418 n PReveNTION OF PReTeRM BIRTH, PReTeRM lABOR, AND lOW BIRTH WeIGHT
and availability of neonatal intensive care preeclampsia (Allen, Joseph, Murphy, Magee
have decreased infant deaths and stillbirths & Ohlsson, 2004; Honest et al., 2009; Zhang,
P across time (Goldenberg, 2002; Institute of Neikle, & Trumble, 2003).
Medicine, 2007). This improvement, how- Prevention of preterm birth focuses on
ever, has resulted in more low-birth-weight identifying and reducing risk using perinatal
infants being born at the lower limits of monitoring systems and risk screening tools
viability and exceptionally high mortality so that health care providers can intensively
rates (Institute of Medicine, 2007). Preterm monitor women and initiate interventions
neonates who survive experience serious to reduce adverse outcomes (Andolesk &
immediate and long-term neurological Kelton, 2000; Institute of Medicine, 2007;
and developmental morbidities that affect Honest et al., 2009; Jordan & Murphy, 2009;
the family and society (Ashton et al., 2009; lyerly et al., 2009). Factors indicative of
Crowther, Hiller, & Doyle, 2009; Honest increased risk for preterm birth can be phys-
et al., 2009; Institute of Medicine, 2007). The iological, psychosocial, behavioral, and
annual cost of preterm birth to American sociodemographic in nature (Institute of
society is more than $26 billion (Institute of Medicine, 2007). Major physiological risk fac-
Medicine, 2007). tors include a history of previous preterm
Reducing preterm labor and preterm birth, multiple gestation, vaginal bleeding
birth has been stymied by the lack of under- from a placenta previa or abruption, second
standing of the factors that initiate labor and trimester bleeding, and disease states such
the causes of preterm birth (Ashton et al., as hypertension or diabetes (Goldenberg,
2009; Institute of Medicine, 2007; Muglia 2002; Institute of Medicine, 2007; Society of
& Katz, 2010). Causes of preterm birth are Obstetricians and Gynaecologists of Canada,
believed to be due to complex multiple etiolo- 2008). Psychosocial risk factors include prob-
gies of medical complications, biological and lems such as stress, which is associated with
genetic factors, behavioral and psychosocial preterm birth, lower birth weight, small for
issues, exposure to environmental terato- gestational age, fetal birth defects, and devel-
gens, and infertility treatments (Ashton et al., opmental delay (Anhalt, Telzrow, & Brown,
2009; Institute of Medicine, 2007; Muglia & 2007; Giscombe & lobel, 2005; Krabbendam
Katz, 2010). Preterm birth is categorized as et al., 2005; Nkansah-Amankra, luchok,
either spontaneous or elective. The cause of Hussey, Watkins, & liu, 2010; Wadhwa et al.,
spontaneous preterm birth, which occurs 2002). Behavioral risk factors include sub-
in 60% to 70% of pregnancies, is unknown stance use, particularly smoking, which is
and includes diagnoses such as spontane- associated with increased risk of preterm
ous preterm labor or rupture of membranes birth, low birth weight, and small for gesta-
and cervical weakness, placental abruption, tional age (Agrawal et al., 2010; Institute of
and infection (DiRenzo et al., 2006; Honest Medicine, 2007; Raatikainen, Huurrinainen,
et al., 2009; Muglia & Katz, 2010). Between & Heinonen, 2007).
30% and 50% of these births are caused by Sociodemographic risk factors for pre-
infection of the fetal membranes and mater- term birth include the extremes of maternal
nal systemic system, including periodon- age, low education, socioeconomic status, and
tal disease (Crowther, Thomas, Middleton, maternal race/ethnicity (Institute of Medicine,
Chua, & esposito, 2009; Goldenberg, 2002). 2007; Osterman, Martin, & Menacker2009;
elective preterm birth, which occurs in 30% Whitehead, Callaghan, Johnson, & Williams,
to 40% of women, results from medical inter- 2009; Wise, Heffner, & Rosenberg, 2010). Racial
vention for maternal or fetal complications disparities in preterm birth exist (Institute of
such as sepsis, fetal distress, or fulminating Medicine, 2007). The rate of preterm birth
PReveNTION OF PReTeRM BIRTH, PReTeRM lABOR, AND lOW BIRTH WeIGHT n 419
is 17.8% for African American women com- 2007). Some tocolytic drugs temporarily delay
pared with 10% to 11.5% for White, Hispanic, preterm birth, allowing for corticosteroid
Asian, and Pacific Islander women (Ashton treatment, but there is no evidence that toco- P
et al., 2009; Institute of Medicine, 2007; lysis prevents preterm birth (Anotayanonth,
Osterman et al., 2009; Muglia & Katz, 2010; Subhedar, Neilson, & Harigopal, 2010;
Whitehead et al., 2009). The causes of dispar- Crowther, Hiller, et al., 2009; Goldenberg,
ity are unclear (Institute of Medicine, 2007; 2002; Institute of Medicine, 2007). Antibiotics
Fry-Johnson & Rowley, 2010; Muglia & Katz, are used for treating suspected maternal
2010; Paul, Boutain, Manhart, & Hitti, 2008; infections, especially Group B streptococcus,
Whitehead et al., 2009). The use of risk assess- which is a cause of significant neonatal mor-
ment tools, however, has not been successful bidity and mortality, but are not effective for
in predicting preterm birth. Between 10% and the single purpose of preventing preterm
30% of women designated as high risk have birth. Cervical cerclage is also ineffective,
normal outcomes, and 20% and 50% of those but further research is needed to differenti-
designated as low risk have a preterm birth or ate the various causes of a shortened cervix.
low-birth-weight infant (Andolsek & Kelton, lastly, there is also no evidence for the effi-
2000). Others report, however, that concep- cacy of maternal hydration, sedation, home
tualization of pregnancy as at risk leads to uterine monitoring, and bed rest (Institute
unnecessary interventions (Jordan & Murphy, of Medicine, 2007; Maloni, 2010; Meher,
2009; lyerly et al., 2009). Abalos, & Caroli, 2010; Say, Gulmezoglu, &
The goals of treatment to prevent pre- Hofmeyer, 2010; Sosa, Althabe, Belizán, &
term birth are to reduce uterine contractions Bergel, 2010).
in order to delay time to delivery and to opti- Some interventions are associated
mize fetal status (Goldenberg, 2002). Delay with adverse effects and are of concern.
of birth allows time for fetal development to Tocolytic drugs are associated with mater-
offset the effects of extreme low birth weight nal pulmonary edema and cardiac arrhyth-
and prematurity and for administration of mia, and magnesium sulfate is associated
a single course of antenatal corticosteroids with increased fetal and neonatal death
that stimulate fetal lung development and (Anotayanonth et al., 2010; Crowther
reduce neonatal respiratory distress syn- et al., 2009; Goldenberg, 2002; Institute of
drome (Crowther & Harding, 2009; National Medicine, 2007). Antepartum bed rest is
Institutes of Health, 1994). Delay also allows associated with an array of physiological and
transfer to a tertiary medical center, as birth psychological side effects, including mus-
near a neonatal intensive care unit is a major cle atrophy, cardiovascular deconditioning,
predictor of neonatal survival (DiRenzo maternal weight loss, and decreased infant
et al., 2006; Goldenberg, 2002; Institute of birth weight, depression, and major family
Medicine, 2007). problems (Maloni, 2010). In contrast, leisure
There is considerable variation in the physical activity is associated with a reduc-
management of preterm labor and preterm tion in preterm birth (Domingues et al.,
birth prevention (Goldenberg, 2002; Institute 2009; evenson, Siega-Riz, Savitz, leiferman,
of Medicine, 2007). Therapeutic treatments & Thorp, 2002; Institute of Medicine, 2007).
include tocolytic drugs, antibiotics, cervi- The repeated use of ineffective interventions,
cal cerclage, bed rest/activity restriction, especially those with major side effects, sug-
hydration, sedation, home uterine monitor- gests lack of attention to research evidence
ing, nurse home visitation, and psychoso- and also suggests that evidence-based prac-
cial support, but the majority are ineffective tice has not been well integrated into obstet-
(Goldenberg, 2002; Institute of Medicine, ric clinical practice (Fox, Gelber, Kalish, &
420 n PRIMARY NURSING
Chasen, 2009, Goldenberg, 2002; Maloni,
2010; Muglia & Katz, 2010; Sprague, O’Brien, Primary nursing
P Newburn-Cook, Heaman, & Nimrod, 2008).
It is unclear whether preterm birth is
preventable (Ashton et al., 2009; Institute of Primary nursing is a delivery system for
Medicine, 2007; Muglia & Katz, 2010). Both nursing care. A delivery system is a set of
the Institute of Medicine and the Surgeon organizing principles that is used to deliver
General call for increased multidisciplinary a product or service. It generally consists of
research efforts into biomedical and epidemi- four elements: decision making, work allo-
ological factors and psychosocial and behav- cation, communication, and management.
ioral issues (Ashton et al., 2009; Fry-Johnson There are four prototypical delivery systems
& Rowley, 2010; Honest et al., 2009; Institute used in hospital nursing: functional nursing,
of Medicine, 2007; Muglia & Katz, 2010). team nursing, total patient care, and primary
Increased understanding of the process of nursing. each of these systems defines the
parturition, the multiple causes of preterm four organizing elements differently.
birth ,predictive biomarkers, risk factors, Primary nursing clearly allocates deci-
and the factors influencing the rise in pre- sion-making responsibility for care delivery
term births is needed before effective inter- and care management to a specific RN. This
ventions can be created (Ashton et al., 2009; individual establishes the responsibility
Institute of Medicine, 2007). Future efforts relationship by explaining it to the patient
to prevent preterm birth include implemen- and his or her family. Commensurate with
tation of evidence-based practice assisted by this responsibility, the RN has the author-
professional education and training, and a ity to decide, in partnership with the patient
return to doing what works, such as regional- whenever possible, how nursing care will
ization of perinatal care rather than interho- be given to this patient. This plan of care
spital competition driven by reimbursement is to be followed by others caring for the
(Braillon & Bewley, 2010; Goldenberg, 2002; patient when the primary nurse is not there,
Institute of Medicine, 2007). Further, recon- unless the patient’s condition changes. The
ceptualization of prenatal care is needed as primary nurse role includes giving direct
the current model does not meet the needs of care as well as comprehensive patient care
women at risk for preterm birth, particularly planning and coordination. Full implemen-
when intensive monitoring occurs during the tation of the primary nursing system has a
last weeks of pregnancy and not when early major impact on all roles and relationships
signs of complications emerge (Goldenberg, among the staff and among other health
2002; lu, Tache, Alexander, Kotelchuck, & professionals.
Halfon, 2003; Maloni, 2010). Prenatal care for Primary nursing is the only nursing care
high-risk pregnancies also needs to include delivery system that clearly establishes the
intrapregnancy care for continued follow-up role autonomy characteristic of a true pro-
between pregnancies to improve maternal fession. Successful implementation requires
preconception health (Ashton et al., 2009). a transformational change process. On the
Ultimately, increased access to insurance basis of the theory of decentralized deci-
and provision of quality woman’s health care sion making, the system requires the staff to
across the life span, beginning at birth, may become empowered, which in turn mandates
be most effective in promoting both maternal a workplace culture that includes good team-
and fetal/neonatal health (Ashton et al., 2009; work and effective leadership.
Maloni, 2010). Primary nursing was developed by
a staff of nurses on a 23-bed medical unit
Judith A. Maloni at the University of Minnesota Hospitals
PRIMARY NURSING n 421
in 1968. The overall project goal was to formal definition, many leaders in both edu-
improve the delivery of support services to cation and practice have assumed that to be a
nursing units, and Station 32 was the pilot requirement. In the first wave of implementa- P
unit. In the course of multiple changes in tion of primary nursing in the United States
a wide variety of services, frustration with in the 1970s and 1980s, some nurse leaders
team nursing led the staff to innovate in used it as a way to increase the RN ratios in
organizing their own work. As their prac- their skill mix, thus perpetuating the myth of
tice changed, it became apparent that a new the all-RN staff. However, by the 1990s, staff
delivery system was being created. The reductions across the United States forced
result of that innovation became primary reintroduction of larger numbers of support
nursing. It is important to note that this staff, with the result that many nurse man-
development was initiated by the nursing agers felt they had to give up primary nurs-
staff of an operating unit. ing. To this day, these misconceptions about
The year l970 saw the first seminar pre- resource requirements for primary nursing
senting primary nursing to the nursing com- are believed by many health care industry
munity and the first published article about leaders.
it, Primary Nursing: A Return to the Concept of Abbreviated lengths of stay, 12-hour
“My Nurse” and “My Patient” (1). Throughout shifts and part-time positions have all con-
the 1970s, interest in primary nursing was tributed to a commonly held belief that pri-
steady but had not yet led to an organized mary nursing does not work in short-term,
movement. Several hospitals quickly real- high-acuity situations. However, recent
ized the benefits to patients and nurses. The innovations in implementing the fundamen-
nursing departments at Boston Beth Israel tal delivery system principles have resulted
Hospital, led by Joyce Clifford, and evanston in changes in both role expectations and role
Hospital, led by June Werner, were early management. The simple notion of short-
adaptors and were recognized as outstand- term goals for short-term patients has freed
ing models of full implementation of a pro- nurses to achieve implementation that is
fessional practice model. pragmatically appropriate for the fast pace
The concept continued to spread gradu- of today’s hospitals. The understanding
ally across the United States and then to other that a responsibility relationship enhances
countries. The Practice of Primary Nursing (1) patient care and creates a more professional
was published in 1980. Articles on the sub- role for RNs is reemerging in today’s prac-
ject appeared in American nursing journals tice settings.
throughout the 1970s and 1980s. The wide variety of settings in which
There was a continuous call for research nurses practice today has also resulted in
to prove the benefits of primary nursing. recognition that primary nursing works in
The challenge of conducting well-designed any setting. It is about establishing a respon-
research projects within the context of oper- sibility relationship between a nurse and a
ating patient care units has consistently been patient—whether in the patient’s home, a
recognized. Despite these difficulties, hun- long-term care setting, an ambulatory cen-
dreds of studies and articles have been pub- ter, or an acute-care setting. Primary nurs-
lished globally. ing is a responsibility relationship that
A misconception that has plagued pri- enhances patient care and the profession of
mary nursing is the myth that more RNs and/ nursing.
or more staff in general are required for its Although changes in the health care sys-
implementation, making it more expensive tem seem to frequently negatively impact pri-
than other care delivery systems. Although mary nursing, the experience of more than
an all-RN staff has never been part of the 40 years demonstrates that after a period
422 n PRIMARY NURSING
of initial adjustment, interest in primary the hospital culture. When this level of sys-
nursing returns, and nurses again apply tem wide change is successful, patients will
P the organization principles to the new real- experience, in addition to a primary nurse, a
ity to return to relationship based care. The primary physical therapist, primary pharma-
application of these principles throughout a cist, and so forth.
hospital system, often called Relationship-
Based Care, results in positive changes to Marie Manthey
Q
about a phenomenon, when little is known
Qualitative ReseaRch about a topic, or when new perspectives are
needed. Secondary purposes for naturalistic
approaches include generating hypothesis,
Qualitative research includes all modes of obtaining the range of possible items for
inquiry that do not rely on numbers or sta- instrument development, providing illustra-
tistical methods. However, the terms qualita- tive examples or cases, and delineating the
tive and quantitative research are misnomers, context from which other data may be better
albeit commonly used. The terms qualitative interpreted.
and quantitative actually refer to the forms of There are several features that are com-
the data, not to specific research designs. It mon to most naturalistic studies. A basic
is more accurate to discuss naturalistic and tenet is that reality is socially constructed;
positivistic designs during which qualitative as such, there are multiple realities for any
or quantitative data may be collected. For this phenomenon, given the multiple lenses
reason, the subject usually considered under through which different individuals per-
the topic of qualitative research will be called ceive and experience a situation. Naturalistic
naturalistic inquiry here. approaches favor conducting research in the
Naturalistic approaches comprise a wide field setting (vs. an artificial laboratory) to
array of research traditions, most often in the observe phenomena as they are lived and to
categories of ethnography, grounded theory, preserve the contextual elements of the phe-
and phenomenology, but they also include nomena. In contrast to positivist approaches,
ethnology, ethnomethodology, hermeneu- which use established instruments, in natu-
tics, oral and life histories, discourse analysis, ralistic inquiry, the investigator is the instru-
case study methods, and critical, philosoph- ment. However, investigators are aware that
ical, and historical approaches to inquiry. their own experiences, biases, and percep-
Each tradition has a distinct set of undergird- tual sets particularize both the data that
ing philosophical or theoretical orientations, they elicit from informants and ultimately
strategies for data collection and analysis, the data analysis and interpretation. There
and forms of research products. are generally accepted standards for rigor in
The ultimate purpose of all research is naturalistic approaches. These include the
the generation of new knowledge. However, degree of intimacy of the investigator to the
different modes of inquiry produce different informants, the auditing of interviews and
kinds of knowledge. Knowledge developed coding structures, trustworthiness, depend-
from naturalistic methods is at the level of ability, conformability, meaning in context,
rich description or in-depth understand- and saturation/redundancy.
ing. Naturalistic inquiry tends to be explor- Naturalistic approaches (also known as
atory in nature and is particularly useful in constructivist or inductive inquiry, Paradigm II,
identifying important contextual features of or field approaches) are often contrasted with
the phenomenon. Naturalistic approaches positivist approaches (also called empiri-
are called for when the purpose of the cism, Paradigm I, or experimental approaches).
research is to obtain in-depth information Naturalistic and positivistic modes of inquiry
424 n QuAlITATIvE RESEARcH
provide different types of data. However, naturalistic methods (although positiv-
these data sets are most fruitfully viewed ist approaches predominated in both jour-
Q as complementary rather than in opposi- nals). With the advent of the Western Journal
tion. Together, they provide a more complete of Nursing Research in 1978, edited by Brink,
understanding than can be obtained by using there emerged an outlet with a balanced
either approach singly. Sometimes the meth- representation of qualitative research. In
ods can be employed simultaneously (meth- 1976, Paterson and Zderad published a book
odological triangulation); at other times, the based on phenomenological observations,
methods must be applied sequentially to and Brink’s (1976) book contained a series
satisfy the requirements of each. The recip- of methodological articles on conducting
rocal interweaving of naturalistic and posi- qualitative (largely ethnographic) research.
tivist research builds nursing knowledge as Nearly a decade later, two broad-based books
each contributes different but important on qualitative research were published (Field
information. & Morse, 1985; leininger, 1985b). With the
Specific approaches to naturalistic advent of the journal Qualitative Health
inquiry were developed primarily in the Research in 1991, also edited by a nurse anthro-
social sciences and philosophy. For example, pologist, Morse, an entire journal was fully
phenomenology as a method derived from dedicated to reporting naturalistic research.
