health nurses needed to adopt a population or patient (Williams, 1996, 2005). Since the
perspective in defining problems and merge 1970s, public health nursing has incorporated
the population focus with their understand- a strong population perspective as evidenced
ing of the needs of individuals and families by the Scope and Standards of Public Health
in proposing and implementing interven- Nursing published by the American Nurses
tions (Williams, 1977). Association (2007) and supported by public
In discussing what population-focused health specialty organizations.
nursing meant, Williams (1977) introduced Numerous changes have taken place in
the term aggregate to the public health nurs- health care in the last 30 years, particularly in
ing literature to broaden the idea of a popula- financing and in the science underlying prac-
tion to denote groups of people who had one tice. One of the most significant drivers of
or more characteristic in common but might change has been what Starr (1982) described
not be part of a defined community, geograph- as the industrialization of health care, the
ically or sociologically. In other words, it was massive introduction of private capital to
meant to expand the idea of a population finance health care provider organizations,
to be more flexible in grouping individuals and the development of various technologies
to see patterns that would be missed if one used in health care. Other drivers have been
looked only at the individual and not a mean- of federal-level decision about the use of the
ingful groupings (aggregates) of individuals. public dollar in paying for health care for
Williams also reflected on the importance those with Medicare and Medicaid coverage
of preparing nurses with other areas of spe- and decisions by health insurance compa-
cialization in aggregate-level skills and in nies, which led to the adoption and spread of
developing practice models, which clearly various prospective payment schemes. Such
demonstrate effective integration of clinical schemes have brought the population perspec-
approaches and strategies for dealing with tive front and center in health care decision
aggregate-level data. making. This is so because so many decisions
What happened to the term aggregate? are made using aggregate or population-level
Although it is still used by some, particu- data. Such decisions include the following:
larly in the international health literature what services will be provided to whom, for
(see Mackenbach, Bouvier-Colle, & Jougla, what types of problem, in what setting (e.g.,
1990), the term population has emerged as in hospital, home, primary care office), by
the term most frequently used in the United whom (which provider groups), and who will
States. pay (private payers, government payers, self-

412 n POSTPARTUM DePReSSION



pay). From a purely economic perspective, a analysis, microsystem, mesosystem, and
population perspective is essential. However, macrosystem. The importance of a pop-
P there is a more important reason for nurses ulation perspective for those who wish to
and other professionals to adopt a popula- assume leadership roles in nursing and
tion perspective and become proficient in health care led the faculty at the University
it. A population perspective is essential for of Kentucky to emphasize a population
research utilization, and it is important in perspective in their doctor of nursing prac-
the pathway to improving health care and tice (DNP) program and make it one of the
patient/client outcomes. four foundational concepts of the DNP
Today there is much attention to curriculum. The other three were research
evidence-based decision making in care utilization/ evidence-based decision mak-
delivery and in the preparation of health ing, processes of change in organiza-
professionals. Taking an evidence-based tional settings, and leadership (Williams,
approach to decision making in nursing Stanhope, & Sebastian, 2001; Chism, 2010).
entails being able to integrate information As the national dialogue about a prac-
from the literature (body of knowledge) and tice doctoral degree for nursing unfolded
apply it to problems in practice. Researchers in 2004 and the essential content for DNP
study samples of populations with specific programs was identified, it is clear that
characteristics. The extent to which a find- the nursing community saw the benefit of
ing in a sample from a particular population a population perspective and embedded
can be predicted in another can be assessed it in the essentials of Doctoral education
primarily by determining the comparability for Advanced Nursing Practice (American
between the populations. If the individuals Association of Colleges of Nursing, 2006), a
in a clinical or community-based program document guiding the development of cur-
were identified as a population or subpopu- ricula for DNP programs nationwide and
lation, with key characteristics in common, the accreditation of DNP program by the
rather than unique individuals, the program Council of Collegiate Nursing education.
population could be compared with another
studied population. For example, nurses Carolyn A. Williams
working with older adults hospitalized with
heart failure can obtain data on their popu-
lation and compare their population to the
sample which Naylor et al. (2004) studied in PostPartum DePression
their randomized controlled trial of transi-
tional care for heart failure patients. If they
determine that the two populations are sim- Postpartum depression (PPD) is an impor-
ilar in important ways, they are in a good tant public health problem because of its
position to infer that the intervention used by prevalence worldwide and substantial
Naylor et al. might work for their population. associated risks. PPD is believed to affect
However, if the intervention is implemented, more than 14% of women following deliv-
it would be important to monitor what hap- ery according to the U.S. Agency of Health
pens in their population. Care Research and Quality (Gaynes et al.,
Although a population-focused app- 2005). However, when self-report depres-
roach has traditionally been central to sion measures are used to identify women
public health practice, it is not recognized with milder symptom levels, including
by many that a population perspective is women from countries other than the
essential to decision making in all areas of United States, higher percentages have
health care practice and at various levels of been reported. According to the Diagnostic

