468 n ShIVeRIng
Thermal Balance). The shivering center in the measurement of shivering by use of a shiv-
posterior hypothalamus is stimulated, send- ering severity scale, originated by Abbey
S ing impulses via anterior spinal routes of the et al. (1973)
gamma efferent system. heat is generated by Although shivering had been stud-
oscillation and friction of the fibrous muscle ied extensively by physiologists in healthy
spindles of the fusimotor system. Shivering humans and animals, little clinical interest
occurs in fever despite rising temperatures was evident until the 1970s. Abbey and Close
because the set point level is raised to higher (1979) used wraps of ordinary terry-cloth
levels by circulating cytokines and other towels as insulation to protect thermosensi-
pyrogens. The elevated set point range causes tive regions of the skin during use of cooling
the patient’s usual body temperature to be blankets. Shivering during surface cooling
sensed as too cool and causes the warming was a significant problem treated at that time
responses known as shaking febrile chills with chlorpromazine, a drug with undesir-
(holtzclaw, 2002). able side effects. The wrapping intervention
The consequences of shivering for seri- was based on existing physiological research
ously ill or vulnerable patients are some- demonstrating dominance of the heat loss
times overlooked because they seem to be sensors on hands and feet in stimulating
harmless compensatory warming responses. shivering. This landmark pilot study demon-
however, the aerobic activity generated by strated that insulation of extremities controls
vigorous shivering activity raises oxygen shivering and improves comfort without
consumption three- to fivefold, approxi- drugs, even when surface cooling induces
mately that of shoveling snow or riding a hypothermic temperatures.
bicycle. The resulting oxidative phosphory- Federally funded studies by nurse inves-
lation of glucose and fatty acids raises meta- tigators (Abbey & Close, 1979; holtzclaw,
bolic demands, but it is only approximately 1990, 1998) using more extensive tempera-
11% efficient in raising body temperature. ture and electromyographic measurements
The energy expenditure of shivering may further supported the usefulness of “wrap-
be tolerated by healthy persons who shiver ping” extremities, with theoretical perspec-
for short periods, but it puts specific patient tive based on Abbey’s original work. Stated
groups at risk for cardiorespiratory, meta- briefly, insulation blunts the neurosensory
bolic, and thermal instability. Uncontrollable stimulus of heat loss from dominant sen-
shivering is distressful to patients, yet sors, whereas larger but less thermosensitive
it occurs frequently in situations where regions of the trunk allow heat exchange
ambient temperatures are cool, patients without inducing shivering.
are exposed, or therapies induce fever. historically, interest in postoperative
Shivering is often recalled by patients as a shivering grew in the mid-1980s with the rise
negative aspect of postoperative recovery, in hypothermic cardiac surgery. Research
childbirth, antifungal drug administration, findings show the hazardous increase in
blood transfusions, or other hospital experi- oxygen consumption, carbon dioxide pro-
ence. nursing research has documented cor- duction, and cardiovascular exertion during
relates and sequelae of shivering in an effort postoperative rewarming from hypother-
to determine adverse consequences in post- mic cardiac bypass (holtzclaw & geer, 1995;
operative care, febrile illness, and during phillips, 1997). Clinical predictors of shiver-
induced hypothermia. Intervention studies ing became of interest as early prevention was
have tested efficacy of nursing measures to indicated. The mandibular hum was detected
prevent shivering during surface cooling by palpation of referred masseter vibrations
and febrile chills. Important to these stud- over the ridge of the jaw (holtzclaw & geer,
ies has been the effort to standardize the 1986). Widening of skin to core temperature
SImUlATIOn n 469
gradients was found to predict shivering in the biobehavioral interface of environmental
this population, presumed to reflect the dis- stimuli, biochemical and neurotransmitter
crepancy between hypothalamic set point activity, energy expenditure, physics of heat S
and peripheral temperatures that initiates exchange, and thermal comfort.
shivering. Sund-levander and Wahren (2000)
found that tympanic-to-toe temperature gra- Barbara J. Holtzclaw
dients predicted shivering in neurologically
injured patients during hypothermic surface
cooling and that patients were more likely to
shiver if cooled too quickly. This study sup- Simulation
ported the earlier contention of Abbey et al.
(1973) that shivering during surface cooling
could be reduced by modifying the rate of Simulations provide an innovative teaching
body heat loss. Studies confirm that little dif- method to enhance the learning of students
ference is found between pharmacological and professionals by engaging them in active
suppressants, warmed blankets, or reflective learning techniques which provide feed-
wraps in preventing shivering during peri- back and allow for reflection on practice and
operative rewarming (hershey, Valenciano, outcomes. A definition from the national
& Bookbinder, 1997); however, newer forced- Council of State Boards of nursing’s (nCSBn,
air warming units (e.g., Bair hugger) and 2005) policy statement describes simulations
radiant lamps have been found in medical broadly as “activities that mimic reality of
studies to maintain normothermia more a clinical environment and are designed to
effectively. extremity wraps were found to demonstrate procedures, decision-making
effectively reduce febrile shivering severity and critical thinking through techniques
and duration (see Fever/Febrile Response) in such as role-playing and the use of devices
immunosuppressed cancer patients and per- such as interactive videos or mannequins”
sons with hIV/AIDS (holtzclaw, 1990, 1998) (Jeffries, 2005; nCSBn, 2005). In using this
As scientific evidence grows about neu- innovative teaching method, faculty mem-
roregulatory and immunological factors bers and staff development personnel use
influencing shivering, new avenues of study patient-specific information to create mean-
emerge. little is known about how shivering ingful real-life scenarios that improves stu-
can be controlled in emergency situations dents’/nurses’ comprehension of the material
during rescue and evacuation. Few studies and situation. These scenarios vary in com-
have examined outcomes of shivering among plexity and expected learning objectives
children. Surgery, trauma, circulatory bypass, dependent upon the level of the learner, the
and hypothermia have all been linked in clinical situation they are being prepared for,
preliminary studies to acute phase reactions and the creativity of the developer. Clinical
that stimulate febrile shivering (phillips, nursing scenarios suspend disbelief of what
1999). Although shivering is estimated to is “real,” thus creating a hands-on opportu-
occur in about 10% of births during the last nity to practice patient monitoring and man-
stage of labor, it is more frequent following agement in a risk-free environment. A variety
epidural anesthesia (Arulkumaran, penne, & of professions benefit from the use of simu-
Rao, 2005, p. 58). however, little attention has lation activities and research demonstrates
been paid to its possible other proinflamma- enhanced learning and skill performance,
tory origins and management beyond con- increased communication, collaboration,
trolling warmth in the environment (Fallis and self-efficacy and improved patient
et al., 2006). Future directions in the study safety and outcomes (Bambini, Washburn, &
of shivering by nursing will likely address perkins, 2009; Kaakinen & Arwood, 2009;
470 n SImUlATIOn
Radhakrishnan, Roche, & Cunningham, teaching students the critical thinking, clin-
2007; Rhodes & Curran, 2005). The next sec- ical decision making, and communication
S tion will explore the historical, societal, and skills they need to function. In addition,
economic issues affecting the contemporary nursing students need enhanced practice in
practice of simulation in nursing. areas such as planning, implementing, and
historically, simulations have been used managing care for multiple patients, prior-
for training astronauts, pilots, military per- itization, and delegation of care all identi-
sonnel, and physicians. Only recently have fied as education–practice gaps with newly
the decreased cost of human patient simula- hired graduate nurses (nursing executive
tors (hpSs) and software allowed for their Center nursing School Curriculum Survey,
increased use in nursing. Societally, the 2007). The nCSBn reported that states have
demand for patient safety has encouraged enacted regulation changes to allow simu-
nurse educators to explore innovative tech- lation as substitution for clinical learning
niques to better prepare nursing students activities with approval of between 10% and
and staff for the complexities of the twenty- 25% of simulation time as clinical experience
first century health care environment (Kohn, (Jeffries, 2009).
Corrigan, & Donaldson, 2001; national On the health care institution side, the
league for nursing, 2008). The Institute of luxury of long, mentored transition expe-
medicine’s 2003 Report, Health Professions riences for new graduate nurses, nurses
Education (HPE): A Bridge to Quality, con- returning to practice, or nurses training in
cluded that nurses, doctors, and other allied different specialty areas has disappeared.
health professionals lack the education and Better graduate nurse retention and job sat-
training necessary to meet health care needs isfaction was found in interactive nurse
suggesting that “distance learning technol- residency programs that incorporated sim-
ogy, standardized patients, and clinical skills ulation (Anderson, linden, Allen, & gibbs,
testing technology also hold potential for 2009). Although clinical simulation will
revolutionizing hpe . . . offering students an never replace actual student and staff con-
opportunity to customize their learning and tact with real patients, it is rapidly earning a
progress at their own pace . . .” (Institute of place in nursing education and professional
medicine, 2003b, p. 90). development as a valuable supplement. The
Societally, many factors have led to the potential to maximize faculty resources and
increased use of simulation as an innovative better prepare students before their entry to
teaching method in academic and health care the clinical setting will make student and
institutions including: the growing shortage faculty time in clinical more valuable and
of nurses and nursing faculty (American cost-effective.
Association of Colleges of nursing, 2009), The past few years have seen an unprec-
an increased interest in nursing as a career edented use and proliferation of simula-
(Tanner, 2006a), and the growing complex- tion for nursing education, research, and
ity of the health care environment, with staff development. The increased use of
increased technology and more highly hpS is related to the economics of the sit-
acutely ill patients. Taken together, the result uation, namely, lower cost of equipment/
in academe has been limited student expo- software, increased national funding for
sure to regular hospital situations, decreased nursing education using technology and
opportunity to practice and maintain skills, innovation, and the acceptance of this teach-
and less availability of specialty area expe- ing method by leaders in nursing (nehring,
riences. Clinical simulation is being used to 2008, p. 109). Contemporary practice of sim-
meet this gap in opportunity and to enhance ulation in the health care field include uses
SImUlATIOn n 471
in military and medical education in areas participants; 4. Collaboration with student
such as emergency room training and anes- and faculty member in planning, implemen-
thesia crisis management or trauma rotation tation, and evaluation; and 5. Debriefing ses- S
and first responder cardiac care training. sion after each hpS experience” (Bremner,
In nursing, simulation has been used to Aduddell, Bennett, & Vangeest, 2006, p. 173).
teach critical care, cardiopulmonary resus- There are many education learning the-
citation, and clinical decision making and ories that support simulation education, to
to provide more consistent experiences for name a few: adult, social cognitive, experien-
specialty areas such as obstetrics and neo- tial, brain-based, constructivism, and novice-
natal nursing (Bambini et al., 2009; Cioffi, to-expert learning theories (Rodgers, 2007,
purcal, & Arundell, 2005; Kappus, leon, pp. 71–109). In fact, one of the criticisms of
lyons, meehan, & hamilton-Bruno, 2006). simulation research is a lack of theory-based
It has been used to examine patient safety studies. Rourke, Schmidt, and garga (2010)
in relation to hand washing, medication reviewed 47 manuscripts and found only
administration, and CpR response as well 10% of the studies used a theory of learn-
as in specialty areas such as labor and deliv- ing. Similarly, Kaakinen, and Arwood (2009)
ery (Broussard, 2008; gantt & Webb-Corbett, reviewed 120 simulation manuscripts to dif-
2010; hamman et al., 2010; lighthall, poon, ferentiate the use of simulation as a teach-
& harrison, 2010; Sears, goldsworthy, & ing method versus a way to design learning
goodman, 2010). Simulation also offers opportunities. In 94 of those manuscripts,
opportunities to evaluate and assess student simulation was described as a teaching
and staff skills providing options for reme- method/strategy; 16 of those had “learn-
diation and life-long learning (greenawalt ing” as the purpose for simulation design,
& Brzycki, 2007). The active learning aspect but only two considered learning as a cog-
of simulation engages learners and leads to nitive task (p. 11). The student learning was
greater retention of the material learned. The not considered as a cognitive/social process
integration of psychomotor, communication, occurring through a planned experience or
clinical judgment and critical thinking skills how the brain acquired and learned concepts
enhances self-efficacy, although research (Kaakinen & Arwood, 2009, pp. 12 and 17).