phenomenological and existentialist philos- The Transcultural Nursing care series orga-
ophy, ethnography from anthropologists’ nized by leininger from 1977 to the present
study of culture, grounded theory, and eth- offered an opportunity for the presentation
nomethodology from sociology (specifically of naturalistic research.
the school of symbolic interactionism). The selection of a particular naturalis-
In the discipline of nursing, there were tic approach depends on the purpose of the
several early reports of qualitative data with- research. For example, phenomenology is
out a specified naturalistic approach. In 1952, the method of choice when the purpose is to
the first issues of the first volume of Nursing understand the meaning of the lived experi-
Research articles report the qualitative results ence of a given phenomenon for informants,
of unstructured interviews. grounded theory is selected to uncover or
In 1962, nurse scientist graduate training understand basic social processes, and eth-
programs were initiated through the divi- nography is selected to understand patterns
sion of nursing for the purpose of increasing and processes grounded in culture.
the number of nurse research scientists with Although most qualitative approaches
doctorates in basic physiological or social sci- do not employ formal theoretical frame-
ences. As a result, many nurses completed works, they do rest on established phil-
programs that trained them in the qualitative osophical assumptions. However, some
methods developed in the social sciences. naturalistic inquiry (particularly ethnogra-
Many nurse anthropologists were trained phy) is conducted in the context of theoret-
during this period. ical orientations that reflect the training of
Over the decade of the 1960s, the num- the investigator and may focus attention on
ber and methodological specificity of nat- particular phenomena, relationships, data
uralistic inquiry increased. By the end of collection techniques, or research products.
the 1960s, Nursing Research had published In most forms of naturalistic inquiry,
articles specifically using grounded the- investigators typically use participant obser-
ory methods, ethnographic methods, and vation, informant interviews, and docu-
other naturalistic approaches. Image: The ment analysis. However, the extent to which
Journal of Nursing Scholarship was initiated the investigator relies on any one strategy
in 1966 and also published research using will vary. For example, phenomenology
QuAlITy OF cARE n 425
relies primarily on informant interviews, medical error mortality and morbidity have
ethnography, and grounded theory and been a continuing epidemic in the united
generally has a more even reliance on partic- States over the past three decades (Brennan Q
ipant observation and interviewing, whereas et al., 1991; HealthGrades, 2010; HHS, 2010).
ethnology relies primarily on observations. Recent studies indicate that patient mortality
Methods for data manipulation include associated with medical errors and subopti-
strategies for taking notes, making memos, mal or substandard medical care in hospitals
and coding and indexing systems. More ranks as the third leading cause of death in
recently, computerized software programs the united States (Heron, 2010; HHS, 2010;
such as ETHNOGRAPH, NuD*IST, and landrigan et al., 2010). Annually, an esti-
MARTIN have been fruitfully employed mated 180,000 Medicare patients die as a
to aid in the management of data. Methods result of harm from the medical care they
used in data analysis are inductive and received during hospitalization, and 27%
include matrix, thematic, and domain anal- (3,216,000) of Medicare patients are harmed
ysis. Finally, the form of the final product by medical care received during hospitaliza-
may vary. In grounded theory, a substantive tion (HHS, 2010). The study findings of HHS
theory with a process model is common; in (2010), HealthGrades (2010), and landrigan
ethnoscience (a form of ethnography), a taxo- et al. (2010) indicate that while there has been
nomic structure is the product. no overall statistically significant improve-
In summary, naturalistic inquiry most ment in medical error morbidity or mortality
commonly occurs in field settings, with rates over the past three decades, there have
investigators collecting data through partic- been significant increases in some categories
ipant observation and unstructured inter- of hospital medical error harm.
views and analyzing data through thematic Attempts to measure the concept of
content analysis. It developed initially in the quality date back to the 1970s and have more
social sciences and began to be incorporated recently taken center stage. Since the release
in nursing research in the 1960s and 1970s. of the landmark Institute of Medicine (IOM,
Today, it is an accepted scientific approach 1999) report that estimated up to 98,000
that complements knowledge derived from patients die annually as a result of hospi-
positivist inquiry. tal medical errors, measuring quality and
reducing health care costs and patient harm
Toni Tripp-Reimer associated with medical care have garnered
Lisa Skemp Kelley renewed emphasis and funding. Efforts
have been made to harmonize common
medical error, patient safety, and quality
lexicon and taxonomy across government
Quality of caRe and nongovernmental enterprises (National
Quality Forum, 2009), although fragmenta-
tion still exists.
Health care quality is commonly assessed care providers today are expected
through measurement of patient safety to provide evidence-based, high-quality,
indicators in hospitals, that is, analyzing accountable, and patient-centered care at
hospital administrative data and conduct- a reasonable cost while attending to the
ing nurse and physician retrospective chart increasing expectations by consumers for
reviews to identify adverse events or medical more information about care choices and
errors (Agency for Healthcare Research and quality outcome data. Gallagher and Rowell
Quality, 2010b; Health and Human Services (2003) suggested that the provision of out-
[HHS], 2010). Research findings show that come-oriented, cost-effective health care is
426 n QuAlITy OF cARE
no longer a goal but a mandate. Part of the practice nurses to evaluate how the unit’s
issue in health care today, according to the structure and that of the larger organization
Q assumptions presented by these authors, is affect quality of care for the patients under
that the costs, processes, and outcomes of their care. Measures of structure have pri-
care are so interrelated and reciprocal that marily included cost and financial resources
changes in one of these areas may have sig- required to provide care, as well as human
nificant effects on the other components. On resources such as skill mix, staff character-
October 1, 2008, the centers for Medicare istics, patient severity of illness factors, and
and Medicaid Services (2007) implemented environmental factors of the hospital or care
a policy that began a paradigm shift in the agency. During the 1970s and 1980s, patient
established model for quality measurement classification systems were developed but
and reimbursement, that is, hospitals will were never extensively implemented. More
no longer be paid for preventable medical recently, diagnosis related groups and
errors defined as hospital-acquired condi- nursing diagnoses are frequently used sep-
tions (HAcs). arately or together to describe patient char-
Recommendations included in the IOM acteristics in research and care effectiveness
(1999) report on the quality of health care evaluations.
in hospitals remain a focal point of national A second component of quality is process
efforts to improve the quality of health care quality, which focuses on the interactions of
in the united States. The IOM stated that nurses with their clients. In nursing, a very
“Health care today harms too frequently and process-focused discipline, we see the histor-
routinely fails to deliver its potential ben- ical contribution of care plans as an impor-
efits” (IOM, 1999). This report further states tant process tool, and more recently, critical
that all health care should be “safe, effective, paths and care maps have added to this pro-
patient-centered, timely, efficient, and equi- cess focus. The best process measures are
table” (IOM, 1999, p. 6). The IOM adopted based on research evidence that the pro-
a definition that states that “quality is the cess leads to better outcomes for patients.
degree to which health services for individu- In today’s health care system, most attempts
als and populations increase the likelihood to measure quality focus on process eval-
of desired outcomes and are consistent with uation by assessing the appropriateness of
current professional knowledge” (IOM, 1999, care and the adherence to professional stan-
p. 244). Patients receive quality care when the dards. Discharge planning and case manage-
services provided are technically competent, ment are nursing interventions included in
provide good communication, share decision the Nursing Interventions classification that
making with the patient and family, and are focus on achieving quality care through a pro-
culturally sensitive. cess format (Dochterman & Bulechek, 2004).
Donabedian’s (1980) model of quality A third component of quality is out-
measurement based on structure, process, and comes, which provides evidence of the effec-
outcome has become the foundation of most tiveness of the interventions nurses provide
current strategies to measure quality of care for the health problems and concerns of
in health care systems. using Donabedian’s patients. The IOM (1999) report states that
model, quality can be evaluated based on the best measures of outcomes are those tied
the three components of structure, process, to the process of care. Attempts by nurses
and outcomes (IOM, 1999). using this frame- to enhance quality strategies, such as criti-
work, structural quality evaluates the capacity cal paths and care maps, have challenged the
of the health care structure to provide high- sacred care plan in nursing and have shifted
quality care. In nursing, this requires lPNs, nurses’ thinking from goals to outcomes.
RNs, nurse practitioners, and other advanced Some of these paths and maps have included
QuAlITy OF lIFE n 427
standardized nursing languages as content measurement programs that provide infor-
areas for nursing. The Nursing Outcomes mation to consumers.
classification (NOc; Moorhead, Johnson, The public health imperative and chal- Q
& Maas, 2004) was developed to mea- lenges to measure quality and improve
sure the effectiveness of nursing interven- patient outcomes are not new issues in the
tions. used with the Nursing Interventions health care system. There is evidence that the
classification and diagnoses from the North genesis of a paradigm shift in the health care
American Nursing Diagnosis Association quality and safety movement is underway.
international, the outcomes are designed What can be viewed as a fourth component
to measure the effectiveness of the nursing has recently been added to Donabedian’s
process. linkage of these three classifica- three-component quality evaluation model:
tions through a recent publication assists The fourth component is an economic incen-
nurses and students to use these languages tive to improve patient outcomes, that is, hos-
more effectively (Johnson et al., 2001). The pitals will no longer be paid for additional
NOc has 330 outcomes that measure along costs associated with certain preventable hos-
a continuum an individual, family, or com- pital medical errors, HAcs. Attention must
munity state, behavior, or perception in remain on these key four factors as nurses
response to a nursing intervention. Each and other health care providers develop bet-
outcome has an associated set of indicators ter structures, processes, outcome measures,
that are measured to determine the patient, and awareness of HAcs to evaluate and
family, or community status in relation to improve the effectiveness of the care we pro-
the outcome. Examples of some of the out- vide. This desire and support for providing
comes relevant to a discussion of quality are safe, high quality of care is central to nursing
pain control, symptom control, quality of practice.
life, participation in health care decisions,
asthma self-management, cardiac disease Patti Hart O’Regan
self-management, risk control, and knowl-
edge disease process. use of this classifica-
tion in practice settings with an evaluation
of the outcomes achieved provides needed Quality of life
knowledge to nurses related to the effec-
tiveness of the interventions provided and
the care planning process. This evaluation Although quality of life (QOl) holds
of real patient data on outcomes allows for inherent meaning to most people and has
a continual review of the structure, process, been studied extensively in a broad range
and outcomes of nursing care. of contexts and from various research
The current environment also is chal- perspectives, the precise definition and
lenged to meet patient expectations. Because measurement of QOl remains elusive.
of this, NOc has added 14 client satisfaction Differences in how QOl is operationalized
outcomes to measure patient perceptions of have made comparisons between studies
their care. Private nonprofit organizations difficult (Garratt, Schmidt, McIntosh, &
such as the National committee for Quality Fitzpatrick, 2002). QOl is composed of
Assurance have been created to improve broad concepts of life satisfaction and
health care. This organization evaluates welfare, including adequate social, educa-
health plans in the areas of patient safety, tional, environmental, political, and eco-
confidentiality, consumer protection, nomic conditions, including accessibility;
access, and continuous improvements. They family safety and well-being; leisure pur-
have both accreditation and performance suits; and physical, emotional, and spiritual
428 n QuAlITy OF lIFE
health (Anderson & Burckhardt, 1999; and data for tracking various aspects of pop-
Bergner, 1989; Frank-Stromberg & Olsen, ulation health (www.cdc.gov/hrqol/index.
Q 2004). However, these (and other) global htm).
QOl concepts may be too broad and inclu- QOl phenomena amenable to nursing
sive to be meaningfully operationalized in studies have enjoyed a long history of pub-
research (Bard, 1984). lished research. using the key terms quality
Thus, interest in the systematic assess- of life and limiting the search to research pub-
ment of specific dimensions of QOl, such lication type and nursing journals, a recent
as health-related quality of life (HRQOl) cumulative Index to Nursing and Allied
has emerged in research and clinical prac- Health literature search yielded 5,147 arti-
tice (Bergner, 1989). One formal definition of cles published between 1977 and August
HRQOl is, “the extent to which one’s usual 2010, with 2,675 or 52% published since 2005.
or expected physical, emotional, and social Similarly, an identical cumulative Index to
well-being are affected by a medical con- Nursing and Allied Health literature search
dition or its treatment” (cella, 1995). This for health-related quality of life yielded 518
definition encompasses both the subjectiv- articles published between 1993 and August
ity and multidimensionality of the concept 2010, with over half (n = 282) published since
of HRQOl, two important aspects of QOl 2006. These data-based research publications
(Aaronson, 1988). The following paragraphs demonstrate the prolific nature of HRQOl
describe QOl in a health-related context for research in nursing.
use in nursing research and practice; thus, QOl research is vital to individual- and
the term QOL is used interchangeably with population-level clinical and policy deci-
HRQOL (varricchio & Ferrans, 2010). sion making and implementation and com-
Nursing and other health care research- parative effectiveness research (Gatsonis,
ers are most often interested in determining 2010; Guyatt, Feeny, & Patrick, 1993; Kaplan
how disease or injury or the treatment of dis- and Bush, 1981; lauer & collins, 2010). The
ease or injury affects QOl. Similarly, health American Recovery and Reinvestment Act
promotion researchers may use specific QOl of 2009 brought comparative effectiveness
constructs to ascertain the effectiveness of research to the forefront in an era of health
measures taken to enhance or improve men- care reform by appropriating $1.1 billion
tal, physical, social, or spiritual health. Health solely to comparative effectiveness research,
care policy makers and third-party payers $400 million to the National Institutes of
may use HRQOl information in public pol- Health, and the remainder to the Agency for
icy and reimbursement decision making. Healthcare Research and Quality (lauer &
The importance of QOl research is collins, 2010). Within this new and evolv-
evident through federal funding of health ing research context, it will be important for
research. For example, strategic areas of QOl phenomena to remain cogent determi-
research emphasis of the National Institute nants of clinical decision making. One of the
of Nursing Research (NINR) include many major challenges for nurse scientists in this
opportunities for research that will improve new research infrastructure will be to deliver
QOl by enhancing individuals’ role in man- meaningful, multifaceted, yet granular QOl
aging disease, relieving symptoms of dis- information for evidence-based clinical deci-
ease and disability, and improving outcomes sion making.
(NINR, 2006). Included in the NINR empha- In a recent concept analysis, Plummer
sis on QOl are self-management, symptom and Molzahn (2009) used critical appraisal
management, and caregiving. The centers for of the literature to enhance conceptual clar-
Disease control and Prevention also have a ity of QOl from a nursing perspective with
division for HRQOl that provides measures five nursing theorists (Peplau, Rogers, King,
QuAlITy OF lIFE n 429
leininger, and Parse). A provisional defini- which allow flexibility in the conceptualiza-
tion was proposed based on the synthesis of tion of QOl while permitting comparability
the theorists’ definitions of QOl as “an intan- of specific dimensions across studies (Frank- Q
gible, subjective perception of one’s lived Stromberg & Olsen, 2004).
experience” (Plummer and Molzahn, 2009). limitations of QOl research include
Although the theoretical paradigms analyzed (a) lack of meaningful findings that can be
by Plummer and Molzahn (2009) encompass used to base clinical and treatment decisions
the holistic perspective of the lived experi- upon, (b) heterogeneity of treatment effects
ence in QOl, researchable middle-range the- across similar or identical patient popula-
ories can provide the substructures needed tions, (c) varying levels of perceived QOl
to build unique nursing knowledge on QOl and health across time, (d) multicultural
and make comparisons between studies that and linguistic translation of QOl instru-
will sufficiently translate into clinical prac- ments, (e) the amount and complexity of
tice and improved outcomes. factors influencing QOl, and (f) use of sur-
Ferrans and Powers (1985, 1992) devel- rogate measures for QOl, such as health,
oped and empirically verified the Quality symptoms, or functional status, alone for
of life Index (QlI), which has moved the measuring HRQOl (Guyatt, 1997; Plummer
science forward in aspects of QOl where and Molzahn, 2009). In addition, some of
nurses can intervene. Weighted satisfaction the questionnaires are lengthy and complex,
responses based on subjective (i.e., patient) rendering them clinically unusable due to
importance ratings are used in the QlI, such the added measurement burden they would
that scores reflect satisfaction with patient- impose on patients and clinicians. Thus, lit-
valued aspects of life. The QlI produces tle continues to be known about dimensions
five scores, including overall QOl, in four of QOl most amenable to nursing interven-
domains, health and functioning, psycholog- tion. This lack of knowledge is a critical prob-
ical/spiritual domain, social and economic lem because, without this understanding,
domain, and family. Although a generic form delivery of effective interventions aimed at
of the QlI is composed of common items, improving QOl is unlikely. However, efforts
individual versions of the questionnaire con- are being made to address these issues.
sist of additional items pertinent to specific using the example of heart failure, the
illnesses and disorders. Kansas city cardiomyopathy Questionnaire
Methodological and logistic challenges (KccQ), designed to collect subjective
in QOl measurement can be daunting. measures of QOl and other health status
Thorough knowledge of conceptual and psy- measures, has been empirically verified
chometric aspects of a QOl measure is essen- in numerous domestic and international
tial in research. Instruments must adequately studies. The KccQ is a self-administered
capture the conceptualization of QOl and 23-item questionnaire that quantifies heart-
must be sensitive to changes over time. failure-specific domains, including physical
Other considerations needed when selecting limitation, symptoms (frequency, severity,
instruments is the level of measurement (e.g., and recent change over time), self-efficacy,
individuals or populations), the study design social interference, and QOl (Green et al.,
(e.g., cross-sectional vs. longitudinal, quanti- 2000). The KccQ was found to be reli-
tative vs. qualitative), and whether objective, able, responsive, and valid in study com-
subjective, or a combination of both objective parisons with the 6-minute walk test, New
and subjective measures are needed (e.g., york Heart Association functional status
QOl relative to a particular disease or illness, classification, the medical outcomes Short
where objective assessments are included). Form-36, and Minnesota living with Heart
Many studies employ multiple instruments, Failure questionnaire. The KccQ captures
430 n QuANTITATIvE RESEARcH
multiple dimensions of QOl and health summarize study data, to determine sam-
status and may replace the need for using pling error, and in studies in which hypoth-
Q multiple QOl instruments in research and eses are tested, to analyze whether results
practice. Applications of the KccQ have obtained exceed those that could be attrib-
been made in research, quality assessment, uted to sampling error (chance) alone. The
and clinical practice (Heidenreich et al., 2006; important role of statistical methodology
Hertzog, Pozehl, & Duncan, 2010; Soto, Jones, in quantitative research should not obscure
Weintraub, Krumholz, & Spertus, 2004). The the fact that other methodologies and sci-
emphasis for future nursing research must entific disciplines play important roles in
include measures that can be used to sup- nursing research. These methods are used
port clinical decision making in improv- in the delineation of research questions
ing patients’ QOl in health and illness and and hypotheses, exposition of conceptual
to provide the underpinnings for health frameworks and hypotheses, design of data
care policy and reimbursement decisions in collection instruments and tools, and inter-
an era of health care reform and economic pretation of study data, particularly determi-
uncertainty. nation of the clinical significance of the data
and dissemination of findings.