POSTPARTUM DePReSSION n 413



and Statistical Manual of Mental Disorders, major risk factors associated with the devel-
fourth edition, text revision (American opment of PPD. A range of risk factors have
Psychiatric Association, 2000), diagnostic been identified with the development of PPD, P
criteria specify onset within 4 weeks post- including a history of depression, difficult
partum. The most frequent symptoms are infant temperament, marital or partner rela-
feelings of inadequacy, sadness, fatigue, tionship problems, child care stress, low self-
anxiety, worry, compulsive thoughts, and esteem, and poor social support. Depressive
diminished functioning that can occur symptoms in mothers of prematurely born
from within 2 weeks postpartum to beyond infants were associated with the stress of
1 year. Women experiencing PPD can expe- their infants’ hospitalizations and maternal
rience symptoms severe enough to require role issues in postpartum (Miles, Holditch-
a combination of pharmacological inter- Davis, Schwartz, & Scher, 2007). Results
ventions and either short- or long-term from a national U.S. survey of 1,359 women
counseling and therapy and even hospital- conducted in 2002 (“listening to Mothers”)
ization. Concerns about the risks of medi- showed that younger women with less edu-
cation used to treat PPD have included the cation had the highest rates of moderate–
effects on breast milk and the developing severe depression symptoms as measured
infant, although a recent systematic review by the edinburgh Postnatal Depression Scale
of relevant studies to date has indicated (ePDS; Mayberry, Horowitz, & Declercq,
that this problem is dependent on the type 2007). Results from a recent large-scale
of drug used (DiScalea & Wisner, 2009). PPD screening initiative of more than 5,000
PPD is distinguished from commonly women showed that race/ethnicity identifi-
experienced “postpartum or maternity blues” cation other than Caucasian and having less
and postpartum psychosis. Postpartum than a high school education were associated
blues is characterized by onset during the with higher PPD scores (Horowitz, Murphy,
first 2 weeks after delivery, presence of mild Gregory, & Wojcik, 2009). Results from these
depressed symptoms with typically rapid two recent studies with large samples sug-
resolution, and prevalence as high as 80% gest that previous mixed results concerning
in the United States. In addition, postpar- demographic risk factors may have due to
tum blues wane without need for interven- small samples and limited diversity among
tion. Postpartum psychosis, in contrast, is samples. Thus, race/ethnicity identifica-
a rare (1–2 per 1,000) and severe disorder. tion other than Caucasian, very young age,
Symptoms may emerge as early as 1 month and low education may in fact increase the
before delivery, and rapid postpartum onset PPD risk.
within 4 weeks postpartum is characteris- The ePDS is the most widely used
tic. Hallucinations, delusions, and paranoia screening instrument in research conducted
are hallmarks and can be associated with worldwide (Gaynes et al., 2005), and many
suicidal and homicidal ideation. Therefore, single sample studies have been published
risk of harm to the infant is a major concern by nurse researchers from countries all
with psychosis and with severe PPD when over the world. One example of an interna-
cognitive distortions are present (American tional multisite study involved 892 women
Psychiatric Association, 2000). from nine countries, which was designed to
During the last two decades, a major shift compare differences in postpartum depres-
in research has occurred from an emphasis sive symptomatology across samples at 4 to
on treatment of PPD by psychiatrists and psy- 6 and 10 to 12 weeks postpartum (Affonso,
chologists, to a multidisciplinary approach, De, Horowitz, & Mayberry, 2000). Average
to research and treatments. Researchers depression scores for women from countries
have aimed specifically at determining the in which postpartum cultural traditions