provides inconsistent results in the mea- One of the major theoretical frame-
surement of these outcomes (Bambini et al., works examined with relationship to simu-
2009; Brannan, White, & Bezanson, 2008; lations is Bandura’s social cognitive theory,
Chronister, 2008; Rhodes & Curran, 2005). specifically, self-efficacy. Although some
Using technology, informatics, and faculty studies have reported a decrease in anxiety
innovation, simulation involves faculty/staff and increase in self-confidence with simula-
development guidance and feedback during tion participation, leigh (2008, p. 11) found
debriefing as well as opportunities for reflec- nursing research in these areas lags behind
tion enhancing the competency of nursing other disciplines, especially examining the
students and practicing nurses to provide relationship between improved self-efficacy
safe patient care. and students’ clinical performance and
With the increased use of hpSs, “best patient safety.
practices” have been proposed for use Two frameworks exist for studying
with novice nursing students as “1. Well- nursing simulations: Jeffries and Rodgers’
articulated learner outcomes; 2. Clear con- (2007) nursing education Simulation
nection to course/clinical objectives; 3. Framework, which takes into account
established ongoing training and super- learning and cognition when creating
vision of faculty and staff members and simulations, and Campbell and Daley’s
472 n Sleep SCIenCe
(2009) Framework for Simulation learning
in nursing education, which combines Sleep Science
S learning (Fink, 2003), ecological, and nurs-
ing theories such as caring (eggenberger
& Keller, 2008), reflective practice (Tanner, Sleep is a fundamental lifestyle behavior
2006b), and vigilance (meyer & lavin, that fits with nursing human health ecology
2005). Research using these frameworks perspectives, that is, people in fit with their
may provide more rigorous testing of the environments. Sleep behavior is seen as a
connection between simulation, learning, function of three interactive components:
and clinical practice. (1) a sleep drive that modulates alertness/
In summary, there are many advantages sleepiness as it waxes and wanes in con-
to the use of simulation for the education cert with the relative balance of brain
of new nurses and continuing education of neuro chemicals, (2) a circadian feature that
practicing nurses. Simulation provides an functions in synchrony with the 24-hour
opportunity to practice teamwork to enhance light–dark environmental cycle, and (3) a
critical thinking skills, clinical performance, behavioral component by which individuals
and competence. There are potential program can willfully facilitate or dampen sleepiness
and agency assessment advantages, allowing driven by the other components. Thus, sleep
for testing of student and staff competencies is a neurobehavioral phenomenon such that
in a controlled environment with reproduc- brain functions, either physical or mental,
ible and predictable results, time-stamped can disrupt sleep. When reduced, absent, or
data output, and evaluation. disturbed, sleep has numerous health-related
Some of the challenges include the consequences, including impaired attention,
financial constraints of equipment purchase, memory, and problem solving as well as
building renovations, and staff/educator/ physical performance, altered immune sys-
student training and resources. Although tem function, and tissue healing, and in some
federal and state funds are available, schools cases it may herald early onset of psychiatric
and agencies are still looking for unique impairment, particularly major depression.
ways to raise funds, including grants, advi- For individuals and society, the burden of
sory boards, and partnerships (Appel, poor sleep is substantial; stemming from
Campbell, lynch, & novotny, 2007; harlow vulnerabilities to injury accidents, absences
& Sportsman, 2007). from work, medical problems, provider vis-
Research and further work is still needed its, and hospitalizations.
in the areas of (1) creating evidenced-based Although the study of sleep regulation
clinical simulation scenarios; (2) enhancing began to emerge in the 1920s, it was not until
the use of theory-based research for the study about the 1950s that sustained study of sleep
of the effect of simulation on student, nurse, began to escalate appreciably and this has
and patient outcomes; (3) developing tools for continued particularly over the past 40 to
use in evaluating simulations (harder, 2010) 50 years. In medical sleep science, foci have
using examples from others who have tested often been on sleep-related disorders such as
various methods of evaluation (gantt, 2010; sleep apnea and narcolepsy. however, most
glavin & gaba, 2008); and (4) using simula- often studied in nursing science is insomnia,
tions to teach patient safety behaviors to the commonest sleep difficulty and defined
nursing students (gantt & Webb-Corbett, as self-report of poor quality or amount
2010) and to reinforce it with nursing staff of sleep or awakening from sleep with-
(Kuehster & hall, 2010). out feeling refreshed. Insomnia can be epi-
sodic and temporary (often associated with
Suzanne Hetzel Campbell stressful social circumstances or personal
Sleep SCIenCe n 473
or environmental interference factors) but report negative impressions, indiscrimi-
is most troublesome when enduring or fre- nately. moreover, perceptions of sleep do not
quent (referred to as chronic and potentially always match physiological indicators, mak- S
related to an inherent propensity toward ing interpretation of the factors influencing
enhanced arousal). Insomnia includes fea- sleep complex and dependent on how sleep
tures of difficulty falling asleep, waking up quality is assessed.
often during usual sleep episodes, or prema- Knowledge about sleep comes from
ture awakening with inability to fall back to a variety of research approaches. experi-
sleep. environmentally, good quality sleep mentally and mainly using animal models,
(pattern and duration) is most evident when physiological sleep/wake regulation and
sleep is initiated on the decline of the circa- genetics are studied. epidemiologically,
dian body temperature curve during grow- sleep patterns are studied across popula-
ing environmental darkness and when sleep tions in the context of culture, age, or gender.
episodes occur consistently over the same Descriptively, studies are done to understand
span of hours on the 24-hour light–dark the function of and need for sleep and to
cycle. Behaviorally, good quality sleep is gain insights into factors predictive of poor
promoted by sleep initiation after a prepara- sleep. many studies are done in the context of
tion ritual and in a relaxed and drowsy state. conditions thought to be stressful, for exam-
Sleep is seen to become less stable with age, ple, disease, illness, pregnancy, menopause,
leading to more frequent awakenings during relocation, or environmental catastrophes.
the night, which are problematic only if sleep nursing scientists most often seek to under-
is difficult to resume. stand how sleep, or more precisely sleepless-
Sleep can be assessed physiologically ness, is related to disease and illness, what
using polysomnography (i.e., brainwave, can be done to promote sleep and how sleep
muscle tension, and eye movement activ- is affected by environments and life contexts.
ity monitoring) to reveal a series of stages Sleep science generated by nursing sci-
and patterns, or by body activity monitors entists largely is built on the premise that
that distinguish sleep from waking. Sleep personal stress, disease/illness, and sleep/
also can be assessed behaviorally (by direct wake quality are interactive. The notions that
observation) or by self-reported perceptions illness/disease and hospitalization/insti-
(retrospective recall or global impressions tutionalization interfere with usual sleep/
as histories or concurrent reporting in dia- wake behavior are prominent. For example,
ries or logs). Somnographically, sleep is seen nursing scientists have developed programs
to begin with transitional signs, progressing of sleep research in the context of renal fail-
into a light stage then into deep (slow wave) ure (parker, Bailey, Rye, Bliwise, & Van
sleep, followed by a period of rapid eye Someren, 2008), heart failure (Redeker, 2008),
movement sleep to complete one sleep cycle, cancer (Berger, 2009), sleep apnea treatment
taking about 60 to 90 minutes. Consequently, adherence (Weaver & Sawyer, 2010), juvenile
a full night of sleep consists of three to six arthritis (Ward et al., 2010), and fibromyalgia
cycles, depending on total sleep duration. (landis, lentz, Tsuji, Buchwald, & Shaver,
Various sleep measures have limitations, 2004) or have expanded research to include
including physiological measures that are sleep, for example, with functional bowel
time consuming, require expensive technol- disorders (heitkemper, et al., 2005). In addi-
ogy, and have the potential to interfere with tion, evident are programs of nursing science
natural sleep. Behavioral observations are research related to women’s reproductive
tedious, time consuming, and potentially status transitions in which sleep changes
inaccurate. Self-report methods are subject are known to manifest, for example (lee,
to preferred answers and the propensity to Baker, newton, & Ancoli-Israel, 2008), during
474 n Sleep SCIenCe
pregnancy and postpartum and menopausal first time mothers using an intervention of a
transition (Woods & mitchell, 2010). Also, a 45-minute meeting with a nurse to discuss
S variety of nursing scientists and clinicians sleep information and strategies, an 11-page
have studied sleep in older adults (Richards booklet to take away, and a weekly phone
& Sawyer, 2010) and in the context of living contact for 5 weeks to reinforce information
in long-term care facilities (Cole et al., 2009) and help problem solve.
and being in intensive care units (Tembo & In summary, sleep as a health-related
parker, 2009). lifestyle behavior influenced by behavioral
The vast majority of nursing science and environmental therapeutics fits well with
remains descriptive, and less is addressed the essence of nursing practice. In the future,
to therapies that promote sleep, for exam- nursing science will benefit from (1) deriving
ple, behavioral therapies or environmen- stronger, validated theoretical/conceptual
tal manipulations. Studies of therapeutics perspectives of sleep quality, sleeplessness,
related for improving sleep are emerging and sleepiness and its relationship to overall
and consistent with the nursing mission to health status and function; (2) creating and
“assist people to lead their lives in the con- testing novel therapies based on validated
text of disease (actual or threatened) or major theoretical perspectives; and (3) understand-
life transitions.” In the sleep field, the use of ing better the complexity, burden, and cost (of
pharmacological interventions for improv- either poor sleep patterns or interventions). It
ing sleep is deemed limited by potential side is imperative for the development of nursing
effects and reduced sleep promotion effects sleep science that sustained study is done to
over time. Therefore, behavioral therapies are predict those at high risk for negative conse-
seen to be an important adjunct or alternative quences within vulnerable populations, par-
to long-term pharmacological interventions ticularly underadvantaged individuals, the
for insomnia. The development and study of very young, the older adults, and the chroni-
cognitive and behavioral interventions, such cally ill; those suffering from sleep disorders
as sleep cognitive behavioral therapy (S-CBT), for which behavioral treatments are promi-
mindful relaxation, stimulus control, sleep nent (e.g., insomnia); and those in high-risk
restriction, and sleep hygiene techniques are environments (e.g., hospitals, high life-strain
prominent, often with combinations of these situations).