K. M. Reeder Much of the history of nursing research
involves quantitative research. Florence
Nightingale, who was a skilled statistician,
used quantitative measures to describe and
Quantitative ReseaRch evaluate hospital performance (Nightingale,
1858). Studies of nursing in the united States,
beginning in the 1940s, used quantitative
Quantitative research consists of the collec- techniques to survey and analyze nursing
tion, tabulation, summarization, and analysis education and supply and distribution of
of numerical data for the purpose of answer- nurses. In the 1960s, with support from the
ing research questions or hypotheses. The federal government, research in nursing
term quantitative research is of recent origin and began to use advanced research designs,
is distinguished from qualitative research in such as controlled experiments, which made
design, process, and the use of quantification extensive use of quantitative tools, tech-
techniques to measure and analyze the data. niques, and processes.
The vast majority of all nursing studies can Quantitative data collected in quan-
be classified as quantitative. titative research are obtained by the use of
Quantitative research uses statistical measurement scales. There are three distinct
methodology at every stage in the research types of scales: nominal, ordinal, and contin-
process. At the inception of a research pro- uous. Nominal scales consist of two or more
ject, when the research questions are for- ungraded or unranked categories of vari-
mulated, thought must be given to how ables, such as eye color (green, blue, brown)
the research variables are to be quantified, or political affiliation (Republican, Democrat).
defined, measured, and analyzed. Study sub- Ordinal scales possess categories that are
jects are often selected for a research project ranked or graded from high to low, small to
through the statistical method of random large, near to far. Graded scales, such as the
sampling, which promotes an unbiased rep- likert and Guttman scales, are commonly
resentation of the target population among used in nursing research to measure inten-
the sample from whom generalizations will sity of opinions, attitudes, and other psycho-
be made. Statistical methods are used to logical variables. When nominal and ordinal
QuANTITATIvE RESEARcH n 431
scales are used, quantitative summaries of techniques are used to test whether there
the data collected consist of aggregating the are significant relationships among study
number of responses in each scale category, variables that are delineated in the hypoth- Q
converting them to relative frequencies such eses, meaning relationships that cannot
as percentages, and if hypotheses are being be explained by random sampling error
tested in the research, applying one of many (chance). Widely used statistical techniques
nonparametric techniques available to test to test hypotheses include parametric tests
the statistical significance of the data. such as the t test and analysis of variance
continuous scales have continuous and nonparametric tests such as chi-square
quantitative values rather than verbal catego- test and rank–order correlation.
ries, as in nominal and ordinal scales. These Quantification in nursing research has
include the scientific measuring instruments helped advance nursing as a scientific disci-
widely used in nursing to measure variables pline. Quantification offers many advantages
such as temperature, weight, height, and to nursing research. There is a rich set of sta-
blood pressure. continuous measurement tistical tools available for data analysis that
scales have certain advantages over other can be applied to practically every research
scales because they yield more precise and question to assist in summarizing the data
sensitive data. Also, the statistical signifi- and evaluating their statistical significance.
cance of continuous data can be analyzed by The internal and external validity of the data
the more powerful parametric techniques. of quantitative research can be readily veri-
Quantitative research is concerned with fied by other researchers. Results of similar
making generalizations from a study sam- quantitative studies can be synthesized and
ple to a target population, a process called analyzed by the meta-analysis technique to
statistical inference. There are two categories shed new light on the research questions.
of generalizations in quantitative research: Dissemination of the results of quantita-
(a) estimates of the quantitative value of tive research is facilitated by the clarity and
selected characteristics of a target popu- objectivity possessed by quantitative data.
lation and (b) results of tests of statistical Some studies in nursing tend to over-
hypotheses concerning relationships among quantify. Reports of these studies are dom-
variables in the target population. Studies in inated by statistical data and tests, with a
the first category are called descriptive stud- minimum of narrative discussion, providing
ies; those in the second category are called little interpretation of the clinical significance
analytical or explanatory studies. The focus of of results. Sometimes, too little time is spent
many early nursing studies was to describe on evaluation of the quality of data used or
nurses and nursing practice using question- on the appropriateness of the statistical tests.
naire or interview techniques to collect data Qualitative research, with its focus on mean-
from large samples of respondents. Recent ing and interpretation of data, can help to
studies using conceptual frameworks from enrich the results of quantitative studies in
emerging nursing theories and models have nursing. The approach called triangulation,
tested hypotheses in controlled or semicon- which utilizes and integrates methodology
trolled settings. from quantitative and qualitative research in
Statistical techniques are used exten- a single study, can help achieve the best of
sively in descriptive studies to compute sum- both worlds of research methodology.
mary measures, such as means, standard The history of nursing research reveals
deviations, and coefficients of correlation, a trend from purely descriptive studies of
and to determine the sampling error of the nurses and nursing to the evaluation of the
measures. In explanatory studies, statistical effects of nursing care. Properly applied
432 n QuASI-ExPERIMENTAl RESEARcH
quantitative research can advance the scien- Quasi-experimental research is a use-
tific basis of nursing and provide a potent ful way to test causality in settings when
Q tool for defining and evaluating the out- it is impossible or unethical to randomly
comes of nursing care. In the future, quan- assign subjects to treatment and control
titative research will play an increasingly groups or to withhold treatment from some
valuable role in nursing effectiveness stud- subjects. The main disadvantage of quasi-
ies. The randomized clinical trial method, experimental research is the increased threat
perhaps the most quantitative of all research to internal validity (see Experimental Research
methods, will find increasing application for a review of types of design validity).
in nursing as attempts are made to deter- Within quasi-experimental designs, a dis-
mine the efficacy of nursing interventions. tinction is made between preexperimental,
clinically oriented research using methods nonequivalent control group designs and
such as randomized clinical trials requires interrupted time series designs. Note also
development of quantitative outcome mea- that the boundaries between experimen-
sures of variables such as quality of care tal and quasi-experimental research have
and quality of life. This will stimulate quan- blurred. Often, investigators like to define
titative research to provide the needed mea- their study as experimental when in fact it
sures and indicators. As more replications of is quasi-experimental.
quantitative nursing research become avail- Preexperimental designs are the weak-
able, the research synthesis techniques of est of the quasi-experimental designs.
meta-analysis will be increasingly applied They may lack a control or comparison
to expand nursing’s knowledge base. group, observation before the intervention
(commonly known as pretests), or both. Their
Eugene Levine use is strongly discouraged because they
do not permit even remote inferences about
the direction and dynamics of change and
causality.
Quasi-expeRimental Nonequivalent control group designs
refer to situations in which naturally occur-
ReseaRch ring groups of subjects are used as a control
or comparison group or situations in which
it is impossible or unethical to withhold
under Experimental Research in this encyclo- treatment from a given group. Despite the
pedia, the definition of cook and campell absence of randomization, nonequivalent
(1979) that experiments are character- control group designs can be considered rel-
ized by manipulation, control, and ran- atively strong designs. The use of a control
domization was cited. However, when group and a pretest significantly increase
conducting research in field settings, it is the strength of nonequivalent control group
not always possible to implement a study designs. Good pretest data will enable the
design that meets these three criteria. researcher to improve the level of analysis.
Quasi-experimental research is similar When subjects from different settings are
to experimental research in that there is used, a nonequivalent control group design
manipulation of an independent variable. It may control some threats to internal validity,
differs from experimental research because such as compensatory rivalry and demor-
either there is no control group, no random alization of controls. When subjects in each
selection, no random assignment, and/or group are naturally kept separate, it is less
no active manipulation. likely that they will have contact with each
QuASI-ExPERIMENTAl RESEARcH n 433
other, and it is often useful to minimize con- point in time. When the researcher studies
tact between treatment and control groups. one group of subjects, the subjects act as their
In time series designs, the researcher own controls, which provides the researcher Q
does not always use a control group and with equivalent control groups. Time series
does not use randomization. An interrupted designs are used when a control group pop-
time series study uses several observations ulation is not available. When only one group
of subjects over time with a treatment given is available to the researcher, the time series
at a specified point (or longitudinally over design significantly increases the strength of
time, with start and end time points). A time the research.
series study can be designed to study the
same individuals at specified intervals or to Ivo Abraham
study different individuals at some common Karen MacDonald
R
is examined through test–retest procedures;
Reliability equivalence is assessed through alternative
forms and internal consistency techniques.
For observational measurement, intrarater
Reliability refers to the consistency of and interrater techniques assess the two
responses on self-report, norm- referenced forms of reliability, respectively.
measures of attitudes and behavior. Stability reliability is considered by
Reliability arises from classical measurement some to be the only true way to measure the
theory, which holds that any score obtained consistency of responses on an instrument.
from an instrument will be a composite of In fact, stability was the primary manner
the individual’s true pattern and error vari- in which early instruments were examined
ability. The error is made up of random and for reliability. Stability is measured primar-
systematic components. Maximizing the ily through test–retest procedures in which
instrument’s reliability helps to reduce the the same instrument is given to the same
random error associated with the scores, subjects at two different points in time,
although the validity of the instrument helps commonly 2 weeks apart. The scores are
to minimize systematic error (see Validity). then compared for consistency, using some
The “true” score or variance in measurement form of agreement testing that depends on
relies on the consistency of the instrument as the level of measurement. Typically, data are
reflected by form and content, the stability continuous; thus, interclass or bivariate cor-
of the responses over time, and the freedom relation coefficients and difference between
from response bias or differences that could mean scores are usually assessed. An inter-
contribute to error. Error related to content class correlation (ICC) is different than a
results from the way questions are asked bivariate correlation as it is computing the
and the mode of instrument administration. relationship among multiple observations
Time can contribute to error by the frequency of the same variable. Specifically, the ICC as
of measurement and the time frame imposed an assessment of stability is determining the
by the questions asked. Error due to response consistency of measurements made at differ-
differences results from the state or mood of ent times by the same group of individuals.
the respondent, wording of questions that The ICC is calculated based on mean squares
may lead to a response bias, and the testing obtained from analysis of variance (ANOVA)
or conceptual experience of the subject. models. The ICC examines the individual’s
There are generally two forms of reliabil- “error” (consistency) over time as it relates
ity assessment designed to deal with random to “error” inherent in the questionnaire and
error: stability and equivalence. Stability is results in a ratio. The values obtained can
the reproducibility of responses over time. range from 0 to 1, with 1 indicating per-
Equivalence is the consistency of responses fect consistency and no measurement error.
across a set of items so that there is evidence There are no absolute cutoffs for what level
of a systematic pattern. Both of these forms the ICC should be, but a good general rule
apply to self-report and to observations made is that a score below .50 should be carefully
by a rater. For self-report measures, stability scrutinized. An ICC is considered superior to
RElIABIlITy n 435
a bivariate correlation as it accounts for more mean differences in a similar manner to sta-
of the error variance inherent in any measure. bility. Consistency is assumed if the scores
A bivariate correlation tells the investigator are equivalent. Assessment with alternative/ R
whether individuals who scored high on the parallel forms is not comparison with two
first administration also scored high on the different measures of the concept. It is com-
second, but it does not provide information parison of two essentially identical tests that
on whether the scores are the same. were developed at the same time through
The problem with stability is that it is the same procedures. Therefore, a difficulty
not always reasonable to assume that the with this approach to equivalent reliability is
concept will remain unchanged over time. If obtaining a true parallel or alternative form
the person’s true score on a concept changes of an instrument.
within 2 weeks, instability and high random A more common way to look at equiva-
error will be assumed—when, in effect, it is lence is through internal consistency proce-
possible that the instrument is consistently dures. The assumption underlying internal
measuring change across time. Reliance on a consistency is that the response to a set of
2-week interval for measuring stability may scale items should be equivalent. All inter-
be faulty and must be directly related to the nal consistency approaches are based in
theoretical understanding of the concept correlational procedures. An earlier form of
being measured. internal consistency is split-half reliability, in
A special case of stability occurs with which responses to half the items’ on a scale
instruments that are completed by raters on are randomly selected and compared with
the basis of their observations. Intrarater reli- responses on the other half.
ability refers to the need for ratings to remain Currently Cronbach’s (1951) alpha reli-
stable across the course of data collection and ability coefficient is the most prevalent
not change due to increased familiarity and technique for assessing internal consis-
practice with the instrument. The ICC assess- tency. Developed in the 1950s, the formula
ment procedures can be used for intrarater basically computes the ratio of variability
reliability as for test–retest reliability but will between individual responses to the total
utilize slightly different formula looking at variability in responses, with total variabil-
absolute agreement versus consistency. A ity being a composite of the individual var-
kappa statistic also can be calculated when iability and the measurement error. As with
dealing with agreement among observers. the ICC, Cronbach’s alpha is a ratio ranging
However, the ICC is adequate to deal with from 0 to 1, with the values closer to 1 indi-
most of these situations, and the kappa sta- cating less measurement error. The ratio
tistic has no clear advantage over the ICC. reflects the proportion of the total variance
Equivalence is evaluated in two major in the response that is due to real differences
ways. The first of these predated the avail- between subjects. A general guideline for
ability of high-speed computers and eas- use of Cronbach’s alpha to assess an instru-
ily accessed statistical packages. This set of ment is that well-established instruments
techniques deals with the comparison of must demonstrate a coefficient value above
scores on alternate or parallel forms of the .80, whereas newly developed instruments
instrument to which the subject responds at should reach values of .70 or greater. This
the same point in time. Parallelism means should not be taken to indicate that the higher
that an item on one form has a comparable the coefficient, the better the instrument.
item on the second form, indexing the same Excessively high coefficients indicate redun-
aspect of the concept, and that the means dancy and unnecessary items. A special case
and variances of these items are equal. These of alpha is the Kuder–Richardson 20, which
scores are compared through correlation or is essentially alpha for dichotomous data.
436 n REMINISCENCE
Cronbach’s alpha is based on correlational the name suggests is focused on the response
analysis, which is highly influenced by the to individual items. Item response theory
R number of items and sample size. It is pos- requires two critical assumptions be made:
sible to increase the reliability coefficient of (a) the scale is unidimensional and (b) the
a scale by increasing the number of items. A probability of responding to any item is not
small sample size can result in a reduced reli- related to the response to any other item.
ability coefficient that is a biased estimate. A These two assumptions allow for determin-
limitation of alpha is that items are consid- ing the response characteristics of each item,
ered to be parallel, which means that they which then allows for prediction of how any
have identical true scores; When this is not particular subject will respond given a set
the case, alpha is a lower bound to reliabil- of factors. Item response theory takes a next
ity; other coefficients for internal consistency, step beyond reliability and dependability to
based within models of principal components predictability. Consequently, item response
and common factor analysis (e.g., theta and theory can be considered an approach that
omega), are more appropriate. Obtaining an bridges reliability and validity through
adequate alpha does not mean that examina- predictability.
tion of internal consistency is complete. Item
analysis must be accomplished and focused Paula M. Meek
on the fit of individual items with the other Joyce A. Verran
items and the total instrument.
Again, observational measures are a spe-
cial case and require different formulas for
the determination of equivalence. Interrater Reminiscence
reliability refers to the need for ratings to be
essentially equivalent across data collectors
and not to differ due to individual rater var- Butler (1963) described reminiscence and
iability. The ICC is the most appropriate pro- life review as naturally occurring universal
cedure in most situations, although kappa processes characterized by the progressive
based on percent agreement and controlling return to consciousness of past experiences
for chance may also be acceptable. and unresolved conflicts. Today reminiscence
Any discussion of reliability as serves as an umbrella term under which all
approached through classical test theory forms of recalling the past are subsumed and
should note more recent approaches for test particular ways of remembering are often
consistency. Of these, generalizability the- referred to as reminiscence work. life review
ory (G theory) has received the most atten- is a particular form of reminiscence work
tion. Unlike classical test theory reliability, and differs from other forms of reminiscing
G theory can estimate several sources of in that it is more structured, deliberate, and
random error in one analysis; in the process, evaluative. Nurses use reminiscence work for
a generalizability coefficient is computed. a variety of purposes: to promote enjoyment,
Proponents of G theory believe that its con- to encourage communication, to learn about
centration on dependability rather than their clients, to further well-being and to help
reliability offers a more global and flexible their clients come to term with their lives.
approach to estimating measurement error. Though most reminiscence procedures are
Another approach to dependability is verbal, they can also be written as in guided
item response theory that also is not based autobiography, or silent, within oneself. The
in classical test theory. While classical test goal of using reminiscence in a purposeful
theory is generally more focused on the pat- way for therapeutic means differentiates
tern of response to the test, item response as therapeutic ways of recall from others such
REMINISCENCE n 437
as oral history where the purpose is to hear study for a graduate nursing student stating
a life story for history’s sake rather than to she was not as skilled as a psychiatrist.
hear the story to benefit the individual telling The lack of pertinent theories has also R
the story. affected the work in life review. But as other
Reminiscence work was first recognized disciplines became involved in reminiscence
and described by Butler (1963) in a seminal work, most notably psychology and social
article that caused other health care provid- work, there have been definitive gains in the
ers to look more closely at the phenomena of growth and sophistication of the research.
reminiscence, particularly in older people. For example, many researchers see a rela-
Since Butler, many articles have been writ- tionship between therapeutic recall and the
ten by clinicians who happened on reminis- writings of Erickson (1950) and so have used
cence quite by chance and thus wanted to Erikson’s work as a theoretical frame. They
share their experiences and techniques with see life review, particularly, as a means of
others. Though interesting, these first manu- achieving Erikson’s eighth stage of integ-
scripts did not demonstrate knowledge of rity. For nurses, Martha Rogers can provide a
the literature or awareness of the work that framework. The important thing is that the-
was going on around them, giving the manu- ory is beginning to guide the research.
scripts less impact than they would have had Over time, researchers began to define
as informed reports. Nurses who have used and describe their interventions so others
life review and reminiscence can under- could replicate their work. To bring some
stand this situation because often, when they clarity to the field, Webster (2003) created a
used reminiscence themselves, they were reminiscence function scale to describe ways
impressed with the outcomes and improve- of reminiscing. Presently there is a great deal
ment in their clients and wanted to share of interest in how these reminiscence func-
their new knowledge with others. tions work within the person and in how
The early research was often poorly they become therapeutic. A group from the
designed. Very few studies had a theoretical Netherlands has conducted studies look-
basis. Authors that published clinical reports ing at the intervention of reminiscence as a
often did not describe their interventions search for new meaning in life. They have
fully so that the reader was not sure what was gone on to publish even more work, describ-
responsible for what outcomes. One study ing their intervention clearly and differenti-
might examine a 1-hour reminiscence ses- ating it from others, making the process of
sion, whereas another might look at a 6-week replication clearer and easier for those who
approach to remembering the past and then follow. Their greatest contribution is a meta-
try to compare them as the same interven- analysis of the effects of reminiscence on
tion. The interventions were often carried psychological well-being and depression in
out singly or in groups without differenti- older people (Bohlmeijer, Roemer, Cuijpers, &
ating one from another. The outcome mea- Smit, 2007). We are at a point where we can
sures were often unsophisticated and had say that a certain type of reminiscence is
little reliability and validity, again making it effective in reducing depression and we are
hard to compare one outcome with another. closer to figuring out how the positive effect
It was also said that recalling the past might happens.
cause depression, making many clinicians Although the research concerning
and researchers wary of using reminiscence reminiscence and life review is still in its
as a therapeutic tool and also making it dif- adolescence, not in its infancy, nurse clini-
ficult to get a reminiscence study approved cians continue to encounter reminiscence
by an institutional review board. As a matter by chance and adopt it as an intervention,
of fact, one board refused to approve such a without benefit of knowing the research and
438 n REMINISCENCE
what has gone before. Encountering the joys creating a tool to examine nursing student’s
of reminiscence is often an “aha” moment for attitudes was well done with a large enough
R nursing clinicians, and thus they continue to sample size and good analyses. I encourage
publish stories of their surprising success with other nurses to use and reaffirm the tool
reminiscence and with their clients because when they wish to look at and use reminis-
it is a discovery they wish to share. Thus, cence with their nursing students.
the nursing work in reminiscence this past Caring and communicating with
decade is a mixture of research and clinical patients who have dementia has been an
reporting that essentially falls into four cat- important area of interest for nurses over
egories: education, dementia, end of life, and the last decade. Reminiscing and life review
psychological well-being. Nurses use a vari- have been tested as tools and interventions
ety of methodologies to include both quanti- for reaching such patients. lai, Chi, and
tative and qualitative methods, case studies, Kayser-Jones (2004) conducted a randomized
and clinical reports. Nursing research would controlled trial to see if a specific reminis-
improve in this area if more editors refused cence program led to higher levels of psycho-
publications that do not include at least some social well-being in nursing home residents
of the research basis in this field. Nursing who have dementia. They found a significant
knowledge should really be beyond publish- improvement in well-being for those in the
ing what an individual nurse believes to be a intervention group. Moos and Bjorn (2006)
new discovery rather than a work based on a reviewed 28 intervention studies using the
previous database and the extant literature. life story as intervention for nursing home
Nurses have discovered that reminis- residents with dementia but reported that the
cence can be an effective tool for educating studies were too diverse in methodologies to
their students. One educator used a reminis- be able to make a positive blanket statement
cence education program to help students regarding their efficacy. They recommended
appreciate other cultures, thus preparing more rigorous designs that measured a few
more caring and knowledgeable students. precociously defined quantitative outcomes.