414 n POSTPARTUM DePReSSION



are practiced were significantly higher than deliver personalized behaviorally targeted
depression scores for women from europe, interventions to promote sensitive, respon-
P Australia, and the United States—“Western” sive maternal–infant interaction is challeng-
industrialized countries without such wide- ing but is supported by the current research
spread rituals. In focus groups conducted (Horowitz et al., 2009). Thus, researchers
in each of the countries, similar patterns are challenged to test additional interven-
of symptoms were described (Horowitz, tions and cost-effective approaches to deliv-
Chang, Das, & Hayes, 2001). Fatigue and pain ering behaviorally based maternal–infant
were common physical symptoms, with irri- interventions,
tability, anxiety, loneliness, worrying, inde- Nurse investigators are also involved in
cisiveness, and poor concentration being developing and testing alternative screen-
emotional and cognitive symptoms. Role and ing tools for early detection of depression
relationship conflicts were described within symptoms as one step toward preventing
the context of cultural variations. These find- illness severity. The Postpartum Depression
ings demonstrate that additional research is Screening Scale (PDSS) (Beck & Gable, 2001)
needed to explore postpartum cross-cultural is the most promising, 35-item self-report
adjustment problems and to test strategies for instrument to identify women who are at
relieving distressing symptoms. In addition, high risk for PPD. However, although both
a gap in PPD research for immigrant women the PDSS and ePDS are well-tested and
in North America has been identified (Fung available, a major hurdle has been the pro-
& Dennis, 2010). vision of universal depression symptom
Convincing research findings indicate screening of women postdelivery. In the
that a major problem associated with PPD “listening to Mothers II” U.S. national sur-
is disturbances in maternal–infant interac- vey, only 58% of 1573 postpartum mothers
tions. Intrusive or withdrawn patterns of interviewed by telephone or Internet, were
behavior have been linked to delays in infant asked by their caregiver if they had experi-
cognitive and emotional development (Field, enced feelings of depression in the weeks fol-
2010). Dunst and Kassow (2008) concluded lowing childbirth (DeClercq, Sakala, Corry, &
that efforts to modify caregiver sensitivity to Applebaum, 2006). In a nurse researcher-led
their children’s behavior using behaviorally study of 674 mothers who actually screened
based interventions that focused on changes positively for depression symptoms with the
in caregiver contingent social respon- ePDS, 26% were not asked about their emo-
siveness were most effective. In response to tional state by clinicians (Horowitz, Murphy,
this growing evidence, nurse investigators Gregory, & Wojcik, 2009). Because one of the
have studied the efficacy of an interactive interferences with adopting screening pro-
coaching approach delivered by a trained tocols is the lack of adequate information,
home visiting nurse that produced promis- Best practice guidelines and Internet educa-
ing findings in terms of a positive effect on tion programs have recently been developed
maternal infant responsiveness (Horowitz for both health professionals and women
et al., 2001). Until PPD screening is a uni- (Neiman, Carter, van Sell, & Kindred, 2010;
versal practice, identification of mothers at Wisner, logsdon, & Shanahan, 2008),
risk for PPD remains a major challenge to Recommendations for the conduct of
this work. Many mothers decline to partic- future research include studies to exam-
ipate in follow-up services (Horowitz et al., ine: (a) short- and long-term effects of both
2001, 2009). Moreover, delivery of personal- in-person and Internet-based early PPD
ized mother–infant coaching interventions symptom screening procedures and pro-
is labor intensive, for example, via home grams; (b) RCT designs to test the efficacy
visits (Horowitz et al., 2001). Testing ways to of nonpharmacological treatments and