techniques to strengthen sleep outcomes. Because sleep is a behavior responsive
Because behavioral change for health- to behavioral interventions, more study is
promoting self-care is core to nursing science needed, which clarifies timing and expo-
and practice, sleep behavioral therapeutics sure (dose) responses, titration, personal-
represents this dimension. Although fewer ized or tailoring dimensions, individualized
interventional than descriptive nursing sci- response types and the factors affecting
ence programs of research are evident, tests behavioral choice and adherence, and the
of sleep therapeutics are emerging. As an effects of improved or optimal sleep on health
example, nursing scientist Berger (2009) and outcomes such as tissue healing or cognitive/
her team (Barsevick et al., 2010), for improv- emotional improvement. From a human eco-
ing sleep and fatigue in women undergoing logical perspective, benefits would be accrued
breast cancer adjuvant chemotherapy, have from testing more interventions with rele-
seen positive results from a personalized vant behavioral modification in concert with
plan intervention that incorporates modified modulation of environments or contextual
stimulus control, modified sleep restriction, factors. The application of emerging wear-
relaxation therapy, and sleep hygiene dimen- able technologies for monitoring and biobe-
sions. Another example is Stremler et al. havioral methods that combine physiological
(2006), who have reported improved sleep in and perceptual measures will do much to
SmOKIng CeSSATIOn n 475
advance our knowledge on the importance of in 1996 by the U.S. public health Service
sleep and its importance to symptom man- Agency for healthcare Research and
agement, illness/disease prevention, and Quality (AhRQ), and revised in 2000. The S
health promotion. 2008 update emphasizes tobacco depen-
dence is a chronic medical condition, requir-
Joan L. Shaver ing repeated interventions and multiple quit
attempts (Fiore et al., 2008). The major strat-
egies to managing tobacco dependence are
the “5 A’s”: ask the patient about tobacco use,
Smoking ceSSation advise tobacco cessation, assess willingness to
quit, assist with the quit attempt, and arrange
for follow-up to prevent relapse. Tobacco use
Forty-six million (18.4%) American adults needs to be confirmed each visit, patients
continue to smoke, despite evidence that should receive a brief intervention at every
tobacco is responsible for 443,000 deaths in visit. All tobacco users attempting to quit
the United States each year and is the sin- should receive one of the seven AhRQ-
gle most preventable cause of death. During recommended first-line pharmacotherapies
2000–2004, the Centers for Disease Control for smoking cessation.
and prevention (CDC) estimated health care O’Connell (2009) reviewed theories used
costs associated with smoking or smoking- in nursing research on smoking cessation.
attributable diseases at $96 billion. lost pro- She reported 65 of 137 studies (47%) used one
ductivity costs exceeded $97 billion (CDC, or more formal theories. The most frequently
2010e). Of concern is the increase in smok- used theory was prochaska and DiClemente’s
ing prevalence in adolescents, with 4,000 (1983) Transtheoretical model (prochaska
children and adolescents smoking their first et al., 1994) followed by Bandura’s (1977, 1977)
cigarette and 1,200 becoming regular ciga- self-efficacy theory. The most widely used
rette smokers every day. Seventy percent of concepts included nicotine dependence,
the approximately 45 million smokers in the social support, high risk situations, affect
United States want to quit, with about 44% mood, and influence of diagnosis. O’Connell
trying each year. Only 4% to 7% will be suc- noted the guideline (Fiore et al., 2008) does
cessful (Fiore et al., 2008). not mention stage of change, although it does
Smoking cessation, or smoking absti- mention several concepts frequently used
nence, differs from a quit episode, which is in nursing research. She also reported the
considered as 24 hours of continuous absti- absence of biobehavioral models, although
nence (Ossip-Klein et al., 1986). Smoking ces- research published by nurses in nonnursing
sation is defined as the discontinuation of a journals was not reviewed. Theory-driven
smoking behavior. The behavior is character- research contributes to the organization and
ized as dynamic and is often accompanied by interpretation of findings, aiding policy mak-
periods of slips and relapses. Smoking cessa- ers lobbying for changes in smoking-related
tion and tobacco use are important areas of laws and health care policies.
research for nurses. nurses are in frequent Written guidelines with recommenda-
contact with smokers, and their high credi- tions for abstinence outcome measurements
bility allows them to represent key smoking were developed by a subcommittee of the
cessation interventionists, capable of imple- Society for Research on nicotine and Tobacco
menting effective cessation programs (Fiore (hughes et al., 2003). prolonged abstinence,
et al., 2008). defined as sustained abstinence after an
Treating Tobacco Use and Dependence initial two week grace period, is the recom-
Clinical Practice Guideline was first published mended as the primary outcome measure. A
476 n SmOKIng CeSSATIOn
7-day point prevalence is also recommended Froelicher, Doolan, yerger, mcgruder,
as a secondary measure. Failure, defined and malone (2010) examined a smoking ces-
S as seven consecutive days of tobacco use or sation intervention randomized clinical trial
using at least 1 day of two consecutive weeks implemented as a community participatory
includes any type of tobacco. nontobacco nic- research project among African Americans
otine use (i.e., nicotine replacement therapy) in an urban low-income neighborhood. A
is excluded (hughes et al., 2003). trained community health nurse delivered
Outcome measures also include bio- a 5-week smoking cessation program, based
chemical verification of tobacco abstinence. on established guidelines, to both the control
A limitation in smoking cessation interven- and intervention groups. The intervention
tion research is the lack of biochemical veri- group also received a community code-
fication to confirm smoking status. Cotinine, veloped industry and media intervention.
the major metabolite of nicotine, has excellent Smoking cessation reported at 6 months was
specificity for tobacco use except in persons 11.5% (control) and 13.6% (intervention) and
using nicotine replacement therapy. Cotinine at 12 months was 5.3% (control) and 15.8%
can be measured in plasma, saliva, and urine. (intervention). Salivary cotinine confirmed
Carbon monoxide (CO), a by-product of ciga- quit status. The findings were not signifi-
rette smoke, can be measured in expired air. cant because of the small sample sizes. The
Unfortunately, CO has a shorter half-life of 2 authors note failure to recruit and enroll a
to 4 hours and is rapidly eliminated, whereas sufficient number of participants resulted
cotinine may be detected for several days in statistical insignificance. lessons learned
after tobacco use. however, CO assessments were discussed to help future investiga-
are often used to confirm abstinence in stud- tors and community workers interested in
ies where nicotine replacement therapy is community based participatory approaches
ongoing. Recommendations include bio- (Froelicher et al., 2010).
chemical verification be used in most or all Smith and Burgess (2009) examined the
studies of smoking cessation among special efficacy of a minimal versus intensive inter-
populations, including adolescents, pregnant vention for smoking cessation delivered by a
women, and medical patients with smoking- research nurse for patients hospitalized for
attributable disease. Biochemical verification either coronary artery bypass graft or acute
provides added precision to participant’s myocardial infarction. The minimal inter-
self-reports (Society for Research on nicotine vention included personalized quit advice
and Tobacco Subcommittee on Biochemical from the nurse and physicians as well as
Verification, 2002). two pamphlets. The intensive intervention
Wells and Sarna (2006) published a list- also included 45 to 60 minutes of bedside
ing of literature focusing on nursing research counseling, take-home materials, and seven
in smoking cessation since 1996, when the nurse-initiated counseling calls, focusing on
guidelines were first published. They iden- relapse prevention, for 2 months after dis-
tified 175 databased articles focused on charge. Stratified randomization was used
smoking cessation and involved nurses. for the intervention assignment (n = 276).
publications steadily increased each year, Self-reported abstinence was higher in the
with more than 40 published in 2005. The intensive intervention than the minimal
minority (35%) were published in nurs- intervention at 3 months (76%, p = 0.009), 6
ing journals, with the Journal of the Academy months (67%, p = 0.003), and 12 months (62%,
of Nurse Practitioners having the most (>4). p = 0.007). Abstinence was confirmed via
Research included experimental (38%), quasi- proxy confirmation at 12 months. Continuous
experimental (24%), and descriptive [quanti- 12-month abstinence was 57% in the inten-
tative (25%), qualitative (8%)], among others. sive group versus 39% in the minimal group
SmOKIng/TOBACCO AS A CARDIOVASCUlAR RISK FACTOR n 477
(p < 0.01). The authors concluded that inten- 2009). The World health Organization proj-
sive smoking cessation programs are effec- ects that by 2030 smoking will kill at least 10
tive in patients admitted for coronary artery million individuals annually, making it the S
bypass graft and acute myocardial infarction, leading cause of death worldwide (peto &
and future research should focus on dissem- lopez, 2001).
inating findings into standard practice for Smoking is a complex addictive disorder
cardiac patients (Smith & Burgess, 2009). that causes physiological and psychological
Smoking continues to be pronounced addiction. nicotine, which has both stim-
in the less educated and poor (CDC, 2009). ulating and tranquilizing effects, leads to
efforts to promote cessation and abstinence addiction. Smoking is also an over learned
in these individuals have, to date, been rel- habit which is associated with many aspects
atively unsuccessful. Their lack of engage- of daily life such as driving in a car, eating a
ment in preventive health care services may, meal, or drinking caffeine. Finally, it is used
in part, be due to barriers to access and lack as a coping mechanism to help individuals
of information about prevention and avail- deal with emotions such as stress, boredom,
able cessation resources (U.S. Department of frustration, and anger. The success of inter-
health and human Services, 2000). Although ventions to help individuals quit smoking
the evidence-based AhRQ clinical prac- must focus on the complexity of the behavior,
tice cessation guideline has been developed including nicotine addiction, the psychosocial
and updated (Fiore et al., 2008), its testing influences, and the habit. Although smoking
among vulnerable populations remains lim- remains a complex condition requiring both
ited. The guideline deserves further exam- pharmacological and behavioral approaches
ination among minority groups, pregnant to helping an individual with cessation, epi-
and postpartum women, hIV+ persons, and demiologic data suggest that 70% of all smok-
smokers who are poor and often experienc- ers in the United States want to quit and
ing a comorbid condition, such as cancer or approximately 44% report they attempt to
chronic obstructive pulmonary disease. quit annually (Fiore et al., 2008). The annual
smoking cessation rate of 4% to 7% associated
Gretchen A. McNally with office practice interventions may dis-
Mary Ellen Wewers courage clinicians and patients; however, it is
important that health care professionals not
become complacent about this behavior. A
small percentage drop in cessation rates has
Smoking/tobacco aS a large population benefits. Recent approaches
to treating both tobacco use and dependence
cardiovaScular riSk factor recognize that smoking is a chronic condi-
tion requiring multiple attempts until success
is reached. It is encouraging that two thirds
Over the past four decades, smoking has of smokers who relapse want to try and quit
declined in the United States by 50% among again within 30 days (Fiore et al., 2008). As
adults 18 years and older. Although this the largest group of health care professionals,
decline has certainly impacted the rate of nurses play a prominent role in helping indi-
reduction in cardiovascular disease and viduals to quit smoking.
other chronic conditions, the annual death The prevalence of smoking in the
toll continues to approach 435,000 individu- United States is now 46,000,000 (24,800,000
als in the United States, and worldwide males and 21,100,000 females), represent-
more than 5 to 6 million deaths occur annu- ing 20.6% of the adult population, or one
ally (American heart Association, 2010; Jha, in five adults (American heart Association,
478 n SmOKIng/TOBACCO AS A CARDIOVASCUlAR RISK FACTOR
2010). Smoking is highest in non-hispanic disease (lu & Creager, 2004). Smoking
American Indians or Alaska natives, and adversely affects the following: (1) endothe-
S lowest in non-hispanic Asians. The preva- lial system, (2) lipoprotein metabolism, (3)
lence of smoking varies considerably from blood coagulation, (4) platelets, and (5) oxy-
state to state and is highest in West Virginia gen supply and demand (miller, 2008).