While doing this, Shellman (2006) created a Recently, Haight, Gibson, and Michele (2006)
tool to examine student nurse’s confidence conducted a study in Northern Ireland using
in caring for ethnically diverse elders. She a structured form of life review with people
used a large sample of 248 students from who have dementia living in care settings.
seven schools of nursing. Principal factor A multivariate analysis of covariance deter-
analysis revealed a four-factor structure mined significant change by group, particu-
accounting for 61% of the variance that larly on depression (p = .015), communication
provided a useful tool for nurse educators. (p = .005), and cognition (p = .0005).
Shellman (2007) then reported on the effec- End-of-life care provides a natural labora-
tiveness of the tool used with her students tory for testing reminiscence and life review.
after they participated in an integrative Using life review is almost a natural segue
reminiscence program with older people for people who are dying when they wish to
during their community health practicum. put the past in order before they leave their
Those that received the reminiscence pro- present life. When life review is used in ter-
gram were significantly higher in cultural minal care, it must be suited to the needs of
self-efficacy than those who did not. There the patient who may be very weak and tired.
is more in the literature about nursing edu- Time for the sessions can be shorter, and the
cators using life review and reminiscence sessions themselves can be more frequent
than there was prior to this decade, but most while the dying person still has strength.
of what is there is still observational report- Often at this stage of life, the dying patient
ing. However Shellman’s (2007) work in will initiate the life review themselves and
REMINISCENCE n 439
the nurse just needs to tap into the ongoing a randomized controlled trial, Hanaoka and
dialogue. Ando (2003) used a shortened life Okamura (2004) looked at the effect of life
review of only 1 week with 68 terminally ill review activities on the quality of life in 80 R
cancer patients after testing both short- and older persons. Repeated measures showed
long-term life review with young adults and direct effects on scores of depression and
found that they both promoted young adults’ hopelessness 3 months after completing a
immediate psychological well-being. With group life review intervention.
terminally ill cancer patients, a short-term In summary, there has been growth in
life review was effective in improving spiri- nursing research on reminiscence work. Now,
tual well-being and promoting a good death 10 years later, the research is clearer, the defi-
(Ando, Morita, Akechi, & Okamoto, 2010). nitions made, more work is replicated, and
Ando’s research is thoughtful and builds on the field is moving ahead with more authority
itself supporting the use of a shortened life and organization. Nonetheless, one notices
review with terminally ill patients in Japan. a greater acceptance of reminiscence work
Jenko, Gonzalez, and Alley (2010) added to in foreign countries and related disciplines
the literature in this area by describing the than those in the United States and in nurs-
use of life review in a critical care setting. ing. Researchers in the Netherlands, Canada,
They saw life review as having a distinct China, and Japan have been far more active
purpose in end-of-life care by upholding the in their research pursuits and are produc-
value of the person no matter the shortness of ing more definitive studies. Perhaps this is
the time left to the individual. They encour- because alternative interventions are more
aged the use of life review as an integral accepted in foreign countries or because
part of clinical practice but added no further Americans are more focused on interven-
research. tions that are billable in the U.S. health care
Finally, the bulk of nursing research in system.
this area focuses on improving well-being, One ongoing problem for everyone is
particularly depression, in older people. that reminiscing is a soft intervention and
Wang, Hsu, and Cheng (2005) conducted the outcomes are measured by paper and
a longitudinal study with two equivalent pencil. To really prove its worth as a mental
groups and 94 subjects. The experimen- health intervention, physical measurements
tal group showed a statistically significant are called for. We should be using MRIs to
difference on depression from pretest to observe the brain while reminiscing. We
posttest after a 4-month intervention of rem- should be testing changes in the immune func-
iniscing. Another group of nurse researchers tion and generally examining body chemis-
conducted a qualitative study looking at the try as a direct result of what we are doing.
feasibility of nurses delivering the interven- When those studies are done, we can then
tion of life review to home-dwelling older accept the intervention more fully. Because
women and found that a 3-hour intervention nursing has been in the forefront of qualita-
was a cost-effective method for enhancing tive research for many years, nurses should
mood in these women at home (Symes et al., apply their expertise to the stories that are a
2007). Gunther (2008) described a phenom- product of reminiscing. Reminiscence work
enological study on deferred empathy and provides much data for qualitative studies in
discovered that the process of reflecting on understanding various phenomena and for
the past resulted in an understanding of oth- understanding individual people and their
ers as well as an understanding of one’s self issues. lastly, researchers need to increase
and therefore a greater acceptance of one’s their sample sizes to provide enough power
self, suggesting an important use in help- to make the work relevant to health care. To
ing people adjust to their circumstances. In do this, more funding is needed because the
440 n REPlICATION STUDIES
interventions are time consuming, and there- procedures and conditions. In virtual repli-
fore, research is costly. cation, the methods of the original study are
R recreated in varying degrees. In systematic
Barbara K. Haight replication, neither the methods nor the sub-
stance of the original study are duplicated.
Pseudoreplication is similar to identical and
virtual replication; however, data for pseu-
Replication studies doreplication are collected at the same time
as those for the original study. The simulta-
neous confirmation of the study is built into
Replication involves repeating or reproduc- the original design.
ing a research study to investigate whether Types of replication include retest, inter-
similar findings will be obtained in differ- nal, independent, and theoretical replication.
ent settings and with different samples. Retest replication involves repeating an origi-
Replication is needed not only to establish nal study with few, if any, significant changes
the credibility of research findings but also in the research design. Internal replication is
to extend generalizability. Blomquist (1986) incorporated into the original study. Data
listed five reasons replication studies should for both the original study and its replicated
be encouraged in nursing: (a) scientific merit study are collected simultaneously to pro-
is established, (b) Type I and Type II errors are vide a cross-check for the reliability of the
decreased, (c) construct validity is increased, original results. In independent replication,
(d) support for theory development is pro- significant modifications in the design of the
vided, and (e) acceptance of erroneous original study are made to verify the empir-
results is prevented. Replication studies are ical generalization. In theoretical replication,
essential for developing a scientific knowl- the inductive process is used to examine the
edge base in nursing. Incorporating research feasibility of fitting the empirical findings
findings into nursing practice has been seri- into a general theoretical framework. The
ously hampered by the limited number of purpose of choosing this type of replication
replication studies. Clarification of repli- is to determine if the original findings can
cation terminology can assist in advancing be confirmed when modest changes in the
replication research. research conditions have been made. When
There are three methods of replication: original findings are replicated, confidence
literal, operational, and constructive. literal in the reliability of these results is enhanced.
replication is an exact duplication of the All classifications include an approach to
original researcher’s sampling, procedure, increase empirical generalization by signifi-
experimental treatment, data collection tech- cantly modifying the original design.
niques, and data analysis. Operational repli- Replication studies conducted in nurs-
cation involves an exact duplication of only ing have addressed topics such as nursing
the sampling and experimental procedures education, nurses’ characteristics, periopera-
in the original research to check whether tive nursing, body image during pregnancy,
the original design when used by another cardiac care, fetal monitoring, and time per-
leads to the same results. In constructive rep- ception. When publishing replicated studies,
lication, duplicate methods are purposely nurse researchers should include the fol-
avoided. lowing information: (a) identification of the
Four replication strategies have been specific type of replication that is conducted,
described: identical, virtual, systematic, and (b) provision of specific information on how a
pseudo. Identical replication involves a one- replicated study is the same as and different
to-one duplication of the original study’s from the original study, and (c) explanation of
RESEARCH DISSEMINATION n 441
what is replicated and how. This information have a responsibility to contribute to the dia-
will help readers to more clearly understand logue so that the movement from innovation
how the researchers methodically revised to application can occur (Rogers, 1995). R
previous studies in a progressive manner. Explicit dissemination occurs as
When publishing original studies, research- researchers present their findings, impli-
ers also should explicitly detail the important cations, and recommendations in articles,
points of their sampling and data collection papers, and posters. Usually, these commu-
techniques and their research design to aid nications include details of the research pro-
replication of their work. Authors must be cess that facilitates a scholarly critique. The
more diligent in identifying the minimum criticism is that too often these communica-
essential conditions and controls necessary tions occur between researchers and that the
for producing findings because replication is nurse caregiver is not linked into the research
crucial for the further development of nurs- communication networks. Fortunately, some
ing knowledge. practitioners do attend research conferences,
and some practice-focused conferences
Cheryl Tatano Beck devote programming to research.
A model for dissemination reported
by Funk, Tornquist, and Champagne (1989)
included practice-oriented research confer-
ReseaRch dissemination ences, edited (specifically for practice) mono-
graphs of presentations, and an information
center. The evaluation of the conference
Research dissemination is the purposeful found the general responses extremely posi-
communication of research, particularly, the tive, but still major communication problems
findings and implications of those findings existed in both oral and written reporting.
to members of society who can utilize them. These problems persisted even with a great
Dissemination is sometimes differentiated deal of support to the research communica-
from diffusion when the latter term is reserved tors. This communication deficit leaves a
for spontaneous spread and use of research. practitioner, who is unsure, responsible for
Most writers on dissemination and diffu- deciding about practice utility (persuasion).
sion talk about a purposeful process aimed Because the “old way” is usually comfortable,
at spread and use of research. Utilization is the innovation may not move from knowl-
another related term. Utilization is specif- edge awareness to the more advanced how-
ically focused on application and is more to or principles knowledge. Consequently,
likely to be initiated at the user end, whereas the nurse prepared at the graduate level has
dissemination is focused on knowledge an important role in dissemination in a clini-
acquisition and more likely is initiated at the cal agency. This nurse is usually the reader of
researcher end. The two are obviously linked research, can interpret the findings, and sees
with overlapping phases in their processes. A the application possibilities. Through means
principal writer/researcher whose work has like continuing education and journal clubs,
directed research dissemination is Rogers, the nurse from a graduate program can assist
who wrote on the “diffusion of innovations.” in filtering the research literature to match
Rogers (1995) noted that in 1962, at the time closely the practicing nurses’ concerns and
of his first book, 405 publications were found interests.
on innovation diffusion, whereas by 1995, Implicit dissemination also occurs. This
the number approached 4,000. Recently, dis- dissemination occurs when educators (aca-
semination/diffusion is seen as a less linear deme, staff development, and continuing
process where the potential users of research education) incorporate relevant research into
442 n RESEARCH IN NURSING ETHICS
their offerings. Audiences frequently trust general heading; together, they address the
that presenters have carefully critiqued the duties and obligations of scientists toward
R research they cite. Although this assumption science and society, fellow scientists, and
usually is well founded, the scholarly practi- their students.
tioner will seek references and do a personal Many codes of ethics state or imply
review. that nurses have a responsibility to conduct
As more nurses are university educated, research to expand the profession’s knowl-
including nurse administrators, familiar- edge base; yet, few provide guidance on the
ity with the relevant research has become a ethics of research. An increasing number of
standard of practice in some organizations. nursing organizations are now turning their
Although this practice is not yet the norm, attention to this very task to provide specific
practice policies, standards, and procedures guidance to their members on sound prac-
should be written, with a literature review tices in their research and for the training
that includes applicable research from nurs- of the new generation of nurse researchers
ing and other relevant disciplines. With a (Ketefian, 2010).
policy or procedure focusing on the “need Until recently, many nurse scientists had
to know” for the practitioner, the review of a limited conception of ethical conduct in sci-
relevant research can be productive in prac- ence, identifying human subject protection as
tical dissemination by providing a context the main concern in their practices and in the
for considering whether to move into the instruction of their students. Further, they
application/utilization phases of knowledge displayed a lack of consensus on research
diffusion. and publication practices and in their views
An additional means of dissemination on the roles of professional organizations,
is currently evolving, and that is via the institutions sponsoring research, journal edi-
Internet. Universities, professional organi- tors, among other important matters (lenz
zations, and individuals have home pages & Ketefian, 1995; Ketefian & lenz, 1995). A
that more and more are including research major change has come about more recently,
information. Online journals also are avail- perhaps occasioned by heightened public
able. Some of the home pages include only awareness of scientific misconduct by a few
researcher names and topics; others include scientists. Government funding agencies,
abstracts and findings. institutions, and professional organizations
alike have recognized the need for greater
Patricia A. Martin rigor, and guidelines and policies have been
put in place.
Why do we want science to be ethical?
Several reasons can be cited: to serve the pub-
ReseaRch in nuRsing ethics lic good and promote public trust in science,
we want to have confidence in the validity
of knowledge; to demonstrate good stew-
Ethics in nursing research, also referred to ardship of public funds; and last, because it
as scientific integrity, is concerned with the is the right thing to do. Several ethical prin-
principles and practices of good science that ciples underlying science aim to assure that
aim to promote the generation of sound and science and scholarly knowledge are accu-
ethically defensible knowledge. The princi- rate and valid, and they protect intellectual
ples are developed within the framework of property rights of all concerned (Midwest
the scientific community and derived from Nursing Research Society [MNRS], 2002).
the field of ethics, a branch of philosophy. A Research is considered ethical when it
number of practices are subsumed under this has scientific value; has scientific validity,
RESEARCH IN NURSING ETHICS n 443
that is, it is soundly conceived and designed; of 5–7 years. Results are shared with quali-
incorporates fair treatment and selection of fied scientists, typically following publica-
subjects; has favorable risk–benefit ratio; pro- tion (MNRS, 2002). R
tects the rights, dignity, autonomy, privacy, Publication practices include author-
and confidentiality of research participants; ship, peer review, and journal editor respon-
has undergone independent review, such as sibilities. Authors are those who contribute
by an institutional review board; incorpo- substantively to the work and can assume
rates the voluntary and informed consent public responsibility and can defend it pub-
of subjects; and protects subjects from harm licly. Substantive contribution involves two
(Burns & Grove, 2005). or more of the following: conception and
Several ethical principles undergird design, execution of the study, analysis and
integrity in science. Autonomy refers to free- interpretation of data, and preparation and
dom and capacity for intentional action and revision of manuscripts. Teams should dis-
self-governance. The concepts of privacy, con- cuss and determine, in advance, responsibil-
fidentiality, and giving voluntary informed con- ities of members in the research, authorship,
sent are based on this principle. Nonmaleficence and ordering of authors. Peer reviewers use
and beneficence together refer to three hierar- the best known standards in the field in their
chically arranged edicts: we ought to prevent reviews, maintain confidentiality, avoid con-
harm, we ought to remove harm, and we flict of interest, and provide constructive and
ought to promote good. Protecting research collegial comments. Journal editors frame pol-
subjects from harm and weighing the risks icies that assure high-quality reviews and
and benefits of a study reflect these principles. provide prompt and fair feedback to authors;
Justice, in this context, refers to the notion of they have the responsibility for determining
fairness, equitableness, and appropriateness, which manuscripts, letters, corrections, or
with respect to how benefits and resources retractions are published (MNRS, 2002).
are distributed. In research, considering the Open access publication is a recent phe-
question of who will benefit from research nomenon facilitated by the Internet, and it
and how the risks and benefits are to be might take several forms. In self-archiving,
weighed refers to this principle. individual scientists post their work online
The most frequently used scientific prior to publication. As this is done prior to
integrity guidelines by nurse scientists are peer review, revision, and editing, an article
those promulgated by the MNRS (2002). The is likely to undergo many revisions before it
topics covered in that document, along with is published. Thus, the use of such material in
the guidance provided, are briefly presented its early form can be misleading. Open-access
below. publishing is when journals make all or parts
The principal investigator has overall of a journal available (JAMA and Archives
responsibility for the project, while research Journals, 2007, p. 184). Those who access and
teams participate in developing procedures use such material need to be meticulous in
regarding data collection, storage, use, and referencing authorship, its source, publisher,
access. Data belong to the institution in the and especially the Web site and exact date
case of a grant and to the funding agency in when it was accessed so readers can be aware
the case of a contract. Team members have of which version they are reading.
access to the data and assume responsibility Several features which some guidelines
for safeguarding it and for preserving sub- do not specifically discuss, perhaps assum-
ject confidentiality; steps are taken to assure ing that they have become fundamental in
data of high quality; data are reported accu- science and our educational process for nov-
rately, avoiding intentional withholding or ices, pertain to protection of the rights of human
selective reporting. Data are kept for periods subjects, including protection from harm.