PReGNANCY n 415



counseling approaches for PPD in multiethnic and found two dimensions to their experi-
and multilingual women including interven- ence. The first was a sense that time is up and
tions to enhance the quality of mother–child the second was a shift in expectations from P
interaction; (c) longitudinal studies to exam- the original birth plan. Women varied from
ine the course of maternal depression over welcoming the end of pregnancy to feeling
time using various combinations of counsel- that their body or baby was not ready for birth
ing and follow-up, that is, home visits, pediat- (Gatward et al., 2010). Women in this study
ric encounters, and virtual Internet settings; also identified a lack of meaningful informa-
(d) family research to explore consequences tion related to the process of labor induction.
of PPD on family health and test family- Induction-related worries included concern
oriented interventions; and (e) cross-cultural for both the baby’s and mother’s health and
studies and inclusion of diverse samples to the loss of a natural birth.
document prevalence rates, discern both risk McGrath and Ray-Barruel (2009) exam-
and protective factors, and test innovative ined mothers’ experience with the decision-
culturally relevant interventions. making process regarding subsequent birth
choice when the previous birth was a cesar-
Linda J. Mayberry ean section. The mothers in the study who
June Andrews Horowitz opted for another (elective) cesarean chose it
because of fear and the desire to retain some
control over the birth process. Women made
this decision before or very early in their
PregnanCy pregnancy and did not present themselves as
being open to considering other options.
Stark and Miller (2009) investigated
Nurse researchers continue to be active in barriers nurses face to using hydrotherapy
conducting research related to pregnancy for women experiencing labor pain. Nurses
and its effects on the mother, newborn, fam- perceived institutional factors as significant
ily, and society at large. Some of the most barriers. Individual characteristics of the
recent “hot topics” in pregnancy research nurse (e.g., age, education, and role) were not
include vaginal birth after cesarean section found to be barriers. Nurses in the study who
(vBAC), elective induction of labor and cesar- reported higher rates of epidural anesthe-
ean section “on demand,” pain management, sia and cesarean births at their facility also
outcomes, pregnancy after previous loss, reported more barriers. The perception of
mental health during the childbearing cycle, institutional barriers was seen across differ-
and effects of obesity epidemic on pregnancy ent types of facilities that provided different
weight gain, postpartum weight loss, and levels of maternity services. Nurses reported
outcomes for mothers and infants. fewer barriers in facilities where nurse mid-
Nurse researchers have investigated wives did the majority of deliveries.
women’s experiences with vBAC, hospital Outcomes of pregnancy have been
policies related to vBAC, and cost analyses addressed by nurse researchers in many for-
of the different delivery methods. Nurses mats. lefebvre et al. (2010) examined women’s
have also examined maternal and neonatal perceptions of an integrated model of sub-
outcomes after vBAC when compared with stance abuse treatment during pregnancy.
repeat cesarean section and how to best pre- Women described feeling more comfortable
pare women for the experience. with treatment teams that shared a consis-
Gatward, Simpson, Woodhart, and tent nonjudgmental attitude. Themes that
Stainton (2010) studied women’s perception of emerged from these focus groups included
having labor induced for postdate pregnancy judgment, physician patient communication,

416 n PReGNANCY



team communication, support groups, and healing birth experience. Subsequent births
self-responsibility (lefebvre et al., 2010). after a traumatic birth are an opportunity to
P Nurse researchers have also addressed heal or present the potential to further trau-
women’s experiences during a subsequent matize women.
pregnancy after a pregnancy loss. Woods- Obesity during pregnancy has gained
Giscombé, lobel, and Crandell (2010) exam- increasing attention over the past decade.
ined the impact of miscarriage and parity on Groth and Kearney (2009) interviewed a
patterns of maternal distress in pregnancy diverse sample of low-income women who
and found that state anxiety and pregnancy- delivered an infant in the last year regarding
specific distress were high during the first their perceptions of gestational weight gain.
trimester and decreased as pregnancy pro- Women in the study were concerned about
gressed. However, women with a history of weight gain during pregnancy, but most of
a prior loss tended to have higher levels of them focused on the effects of insufficient
state anxiety in the second and third trimes- gain on the developing fetus, without con-
ters when compared with women who had cern for the risks of excessive gain. Inaccurate
not experienced a loss (Woods-Giscombé information regarding appropriate gesta-
et al., 2010). tional weight gain and the difficulty of return
Depression during the childbearing to prepregnancy weight was common.
cycle has received increased attention in Nurse researchers have also investi-
recent years. Studies have focused on antena- gated weight gain behaviors during preg-
tal depression and postpartum depression. nancy, interventions to improve weight loss
A recent pilot study (Jesse et al., 2010) found after pregnancy, and maternal eating behav-
that an exercise intervention helped low- iors. Obesity and its effects on pregnancy
income women who were at risk for antena- and pregnancy outcomes have also been
tal depression. Dennis (2010) found that peer addressed by nurse researchers. The idea that
support in the form of a volunteer who made fetal genes can be influenced both positively
phone calls to women during the postpartum and negatively by the in utero environment
period contributed to prevention of postpar- is a newer concept that is gaining momen-
tum depression. tum in nursing research, particularly in the
Beck and Watson (2010) examined the area of maternal obesity and later affects on
experience of pregnant women who gave the offspring.
birth to a second child after a traumatic first various health-promoting behaviors
birth. Women in the study met the criteria for during pregnancy have been examined by
posttraumatic stress disorder. Women who nurse researchers. Yeo, Cisewski, lock, and
experience a traumatic first birth tend to have Marron (2010) examined exercise adherence
fewer total children and wait a longer length in pregnant women and found that adher-
of time before becoming pregnant again. ence decreased as gestation increased and
Childbirth-related posttraumatic stress dis- that “top adherers” maintained their level of
order impacted women’s relationships with adherence whereas those with lower levels of
their partner, communication, conflict, emo- adherence decreased their participation (Yeo
tions, and bonding with their infants (Beck et al., 2010). Adherence was also influenced
& Watson, 2010). Four themes emerged from by exercise type and sedentary pregnant
these interviews: riding the turbulent wave women were found to adopt exercise habits
of panic during pregnancy; strategizing: differently than other sedentary populations
attempts to reclaim their body and complete (Yeo et al., 2010).
the journey to motherhood; bringing rever- Weiss, Fawcett, and Aber (2009) inves-
ence to the birthing process and empower- tigated adaptation, postpartum concerns,
ing women; and still elusive: the longed-for and learning needs in the first 2 weeks after