(26.5%) and lowest in Utah (9.3%) (Centers The hazardous effects of smoking are
for Disease Control, 2009). Smoking prev- also found for those exposed to tobacco.
alence is highly dependent on the success nonsmokers exposed to environmental
of tobacco-related legislation and policies tobacco smoke suffer an increased 30% risk
within states and is often higher in states of developing ischemic heart disease. On
where tobacco is grown. Although the time the basis of measurements of urinary coti-
of initiation of smoking is 14 to 15 years, nine, the national Research Council (1986)
the percentage of students ever trying ciga- estimates that environmental tobacco expo-
rettes declined from 70.4% in 1999 to 50.3% sure is equivalent to actively smoking 0.1 to
in 2007 (American heart Association, 2010). 1.0 cigarettes per day. An estimated 35,000
prevention strategies within schools and ischemic heart disease deaths annually are
a greater focus on tobacco legislation have believed to be due to the effects of environ-
likely led to this decline. mental tobacco exposure which includes
Smoking affects almost every tissue and both sidestream (burning cigarettes) and
organ in the body and is associated with high mainstream (smokers’ exhalation) smoke
rates of common diseases such as chronic (glantz & parmley, 1991).
obstructive pulmonary disease, most can- Smoking also imposes a significant social
cers, and cardiovascular disease. Smoking burden due to the high costs of tobacco-
is a major risk factor for coronary heart dis- related illnesses. The health care expendi-
ease, peripheral vascular disease, aortic tures associated with smoking are estimated
aneurysm, and stroke. The relative risks are at $96 billion in direct medical costs and $97
greatest for those with peripheral vascular billion in lost productivity (American heart
disease and lowest for stroke, with interme- Association, 2010).
diate relative risks in those with coronary In 2008, the U.S. Department of health
heart disease and aortic aneurysm. In addi- and human Services updated the Clinical
tion, smoking increases the risk of coronary practice guideline on Treating Tobacco Use
thrombosis and sudden cardiac death. The and Dependence. published initially in 1996,
risk of coronary heart disease, the leading the guideline reviewed over 8,700 studies on
cause of death in those less than 45, relates smoking conducted from 1975 to 2007. On the
to all levels of cigarette smoking, including basis of strong evidence from randomized
those individuals smoking less than 5 ciga- controlled trials, this guideline recommends
rettes per day (Burns, 2003). Finally, smoking the following: (1) brief interventions of 3 min-
reduces the life span of males by 13.2 years utes are recommended for all current smok-
and of women by 14.5 years (American heart ers, those unwilling to make an attempt,
Association, 2010). and former smokers who have recently quit;
Smoking has important adverse path- (2) both pharmacotherapies and behavioral
ophysiological effects on the vascular sys- counseling work best when combined; (3) the
tem. most of the toxic effects of smoking are 5 “A’s” of asking about smoking, advising to
found in the 4,000 compounds in cigarettes. quit, assessing willingness to quit, assisting
Although carbon monoxide and nicotine are those ready to make an attempt, and arrang-
often thought to be the worst culprits asso- ing for follow-up continue to be advocated;
ciated with smoking, toxins cause damage (4) medications should be offered to every-
along different pathways leading to vascular one except those populations with lack of
SmOKIng/TOBACCO AS A CARDIOVASCUlAR RISK FACTOR n 479
evidence (e.g., pregnant women, smokeless increases the likelihood that health care pro-
tobacco users, light smokers [<10 cigarettes fessionals will intervene to fully provide the
per day], and adolescents); (5) state quit lines 5 “A’s” that support cessation (Fiore et al., S
and the 1–800-QUIT-nOW are effective 2008). A large number of nurses intervene
compared with no or minimal intervention; to ask and assist individuals with cessation
and (6) having tobacco covered as a bene- (73%), but far fewer intervene to offer phar-
fit is likely to increase the rate of those who macotherapies (24%), community resources
receive treatment, make a quit attempt, and (22%), or a quit line (10%) (Sarna et al., 2009).
attain abstinence (Fiore et al., 2008). evidence nurses are in unique settings such as schools
continues to indicate that in health care set- whereby prevention curricula may be offered,
tings smoking cessation is enhanced when home health settings where interventions
multiple health care professionals offer the may be provided, and in large organiza-
same message about the importance of ces- tions where they can advocate for significant
sation, high intensity counseling greater changes in public policy such as increasing
than 10 minutes with a total duration of 30 tobacco taxes.
minutes or more, multiple follow-up sessions nurse investigators have played a key
(four to eight times), and provide multiple role in developing and testing efficacious
formats such as self-help materials combined interventions in various treatment settings
with individual counseling and pharmaco- such as hospitals and clinics. Their work
therapy (Fiore et al., 2008). most notably increases the odds ratio that
Seven medications approved by the Food a patient will quit by approximately 1.28
and Drug Administration are now being rec- (Rice & Stead, 2009). hospital-based nursing
ommended as effective pharmacotherapies interventions have shown considerable suc-
for use with smoking cessation, including five cess when highly systematized for both car-
nicotine replacement therapies, buproprion diovascular patients and those with various
chloride (zyban, Wellbutrin), and varenicline medical and surgical diagnoses (Froelicher
(Chantix). Cessation rates are more than dou- et al., 2004; miller, Smith, DeBusk, Sobel, &
ble compared with placebo when any med- Taylor, 1997; Rigotti, munafo, & Stead, 2008;
ication is used to helped smokers quit, and Smith & Burgess, 2009).
combining medications may further increase Future research is needed by nurse inves-
success (Fiore et al., 2008). nurses have a key tigators who ultimately care for patients in
role to play in not only educating individuals multiple health care settings. Such research
about pharmacotherapies but also providing includes testing successful interventions in
follow-up as unless carefully prescribed use disadvantaged populations, using teach-
is often ineffective (Sarna et al., 2009). able moments in settings such as emergency
nurses may contribute significantly rooms to advocate for cessation, replicating
to both prevention and tobacco cessation. hospital-based interventions online, and
Although 13.9% of nurses continue to smoke, examining further training with the 5 “A’s” to
this rate has declined significantly over the determine if greater multicomponent strate-
last three decades, increasing the likelihood gies (pharmacotherapies, self-help materials,
that more nurses will intervene with indi- quit-line referrals, etc.) might be improved.
viduals to help them in the quitting process In summary, the smoking decline over
(Sarna et al., 2009). Because of their key role the past three decades offers hope that this
and the health hazards of smoking, nurses addictive behavior may someday become a
who smoke must seek support for quitting. distant memory. however, continued work
In addition, studies indicate that having ces- in the United States and in developing coun-
sation training and believing that offering tries is needed to achieve this goal. nurses
treatment is a professional responsibility and other health care professionals are in key
480 n SnOmeD ClInICAl TeRmS
positions to advocate in clinical practice and concepts (impaired, coping, and caregiver)
community settings to reduce the burden from the findings and social context hier-
S associated with the leading cause of prevent- archies. Research occurred with attention
able death and disability worldwide. to the evolving International Standards
Organization standard on a reference ter-
Nancy Houston Miller minology model for nursing (Bakken,
Coenen, & Saba, 2004) and the axes of the
International Classification of nursing
practice (International Council of nurses,
Snomed clinical termS 2010). In particular, studies highlighted the
need to represent the “who” of nursing diag-
noses and interventions (e.g., patient, fam-
SnOmeD Clinical Terms (CT) is a compre- ily, group, caregiver), actual versus potential
hensive health care terminology organized problems, and a broad array of nursing
into 18 hierarchies including the following of actions (e.g., teaching, administering, coor-
key relevance to nursing: (a) clinical finding/ dinating) (Bakken et al., 2002; hardiker,
disorder, (b) procedure/intervention, (c) envi- Bakken, Casey, & hoy, 2002; moss, Coenen, &
ronment or geographic location, (d) social mills, 2003).
context, (e) event, and (f) staging and scales Although initially the intellectual prop-
(International health Terminology Standards erty of the College of American pathologists
Development Organization [IhTSDO], 2010). (Côté, Rothwell, palotay, Beckett, & Brochu,
SnOmeD CT evolved from the convergence 1993), in 2007 SnOmeD CT was transferred
of SnOmeD (Systematized nomenclature to the SnOmeD Standards Development
of medicine) and national health Service Organization through the creation of the
Clinical Terms through a collaborative pro- IhTSDO. As one of nine charter members
cess initiated in 1999. of the IhTSDO, the United States distributes
nursing research in the early 1990s sug- SnOmeD CT through the national library of
gested that although SnOmeD had terms medicine’s Unified medical language System
of utility to nursing, further expansion license. Thus, SnOmeD CT is now broadly
was required (henry, holzemer, Reilly, & available for use in the United States.
Campbell, 1994; lange, 1996). Subsequently, SnOmeD CT has grown to more than
SnOmeD CT integrated content from a 300,000 concepts. An IhTSDO nursing
variety of nursing language systems. These Special Interest group reports to the
include north American nursing Diagnosis Innovation and Implementation Committee
Association International (2008), nursing and provides advocacy for nursing. In 2010,
Interventions Classification (Dochterman & the International Council of nurses—the
Bulechek, 2004), nursing Outcomes developers of the International Classification
Classification (moorhead, Johnson, & maas, of nursing practice—and the IhTSDO signed
2004), Clinical Care Classification (Saba, a collaboration agreement to further advance
2007), Omaha System (martin, 2004), and peri- terminology harmonization. These policy
operative nursing Data Set (AORn, 2008) efforts as well as additional research are
nurse researchers also influenced essential to integration nursing concepts into
the SnOmeD CT reference terminology computer-based systems such as electronic
model that specifies how atomic concepts health records to support nursing practice
can be combined to construct a more com- and practice-based evidence generation.
plex term. For example, impaired caregiver
coping can be constructed from atomic Suzanne Bakken
SOCIAl SUppORT n 481
The two models of social support—the
Social Support direct effect and the stress buffering—have
been widely discussed (Cohen & Wills, 1985). S
The direct-effect model indicates the effect of
The concept of social support is a complex social support on certain variables such as job
one that has many dimensions or constructs. performance and job satisfaction regardless
Dimensions of social support include the of the level of stress, whereas the stress-buff-
function (e.g., emotional support, tangible ering model indicates the effect of social sup-
aid), source of support (e.g., coworker, super- port on certain outcomes through decreasing
visor, spouse), and structure of support (e.g., the level of stress. Selected literature of the
network, frequency of social interactions; direct and buffering effects of social support
hobfoll & Vaux, 1993). Cohen and Wills on organizational outcomes among nurses is
(1985) described the function of social sup- discussed below.
port as emotional, instrumental, informa- The literature revealed the consis-
tional, and social companionship. emotional tency for the direct effect of social support
support is to provide one with love and care. on outcomes such as burnout, job perfor-
On the other hand, instrumental support is mance, job satisfaction, and intention to stay.
to provide one with financial aid, material emotional social support has been found
resources, and services, whereas informa- to associate negatively with stress and
tional support (appraisal support) is to assist burnout (Bartram, Joiner, & Stanton, 2004;
one to understand and deal with problem- hare, pratt, & Anderaw, 1988). AbuAlRub
atic situations, and social companionship is (2004) and Amarneh, AbuAlRub, and Abu
to spend good time (recreational activities) Al-Rub (2009) found that as social support
with others (Cohen & Wills, 1985). The bulk from coworkers increased, job performance
of social support studies were conducted increased. AbuAlRub, Omari, and Al-zaru
during the 1980s and early 1990s. This might (2009) showed that as social support from
be attributed to the increased interest of both coworkers and supervisors increased,
researchers in occupational stress and its job satisfaction increased among hospital
management in the late 1970s. Social support nurses.
was among the approaches that were investi- mcCloskey (1990) found that social inte-
gated in relation to dealing with stress. gration (social support from coworkers) was
Research indicates that nursing is a correlated positively with job satisfaction,
stressful profession. Occupational stres- work motivation, commitment to the organi-
sors, if not managed successfully or effec- zation, and intention to stay. Social integra-
tively, could affect the psychological as well tion also was found to buffer the bad effects
as physiological capacities of the individual. of low autonomy. The autonomy–integration
however, some employers might consider the interactions for intent to stay and organi-
stress of their employees as a personal psy- zational commitment at 6 months and job
chological state and ignore its consequences satisfaction at 12 months were statistically
on the organizations and the physiological significant. The positive association between
and behavioral functions of the employees. social integration and job satisfaction was
The direct and indirect effects of stress in also supported by the studies of Bartram
terms of job dissatisfaction, low job perfor- et al. (2004), Chu, hsu, price, and lee (2003),
mance, turnover, and absenteeism motivate and Ko and yom (2003). AbuAlRub, Omari,
researchers to investigate variables such as and Abu Al Rub (2009) supported the find-
social support that might offset or reduce the ings of the relationship between social sup-
impact of occupational stress and enhance port and intention to stay at work among
the morale and satisfaction of the staff. hospital nurses. They showed that as social
482 n SpIRITUAlITy
support from both supervisors and cowork- a global problem, comprehensive strategies
ers increased, intention to stay at work including workplace support groups should
S increased. ellenbecker (2004) also found a be designed to enhance nurses’ retention.
positive association between retention and
group cohesion. That is, as group cohesion Raeda Fawzi AbuAlRub
increased, retention increased too.