444 n RESEARCH INTERVIEWS (QUAlITATIVE)
As there are strict government guidelines attempted to understand other societies and
regarding this matter, institutions are care- cultures. As nurse scientists were trained in
R ful to enforce these. Another such area per- these methods in the late 1960s and the 1970s,
tains to the need for attribution when either they began using research interviews in nurs-
ideas or words from others are used, either ing studies. Some researchers who seek quan-
by paraphrasing or by quoting. titative data from questionnaires may refer
It is important to note that within the to the structured, standardized survey that
United States we assume many of the above is administered face-to-face to large groups
principles and practices to be universal; yet, of people. The present definition, however,
this is not the case. In reality, there are many refers to the in-depth and generally less struc-
variations across nations and cultures with tured interview used in qualitative research.
regard to these matters. Thus, we need to The research method (e.g., grounded the-
be especially mindful of the training our ory, phenomenology, and ethnography) sug-
international students may have received in gests the style and purpose of the interview
their education prior to coming to the United questions. The research objectives are funda-
States. Careful attention to the socialization mental to the interview questions to maintain
and mentoring of this group of students is the integrity of the research. Grounded the-
merited. ory research intended to discover contexts,
Truthfulness and honesty are basic tenets phases, and processes of a given phenome-
in science. Scientific knowledge is a cumula- non requires questions designed to acquire
tive process to which generations of scientists knowledge, such as, what is the context of
contribute insights over time. A quote attrib- death in a nursing home or at home or what
uted to Sir Isaac Newton expresses this best: are the phases of dying? Phenomenological
“If I have seen further, it is by standing upon research that aims to capture what is referred
the shoulders of giants.” to as “the lived experience” may use only one
general question: Please tell me all that you
Shaké Ketefian can about dying. Ethnographic research that
is focused on culture may ask about which
family members are involved in decisions
concerning death and what their roles are.
Interviews are structured in phases—
ReseaRch inteRviews the introduction, the working phase, and ter-
(Qualitative) mination. In the introduction, the researcher
gives a personal introduction, states the
anticipated length of time of the interview,
The interview is a major data collection and makes some initial comments to relax the
strategy in qualitative research that aims to participant and to assist with the transition
obtain textual, qualitative data reflecting the from social conversation to research inter-
personal perspective of the interviewee. The view. In the working phase, the themes of the
interview creates an interactional situation in research are introduced, and the researcher
a face-to-face encounter between researchers and participant work toward generating a
and participants. In the study, the interviewer shared understanding. In the termination
acts as the instrument and through carefully phase, the interview draws to a close, and
designed questions, attempts to elicit the often, brief social conversation occurs again.
other person’s opinions, attitudes, or knowl- The interview demands careful thought
edge about a given topic. Research interviews about the nature, wording, and sequence of
have historically provided the foundation for questions. Generally, questions move from
sociological and anthropological studies that general to specific, becoming more focused
RESEARCH INTERVIEWS (QUAlITATIVE) n 445
as themes emerge and as data from other par- interview to return to a topic, to ask a hypo-
ticipants suggest additional leads. Questions thetical question, or to request new, related
should be unambiguous, meaningful, and information. These taped interviews are tran- R
successful in involving the interviewee in scribed as soon as possible by the researcher
the process. The participants in the research or a transcriptionist and cross-checked
are often helpful in critiquing the usefulness against the audiotape for accuracy.
and appropriateness of the questions and Interviewing establishes the foundation
suggesting others that may be more relevant for data analysis. The researcher’s interview
or successful in obtaining the desired data. questions and responses to the interviewee
Interviews are of two types: formal and must be analyzed in a reflexive manner to
informal. Formal interviews are scheduled as ascertain the quality of the interview. Is the
to time and place and generally occur over a interviewer cutting off the interviewee? Is the
period of 1 to 2 hours. Informal interviews are interviewer asking closed instead of open-
those used in participant observation, when ended questions? Is the interviewer asking
the interviewer spends time in a specific envi- relevant questions in a sensitive way? Is
ronment and interviews participants as they the interviewer giving the interviewee time
appear on the scene or around a significant to reflect and to complete his or her com-
event. Although effective interviews, espe- ments? Unfocused, insensitive interviewing
cially informal ones, may appear simple and yields poor data. Quality data result from
comfortable, an expert interviewer is always the expression of affective responses and
both in and out of the interview. The inter- detailed personal information.
viewer listens carefully to the interviewee The complexity of interviewing becomes
and anticipates how to direct the interview apparent in varied contexts. Interviewing
to accomplish the aims of the research. individuals from a culture different from
Interviews are characterized as struc- that of the interviewer presents other issues;
tured and focused when all questions are likewise, interviewing the extremely poor or
given in the same order to participants. the extremely rich has its own sets of prob-
Interviews in qualitative research studies are lems. In the past, nurses have relied on socio-
generally semifocused ones in which infor- logical and anthropological researchers for
mation about a certain subject is desired guidance. Nurse methodologists agree that it
from all participants, but the phrasing and is now time to identify and address issues in
sequence of the questions may be varied to interviewing that are especially relevant to
reflect the characteristics of the participants nursing topics and populations.
in the context. Time is permitted to encour- Good interviews provide access to the
age participants to introduce other subjects heart. Such personal information, essential
that they believe are relevant and to elabo- to qualitative research that aims to access
rate, often with the help of the interviewer’s human meaning, is a gift. The researcher
probes, on earlier comments. Participants’ reciprocates by listening carefully and
interpretations of meanings and definitions attempting to render or interpret the expe-
are valued. Such information is obtained rience of the other as accurately as possible.
only through open-ended questions and An insensitive interviewer can harm the
free-flowing conversation that follow the interviewee, leaving the person psychologi-
thinking of the interviewee. In a sense, the cally depleted or even wounded. Good inter-
interviewee teaches the researcher about a viewers leave interviewees feeling that they
particular experience or event. gained from the interview.
Interviews are generally tape-recorded,
and the researcher takes handwritten notes Sally A. Hutchinson
that jog his or her memory during the Holly Skodol Wilson
446 n RESEARCH UTIlIzATION
of a team approach for reviewing research
ReseaRch utilization results related to specific patient care prob-
R lems, developing clinical protocols, and then
testing the protocol in an acute care clinical
Research utilization is a process in which setting. A key component of research uti-
knowledge generated from research is trans- lization in this model was the replication
lated into practice. It is a term that was used of previous studies. The focus of the Iowa
before the introduction of the term evidence- model was similar to that of the CURN pro-
based practice. The goals of research utili- ject, with particular attention to developing
zation and evidence-based practice are the support for research utilization strategies at
same: improving patient care and advancing the organizational level. Both models were
the discipline of nursing. The importance developed specifically to bridge the gap
of using research findings in clinical prac- between research and practice. Both recom-
tice has been discussed for at least 45 years. mended that organizational resources, such
The first research utilization models were as personnel, equipment, time, and money, be
developed in the 1970s, beginning with the available to support the nursing staff. Policy,
Western Interstate Commission for Higher procedures, committee structures, and role
Education in Nursing (WCHEN) Regional expectations must exist in relation to staff
Program for Nursing Research Development involvement in research utilization activities.
(Krueger, 1978). Other models included Both models also supported a fundamental
the Conduct and Utilization of Research in belief that research can and must be applied
Nursing (CURN) project (Horsley, Crane, to practice if patient care is to improve.
Crabtree, & Wood, 1983), the Stetler/Marram The Stetler/Marram model was devel-
model (Stetler, 1994), the Iowa model of oped primarily for use at the individual level
research in practice (Titler et al., 1994), and and specifically outlined the role clinical
the Retrieval and Application of Research in specialists have in facilitating the application
Nursing (RARIN) model (Bostrom & Wise, of research findings to clinical practice. The
1994). This list is not exhaustive; rather, it is model includes specific steps related to the
a representation of several well-known and need for a sound foundation in the conduct
referenced models found in the literature. of research, and what is more important,
The WCHEN model was focused on it demonstrates how to interpret and vali-
cross-organizational planning and enhanc- date findings that can be used to change the
ing the value for research utilization. Nurses practice.
from a variety of clinical agencies were pro- The RARIN model, funded by a National
vided with 3 days of research training. Each library of Medicine grant, was developed at
clinician would identify a clinical problem, Stanford University Hospital in Palo Alto,
review the research in that area, and develop CA. Distinct from the other models, which
a plan for implementing and evaluating the focused on providing nurse education, skill
outcomes of the practice change. The annual building, and organization support strate-
Communicating Nursing Research confer- gies, the RARIN model focused on improving
ences also resulted from the initial WCHEN staff access to research findings through the
work group, with emphasis on dissemina- use of computerized linkages to established
tion of research results across academic and research databases. Training a small set of
nursing service settings. There have been 30 nurses from each unit on the use of the com-
conferences prior to 1997. puter network and the basics of the research
The CURN project was a federally critique was the other major component. The
funded initiative that focused on the use computer technology provided direct access
RESEARCH UTIlIzATION n 447
to the MEDlINE citation system (including increase the adequacy of research skills, (c)
CINAHl) as well as databases of research improving access to computerized databases
abstracts that were written by experts. Hence, and research literature, (d) allotting time and R
nurses could access almost any database via money to support conference attendance and
the use of the developed tools and technolo- participation, (e) developing performance
gies while working in a patient care unit. The standards that include behavioral expecta-
model assumption was based on a belief that tions to support research-based practice,
if access to research findings was improved and (f) obtaining grants to support research
and the findings were represented in an eas- projects.
ily understood, yet clinically sound frame- The literature related to research utiliza-
work, then practicing nurses would be able tion is almost exclusively focused on nursing
to improve patient care. practice environments, with little attention
Outcome results from these and other to how research utilization is introduced into
models have been limited. Numerous bar- the nursing curricula at all levels. Research
riers to transferring research-based knowl- utilization is a critical professional account-
edge into nursing practice persist. Staff ability issue to resolve if the discipline of
nurses reported the following as barriers nursing is to advance. Therefore, it is essential
to research utilization: (a) insufficient skills for nursing educators to socialize students at
and knowledge about evaluating research, all levels to the value of research utilization
(b) lack of awareness or access to research, and to model the required skills. For exam-
(c) minimal value of research for practice, ple, most teaching about the research process
(d) insufficient authority to actually change at the baccalaureate level is isolated from
practice, (e) insufficient time to read research discussions about actual caregiving and
and to learn research skills and how to how that care might be improved by apply-
implement changes when necessary, (f) lack ing research findings. Graduate students are
of cooperation and support from administra- not adequately prepared for the integration
tion and other staff, (g) little personal benefit, of research into the care of specific patient
(h) unclear and unhelpful statistical repre- populations and have little preparation in
sentation of results, (i) few replication studies areas of quality improvement and outcomes-
to determine if sufficient evidence exists to evaluation methodologies. Doctoral educa-
change practice, and (j) lack of access to data- tion continues to be focused on the conduct
bases and research literature. Nurse admin- of research, with minimal emphasis on how
istrators also reported barriers, such as (a) to report results in ways that are under-
isolation from research colleagues, (b) lack standable to practicing clinicians. Although
of time because of heavy workloads, (c) dif- learning a thesis format of writing is impor-
ficulty in reading and interpreting research tant, it is equally important to learn how to
findings and statistics, (d) insufficient skills convert research jargon into useful, specific,
in research critique, (e) lack of replication and direct reports for clinicians. In addition,
studies to determine if practice requires more value and attention should be given
change, and (f) lack of access to databases to replication research that would advance
and research literature. results that are more generalizable and easily
Facilitators for the research utiliza- applied to clinical practice.
tion process have also been identified. They The health care environment is changing
include (a) creating practice environments rapidly, with increased attention to outcomes-
that require research-based clinical stan- based practice, evaluating patient outcomes,
dards, (b) providing expert consultation and and demonstrating cost-efficiency and effec-
activities such as research committees to tiveness. Technology is now available to
448 n RESOURCEFUlNESS
provide much access to research and rele- standard psychometric studies to designs
vant databases; however, there is still need that characterize individuals with high or
R for timely and readable reports of completed low resourcefulness and investigation of
research. predictive models, to testing of interven-
tions that teach resourcefulness to elders.
Carol A. Ashton However, studies of resourcefulness in chil-
dren and adolescents remain few and many
opportunities exist in this area.
The synthesis of theoretical notions and
ResouRcefulness empirical findings has facilitated the crea-
tion of a middle range theory of resource-
fulness (zauszniewski, 2006) for nursing
Resourcefulness is a collection of cognitive and health care research. This theory of
and behavioral skills that are used to attain, resourcefulness is based on the conceptual-
maintain, or regain health. Resourcefulness ization of the two forms of resourcefulness:
involves the ability to maintain indepen- personal (self-help) and social (help-seeking)
dence in daily tasks despite potentially resourcefulness. Other major constructs of
adverse situations (i.e., personal resourceful- the theory of resourcefulness include ante-
ness; Rosenbaum, 1990) and to seek help from cedents or contextual factors (intrinsic and
others when unable to function indepen- extrinsic), intervening variables or process
dently (i.e., social resourcefulness; Nadler, regulators (i.e., perceptions, cognitions,
1990). Thus, two forms of resourcefulness affect, and motivation), and quality of life
exist, and the skills comprising the two are outcomes (i.e., physical, psychological, and
complementary and equally important for social functioning).
health promotion (zauszniewski, lai, & Contextual factors affecting resourceful-
Tithiphontumrong, 2006). Both the self-help ness are both intrinsic and extrinsic. Intrinsic
and help-seeking skills constituting personal factors that have been identified from empir-
and social resourcefulness, respectively, are ical research include demographic character-
believed to be learned through either formal istics (e.g., age, gender, and race/ethnicity),
or informal instruction (Rosenbaum, 1990) chronic conditions or health status (Huang,
and can therefore be taught (zauszniewski, Perng, Chen, & lai, 2008; Huang et al.,
Bekhet, lai, McDonald, & Musil, 2007). 2007; Huang, Sousa, Tu, & Hwang, 2005;
Numerous studies since the early 1980s have zauszniewski, Bekhet, & Suresky, 2009;
suggested that teaching personal and social zauszniewski & Chung, 2001; zauszniewski,
resourcefulness skills is beneficial in pro- Chung, & Krafcik, 2001; zauszniewski,
moting and maintaining healthy physical, Eggenschwiler, Preechawong, Roberts, &
psychological, and social functioning across Morris, 2006; zauszniewski et al., 2005),
the life span. and perceived caregiver burden (Musil,
Over nearly three decades, theoret- Warner, zauszniewski, Wykle, & Standing,
ical notions about resourcefulness have 2009; Wang, Rong, Chen, Wei, & lin, 2007;
been developed whereas numerous stud- zauszniewski, Bekhet, & Suresky, 2008;
ies of resourcefulness have been conducted. zauszniewski et al., 2005). Extrinsic factors
Resourcefulness research has expanded from include social network size, social support,
healthy college students, to adults with vari- and environmental/milieu characteris-
ous psychological and physical conditions, tics (Bekhet, zauszniewski, & Wykle, 2008;
to community-dwelling and chronically ill Dirksen, 2000; Huang & Guo, 2009; Kreulen
elders. In addition, research methods used in & Braden, 2004; Ngai, Chan, & Ip, 2010;
studies of resourcefulness have evolved from zauszniewski et al., 2005).
RESOURCEFUlNESS n 449
Depressive cognitions and negative Self-Control Schedule in which respon-
emotions associated with lower personal and dents indicate the degree to which each
social resourcefulness have been found in item describes their behavior, ranging from R
elders with chronic conditions (zauszniewski extremely descriptive to extremely nonde-
et al., 2007) and family members of persons scriptive. Internal consistency estimates
with serious mental illness (zauszniewski have ranged from .78 to .85 in adults, includ-
et al., 2009). Self-esteem has also been ing elders (Rosenbaum, 1990). The SCS is
reported to be significantly associated with moderately correlated with locus of control,
personal resourcefulness and well-being in religious orientation, anxiety, and depres-
women survivors of breast cancer (Dirksen, sive symptoms, supporting its construct
2000; Dirksen & Erickson, 2002). Health self- validity (Rosenbaum, 1990). A 20-item Social
determinism was found to be a significant Resourcefulness Scale was developed by
predictor of personal and social resourceful- Rapp, Schumaker, Schmidt, Naughton, and
ness in chronically ill elders (zauszniewski Anderson (1998). Respondents indicate the
et al., 2001). Studies have also identified frequency of use of behaviors to obtain and
uncertainty as an antecedent of personal maintain help from others, ranging from
resourcefulness (Dirksen, 2000; Dirksen & never to always. Acceptable internal consis-
Erickson, 2002; Kreulen & Braden, 2004). The tency has been reported and construct valid-
specific roles played by various process reg- ity was supported by significant correlations
ulators, including cognition, affect, percep- with social support and self-control (Rapp
tion, and motivation, in affecting personal et al., 1998).
and social resourcefulness need examination Although these reliable and valid indi-
that is more systematic. vidual measures of personal and social
Positive health outcomes of personal resourcefulness exist, zauszniewski,
and social resourcefulness have been well- lai, et al. (2006) developed the 28-item
documented through empirical research. Resourcefulness Scale, which contains
These outcomes, including adaptive func- items reflecting both personal and social
tioning in school-aged children (Chang, resourcefulness. The Resourcefulness Scale
zauszniewski, Heinzer, Musil, & Tsai, 2007), has acceptable internal consistency (α = .85)
adjustment to relocation in elders (Bekhet and two correlated subscales reflecting per-
et al., 2008), maternal role competence and sonal and social resourcefulness (r = .41)
satisfaction in first-time pregnant women were confirmed through factor analysis
(Ngai et al., 2010), perceived health in dia- (zauszniewski, lai, et al., 2006).
betic women (zauszniewski et al., 2001), Fostering the development and mainte-
psychological well-being in women survi- nance of both personal and social resource-
vors of breast cancer (Dirksen, 2000; Huang fulness is well within the purview of
et al., 2010) and in elders (zauszniewski et al., nursing interventions. Clinical trials are
2001), health practices in women with type 2 currently examining various methods for
diabetes (zauszniewski & Chung, 2001), pre- teaching personal and social resourceful-
natal self-care of pregnant women with HIV ness skills to elders with chronic condi-
(Boonpongmanee, zauszniewski, & Morris, tions, grandmothers raising grandchildren,
2003), and mental health of family members caregivers of elders with dementia, and
of adults with mental illness (zauszniewski family members of persons with mental
et al., 2009) fall under the “umbrella” concept illness. Additional research with children,
called quality of life. adolescents, and ethnically diverse popula-
Personal resourcefulness, also termed tions is needed.
learned resourcefulness, has been mea-
sured using Rosenbaum’s (1990) 36-item Jaclene A. Zauszniewski
450 n RIGHTS OF HUMAN SUBJECTS
the opportunity for questions about or with-
Rights of human subjects drawal from the project after treatment has
R begun, should all be provided to the research
subject.