PReveNTION OF PReTeRM BIRTH, PReTeRM lABOR, AND lOW BIRTH WeIGHT n 417



birth of women who experienced cesarean coercion. Reproductive coercion is when a
section. Women with unplanned cesarean male partner tries to force a female partner
sections and those experiencing birth for the to become pregnant. Coercion can take many P
first time reported less favorable adaptation forms, including sabotaging contraception.
than women who had a scheduled (planned) Research in this area is in its infancy but is
cesarean birth or already had a child. Black expected to increase among nurses.
women reported lower social adaptation and In summary, nurse researchers have
Hispanic women had more role concerns. been instrumental in improving care to
Both Black women and Hispanic women pregnant women through their dedicated
reported more learning needs than White research efforts.
women.
Nurse researchers have also investi- Kristen S. Montgomery
gated maternal pushing during delivery.
Kelly et al. (2010) reported a study of delayed
pushing versus immediate pushing in the
second stage of labor among nulliparous Prevention of Preterm
women with continuous epidural anesthe- birth, Preterm labor, anD
sia. Women in the delayed pushing group
had shorter durations of pushing, and low birth weight
maternal fatigue scores, perineal injury, and
fetal heart rate decelerations (the secondary
outcome measures) were similar for both Prevention of preterm birth is the major
groups. Delayed pushing resulted in a sig- maternal–child health issue across devel-
nificant decrease in time spent pushing but oped countries and the leading cause of peri-
did not increase the total time in second natal mortality and long-term morbidity in
stage labor (Kelly et al., 2010). the United States (Ashton, lawrence, Adams,
On a related note, considerable amounts & Fleishman, 2009; Institute of Medicine,
of nursing research efforts have been devoted 2007; Williamson et al., 2008). Despite a
to the prevention of pregnancy and unin- recent slight decrease, preterm births in
tended pregnancy. Much of the prevention the United States have increased 36% since
work has addressed adolescent pregnancy 1984 (Macdorman & Mathews, 2009; Martin,
and interventions for both primary preven- Osterman, & Sutton, 2010). In 2007, 12.7% of
tion and prevention of a second pregnancy U.S. births were preterm compared with 5%
during adolescence. Noone and Young (2010) to 7% in most developed countries (Ashton
found that characteristics and behaviors of et al., 2009; Domingues, Matijasevich, &
adolescent daughters and mothers were bar- Barros, 2009; Hamilton, Martin, & ventura,
riers and facilitators to adolescent pregnancy 2009). As a result, the United States ranks
prevention. Over half of all pregnancies that 30th in the world for infant mortality. The
occur in the United States are unplanned; reasons for the increase are unclear (Institute
therefore, many women experience of Medicine, 2007; Macdorman & Mathews,
unplanned pregnancy and need resources 2009; Takayama & Matsuo, 2010).
to cope with decision making regarding the Preterm birth, that is, birth occurring at
pregnancy and how to manage the preg- less than 37 weeks of completed gestation, is
nancy. In addition, nurse researchers have associated with significantly increased peri-
examined outcomes for women and infants natal mortality and morbidity, including low
related to unplanned pregnancy. birth weight (<2,500 g). Both neonatal death
An emerging new topic in nursing and morbidity increase as birth weight and
research is the concept of reproductive gestational age decrease. Improvements in