On the other hand, the literature showed
inconsistent results for the buffering effect
of social support. For example, the results of Spirituality
Stewart and Barling (1996), who examined
the effect of social support on the stress–per-
formance relationship, indicated that only Spirituality in the broadest sense is con-
informational social support moderated or cerned with the facet of human being that
buffered the subjective stress–performance is an unseen yet vital life force, the pneuma
relationship. That is, increased informational (greek), ruach (hebrew), or Geist (german)
social support reduces the negative impact of aspect of humanness (Smith, 1988).
stress on job performance. AbuAlRub, Omari, Spirituality and science seem to be contra-
and AbuAlRub (2009) showed that social dictory notions as spirituality is inherently
support form supervisors moderated or buff- subjective and science seeks objective evi-
ered the stress–satisfaction relationship. dence. however, a health crisis often precip-
AbuAlRub (2004) found that social sup- itates a spiritual crisis, so nurses, especially
port did not buffer the relationship between those working with critically ill or termi-
job stress and job performance; that is, as nally ill people, are in a position to attend to
perceived job stress increased, nurses with spiritual as well as physical and emotional
high social support in the workplace did not needs. By viewing health as wholeness or
perform better than nurses with less support. integration of body, mind, and spirit, and
Fong (1990) examined the stress–support– healing as restoring the integrity of that
burnout relation among nursing faculty. The wholeness, spirituality then is an apt con-
results showed that (1) support from super- cept for nursing science. neuroscientists
visors and work peers was positively corre- have also established physiological connec-
lated with all dimensions of burnout, and (2) tions between spiritual practices, such as
support from supervisors and coworkers did prayer and meditation, and the brain and
not moderate or buffer the stress–burnout neurochemical processes (hagerty 2009,
relation; that is, as stress increased, the indi- newberg & newberg, 2005). The growth
viduals with high support did not experience of Faith Community nursing as a practice
less burnout than those with less support. specialty has also brought attention to spir-
Further research using different designs ituality as an important concept for nursing
and methodologies is needed to test the buff- knowledge development.
ering models of social support. On the basis Spirituality has been a component of
of the research studies that provide evidence the frameworks of several nursing philoso-
for the direct and buffering effects of social phies and theories as well as the focal point
support on the organizational outcomes such of middle-range theories. For example, Joyce
as job stress, job performance, job satisfac- Travelbee (1971), while not using the term
tion, and intention to stay at work, peer and “spirituality,” discusses suffering and finding
superior support programs are paramount meaning in the illness experience, concepts
to enhance the well-being and satisfaction of that are associated with spirituality. Finding
the staff and the quality of care they provide meaning and connectedness, two attri-
for patients. As nursing shortage has become butes of spirituality, are central to margaret
SpIRITUAlITy n 483
newman’s (2008) theory of health as expand- power as well as others, and religion as a way
ing consciousness. presence, a nursing inter- to organize spiritual beliefs and customs. A
vention for spiritual distress, is also a key common element in many definitions of spir- S
aspect of newman’s theory. Jean Watson ituality is “connection with what is perceived
(2008b) includes spirituality in caring theory as sacred in life” (Thoresen, 2007, p. 5).
and in the caritas processes associated with Differentiating spirituality and religi-
the caring theory. The middle range Theory osity is another important consideration for
of Self-Transcendence (Reed, 2008) reflects those interested in researching spirituality.
spirituality in both the assumptions of the Religious practices may be components of
theory (that humans are pan-dimensional, spirituality as well as supportive nursing
which includes “reaching out to others, interventions for enhancing spiritual well
nature, and god,” p. 105) and in the descrip- being, but defining spirituality solely in reli-
tion of the transpersonal aspect of the major gious terms excludes nonreligious people
theoretical concept of self-transcendence. from research populations. Attending reli-
Spirituality, central concept in the middle gious services or participating in religious
range theory of spiritual well-being in illness activities may be more an indicator of physi-
(O’Brien, 2008), focuses on finding spiritual cal and social capabilities rather than a mea-
meaning during illness experiences. sure of spirituality.
nurse researchers interested in examin- measuring spirituality presents another
ing spirituality are faced with several chal- set of challenges. measurements used in
lenges. Because spirituality is inherently spirituality and health research are primar-
subjective, one consideration is defining and ily self-report scales that measure either a
measuring spirituality as a research variable. disposition of an individual to be spiritual
Although concept analyses on “spiritual- or religious or the function of spirituality
ity” have identified attributes of spirituality or religion in a person’s life (hill, 2005; hill,
(Buck, 2006; emblen, 1992; Sessanna, Finnell, Kopp, & Bollinger, 2007). hill (2005) classi-
& Jezewski, 2007; Tanyi, 2002) and the inclu- fies disposition measures into four categories
sion of “spiritual distress,” “spiritual well- and functional measures into eight cate-
being,” “spiritual health,” “spiritual growth gories, related to health-relevant domains
facilitation,” and “spiritual support” in the originally identified by the Fetzer Institute/
nursing diagnosis, intervention, and out- national Institute on Aging Working group
comes lexicon (Johnson et al., 2006), it can- (1999). Disposition measures include scales
not be assumed that spirituality means the related to general spirituality or religious-
same to everyone. For example, Burkhardt ness, religious or spiritual commitment, reli-
and nagai-Jacobson (2005) discuss inner gious or spiritual development, and spiritual
peace, trust in the ability to deal with life or religious history. Functional measures are
challenges, interconnectedness between a categorized as focusing on religious or spir-
person and the sacred, nature, self, and oth- itual social participation, private practices,
ers as characteristics of spirituality. O’Brien support, coping, beliefs and values, moti-
(2008) includes love, compassion, caring, vating forces, techniques for regulating or
transcendence, a relationship with god, and reconciling relationships (forgiveness), and
the connection of body, mind, and spirit as religious or spiritual experiences. The Fetzer
important features of spirituality. Stranahan Institute working group also developed a
(2008) identified important attributes of spir- multidimensional measure of religiousness/
ituality as the need to find meaning and pur- spirituality that includes both functional and
pose in life, inner strength for coping with the dispositional domains.
present and hoping for the future, transcen- establishing causal relationships
dence in relationships with god or higher between spiritual practices and changes
484 n STATISTICAl TeChnIQUeS
in health have been difficult to determine. variance (AnOVA) can accomplish the same
Although clear neurochemical and brain results, the t test continues to be used when
S pattern changes have been demonstrated appropriate as it is easy to present and to
with the use of meditation, prayer, and mys- understand.
tical experiences (hagerty, 2009; newberg & AnOVA is a parametric statistical test
newberg, 2005), the effect of interventions that measures differences between two or
such as distant intercessory prayer have not more mutually exclusive groups by calcu-
been well supported in research (masters, lating the ratio of between- to within-group
2007). In the studies of distant intercessory variance, called the F ratio. It is an extension
prayer, people who were being prayed for of the t test, which compares two groups. The
were also receiving medical treatment, so the independent variable(s) is categorical (mea-
effects of prayer could not be determined. sured at the nominal level). The dependent
Despite these challenges, when people variable must meet the assumptions of nor-
are considered from a holistic perspective, mal distribution and equal variance across
it is essential to include concepts and inter- the groups. A one-way AnOVA means that
ventions related to spirituality in studying there is only one independent variable (often
health and illness. called factor), a two-way AnOVA indicates
two independent variables, and an n-way
Carol D. Gaskamp AnOVA indicates that the number of inde-
Martha G. Meraviglia pendent variables is defined by n.
Analysis of covariance (AnCOVA) is a
statistical technique that combines AnOVA
with regression to measure the differences
StatiStical techniqueS among group means. AnCOVA has been used
in both experimental and nonexperimental
studies to “equate” the groups statistically.
There are many statistical techniques that When the groups differ on some variable,
are useful to nurses in the analysis of quanti- AnCOVA is used to reduce the impact of
tative research findings. Research questions that difference. Although AnCOVA has been
will provide the foundation for selecting the widely used for such statistical “equaliza-
statistical method. This entry reviews basic tion” of groups, there is controversy about
statistical techniques. The t test involves an such efforts, and careful consideration should
evaluation of means and distributions of two be given to the appropriateness of the manip-
groups. The t test, or Student’s t test, is named ulation. AnOVA and AnCOVA require that
after its inventor, William gosset, who pub- post hoc tests are used for pairwise compari-
lished under the pseudonym Student. gosset son of group means.
invented the t test as a more precise method An AnOVA may include more than one
of comparing groups. The t test reflects the dependent variable. Such an analysis usually
probability of getting a difference of a given is referred to as multivariate AnOVA and
magnitude in groups of a particular size allows the researcher to look for relationships
with a certain variability if random samples among dependent as well as independent
drawn from the same population were com- variables. When conducting a multivariate
pared. Three factors are included in the anal- AnOVA, the assumptions underlying the
ysis: difference between the group means, univariate model still apply; in addition,
size of each group, and variability of scores the dependent variable should have a “mul-
within the groups. The t tests are very useful tivariate normal distribution with the same
when two groups or two correlated measures variance covariance matrix in each group”
are being compared. Although analysis of (norusis, 1994, p. 58). The requirement that
STATISTICAl TeChnIQUeS n 485
each group will have the same variance The correlation coefficient is a mathemat-
covariance matrix means that the homoge- ical representation of the relationship that
neity of variance assumption is met for each exists between two variables. The correlation S
dependent variable and that the correlation coefficient may range from +1.00 through
between any two dependent variables must 0.00 to –1.00. A +1.00 indicates a perfect pos-
be the same in all groups. Box’s M is a mea- itive relationship, 0.00 indicates no relation-
sure of the multivariate test for homogeneity ship, and –1.00 indicates a perfect negative
of variance. relationship. In a positive relationship, as
Repeated measures AnOVA is an exten- one variable increases, the other increases.
sion of AnOVA that reduces the error term In a negative relationship, as one variable
by partitioning out individual differences increases, the other decreases. The strength
that can be estimated from the repeated of correlation coefficients has been described
measurement of the same subjects. There as follows: .00–.25—little if any; .26–.49—
are two main types of repeated measures low; .50–.69—moderate; .70–.89—high; and
designs (also called within-subjects designs). .90–1.00—very high (munro, 1997, p. 235).