Rights are just claims that are due to some- For adequate comprehension of infor-
one. legal rights are valid claims recognized mation, the research subject must have time
by a legal system. Moral rights are valid to consider the information and to ask ques-
claims derived from customs, traditions, or tions. This means that when the ability to
ideals which may be upheld or protected by comprehend information is limited (such as
the law. Human rights are valid claims that when a subject’s mental competence is lim-
are due to members of the human species ited), the researcher must allow the research
and may be legal, moral, or both. subject additional opportunity to consider
The rights of human subjects in research whether or not to participate in the study.
include the right to informed consent, the Voluntary consent to participate in
right to privacy, the right to refuse to partic- research means that the research subject has
ipate in research, and the right to withdraw exercised choice, free of coercion and other
from a research study, without penalty, at any forms of controlling influence by other per-
time. These four rights are all derived from sons. A research subject’s consent is valid
a general right to liberty and are both moral only if it is voluntarily given. Voluntariness
and legal. They are supported by moral prin- protects the patient’s right to choose goals
ciples of the social community, professional and to choose among several goals when
codes of research ethics, and by legal pro- offered options. However, consent cannot be
tections. They become relevant in nursing given unless the research subject is “compe-
research because all nurses have a responsi- tent,” or can make decisions based on rational
bility to protect, and sometimes defend, the reasons. Both competence and voluntariness
basic rights of patients within the health care are required for a subject’s consent to be truly
system. When the nurse is also a researcher, informed.
the nurse has the added responsibility to Nursing research on the informed con-
make sure that these particular rights are not sent of human subjects has focused on the
violated by the research process. comprehension of information by research
Informed consent is a process that pro- subjects, subjects’ competency for informed
tects research subjects’ autonomy, protects consent (i.e., adolescents and mentally
research subjects from harm, and assists retarded minors), and the factors that influ-
the researcher to avoid fraud and coercion ence the informed consent of adolescents and
in the role of researcher. It is also a process adults. The study designs have been explor-
that encourages researcher responsibility atory and quasi-experimental and have
for how information is communicated in included relatively small sample sizes.
research, promotes rational decision making The right to privacy includes the right
by human subjects, and involves the public to keep personal information about one-
in promoting self-determination as a social self private, undisclosed, and away from
value. Informed consent has information ele- public scrutiny. It also includes the right to
ments and consent elements. bodily integrity, or freedom from unwanted
For adequate disclosure of information, intrusions on body parts. One way that the
the research subject must be informed of research subject’s right to privacy is pro-
the procedures to be used throughout the tected is by following rules of confidentiality.
study. Information about available alterna- For example, information about the research
tive treatment procedures, a discussion of subject may not be disclosed without the sub-
risks and benefits of these procedures, and ject’s permission and then only under certain
ROGERS’S SCIENCE OF UNITARy PERSONS n 451
conditions. In a similar manner, research data subjects who do and do not withdraw from
is not publicly connected to the research sub- studies involving particular diseases.
ject, thereby assuring the subjects’ privacy. The protection of human rights in R
Another way that the research subjects’ research studies is important to the moral
right to privacy is protected is by obtaining an integrity of nursing research. International
informed consent and signed permission for and professional codes of research ethics
invasive procedures used during the research strongly support the morality of research,
process. For example, informed consent must and the American Nurses Association’s
be obtained before passing a levine tube to Ethical Guidelines in the Conduct, Dissemination,
obtain gastric contents for analysis. Nursing and Implementation of Nursing Research (Silva,
research on the privacy of human subjects is 1995) supports the morality of nursing
not yet documented. Potential areas for nurs- research. However, nursing research on the
ing research are identifying how research protection of human rights in research is at
studies protect or do not protect the privacy an early stage of development. As the 21st
of human subjects, describing research sub- century approaches, nursing research should
jects’ perceptions of how their privacy was include studies of how human rights are pro-
protected or not protected during a study, tected in research and the factors that inhibit
identifying researchers’ attitudes toward or promote their protection in various kinds
rules of confidentiality under different of research designs.
research conditions, and identifying insti-
tutional review board members’ knowledge Sara T. Fry
of and attitudes toward protection of human
subject privacy in research studies.
The right to refuse to participate in
research protects the subject from being RogeRs’s science of
coerced to participate in research and assures
that research subjects are truly voluntary. unitaRy peRsons
Nursing research on the right to refuse to
participate in research is not yet documented.
Potential areas for nursing research are iden- In 1970, Martha Rogers initially published
tifying the conditions under which research The Science of Irreducible Unitary Human
subjects refuse to participate in a study and Beings (1990). The model is derived from
describing why subjects have refused to many disciplines and results in an integrated
participate in particular types of research whole, unique to nursing. Within this frame-
studies. work, Rogers describes the natural process
Human subjects have the right to with- of change, the inherent quality of human
draw from a research study without any beings’ right to choose, and the infinite
untoward treatment of them. Even though nature of the relationship between man and
they had previously consented to participate the universe. Her description of nursing as a
in a research study, subjects have the right to learned profession, resulting from a strong aca-
change their minds and withdraw from the demic preparation and based in knowledge
study at any time. unique to nursing, was equally stunning
Nursing research on the right to with- and controversial. Through 1994, she revised
draw from a research study is not yet docu- and refined her theory. She makes several
mented. Potential areas for nursing research assumptions to be tested so that further
are identifying the conditions under which nursing knowledge can be formulated: the
research subjects withdraw from a study human being is greater than the sum of his parts;
and describing the course of treatment for there is constant, progressive interaction between
452 n ROy ADAPTATION MODEl
the human being and environment; the environ- received externally from the environment
ment is infinite—it extends to the universe and (external stimuli) and internally from within
R beyond; reality is as it appears—it is constructed; the self (internal stimuli). These stimuli are
energy is matter is energy; the human being can classified as focal, contextual, or residual.
choose to engage in change. Rogers defined four The stimuli immediately confronting the
postulates as the basis of her theory: energy person are called focal stimuli. All other
fields—in Rogers’s world we are energy fields, stimuli in the situation that contribute to the
as is everything around us. She uses the term effect of the focal stimuli are called contex-
“unitary” to describe the indivisible and irre- tual stimuli. Stimuli whose effects on the
ducible nature of the human being–environ- given situation are unclear are called resid-
ment interaction. Openness—an attribute of ual stimuli (Roy & Andrews, 1999).
all energy fields—a constant mutual interac- The goal of nursing is “the promotion of
tion and flow, as opposed to a cause and effect adaptation in each of the four modes, thereby
relationship. Pattern—the manifestation of contributing to the person’s health, qual-
energy fields experienced and known by all ity of life, and dying with dignity” (Roy &
senses. Pandimensionality—the boundless- Andrews, 1999, p. 55). Roy defines health as
ness of the universe, without spatial or lin- “a state and a process of being and becom-
ear limits. Furthermore, Rogers proposed ing an integrated and whole person” (Roy
three principles of homeodynamics: helicy— & Andrews, 1999, p. 54). In essence, health
continuous, nonrepetitive, and innovative reflects the adaptation of the individual’s
patterning (moving forward/diversifying). adaptive systems in an ever-changing envi-
Resonancy—patterning which changes from ronment. Within the Roy adaptation model,
lower to higher frequency (responsiveness— nursing interventions are conceptualized as
increasing vibration). Integrality—the contin- the management or manipulation of stimuli
uous mutual process between person and (Roy & Andrews, 1999).
environment (feeling “at one” with the uni- The elements and assumptions of the
verse). Martha Rogers epitomized her theory: Roy adaptation model provide a perspective
open, constantly changing, diverse, thinking for nursing research by suggesting what phe-
without boundaries, and resonating to her nomena to study, identifying the research
world, her profession, and the future. questions, and identifying appropriate meth-
ods of inquiry. The distinctive nature of
John Phillips the research question is related to basic life
Updated by Elaine K. Shimono processes and patterns, coping with health
and illness, and enhancing adaptive coping.
Multiple methods are appropriate when con-
ducting research based on the Roy adapta-
Roy adaptation model tion model (Roy & Andrews, 1999).
Numerous researchers have used the
Roy adaptation model as the conceptual
The Roy adaptation model for nursing framework for research. Some studies used
defines a person as a holistic adaptive sys- the model in the development of data collec-
tem that is in constant interaction with the tion instruments within the four adaptive
environment (Roy & Andrews, 1999). As a models, whereas other studies used the four
holistic adaptive system, the person can be adaptive modes as a framework for data anal-
described as a set of interrelated arts with ysis. Chiou (2000) conducted a meta-analysis
inputs, control and feedback processes, and of nine empirical studies based on Roy’s
outputs functioning as a whole for some Adaptation Model to determine the mag-
purpose. Inputs for the system are stimuli nitude of the interrelationships of the four
ROy ADAPTATION MODEl n 453
modes. Additional studies identified specific model in young women contemplating smok-
concepts from the model, such as interdepen- ing cessation. The Roy adaptation model
dence mode or physical self, and used them has also been applied in practice when car- R
as the basis for the research. A number of ing for menopausal women (Cunningham,
studies identified specific links, conceptually 2002). Rogers and Keller (2009) applied the
and operationally, between the Roy adap- Roy adaptation model to promote physical
tation model and the research variables. In exercise among sedentary older adults. The
these studies, specific concepts were linked intervention used was mind-body-spiritual
to various aspects of the model, including physical exercise impacting the physiological,
focal, contextual, and residual stimuli control psychological, and self-concept modes of the
processes and adaptive modes. yeh (2003) model with the main focus on adaptation to
used this approach in research examining aging. Isbir and Mete (2010) applied the Roy
the relationships among social support, par- model to the care of women with nausea and
enting stress, coping style, and psychological vomiting in pregnancy. Nayback (2009) iden-
distress in parents caring for children with tified the Roy adaptation model as a suitable
cancer. zhan (2000) examined the relation- framework to help understand posttraumatic
ship between cognitive adaptation processes stress disorder in combat veterans.
and self-consistency in hearing-impaired Among those who have built a program
elderly. Chen, Chang, Chyun, and McCorkle of research using the Roy adaptation model
(2005) evaluated the dynamics of nutritional are Fawcett, Pollock, and Tulman. Fawcett
health in community elders using the Roy and Tulman (1990) conducted methodologi-
adaptation model. In one study, a second- cal instrument development and substantive
ary analysis of the meaning of living with a research related to childbearing families.
spinal cord injury was conducted using the Retrospective and longitudinal studies exam-
Roy adaptation model as a guiding frame- ined factors associated with functional status
work (De Santo-Madeya, 2006). Several stud- during the postpartum period, and one study
ies identified nursing interventions as the (Fawcett, 1990), tested an intervention derived
management or manipulation of stimuli, from the Roy adaptation model. Fawcett et al.
and some specifically tested propositions (2005) have expanded the initial research
derived from the model (e.g., Jirovec, Jenkins, (Fawcett, 1990) to a large international mul-
Isenberg, & Baiardi, 1999). tisite research program focused on adap-
Among the studies, there were dif- tation to cesarean birth. Pollock (1993) and
ferences in methodologies, designs, data colleagues conducted a series of five longitu-
collection procedures, and data analysis tech- dinal studies to examine human responses
niques. Barone, Roy, Keville and Frederickson to chronic illness by identifying predictors of
(2008) identified and critiqued the instru- adaptation to chronic illness and determin-
ments most frequently used to measure the ing whether adaptive responses differed by
concepts of the Roy adaptation model. Shyu diagnostic group. A number of middle range
(2000) illustrated the role function mode in theories have been developed from the Roy
Roy’s Adaptation Model using constant com- model. These include middle range theory of
parison to analyze the data. yeh (2001) used chronic pain (Dunn, 2005) and one on adap-
a qualitative approach to establish a frame- tation to diabetes (Whittmore & Roy, 2002).
work for the adaptation process of Taiwanese These studies demonstrate the usefulness
children with cancer. The studies reviewed of the Roy adaptation model as a guide for
revealed that the Roy adaptation model was nursing research and support the credibility
appropriate for guiding research in a variety of the model. In 2009, De Santo-Madeya and
of settings and populations. Villareal (2003) Fawcett (2006) observed that Roy’s concept of
demonstrated the use of the Roy adaptation adaptation was seldom used research guided
454 n RURAl HEAlTH
by the Roy adaptation model. This prompted 2007). No matter the definition, the num-
them to translate Roy’s concept of adapta- ber of rural dwellers varies greatly by state,
R tion into a congruent middle range theory for example, using the U.S. census defini-
concept of adjustment (De Santo-Madeya & tion, Maine, Mississippi, Vermont, and West
Fawcett, 2006). In addition, they developed Virginia have more than 50% of their resi-
a single-item scale to measure this new con- dents in rural areas, and states like California
cept (De Santo-Madeya & Fawcett, 2006). and Nevada have less than 10% (U.S. Census
Using the Roy adaptation model to guide Bureau, 2000). looking beyond the numbers,
nursing research has contributed to both the the term rural brings to mind landmasses
basic and clinical sciences of nursing. Studies between urban areas with farmland, moun-
have provided some confirmation for the tains, forests, and open ranges with sparsely
model, demonstrated its ability to generate populated remote areas and small towns. For
new information, and contributed to clinical some rural residents, it is the place where, for
practice. generations, they have engaged in farming,
The Roy adaptation model is being used ranching, mining, or logging; and for others,
by nurses throughout the world. Researchers it is an escape from urban tensions—a place
and scholars as far afield as Japan, Columbia, to recreate and to relax. For those providing
Mexico, and Puerto Rico are testing and health care, there are unique challenges and
applying the model in a variety of settings opportunities in the rural setting.
(Roy, Whetsell, & Frederickson, 2009). Many One of the greatest challenges is the
of these countries have set up chapters of the high rates of poverty in rural areas. The last
Roy adaptation association, and held confer- decade’s bouts of recessions have hit rural
ences and workshops related to the model areas harder than the surrounding urban
(Roy et al., 2009). This global expansion pro- areas (Economic Research Services, 2009).
vides new horizons and different cultural The national poverty rate was 12.5% in 2007,
perspectives for the application and testing but in rural areas, it was 15.4%. Concurrently,
of the Roy adaptation model. Overall, the rural areas also saw a sharper increase in
Roy adaptation model is a very useful model unemployment rates and, subsequently, the
in practice and as a guide to research. The uninsured. Although rural areas in gen-
Roy adaptation model continues to make a eral have higher rates of unemployment,
significant contribution to nursing science as decreases in employment were seen in both
it continues to evolve. traditional rural jobs, for example, the tim-
ber industry, and jobs in employment sec-
Updated by Mary T. Quinn Griffin tors that cover both rural and urban areas,
such as manufacturing, construction, trans-
portation and utilities, wholesale and retail
trade, and professional business services.
RuRal health The higher unemployment rate is partly
because rural residents are less likely to have
completed high school and even fewer have
It is estimated that about 20% of the U.S. pop- a college degree (IOM, 2006). The problem is
ulation lives in the 75% of the U.S. land mass not necessarily the lack of educational oppor-
considered rural (Institute of Medicine [IOM], tunities but rather that young people often
2005, 2006c). However, there is no single def- move to metropolitan areas after graduation.
inition for what constitutes rural. There are Rural America is still the site of our food
more than 15 definitions of rural used in fed- production, but only 1.1% of the U.S. popu-
eral programs in the United States (Coburn, lation lives on farms (IOM, 2006). Even fewer
MacKinney, McBride, Slifkin, & Wakefield people live off the farm. About 70% of either
RURAl HEAlTH n 455
the farmer or the spouse works off the farm (IOM, 2005). There are 53 primary care phy-
for their income. A major employer in many sicians per 100,000 rural residents compared
rural communities is the hospital, which thus with 78 per 100,000 urban residents. The gap R
plays an essential part in the economic and between rural and urban is even wider for
social identity of a community (Moscovice & specialists, with 54 and 134 specialists per
Stensland, 2002). 100,000 residents, respectively (Reschovsky
Rural areas have a high percentage of & Staiti, 2005). For nurses, the issues are a
older adults and people with chronic diseases bit different. From 1980 to 2004, the propor-
(IOM, 2006). Rural residents have higher rates tion of registered nurses who lived in rural
of chronic conditions caused by unhealthy areas grew from 14.9% to 18%, but so did
lifestyles such as smoking, lack of exercise, the number of nurses who resided in rural
and obesity (IOM, 2005). Depression and areas but commuted to work to an urban area
substance abuse are more common among (Skillman, Palazzo, Hart, & Butterfield, 2007).
rural residents compared with urban resi- In 1980, 86.1% of registered nurses lived and
dents (Kessler, Chiu, Demler, Merikangas, worked in rural areas, and by 2004, the num-
& Walters, 2005). With 41% of rural women ber was 62.9%; leaving rural areas with fewer
reporting symptoms of depression com- nurses and vacancies that are hard to fill.
pared with 13% to 20% of urban women, sui- With the burden of chronic diseases and
cide rates are as much as three times higher disability for rural populations, the resource-
for rural women (American Psychological poor rural care system is experiencing great
Association, 2005). The aging of rural resi- demands. For these reasons, rural residents
dents, along with the higher likelihood of are considered an underserved popula-
having chronic health problems and poorer tion that needs special attention. In recent
health status, are factors when planning and years, many approaches have been devel-
providing health care in rural areas. oped to close the health care gap between
Other health care concerns include rural and urban areas. One example is the
the high rates of farm injuries, especially approximately 1400 critical access hospitals
among the youth. According to the National (CAHs) in rural areas. Recognizing the vital
Institute of Occupational Safety and Health role of (especially the small) rural hospitals
(2008), it was estimated that 23,100 children prompted Congress in 1997 to create the
and adolescents were injured on farms in Medicare Rural Hospital Flexibility program
2006. Rural health care providers also need (Flex Program). This initiative allows small
to be prepared to care for recreational visi- hospitals to be licensed as CAHs and offers
tors in areas with a high influx of tourists grants to states to help implement initiatives
during certain times of the year. Both gen- to strengthen the rural health care infrastruc-
eral services and specialized services, such ture. To be a CAH requires certification as
as those needed to treat people involved in such before January 1, 2006 or rural location,
accidents, are higher demands during these and to be more than 35 miles (or 15 miles in
seasonal peaks (IOM, 2006). areas with mountainous terrain or only sec-
It is not only the characteristics of rural ondary roads available) from another hospi-
populations that challenge the delivery of tal (Gale, Coburn, Gregg, Slifkin, & Freeman,
rural health care, but also whether health 2007). In return for CAH status, hospitals
care services are available. The major barri- provide 24-hour emergency care services
ers for rural residents to have access to health availability, have a maximum of 25 acute care
care are shortages of clinicians, facilities, and and swing beds (a bed used for either acute
specialized services as well as geographical or skilled nursing facility care), and maintain
and climatic conditions that affect travel con- an annual average length of stay of 96 hours
ditions to health care providers and facilities or less for their acute care patients.
456 n RURAl HEAlTH
The problems and disadvantages that Knowledge generation and acquisi-
rural areas experience may contribute to the tion are needed for rural nursing practice.
R often strong sense of a unique rural culture Although the knowledge base is growing,
and community connectedness among rural there continues to be a limited number of
residents. The value and beliefs in a rural cul- data-based articles in the rural nursing liter-
ture play key roles in how rural people define ature. Continuing shortfalls in the literature
health and from whom they seek advice, include small sample sizes, lack of random
treatment, and care. The culture combined sampling, cross-sectional designs, problems
with realities of rural living, such as weather, with operationalization and measurement
distance, and isolation, affects the practice of of rurality, and small specific populations.
nursing in rural areas. Knowledge of the rural Studies lack clear descriptions of comparison
culture is a basic requirement if a nurse wants groups and often fail to adequately account
to work effectively in a rural community, for key variables (Merwin, 2008).
but also a strong influence on the individu- Positive signs of the growth of rural
al’s health (Baernholdt, Jennings, Merwin, & nursing science are appearing. Among these
Thornlow, 2010; leipert & George, 2008). The are more articles about rural nursing in jour-
community connectedness where nurses and nals of rural health, the creation of the Online
patients know one another outside the health Journal of Rural Nursing and Health Care, a
care setting can create boundary-related eth- whole issue of the Annual Review of Nursing
ical conflicts (Nelson, Pomerantz, Howard, & Research focused on rural health, programs
Bushy, 2007). Such situations are challenging of rural nursing research (including multi-
because they bring into play competing roles site projects), National Institute of Nursing
of values, duties, and community expecta- Research (NINR)–funded research centers
tions to the classic ethical understanding of focused on rural health, new graduate pro-
the nurse–patient relationship. However, the grams (including at the doctoral level for
community connectedness can also translate preparation in rural health), and use of new
into the nurses’ commitment to give quality technologies for education and in nursing
care and attempts to break unhealthy family research.
histories of obesity-related diabetes or teen The Online Journal of Rural Nursing and
pregnancy (Baernholdt et al., 2010). Rural Health Care, which focuses on dissemination
nurses also have to be a “Jack-of-all trades.” of rural nursing research and health care
They have to take on nonnursing roles, such information, is a sign of progress. In the
as transporting patients, cleaning, and secre- first decade of the journal, there have been
tarial duties in hospitals when nobody else is a cluster of projects published addressing
available on the off-hours. Their nursing prac- some of the pressing health issues, such as
tice also has to be very broad (Scharff, 2010). women’s health, children and adolescents,
They are advanced generalist nurses who the elderly, caregiving, and issues associated
are able to care for a great variety of patients with managing cancer, stroke, Alzheimer’s
beyond a regular nurse’s scope of practice. disease, and end-of-life care in the rural set-
In addition, they often have to do so with ting. Programs of rural nursing research
limited resources and support systems. yet are developing: Fahs and colleagues at
the rural nurses face challenges keeping up Binghamton University, on cardiovascu-
with their professional knowledge and skills lar disease and rural women; Hauenstein
because of limited educational opportunities and colleagues at University of Virginia, on
(Newhouse, 2005). Despite these shortcom- rural women’s mental health; Magilvy and
ings, rural nurses are not less satisfied with colleagues, at the University of Colorado,
their jobs compared with their urban coun- on the community health needs of elderly
terparts (Baernholdt & Mark, 2009). rural populations; Utz and colleagues at the
RURAl HEAlTH n 457
University of Virginia, using community The launching of the nursing doctoral
participation to increase diabetes self-care program at Binghamton University will
in rural areas; Weinert and colleagues, at the increase the number of individuals pre- R
Montana State University–Bozeman, using pared to conduct necessary rural research.
computer-based technology to provide Although the masters’ degree and Doctor of
support and health information to isolated Nursing Science programs at the University
rural women living with a chronic health of Virginia will increase nursing leaders in
condition. Cross-state studies are being community/public health leadership, health
designed to tease out which characteristics systems management, or psychiatric mental
are somewhat universal across rural popu- health with expertise in rural health care.
lations and which may be specific to a cer- The program uses a distance learning plat-
tain rural population. One example is the form in which technology allows students to
work of Shreffler-Grant at Montana State interact live weekly from remote locations in
University–Bozeman, and her colleagues a virtual classroom. The program is a good
at the University of North Dakota, who are example of how the explosion of activity in
exploring the use of complementary ther- the arena of telecommunications has been
apy by rural older adults. Another is Fahs’ a boon to rural nursing education, bringing
group, from Binghamton University, who whole degree programs and current practice
examined how to promote heart health in and research knowledge to the fingertips of
rural women across state lines. nurses in the remotest of areas.
The Center for Research on Chronic Clearly, there is progress in the develop-
Health Conditions in Rural Dwellers at ment of the body of knowledge about rural
Montana State University-Bozeman, funded health and rural health nursing, as well as in
through the NINR Exploratory Centers the ways in which rural nurses can continue
Program, provides an opportunity to their education and keep competencies and
strengthen rural research and is forging knowledge up-to-date. However, the pro-
research linkages between Montana nurse gress will stop without sustained efforts to
scientists and rural nurse investigators in increase rural nursing research and availabil-
Oregon, Iowa, Wyoming, North Dakota, and ity of technology in rural areas. The advances
Nebraska. likewise, the NINR-funded mul- in nursing science and education, along with
tidisciplinary Rural Health Care Research better understanding of historical factors,
Center at the University of Virginia brings changing demographics, health disparities,
key stakeholders in rural health together to strengths, and resources of rural communi-
set the rural research agenda for Virginia ties/individuals, can enhance health for peo-
at its surrounding states with pilot studies ple in rural settings.
including telehealth, community participa-
tory research, and palliative care. Marianne Baernholdt
S
of simple random sampling is that each case
Sampling has a known, nonzero probability of being
selected. This approach, however, is often
impractical and tedious and is not used
Sampling is a process for selecting a much. A more commonly used type of ran-
representative part of the population of dom sampling is systematic random sam-
interest so that one can make valid infer- pling. Systematic random sampling involves
ences and generalizations from the sample the use of a random start, and then the selec-
to the population. A sample is more feasi- tion of every kth case or incidence (e.g., every
ble, economical, and practical than using 5th, 10th, and 35th case). This approach is
the whole population. It also often is more more convenient than simple random sam-
accurate than trying to measure the entire pling, but it can have variance estimation
population. This is because the greater num- problems. A minimum of two systematic
ber of cases in a population, as compared random samples with independent ran-
with a sample, increases the likelihood of dom starts are needed to estimate variance,
nonsampling errors such as measurement unless one can assume a random distribu-
errors, nonresponse biases, and recording tion of the cases on the list from which one
and coding errors. Although many think has sampled.
of sampling representativeness in descrip- When using systematic random sam-
tive terms as only an issue of external pling, one must be very careful that the list
validity, or generalization, sampling also used does not have some systematic order
is concerned with the relationships found. or periodicity. If so, systematic random sam-
Therefore, sampling errors or biases may pling may lead to a seriously misrepresented
threaten the internal validity of studies sample or pattern. For example, one might
as well. Samples, however, are not techni- inadvertently select all nurse managers or
cally in and of themselves “representative,” obtain blood samples only when certain
“unbiased,” or “fair.” It is the sampling pro- hormones are at their peaks, if the sampling
cess that is representative, unbiased, or fair. interval mimics the sequencing of nurse
This is because we rarely if ever know the managers on the list or the time interval at
true population values and therefore can- which the hormone peaked.
not determine if any given sample is truly Stratified sampling is another type of
representative of the population. Rather, random sampling. It involves identifying
we rely on the assumptions underlying our one or more classification variables to use for
sampling process to make assertions about sampling purposes. With stratified sampling,
representativeness or bias. one randomly samples within each nonover-
There are several types of sampling. lapping strata of the classification variables.
Simple random sampling, or probability For example, if sex is the classification var-
sampling, is a procedure that may involve iable, then one randomly samples men and
the use of a table of random of numbers or women separately; if basic educational prep-
the flip of a coin to determine who or what aration of nurses is the classification variable,
will be included in the sample. A key feature then one randomly samples from those with
SAmplIng n 459
associate degrees and those with baccalaure- all elements (or a relevant, random subset)
ate degrees separately. within each cluster. In contrast to stratified
For research purposes or gains, it is best sampling where one samples from all strata S
to select classification variables based on their of the classification variable, with cluster
assumed association with the dependent var- sampling one samples only some clusters,
iable. If more than one classification variable for example, some practice sites or some
is used, it also is advantageous if they are hospitals.
uncorrelated with each other. Stratified sam- Whereas the goal of stratified sampling
pling facilitates obtaining subgroup param- is to obtain homogeneous strata, when one
eter estimates and comparisons—especially does cluster sampling one wants the clusters
when some strata are rarer and stratification to be as heterogeneous as possible. To the
is used to ensure an adequate number of extent that the clusters are not heterogeneous,
cases in each stratum for valid comparisons. one loses precision and the cluster sample is
Stratified sampling also may increase the sta- less efficient than a simple random sample of
tistical efficiency of estimates if proportional the same size. At the extreme, if the cluster
allocation (as opposed to equal allocation) is is completely homogeneous, one achieves
used, and may be more convenient if sam- no gain from more than one case per cluster.
pling lists are organized according to the Cluster sampling generally is used for prag-
selected strata. matic purposes when there is no other way
The intent with stratified sampling is to to easily obtain the targeted sample than
decrease sampling variability by increasing through the identification of clusters.
the homogeneity of the strata. If one forced The last type of sample discussed here
equal numbers of cases in each stratum, it is convenience samples or nonprobability
is important to remember that the resulting samples. These are frequently used in nurs-
sample will not reflect the natural distribu- ing research, but their implications often
tion of the classification variable. In those are ignored. First, it is not possible to esti-
cases, one must assign weights to the cases to mate sampling errors with such samples.
reflect the known proportionate distribution Therefore, the validity of inferences drawn
of the strata in the population if one wishes to from nonprobability samples to the popula-
conduct analyses involving the classification tion remains unknown and whenever non-
variable in addition to analyses comparing random selection is used, the potential for
the strata within each classification variable. serious sample selection biases exists.
Stratified sampling, however, may be more lastly, it is important to note that sample
costly and complex. lastly, the control advan- selection bias may threaten internal as well
tages of using stratified sampling are limited as external validity (Berk, 1983). One way in
because stratification generally is applied to which this may happen is when investigators
some, but not all, variables of interest. inadvertently sample on their dependent var-
Cluster sampling is a fourth type of ran- iable by excluding cases at either the high or
dom sampling. With cluster sampling, the low end of values on the dependent variable.
elements of interest for the study and the For example, if one is studying the impact of
sampling units are not same. The sampling amputation on depression and quality of life,
unit, or cluster, is a convenient, practical, and but screens out all those currently diagnosed
economical grouping—for example, prac- with and on medications for depression, one
tice sites; hospitals—whereas the elements may obtain an erroneous or misspecified
of interest for the study may be the individ- model because those at one end of the depres-
ual patients obtained at the practice sites or sion continuum have been excluded from the
hospitals. With cluster sampling, one ran- sample. In a bivariate analysis, this misspeci-
domly samples the clusters and then takes fication will include either an attenuation or
460 n SChIzOphRenIA
exaggeration of the relationship between the Diagnostic and Statistical Manual (4th edition,
dependent and independent variable depend- text revision) requires that at least two of the
S ing on the location of the excluded cases. In following be present for a significant por-
the more common multivariate situation, we tion of time during a 1-month period: delu-
cannot predict whether the relationship we sions, hallucinations, disorganized speech,
seek to identify is attenuated or exaggerated, grossly disorganized or catatonic behavior,
but we do know it will be misspecified. For and negative symptoms that refer to cogni-
this reason, sampling on one’s dependent tive deficits such as alogia, poverty of speech,
variable should never be done. avolition, and flattening of affect. For a sig-
nificant portion of the time since the onset
Lauren S. Aaronson of the disturbance, one or more major areas
of functioning, such as work, interpersonal
relations, or self-care, is markedly below the
level achieved before the onset. Continuous
Schizophrenia signs of the disturbance must persist for at
least 6 months. Diagnostic criteria require
that medical and substance abuse etiology be
Schizophrenia, the most serious and per- ruled out.
sistent of the brain diseases in psychiatry, The difficulty with the current diagnos-
strikes about 1.3% of the population world- tic criteria is that two different people with a
wide regardless of race, ethnic group, gen- combination of these various symptoms can
der, or country of origin (national Institute each be diagnosed with schizophrenia, yet
of mental health, 2010). Research and tech- have a totally different symptom configura-
nological advances over the past 25 years has tion. none of these symptoms is unique to
redefined schizophrenia as a major neurobi- schizophrenia alone as each of these symp-
ological disease, a concept in psychiatry that toms can be found in many other psychiatric
now replaces outdated psychological theo- diagnoses. A more recent approach to symp-
ries of causation, yet schizophrenia remains tom clusters includes three categories of
the most stigmatized illness of all medi- symptoms: positive, negative, and cognitive.
cal diagnoses. Worldwide there are at least positive symptoms refer to symptoms that
450,000,000 persons with mental health result from an exaggeration of normal brain
diagnoses, yet more than 80% do not receive functions and include delusions and halluci-
treatment (World health Organization, nations. negative symptoms are those that
2004). Approximately 2,200,000 people in result in a loss of normal functioning and
the United States suffer from schizophrenia include apathy, emotional flatness, loss of
and the accompanying stigma. In three out the ability to initiate speech, loss of pleasure
of four cases, the illness begins between the in activities that normally result in enjoy-
ages of 17 and 25 years, robbing its victims ment, inability to initiate movement, inabil-
of their most productive young adult years. ity to motivate self, and inability to sustain
The disease typically strikes males at a youn- attention. Cognitive symptoms refer to loss
ger age than females. The average life span of of ability to understand the source of symp-
a person with schizophrenia is 20% shorter toms, loss of executive functioning includ-
than that of the general population due to ing judgment, orientation, communication,
the frequent occurrence of comorbid medical memory, and ability to prioritize and orga-
and psychiatric conditions (Carney, Jones, & nize thoughts.
Woolson, 2006). Approximately 400,000 acute episodes
The criteria for diagnosis in the occur annually in the United States and three
American psychiatric Association’s (2000) million occur worldwide. Complete recovery
SeCOnDARy DATA AnAlySIS n 461
from a psychotic episode can take months to Solomon, 2007). At least 75% of persons with
years depending on the severity, presence of schizophrenia respond well to psychotropic
psychosocial support, and response to medi- medications and psychiatric rehabilitation S
cations. Schizophrenia is ranked fourth of and can live successfully in the community
the top 10 of all diseases worldwide in terms with the proper social support. early diagno-
of burden of illness. The top three are unipo- sis and treatment has been proven to decrease
lar disorder, alcohol use, and bipolar disor- disability (Addington & Addington, 2009).
der. Schizophrenia ranks second in women however, the majority of the persons with
age 14 to 44 years of all diseases worldwide chronic schizophrenia do not receive treat-
in terms of burden of illness. It is projected ment, which contributes to the chronicity
that by 2020, neurobiological illnesses will often associated with this illness.
account for almost 15% of all illnesses world- A CInAhl and OVID search of schizo-
wide (World health Organization, 2004). phrenia research articles published in all
Twenty to fifty percent of patients with nursing journals from 2005 to 2010 returned
schizophrenia attempt suicide, and 10% of 119 articles that were categorized as (1) care-
them succeed. giver and family burden (N = 18); (2) children
Schizophrenia accounts for 40% of all and adolescents (N = 2); (3) inpatient treatment
long-term care hospital days. The cost of (N = 8); (4) management of hallucinations and
schizophrenia in the United States in 2002 delusions (N = 9); (5) outcomes measures and
was estimated to be $62.7 billion (mcevoy, assessment tools (N = 10); (6) psychoeducation
2007). These costs include direct care in (N = 4); (7) psychosocial rehabilitation (N = 15);
institutions and the community as well (8) psychotherapy (N = 6); (9) stigma (N = 4);
as in indirect costs of loss of productivity, (10) symptom management and relapse pre-
caregiver burden, and law enforcement. vention (N = 8); (11) treatment adherence and
Tragically, in 2010, it is now three times more medication management (N = 15); (12) well-
likely that a person with schizophrenia will ness, lifestyle, and medical comorbidity (N =
be treated in a forensic setting as compared 13); and (13) women’s issues (N = 6). This dis-
with a hospital (Torrey, entsminger, geller, tribution of nursing research reflects a dra-
Stanley, & Jaffe, 2010). Currently, there are matic increase in programmatic and treatment
280,000 persons with mental illness in jails innovations by nurses in the past 5 years.
and prisons compared with 70,000 in hos-
pitals. On any given day, 1.8 million people Mary Moller
with schizophrenia and bipolar disorder go Kathleen Fentress
without treatment. more than two-out-of-five
of our most severely mentally ill people go
untreated. This places the people who need
treatment the most, and the whole nation, Secondary data analySiS
at risk. Approximately 200,000 Americans
with untreated severe mental illness are
homeless. Secondary data analysis uses the analysis of
The cause remains unknown, but neuro- data that the analyst was not responsible for
anatomical, neurophysiological, and neuro- collecting or data that was collected for a dif-
electrical abnormalities have been identified. ferent problem from the one currently under
genetic associations have also been discov- analysis. The data that are already collected
ered. The cure remain elusive; however, and archived in some fashion are referred to
treatments have dramatically improved since as secondary information. Statistical meta-
the initiation of the recovery philosophy in analysis might be considered a special case
the 1970s (Corrigan, mueser, Bond, Drake, & of secondary analysis (see Meta-Analysis).