One involves taking repeated measures of The coefficient of determination, r , often is
2
the same variable(s) over time on a group used as a measure of the “meaningfulness”
or groups of subjects. The other involves of r. This is a measure of the amount of vari-
exposing the same subjects to all levels of the ance the two variables share. It is obtained by
treatment. This is often referred to as using squaring the correlation coefficient.
subjects as their own controls. logistic regression is used to determine
Correlation is a procedure for quanti- which variables affect the probability of the
fying the linear relationship between two occurrence of an event. In logistic regression,
or more variables. It measures the strength the independent variables may be at any level
and indicates the direction of the relation- of measurement from nominal to ratio. The
ship. The pearson product–moment corre- dependent variable is categorical, usually a
lation coefficient (r) is the usual method by dichotomous variable. Although it is possible
which the relation between two variables to code the dichotomous variable as 1/0 and
is quantified. There must be at least two run a multiple regression or use discriminant
variables measured on each subject; and function analysis for categorical outcome
although interval- or ratio-level data are most measures (two or more categories), this is gen-
commonly used, it is also possible in many erally not recommended. multiple regression
cases to obtain valid results with ordinal and discriminant function are based on the
data. Categorical variables may be coded for method of least squares, whereas the max-
use in calculating correlations and regres- imum-likelihood method is used in logis-
sion equations. Although correlations can be tic regression. Because the logistic model is
calculated with data at all levels of measure- nonlinear, the iterative approach provided
ment, certain assumptions must be made to by the maximum-likelihood method is more
generalize beyond the sample statistic. The appropriate. logistic regression has been
sample must be representative of the popu- reported in the medical literature for some
lation to which the inference will be made. time, particularly in epidemiological stud-
The variables that are being correlated must ies. Recently, it has become more common
each have a normal distribution. The rela- in nursing research. This is the result of a
tionship between the two variables must new appreciation of the technique and the
be linear. For every value of one variable, availability of software to manage the com-
the distribution of the other variable must plex analysis. This multivariate technique for
have approximately equal variability. This is assessing the probability of the occurrence
called the assumption of homoscedasticity. of an event requires fewer assumptions than
486 n STATISTICAl TeChnIQUeS
does regression or discriminant function tetrachoric coefficients are estimates of r,
analysis and provides estimates in terms of given certain conditions. True nonparametric
S odds ratios that add to the understanding of measures of relationship include Kendall’s
the results. tau and the contingency coefficient. Kendall’s
Chi-square is the most frequently tau was developed as an alternative proce-
reported nonparametric technique. It is used dure for Spearman rho. It may be used when
to compare the actual number (or frequency) measuring the relation between two ranked
in each group with the “expected” number. (ordinal) variables. The contingency coef-
The expected number can be based on theory, ficient can be used to measure the relation-
previous experience, or comparison groups. ship between two nominal-level variables.
Chi-square tests whether or not the expected The calculation of this coefficient is based on
number differs significantly from the actual the chi-square statistic. nonparametric tech-
number. Chi-square is the appropriate tech- niques should be considered if assumptions
nique when variables are measured at the about the normal distribution of variables
nominal level. It may be used with two or cannot be met. These techniques, although
more mutually exclusive groups. When the less powerful, provide a more accurate
groups are not mutually exclusive, as when appraisal of group differences and relation-
the same subjects are measured twice, an ships among variables when the assump-
adaptation of chi-square, the mcnemar test, tions underlying the parametric techniques
may be appropriate. The mcnemar test can be have been violated.
used to measure change when there are two Regression is a statistical method that
dichotomous measures on the subjects. When makes use of the correlation between two
comparing groups of subjects on ordinal variables and the notion of a straight line to
data, two commonly used techniques are the develop an equation that can be used to pre-
mann–Whitney U, which is used to compare dict the score of one of the variables, given
two groups and is thus analogous to the t test, the score of the other. In the case of a multiple
and the Kruskal–Wallis H, which is used to correlation, regression is used to establish a
compare two or more groups and is thus anal- prediction equation in which the indepen-
ogous to the parametric technique AnOVA. dent variables are each assigned a weight
When one has repeated measures on two based on their relationship to the dependent
or more groups and the outcome measure is variable, while controlling for the other inde-
not appropriate for parametric techniques, pendent variables.
two nonparametric techniques that may be Regression is useful as a flexible tech-
appropriate are the Wilcoxon matched-pairs nique that allows prediction and explanation
signed rank test and the Friedman matched of the interrelationships among variables
samples. The Wilcoxon matched-pairs is and the use of categorical as well as contin-
analogous to the parametric paired t test, and uous variables. Regression literally means a
the Friedman matched samples is analogous falling back toward the mean. With perfect
to a repeated-measures AnOVA. correlations, there is no falling back; using
In addition to nonparametric tech- standardized scores, the predicted score
niques for making group comparisons, there is the same as the predictor. With less than
are nonparametric techniques for measur- perfect correlations there is some error in
ing relationships. There is some confusion the measurement; the more error, the more
about these techniques. For example, point- regression toward the mean.
biserial and Spearman rho are often con- In multiple regression, the multiple cor-
sidered nonparametric techniques but are relation (R) and each of the b-weights are
actually shortcut formulas for the pearson tested for significance. In most reports, the
product–moment correlation (r). Biserial and squared multiple correlation, R , is reported,
2
STORy TheORy n 487
as that is a measure of the amount of vari- questions being addressed. multiple regres-
ance accounted for in the dependent variable. sion is the most commonly reported statisti-
A significant R indicates that a significant cal technique in health care research. It can S
2
amount of the variance in the dependent be used for both explanation and prediction
variable has been accounted for. Testing the but is more commonly reported as a method
b-weight tells us whether the independent for explaining the variability in an outcome
variable associated with it is contributing measure.
significantly to the variance accounted for in
the dependent variable. Barbara Munro
Although variables at all levels of mea-
surement may be entered into the regression
equation, nominal-level variables must be
specially coded prior to entry. Three main Story theory
types of coding are used: dummy, effect, and
orthogonal. Regardless of the method of cod-
ing used, the overall R is the same, as is its Collaborative work on story theory began
significance. The differences lie in the mean- in 1996, and the theory was first published
ing attached to testing the b-weights for sig- in 1999. In the 14 years since we first began
nificance. With dummy coding the b-weight thinking through the meaning of story shar-
represents the difference between the mean ing for health, we have accomplished a great
of the group represented by that b and the deal and have moved a short distance from
group assigned 0s throughout. In effect, cod- where we began. Story theory proposes that
ing the b’s represent the difference between story is a narrative happening of connecting
the mean of the group associated with that with self-in-relation through nurse–person
b-weight and the grand mean. With orthog- intentional dialogue to create ease. All nurs-
onal coding, the b-weight measures the dif- ing encounters occur within the context
ference between two means specified in a of story. The stories of the nurse, patient,
hypothesized contrast. Interactions among family, and other health care providers are
variables also may be coded and entered into woven together to create the tapestry of the
the regression equation. moment . . . the unfolding story about a com-
When using regression, it is of utmost plicating health challenge.
importance to select variables for inclusion Story theory directly connects to the
in the model on the basis of clear scientific focus through caring as intentional dia-
rationale. The method for entering variables logue about an experience of a complicating
into the equation is important, as it affects health challenge. When introduced, story
the interpretation of the results. Variables theory was named Attentively embracing
may be entered all at once, one at a time, Story (Smith & liehr, 1999), and the name
or in subsets. Decisions about method of was changed between 2003 and 2006 to story
entry may be statistical, as in stepwise entry theory. Attentively embracing is still cen-
(where the variable with the highest correla- tral to the underlying meaning of the theory
tion with the dependent variable is entered indicating the importance of accepting self-
first), or theoretical. Stepwise methods have in-relation to one’s world to create a sense
been criticized for capitalizing on chance of comfort. Story theory provides a relevant
related to imperfect measurement of the structure for guiding advanced practice
variables being correlated. It is generally rec- nursing where gathering stories is a central
ommended that decisions about the order of activity in the nurse–patient interchange.
entry of variables into the regression equation Story theory is based on three assump-
should be made on the basis of the research tions that underpin the conceptual structure:
488 n STReSS
(a) people change as they interrelate with challenge. A story path is a useful way to
their world in a vast array of flowing con- gather stories by centering the story teller
S nected dimensions; (b) live in an expanded on the present experience, past influence,
present moment where past and future events and hopes and dreams regarding a compli-
are transformed in the here and now; and (c) cating health challenge. (2) Begin decipher-
experience meaning as a resonating aware- ing dimensions of the complicating health
ness in the creative unfolding of human challenge. Dimensions of the challenge are
potential (liehr & Smith, 2008b, p. 209). The unique descriptions of the story teller’s expe-
three concepts of the theory are connecting rience. (3) Describe the developing story plot.
with self-in-relation, intentional dialogue, and Story plot includes high points when things
creating ease. Intentional dialogue is query- are going well, low points when things are
ing emergence of a health challenge story in not going so well, and turning points where
true presence (Smith & liehr, 1999). It is pur- there are important decisions or twists in
poseful engagement with another to summon the story (liehr & Smith, 2008b). (4) Identify
the story of a complicating health challenge movement toward resolving. movement to
(liehr & Smith, 2008b). Connecting with self- resolve the complicating health challenge
in-relation occurs as reflective awareness on encompasses actions taken by the partici-
personal history (Smith & liehr, 1999). It is an pant to address their situation. (5) Synthesize
active process of recognizing self as related findings to address the research question.
with others in a developing story uncovered When using the story inquiry process, the
through intentional dialogue (liehr & Smith, researcher will center the research question
2008b). Creating ease is remembering dis- on dimensions of the complicating health
jointed story moments to experience flow in challenge; high points, low points, and/
the midst of anchoring (Smith & liehr, 1999). or turning points; or actions taken to move
The remembering creates a space of fit where toward resolving.
one can anchor even for only a moment. Story theory offers potential for guid-
paradoxically, anchoring is accompanied by ing research and building knowledge tied
flowing as energy surfaces with the coming to the disciplinary perspective of nursing.
together of story moments into a comprehen- providing a theory-based substantive guide
sible whole and there is movement toward for story-gathering and data analysis brings
resolving the complicating health challenge depth and coherence to scientific inquiry
(liehr & Smith, 2008b). when the nurse–researcher is questioning
When using story theory to guide the experience of participants who are facing
research, the nurse researcher poses a ques- a health challenge.
tion about a particular health challenge and
the participant is queried to understand how Mary Jane Smith
the health challenge has been lived. liehr Patricia Liehr
and Smith (2008b) propose approaches for
qualitative and quantitative analysis of story
data. Quantitative analysis is accomplished
with narrative analysis software, linguistic StreSS
Inquiry and Word Count using story tran-
scriptions. A story inquiry method has been
proposed for qualitative analysis of story The term “stress” first appeared in the
data (liehr & Smith, 2011). The method incor- Cumulative Index to Nursing and Allied Health
porates the following inquiry processes: (1) Literature in 1956. nursing’s interest in stress
gather stories about a complicating health as a focus of research has mushroomed since
STReSS n 489
1970. Although the word “stress” is familiar theory is the life event theory proposed by
to many and has become part of our every- holmes and Rahe (1967). Stress is operation-
day vocabulary, the term conveys divergent alized as a stable additive phenomenon that S
meanings, and multiple theories have been is measurable by researcher-selected life
proposed to explain it. most of the theories events or life changes that typically have
attempting to describe and explain stress preassigned normative weights. The pri-
as a human phenomenon can be catego- mary theoretical proposition of the stimu-
rized under one of three very different ori- lus-based orientation is that too many life
entations to the concept: response based, events or changes increase vulnerability to
stimulus based, and transaction based. The illness. Results of studies (lyon & Werner,
response-based orientation was developed 1983) using the life event perspective have
by Selye (1976), who defined stress as a non- failed to explain illness, accounting for only
specific response of the body to any demand. 2% to 4% of the incidence of illness. noting
That is, regardless of the cause, situational the limitations of the stimulus-based ori-
context, or psychological interpretation of entation yet recognizing the need to attend
the demand, the stress response is charac- the “initiator” of a stress experience, Werner
terized by the same chain of events or same (1993) proposed a useful classification of
pattern of physiological correlates. Defined stressors that includes dimensions of locus,
as a response, stress indicators become duration, temporality, forecasting, tone, and
the dependent variables in research stud- impact.