462 n SeCOnDARy DATA AnAlySIS
Secondary information is an inexpensive The question of using clinical nursing
data source that facilitates the research pro- data sets for secondary analysis comes with
S cess in several ways. It is also useful for gen- the advent of clinical nursing information
erating hypotheses for further research. It is systems. The use of clinical databases as
useful in comparing findings from different research data sets must be examined care-
studies and examining trends. population fully. One difficulty is that restricted data
data sets, such as Bureau of the Census data, resources force clinicians to choose carefully
may be used to compare sample with pop- which data to collect. These data are usually
ulation characteristics to examine the repre- not identical with what the researcher needs.
sentativeness of the study sample. Beyond data restrictions, another major
The analysis of secondary information difficulty is that the sample biases of clinical
is a useful strategy for learning the research databases and research data sets for random-
process. The secondary data sets that have ized control studies are different. This differ-
used optimum sampling techniques provide ence in bias of the data from clinical databases
an optimum resource for students by virtue and randomized controlled trial research
of the quality of sampling and the time and data sets can be exploited as a strategy for
expense involved in data collection. given doing cross-design synthesis. however, this
that students are expected to understand, to special case aside, the issue is that of sam-
explain, and to defend the data set in terms ple representativeness. The research sample
of purpose, sample selection, methods, and is selected for a specific reason, with specific
instruments, only the real-life collection and delimitations in mind, to be representative
recording of data remain are not experienced of the general population. In contrast, the
by the student. Another advantage of using clinical population from which the clinical
secondary data analyses while learning to do data set is drawn is representative only of
research is that it protects the pool of poten- that type of patient or client on whom data
tial research participants and agencies for is being collected in that location and rarely,
participation in studies conducted by quali- if ever, typical of the general population or
fied researchers. even all persons with that clinical problem.
every research study is conducted with For example, patients with congestive heart
a specific purpose in mind. Delimitations are failure in Alabama are not necessarily rep-
specific to the original study and introduce resentative of patients with congestive heart
specific types of sampling and other bias failure in new england or California. The
into the original study. Operational defini- same is true of patients with congestive heart
tions may not be replicable in a second study. failure in a community hospital versus those
For learning purposes, differences in the in a teaching hospital in the same county.
original study and data set can be handled These caveats necessitate close evalu-
through careful critique processes by stu- ation of data sets to be used for secondary
dents. however, the biases and differences analysis. The information needed for such
that exist may be too extreme to permit a evaluation must be archived along with the
valid secondary analysis outside the practice data set. Such information includes study
situation. purpose; data collection details, such as
Archived data sets are rarely held in the who collected the data, when, and where;
form of raw data because the data are usu- sampling criteria and delimitations; known
ally summarized. The summarization may biases; operational definitions; and methods
or may not be appropriate for the research of data collection.
question under consideration for secondary Traditionally, nursing has not archived
analysis. To analyze such data further con- research data sets of its own for use in teach-
founds results beyond acceptable limits. ing or secondary analysis. nursing students
SelF-eFFICACy n 463
and nurse researchers do use large govern- actually touching the snakes, (2) role model-
ment databases, but none are collected specif- ing or seeing others touch the snakes, and
ically by nurse researchers to answer nursing (3) the control group. Results suggested that S
research questions. This is a problem to the self-efficacy was predictive of subsequent
extent that learning takes place best when behavior, and enactive attainment resulted
examples and experiences relate closely to in stronger and more generalized (to other
daily (nursing) experience. Certainly, prob- snakes) self-efficacy expectations. Since that
lems peculiar to but not exclusive to nursing early work, Bandura and colleagues have
research are more easily taught with exam- repeatedly demonstrated that individuals
ples from real life. This is a problem also to become efficacious in a particular domain of
the extent that nursing research data sets can, function through four mechanisms: enactive
in fact, generate new knowledge, whether by mastery experience, vicarious experience,
reanalysis or by stimulation of further inves- verbal persuasion, and physiological and
tigation and hypothesis generation. affective states (Bandura, 1997, p. 4).
The theory of self-efficacy has been used
Judith R. Graves extensively in nursing research with regard
to describing and evaluating behaviors as
well as developing and implementing inter-
ventions. most recently, the use of self-effi-
Self-efficacy cacy theory in nursing has focused on health
behaviors (e.g., exercise, cancer screening),
cultural competence of nurses, function
Self-efficacy, which is the primary component and self-care, nursing care competence and
of social cognitive theory, is defined as an behaviors (e.g., dementia care), patient self-
individual’s judgment of his or her capabili- management, breastfeeding for new moth-
ties to organize and execute courses of action ers, and infant self-care. Increasingly, use of
to achieve a certain goal (Bandura, 1977, self-efficacy has extended to include multi-
p. 1; 1986, p. 2; 1995, p. 3; 1997, p. 4; Bandura, ple cultures (e.g., Chinese, Korean, African
Adams, & Beyer, 1977, p. 7). Bandura differ- American), all age groups and both men and
entiates self-efficacy expectations from out- women. What is central to the use of the the-
come expectations. Outcome expectations ory of self-efficacy in nursing research is for
are a person’s judgment that a given behav- the researcher to maintain a fit between the
ior will lead to certain outcomes. Self-efficacy behavior that is being considered and effi-
and outcome expectations were differenti- cacy and outcome expectations. For exam-
ated because individuals can believe that ple, if the behavior of interest is adhering
a certain behavior will result in a specific to a low-salt diet, the self-efficacy measure
outcome; however, they may not believe that should focus on the challenges related to this
they are capable of performing the behavior specific behavior (when out to dinner, etc.).
required for the outcome to occur. Self-efficacy has been used to improve
The early research using the theory of and understand health behaviors with
self-efficacy was done to test the assumption regard to exercise (Chang, Fang, & yang,
that exposure to treatment conditions could 2006, p. 13; hays, pressler, Damush, Rawl, &
result in behavioral change by altering an Clark, 2010, p. 14; lee, Arthur, & Avis,
individual’s level and strength of self-efficacy. 2008, p. 15; murrock & madigan, 2008,
In the initial study (Bandura, 1977, p. 7), 33 p. 12; Resnick, gruber-Baldini, et al., 2009;
subjects with snake phobias were randomly Resnick, luisi, et al., 2008; van den Akker-
assigned to three different treatment condi- Scheek et al., 2007, p. 8). Specifically, these
tions: (1) enactive attainment, which included nursing studies considered the impact of
464 n SelF-eFFICACy
motivational interventions and engaging particularly with regard to adults under-
individuals in exercise activities on self-effi- going orthopedic interventions (Resnick,
S cacy expectations and explored relationships gruber-Baldini, et al., 2009; van den Akker-
between self-efficacy and outcome expecta- Scheek et al., 2007, p. 8). Although interven-
tions and exercise behavior. In contrast to tions did not always strengthen self-efficacy
Bandura’s earlier findings (Bandura, 1997, with regard to functional behaviors, there
p. 4), which stressed that self-efficacy expec- was an association between these beliefs and
tations were better predictors of behavior performance of function.
than outcome expectations, in several nurs- nursing research frequently uses self-
ing studies outcome expectations, rather than efficacy theory to address self-care and
self-efficacy expectations, were predictive of self-management across a variety of clinical
exercise behavior (murrock & madigan, 2008, problems. For example, self-efficacy has been
p. 12; Resnick, luisi, et al., 2008). used with regard to self-care management
Self-efficacy theory has also been used after acute cardiac events and associated
to address health behaviors such as healthy with congestive heart failure (hiltunen et al.,
eating in rural women (Walker, pullen, 2005, p. 30; padula, yeaw, & mistry, 2009,
hertzog, Boeckner, & hageman, 2006, p. 16), p. 29), diabetes self-care management (Utz
health promoting behaviors in incarcerated et al., 2008, p. 31), and self-management for
men (loeb, Steffensmeier, & lawrence, 2008, peritoneal dialysis (Su, lu, Chen, & Wang,
p. 17), osteoporosis screening (hsieh, Wang, 2009, p. 32) for managing depression (Weng,
mcCubbin, zhang, & Inouye, 2008, p. 18), Dai, Wang, huang, & Chiang, 2008, p. 33),
papanicolaou (pap) testing (Tung, nguyen, & back pain (göhner & Schlicht, 2006, p. 34),
Tran, 2008, p. 19) in Asian adult samples, and and birth control. nursing interventions
smoking cessation (Kim, 2006, p. 36). Across intended to improve adherence to self-care
all of these studies, there were significant behaviors were guided by self-efficacy the-
positive relationships between self-efficacy ory in these studies, and findings indicated
and the behavior of interest. that there were improvements in self-efficacy
Cultural competence in nurses has been as well as anticipated behaviors.
considered by using a measure of knowledge Another common use of self-efficacy
of cultural concepts, knowledge of cultural theory in nursing research is around the
life patterns for specific ethnic groups, and area of mothering, specifically with regard
self-efficacy in performing cultural nursing to breastfeeding and infant care (noel-Weiss,
skills (hagman, 2006, p. 20). Findings indi- Rupp, Cragg, Bassett, & Woodend, 2006, p.
cated that nurses were moderately efficacious 38; padula et al., 2009, p. 29; prasopkittikun,
in cultural knowledge and abilities. Self- Tilokskulchai, Sinsuksai, & Sitthimongkol,
efficacy expectations associated with demen- 2006, p. 39). Self-efficacy expectations were
tia care management has also been considered shown to be associated with breastfeed-
(Connor et al., 2009, p. 22), as has self-efficacy ing and infant care and interventions to
for providing restorative care (Resnick, luisi, strengthen self-efficacy associated with these
et al., 2008), self-efficacy for knowledge of behaviors improved adherence to nursing
use of assistive devices (Roelands, Van Oost, behaviors.
Depoorter, Buysse, & Stevens, 2006, p. 24), and Self-efficacy is situation specific, and it
self-efficacy for professional nursing behav- is not clear how generalizable self- efficacy
ior (manojlovich, 2005, p. 25). Self-efficacy expectations are from one behavior to
either directly influenced outcome behaviors another. Future nursing research needs
or mediated these behaviors. to focus on the degree to which specific
Self-efficacy has been considered self-efficacy behaviors can be generalized.
with regard to functional performance, measurement of self-efficacy and outcome
SeRIOUS menTAl IllneSS n 465
expectations requires the development of disorders and are disabled enough to qual-
situation-specific scales with a series of activ- ify for disability benefits from the Social
ities listed in order of increasing difficulty, or Security Administration” (U.S. Department S
by a contextual arrangement in nonpsycho- of health and human Services, 1999).
motor skills such as dietary modification. It Schizophrenia is characterized by so-
is important for nurse researchers to care- called “positive” symptoms of delusions and
fully construct relevant scales and establish hallucinations and “negative” symptoms,
evidence of reliability and validity. such as apathy, social withdrawal, and amo-
There has been some evidence in nurs- tivation. mood disorders, particularly bipo-
ing research that outcome expectations lar disorders, are characterized by mood
have an important influence on behavior, in swings, negative or grandiose thinking, and
some cases may be more relevant than self- increased risk of suicide. In both groups,
efficacy expectations. Ongoing studies are social functioning is often impaired, and in
needed to continue to evaluate the impact the most severe cases, employment and inde-
of both self-efficacy and outcome expecta- pendent living are difficult if not impossible.
tions on behavior change as well as develop The illnesses can have episodic trajectories,
and test interventions that strengthen these with periods of relatively high functioning
expectations. punctuated by periods of low functioning or
lastly, self-efficacy-based interventions even crises requiring immediate treatment.
need to continually be tested and evaluated Symptoms of SmIs often make adherence to
and specifically to be considered among dif- treatment recommendations difficult.
ferent cultural groups. In so doing, nursing historically, the treatment of SmI
will be able to accrue evidence-based, theoret- changed dramatically with “de-institution-
ically driven interventions to guide practice alization” that followed the Community
across multiple settings and populations. mental health Centers Act of 1963 and
involved a large-scale shift from caring for
Barbara Resnick mentally ill persons in large state psychi-
atric facilities to more community-based
treat ment programs. One model that was
developed in the 1970s and has since been
SeriouS mental illneSS replicated in various forms across the United
States is the Assertive Community Treatment
model. The Assertive Community Treatment
Serious mental illness (SmI) is “a diagnosable delivers comprehensive 24-hour treat-
mental, behavioral, or emotional disorder of ment to clients with SmI in the community.
sufficient duration to meet diagnostic criteria Interdisciplinary teams address a myriad of
specified within the Diagnostic and Statistical clients’ needs, from basic daily requirements,
Manual for Mental Disorders (DSM) that has employment, financial assistance, and hous-
resulted in functional impairment which sub- ing to clinical interventions to enhance med-
stantially interferes with or limits one or more ication management (Stuart, 2009).
life activities” (president’s new Freedom Inpatient stays have become increas-
Commission on mental health, 2003). In con- ingly short, in some cases, only a few days.
trast, “serious and persistent mental illness” As a result, community treatment is critical
is defined as “a sub-population of patients to address residual symptoms remain that
with SmI (approximately 2.6% of all adults) must receive treatment in the community
who generally have diagnoses of schizophre- setting. Relapse is common in the first year
nia, severe depression or bipolar disorders, following initial diagnosis and readmission
obsessive-compulsive disorders and panic to inpatient treatment is a significant feature
466 n SeRIOUS menTAl IllneSS
of the illness trajectory of patients with SmI. of a higher incidence of obesity, hyperlipid-
Relapse rates ranging from 40% to 80% in emia, and diabetes. patients receiving anti-
S the first year after discharge have been psychotic medications often suffer from
reported (Irmiter, mcCarthy, Barry, Soliman, significant abdominal weight gain, hyper-
& Blow, 2007; Stevens & Sin, 2005). The cost cholesterolemia and elevated blood pressure
of relapse in this population has been esti- (Usher, Foster, & park, 2006).
mated to be almost $2 billion annually in the evidence-based practice guidelines
United States (Weiden & Olfsson, 1995). In (Kreyenbuhl, Buchanan, Dickerson, &
a recent prospective study of 1,557 patients Dixon, 2010) include specific new recom-
with schizophrenia, 20% had relapsed in mendations that target weight gain, smok-
the 6 months before the study, their cost of ing cessation and substance abuse. Current
health care was almost three times as much research is beginning to target interventions
as those who had not relapsed (Ascher- to help patients manage these factors that
Svanum et al., 2010). are prevalent in this population an adversely
most SmIs are treated with medications. affect their physical health. physical health
newer “second-generation” antidepressants of patients with SmI has been a recent focus
and antipsychotic medications present more of research because persons with SmI have
treatment options with fewer disabling or a life span that is shortened by as much as
disturbing side effects. Second-generation 25 years compared with the general popula-
antipsychotic medications for schizophrenia, tion. premature death in this population is
for example, are more successful for some caused by common medical conditions such
patients in targeting the negative symptoms as untreated cardiovascular diseases noted
(e.g., amotivation, anhedonia) than earlier above, cancers undetected due to lack of
drugs. however, they have increased risk for screening, and medical conditions related to
metabolic syndrome, and weight gain is a risk-taking behaviors, such as hepatitis and
serious concern for patients. moreover, medi- hIV. As many as 50% of patients with SmI
cation adherence continues to be a significant have a co-occurring diagnosis of substance
problem for patients with SmIs, suggesting abuse. patients with SmI often have diffi-
that more research is needed to understand culty consistently accessing primary care
and address this important problem. providers who attend to preventive health
A contemporary concern for researchers care needs.
is the increased risk for cardiovascular dis- From the societal perspective, SmI
ease in patients with SmI. prevalence of car- remains poorly understood by the general
diovascular risk factors is greater in patients public. Stigmatizing attitudes toward per-
with SmI than in the general population (27% sons with mental illness persist, despite the
vs. 17%) and mortality risk from cardiovas- fact that most people acknowledge that the
cular disease is two to three times that of the illnesses are outside the patients’ control.
general population (Robson & gray, 2006). The economic costs associated with SmI
In a recent meta-analysis of risk factors for have been estimated to be in the billions
cardiovascular disease (Osborn et al., 2008), and include loss of earnings as well as the
diabetes was found to be the strongest car- direct costs associated with care (Insel, 2008).
diovascular risk factor and patients with a Almost a quarter of incarcerated persons have
diagnosis of schizophrenia are almost twice mental illnesses; it has been estimated that a
as likely to have diabetes. “metabolic syn- third of homeless persons have an SmI (Insel,
drome” is a cluster of medical conditions that 2008). Family members continue to take on a
have been identified in patients with schizo- caregiving role, with limited resources and
phrenia taking newer generation antipsy- accompanying caregiver stress and burden.
chotic medications. This syndrome consists Some interventions to reduce the burden
ShIVeRIng n 467
and provide support to caregivers have been of life, including an emphasis on education
tested, in particular, psychoeducational pro- and employment, is an important outcome of
grams for families (Schulze & Rossler, 2005), treatment in addition to symptom manage- S
but widespread adoption of family interven- ment. An effective therapeutic relationship
tions has been slow (lehman et al., 1998). The with health care professionals, including
national Alliance for mental Illness, a grass- nurses, remains paramount to good care
roots consumer-based organization, contin- (Ware, Tugenberg, & Dickey, 2004). Finally,
ues to provide important support services to cognitive behavioral therapy is effective with
families. persons with SmIs (leclerc, lesage, Ricard,
Theoretical perspectives of treatment lecomte, & Cyr, 2000).
have shifted in the last ten years to focus less In summary, the disabling effects of the
on management of SmI as a chronic condition illnesses, including impact on physical health
to a focus on recovery. Recovery is defined status, are significant. There are encouraging
as “a journey of healing and transformation trends, however, in the shift to a focus on
enabling a person with a mental health prob- recovery rather than chronicity. Community-
lem to live a meaningful life in a community based care, with nurses at the forefront, has
of his or her choice while striving to achieve an important role in achieving optimal qual-
his or her full potential” (U.S. Department ity of life for these patients. more research is
of health & human Services, 1999). From needed to build a science of effective recovery
the patients’ perspectives, a recovery model interventions. Finally, research to address the
of care includes the following components: needs of family caregivers that is feasible and
an attitude of hope, empowerment, holism, cost effective and ultimately benefits patients
strength based, peer support, respect, non- with SmI in need to be conducted.
linear progress, self-responsibility, and
empowerment (president’s new Freedom Linda Rose
Commission on mental health, 2003; U.S.
Department of health & human Services,
1999). The model emphasizes collaboration
between patients and practitioners (Anthony Shivering
& greenley, 1993; Jacobson & greenley, 2001).
This recovery model of care will have a major
impact on nursing research in the foresee- Shivering is defined as involuntary shaking
able future. Contemporary nursing practice of the body and is the adult human’s primary
that focuses on the support and educational defense against the cold and is character-
needs of persons with SmIs will do so within ized by a protracted generalized course of
a recovery framework. Research evidence is involuntary contractions of skeletal muscles
scant, however, on the specific interventions that are usually under voluntary control.
that will achieve the goals of recovery for Thermoregulatory shivering differs from
patients with SmIs. transient tremors or “shivers” associated
new avenues for research are emerging. with fear, delight, or other forms of sympa-
Social support is important for patients with thetic arousal. Shivering occurs when heat
SmIs, but recent studies suggest that women loss stimulates specific heat-loss sensors
in particular have reported a need for recip- in the skin, spinal cord, and brain. Sensory
rocal relationships in feeling socially con- impulses are received and integrated at the
nected (Chernomas, Clarke, & marchinko, preoptic area of the hypothalamus. Shivering
2008). Interventions recognizing the different is stimulated when integrated thermosen-
needs of men and women with SmI are being sory impulses indicate body temperature is
tested (Kelly, Wellman, & Sim, 2009). Quality falling below optimal “set point” range (see
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Encyclopedia of Nursing Research
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