ies. nurse researchers who have used the The third way to conceptualize stress
response-based orientation measure cat- is a transaction between person and envi-
echolamines, cortisol, urinary na/K ratio, ronment. In this context stress refers to
vital signs, brain waves, electrodermal skin uncomfortable tension-related emotions
responses, and cardiovascular complaints as that arise when demanding situations tax
indicators of stress. The demand component available resources, and some kind of harm,
of Selye’s definition is treated as an inde- loss, or negative consequence is anticipated
pendent variable, whereas hospitalization (lazarus, 1966; lazarus & Folkman, 1984). As
surgery or critical care unit transfer were a special note, the lazarus (1966) reference
commonly the assumed stressor in much of represents a class work in demonstrating
the nursing research using this orientation. how theory informs research and then how
The response-based model of stress is not research in turn shapes and reshapes theory.
consistent with nursing’s philosophical pre- In the transactional orientation, stress repre-
suppositions that each individual is unique sents a composite of experiences, including
and that individuals respond holistically threatening appraisals, stress emotions (anx-
and often differently to similar situations iety, fear, anger, guilt, depression), and cop-
(lyon & Werner, 1987). ing responses. As such, the term “stress” has
The stimulus-based theoretical expla- heuristic value but is a difficult construct to
nation treats stress as a stimulus that causes study. Use of a transactional theoretical ori-
disrupted responses. As a stimulus, stress entation requires that the researcher clearly
is viewed as an external force similar to the delineate which aspects of the person–
engineering use of the term to represent environment transaction are to be studied
dynamics of strain in metals or an external (lazarus; lazarus & Folkman). Commonly,
force directed at a physical object. Defined the independent variables in experimental
in this way, stress becomes the independent and quasi-experimental studies based on
variable in research studies. The most fre- the transactional orientation are personal
quently cited example of a stimulus-based resources such as self-esteem, perceived
490 n STReSS
control, uncertainty, social support, and har- The phenomenon of stress is not a
diness. Appraisal of threat versus appraisal new interest within the context of nursing
S of challenge is commonly studied as a medi- research, as previously stated. literature from
ating factor between resource strength and 2000 to 2010 indicated that the vast major-
coping responses. Dependent variables often ity of the findings are focused on reported
include somatic outcomes such as pain, emo- sources of stress, potentially harmful physio-
tional disturbances such as anxiety and logical effects of prolonged periods of stress,
depression, and well-being. The transactional categorization of reported coping strategies,
model was deemed by lyon and Werner identification of possible interventions aimed
(1987) to be compatible with nursing’s philo- at reducing the negative effects of stress, and
sophical suppositions. transdisciplinary collaboration to advance
lyon and Werner (1987) published a crit- the science related to stress.
ical review of 82 studies conducted by nurses A total of 41 studies were identified
from 1974 to 1984. The studies reviewed fell between 2000 and 2010. Key concepts that
evenly across the three different theoretical emerged from the literature include that of
orientations, and approximately 25% of the hardiness, resiliency, workload, and coping
studies were atheoretical in nature. In 1993, strategies. The researchers provided recom-
Barnfather and lyon edited a monograph mendations for future research.
of the proceedings of a synthesis confer- It is clear from all of the aforementioned
ence on stress and coping held in conjunc- critical reviews that our knowledge of how
tion with the midwest nursing Research stress affects health is evolving. The sig-
Society. This critical review of the research nificance of nursing research in the area of
covered 296 studies published from 1980 stress grows even more important in the era
to 1990. Both the 1987 and the 1993 critical of escalating costs for health care services. It
reviews noted a disturbing absence of pro- is widely recognized that as many as 65% of
grams of research, making it difficult to visits to physician offices are for illnesses that
identify what we have learned from the dis- have no discernible medical cause, and many
cipline’s research efforts. A compilation of of those illnesses are thought to be stress
critical reviews of the nursing research lit- related. Furthermore, productivity in the
erature from 1991–1995 focused on stressors workplace is thought to be greatly affected
and health outcomes, stressors and chronic by the deleterious effects of stress.
conditions, coping, resources, and appraisal Future opportunities for nursing
and perception; the influence of nursing research include (a) psychosomatic illness
interventions on the stress-health outcome as it relates to prolonged presence of stress,
linkage consistently noted the increase in debility over time, and long-term effects
well-designed studies (Werner & Frost, on quality of life; (b) personal resiliency;
2000). each of these critical reviews noted (c) vulnerability to illness based on style
knowledge gained and gaps in knowledge of coping stress; and (d) evaluation of var-
to guide future research. ious coping strategies for effectiveness to
In the landmark Handbook of Stress, include meditation, quality family or lei-
Coping, and Health: Implications for Nursing sure time, regular physical activity, and
Research, Theory and Practice (Rice, 2000), the educational sessions designed to present
evolution of the efforts of nurse researchers information about the concept of stress,
to test various theoretical models of stress, internalization of stress, alternate coping
coping, and health is critically reviewed. strategies, avoidance of stress, and adapta-
Importantly, the handbook includes critical tion to stress.
reviews of developing programs of nursing
research. Kimberly B. Hall
STReSS mAnAgemenT n 491
yielded equivocal results. Snyder (1993) crit-
StreSS management ically reviewed all 54 stress-related inter-
vention studies appearing in the nursing S
literature from 1980 through 1990. The types
Stress management is a broad term that of stress management interventions used
encompasses a wide range of methods included relaxation strategies (e.g., progres-
intended to prevent stress or effectively sive muscle relaxation, imagery, meditation,
manage it as evidenced by low levels of breathing techniques, massage, music), edu-
stress emotions and improved coping abil- cational strategies, and use of social support
ities. “Stress management interventions are groups. A major flaw of most of the inter-
deliberate actions taught to patients to help vention studies was an inadequate descrip-
achieve outcomes” (Synder, 2000, p. 179). tion of the intervention used, and there was
Coping strategies are actions self-initiated a lack of attempts to explain the theoretical
by a person to manage stress. Coping strat- link between the intervention and outcome
egies are typically categorized as direct measures. manipulation checks as a way to
action/problem focused aimed at alleviat- assure that subjects mastered the interven-
ing or decreasing the intensity of perceived tion also were lacking in the intervention
threat or palliative/emotion focused aimed studies. Studies using sensation information
at decreasing or keeping in check the inten- (e.g., Johnson, Rice, Fuller, & endress, 1978)
sity of stress emotions experienced (lazarus and studies using progressive relaxation
& Fokman, 1984). techniques (e.g., pender, 1985) have demon-
nurse researchers have studied stress strated positive effects on health-related out-
management interventions and coping strat- comes such as less anxiety and an increased
egies in various groups of people, including sense of well-being.
nurses, student nurses, and patients. It is inter- Since 1995, there has been little theo-
esting to note that majority of these studies retical knowledge gained through nursing
have been conducted by nurse researchers in research about the effectiveness of stress
european and Asian countries. Some of the management interventions or coping strat-
coping strategies frequently used by nurses to egies. The two common findings, consis-
manage stress include taking action, drawing tent with lazarus (1966) and lazarus and
on past experiences, using problem-solving Folkman (1984), are that (a) direct action or
techniques, using humor, talking over prob- problem-focused coping strategies and cog-
lems with coworkers, accepting the situation, nitive restructuring strategies are related to
taking breaks (escaping from the situation), decreased stress-related outcomes such as
using diversions, using relaxation, and exer- anxiety, other negative mood states, and an
cise (lewis & Robinson, 1986; petermann, increased sense of well-being; and (b) pallia-
Springer, & Farnsworth, 1995). Coping strate- tive or emotion-focused strategies are related
gies taken to prevent stress involve balancing to increased anxiety, other negative mood
demands and resources, focusing on the pos- states, and distress. The most common theme
itive in difficult situations, maintaining per- is that stress is a subjective phenomenon that
ceived choice and sense of personal control, is experienced differently by each person.
building social support, and viewing diffi- The most common outcomes measured as
cult situations as challenges that can bring dependent variables have been stress emo-
gain or benefit through learning (Dionne- tions such as anxiety, other negatively toned
proulz & pepin, 1993; lyon, 1996). mood states, and depression.
nursing research studies on the effects A comprehensive review of litera-
of stress management interventions with ture dated 2005–2010 revealed that both
various patient population groups have qualitative and quantitative studies have
492 n STROKe
been conducted regarding strategies and also essential that the researcher incorporate
approaches designed to manage stress. manipulation checks into the methodology
S Study results indicated that acknowledge- to verify that the intervention “took.” For
ment of stress, and related causes, serve as example, when using a progressive muscle
the initial step in the process of managing relaxation or autogenic relaxation strategy,
stress. Approaches to stress management it is important to verify that the participant
ranged from holistic and alternative meth- experienced a sense of “relaxation.” likewise
ods to avoidance or elimination of stressors. it is equally important for the researcher to
not all interventions were clearly defined, verify that participants implement coping
consistent in design, and few of the studies strategies correctly following a psychoedu-
would be able to be replicated. The following cational intervention. Results must be able
themes emerge from the studies reviewed: to demonstrate that the intervention actu-
(a) subjects must identify the stressor(s) and ally altered the target variable as proposed
examine which variables are controllable or in the theoretical formulation. Furthermore,
manageable; (b) individualized strategies research designed to contribute to knowl-
are designed to counteract the effects of the edge generation offers little meaning if the
stressor(s); (c) one or more coping strategies researcher does not reflect on the meaning of
are implemented, which may include medita- the findings in relation to proposed theoreti-
tion, physical activity, creative outlets which cal formulations.
offer diversion during periods of high stress, Current developments in testing “ABC”
massage, removing oneself from a stressful codes (Alternative link, 2004) representing
situation; and (d) assess whether or a not a nonpharmacological interventions and com-
stressor can be accepted and therefore no plementary and alternative therapies offer
longer be viewed as a stressor. nursing the opportunity to demonstrate
A new theoretical model relative to the effectiveness of stress management interven-
management of stress evolved from the work tions in assisting patients to achieve desired
of zander and hutton (2009). The theoreti- health-related outcomes (lyon, 2000). The
cal model of effective coping illustrates the latter half of this decade will offer unprec-
interrelatedness of the concepts of mean- edented opportunities for nurse scientists
ing, interventions and strategies, and com- to demonstrate the cost-effectiveness of
mitment. The idea expressed is that the stress management interventions in nursing
combination of meaning in one’s effort, a practice.
commitment to one’s efforts, and purpose-
ful stress management strategies will result Kimberly B. Hall
in effective coping abilities. The authors con-
tinue to actively test this theory.
Future directions for nursing research
should focus on identifying patterns of Stroke
appraisal, emotions, and coping that result
in health-related outcomes. Additionally, for
the discipline’s research efforts to meaning- Stroke, also known as cerebrovascular acci-
fully contribute to knowledge generation, it dent or apoplexy, is a sudden loss of con-
is imperative that nurse researchers clearly sciousness due to either a loss of blood flow to
define and delineate stress management the brain or a sudden rupture of a blood ves-
interventions and offer testable theoretical sel in or near the brain. There are two main
formulations that explain how the interven- types of strokes. An ischemic stroke is caused
tions affect outcome variables within speci- by thrombus formation due to narrowing of
fied person and environment contexts. It is the arteries from arteriosclerosis, an embolus
STROKe n 493
that has dislodged and traveled to the brain, There are a number of treatments for
or a lack of blood flow to the brain due to cir- stroke. Carotid endarterectomy is the most
culatory failure (American heart Association common surgical procedure, and antico- S
[AhA], 2004). A hemorrhagic stroke results agulants and antiplatelet agents are the
from the rupture of a blood vessel either in most common medications used to pre-
the space between the brain and the skull vent stroke (AhA, 2004). Tissue-type plas-
(subarachnoid hemorrhage) or deep within minogen activator (tpA) is a drug that must
the brain tissue (intracerebral hemorrhage; be given intravenously to patients with
AhA, 2004). A transient ischemic attack is ischemic stroke within 3 hours of the first
a brief neurological dysfunction resulting warning sign to prevent disability from
from focal cerebral ischemia; however, it is stroke. Unfortunately, few stroke survi-
not associated with any permanent cere- vors are able to make it to a physician who
bral infarction (easton et al., 2009). Transient can administer tissue-type plasminogen
ischemic attacks are considered warning activator within the 3-hour time window.
signs of stroke. Specific warning signs of This dilemma has prompted the develop-
stroke include (a) sudden numbness or weak- ment of primary stroke centers, which the
ness of the face, arm, or leg; (b) sudden con- Joint Commission on the Accreditation
fusion, trouble speaking, or understanding; of healthcare Organizations began cer-
(c) sudden trouble seeing in one or both eyes; tifying in 2003 (lichtman et al., 2009).
(d) sudden trouble walking, dizziness, loss Certification by Joint Commission on the
of balance, or coordination; or (e) a sudden Accreditation of healthcare Organizations
severe headache (lloyd-Jones et al., 2010). is given to those centers that are compliant
Common disabilities from stroke include with national stroke standards, follow the
hemiparesis (50%), inability to walk with- primary Stroke Center recommendations
out assistance (30%), activities of daily living and recent clinical practice guidelines, and
dependency (26%), aphasia (19%), depressive are active with performance measurement
symptoms (35%), and institutionalization in a and improvement activities (lichtman et al.,
nursing home (26%) (lloyd-Jones et al., 2010). 2009). Recommendations for primary stroke
Stroke is the third leading cause of centers include an integrated emergency
death in the United States, behind heart response system, acute stroke team, inpatient
disease and cancer, and about a quarter of stroke unit, and written care protocols. The
first-time stroke survivors die within 1 year acute stroke team must include a physician
of having a stroke (lloyd-Jones et al., 2010). and a nurse who are available 24 hours a day
Approximately 610,000 people each year for rapid evaluation of patients experienc-
experience a stroke for the first time, and ing the warning signs of stroke (Alberts
another 185,000 suffer a recurrent stroke et al., 2000). get With the guidelines-Stroke
(lloyd-Jones et al., 2010). Stroke is also a (gWTg-Stroke), an improvement program
leading cause of serious, long-term disability that aligns patient care with the latest up-to-
in the United States (lloyd-Jones et al., 2010). date stroke guidelines, has been extremely
Between 50% and 70% of stroke survivors beneficial in the care and treatment of acute
will recover their independence; however, stroke. gWTg-Stroke has generated a lot of
15% to 30% become permanently disabled interest in research and in hospitals nation-
(lloyd-Jones et al., 2010). In 2010, stroke was wide. In a study of 790 U.S. academic and
estimated to cost $73.7 billion, with a mean community hospitals using gWTg-Stroke,
lifetime cost for ischemic stroke estimated at Schwamm et al. (2009) reported substantial
$140,048 per person including inpatient care, and sustained improvement in adherence to
rehabilitation, and follow-up care (lloyd- all acute stroke care and secondary preven-
Jones et al., 2010). tion performance measures.
494 n STROKe
Once stroke survivors are stabilized, nursing practice as a clinical stroke assess-
they enter the rehabilitation phase of treat- ment tool. It is now widely used in stroke
S ment where they learn how to live with their centers across the nation. Recently, two AhA
disabilities from stroke. multidisciplinary Scientific Statements have been published
rehabilitation teams consist of physicians, that provide comprehensive overviews of
physiatrists, nurses, psychologists or psychia- nursing and interdisciplinary care of stroke
trists, counselors, and physical, occupational, patients across the care continuum (miller
recreational, and speech therapists (AhA, et al., 2010; Summers et al., 2009). Summers
2004). To reduce fragmentation of stroke care et al. (2009) provide levels of evidence for
across settings and to ensure that scientific nursing interventions directed toward the
knowledge is translated into practice, recom- care of acute ischemic stroke patients. miller
mendations have been developed to establish et al. (2010) provide levels of evidence for
stroke systems of care (Schwamm et al., 2005). rehabilitation care of stroke survivors and
These recommendations address how state their family members across inpatient reha-
and local communities can engage in efforts bilitation, outpatient, and chronic care set-
to promote primary stroke prevention, com- tings. These AhA Scientific Statements
munity education, emergency medical ser- provide a useful resource for practicing
vices, acute and subacute stroke treatment, nurses, and they identify areas for future
rehabilitation, and quality improvement nursing research to demonstrate best prac-
activities (Schwamm et al., 2005). tices in the care of stroke survivors and fam-
learning how to live with disabilities ily caregivers across the care continuum.
resulting from stroke is challenging not only A recent search of the RepORT expen-
for stroke survivors but also for their fam- ditures and Results (n.d.), a database of bio-
ily caregivers. After stroke, depression is a medical research funded by the national
major complication of stroke and can greatly Institutes of health, revealed two studies
impede recovery (AhA, 2004). Other qual- of interest funded by the national Institute
ity of life issues for stroke survivors include for nursing Research (nInR). pamela
disruption of personality and moods, mitchell has been funded to evaluate a
diminished self-care, changes in social and nurse-deli vered psychosocial/behavioral
family roles, and loss of work or productiv- intervention, which has been shown to be
ity, among others (Williams, Weinberger, effective in reducing post-stroke depression
harris, Clark, & Biller, 1999). Family care- (mitchell et al., 2009). Sharon Ostwald has
givers often experience negative changes in been funded to evaluate her intervention for
social functioning, subjective well-being, stroke survivors and spousal caregivers. It
and perceived health as a result of provid- is hopeful that these intervention programs
ing care (Bakas, Champion, perkins, Farran, will provide promise for the future care of
& Williams, 2006). Caregiver needs and con- stroke survivors. Another leader in stroke
cerns typically focus on finding informa- nursing research is patricia hurn, who has
tion about stroke, managing emotions and been funded by nInR since 1993 to study
behaviors of the stroke survivor, providing the role of estrogen in immunoprotection
physical and instrumental care, and dealing following stroke.
with one’s own personal responses to care- A search of the RepORT expenditures and
giving (Bakas, Austin, Okonkwo, lewis, & Results (n.d.) database also revealed many stud-
Chadwick, 2002). ies funded by nInR focused on family caregiv-
nurses are involved with the care of ers of stroke survivors. For example, patricia
stroke survivors throughout the continuum Clark has been funded to explore family func-
of care. Judith Spilker et al. (1997) integrated tion, stroke recovery, and caregiver outcomes.
the use of the nIh Stroke Scale into current Barbara lutz has been funded to develop a
STRUCTURAl eQUATIOn mODelIng n 495
dyad risk assessment profile to determine relationships. It is used interchangeably with
patient needs and caregiver concerns prior to the terms causal modeling, covariance struc-
discharge. Joan grant documented the effec- ture modeling, and lISRel modeling. The S
tiveness of her problem-solving intervention theoretical issues are discussed in the entry
in reducing stroke caregiver depression and on Causal Modeling. A description of the ana-
improving caregiver perceived health (grant, lytic issues when programs such as lISRel
elliott, Weaver, Bartolucci, & giger, 2002). or eQS are used will ensue.
Rosemarie King has also been funded to eval- Sem techniques are extremely flexible.
uate the effectiveness of her problem-solving most models of cause can be estimated. In
intervention for stroke caregivers. Tamilyn some models, the causal flow is specified only
Bakas was funded to develop and pilot test the between the latent variable and its empirical
Telephone Assessment and Skill-Building Kit, indicators, such as in a factor analysis model.
which has shown evidence of content validity This is known as confirmatory factor analy-
and satisfaction in stroke caregivers (Bakas sis. In other models, causal paths among the
et al., 2009). The Telephone Assessment and latent variables also are included.
Skill-Building Kit program is currently being Conducting a confirmatory factor analy-
tested in a larger randomized controlled clin- sis with Sem has many advantages. With
ical trial. linda pierce has been funded to test Sem, the analyst can specify exactly which
her intervention titled, “The Caring Web” for indicators will load on which latent variables
stroke caregivers, which has been found to (the factors), and the amount of variance in
reduce emergency department visits and hos- the indicators not explained by the latent
pital readmissions of stroke survivors (pierce, variable (due to error in either measure-
Steiner, Khuder, govoni, & horn, 2009). All ment or model specification) is estimated.
of these studies show great potential toward Correlations between latent variables and
improving the care and well-being of families among errors associated with the indicators
of stroke survivors. can be estimated and examined. Statistics
now is a very fruitful time for nurses to that describe the fit of the model with the data
conduct research in the area of stroke and allow the analyst to evaluate the adequacy
stroke caregivers. With stroke being a lead- of the factor structure, make theoretically
ing cause of serious, long-term disability in appropriate modifications to the structure
the United States, it is imperative that nurses based on empirical evidence, and test the
take the lead in developing programs that change in fit caused by these modifications.
improve the care of stroke survivors and Thus, confirmatory factor analysis provides
their family members. a direct test of the hypothesized structure of
an instrument’s scales.
Tamilyn Bakas An advantage of using Sem to estimate
Staci S. Wuchner models containing causal paths among the
latent variables is that many of the regression
assumptions can be relaxed or estimated. For
example, with multiple regression, the ana-
Structural equation lyst must assume perfect measurement (no
measurement error); however, with Sem,
modeling measurement error can be specified and the
amount estimated. In addition, constraints
can be introduced based on theoretical expec-
Structural equation modeling (Sem) is tations. For example, equality constraints, set-
used to describe theoretical and analytic ting two or more paths to have equal values,
techniques for examining cause-and-effect are useful when the model contains cross-
496 n STRUCTURAl eQUATIOn mODelIng
lagged paths from three or more time points. on the inclusion of omitted paths (causal or
The path from latent variable A at Time 1 to correlational). Any path that is omitted speci-
S latent variable B at Time 2 can be set to equal fies that there is no relationship, implying a
the path from latent variable A at Time 2 to parameter of zero; thus, analysis programs
latent variable B at Time 3. equality con- constrain these paths to be zero. After esti-
strains also are used to compare models for mating the specified model, most programs
two or more different groups. For example, provide a numerical estimate of the “strain”
to compare the models of effects of maternal experienced by fixing parameters to zero or
employment on preterm and full-term child improvement in fit that would result from
outcomes, paths in the preterm model can be freeing the parameters (allowing them to
constrained to be equal to the corresponding vary). Suggested paths must be theoretically
paths in the full-term model. defensible before adding them to the respeci-
Data requirements for Sem are simi- fied model.
lar to those for factor analysis and multiple Because model respecification is based
regression in level of measurement but not on the data at hand in light of theoretical evi-
sample size. exogenous variables can have dence and those data are repeatedly tested,
indicators that are measured as interval, the significance level of the χ is actually
2
near interval, or categorical (dummy-, effect-, higher than what the program indicates.
or orthogonally coded) levels, but endog- Thus, other criteria are necessary to evalu-
enous variables must have indicators that ate the adequacy of the final model. First is
are measured at the interval or near-interval the theoretical appropriateness of the final
level. The rule of thumb regarding the num- model. Comparison of the original model
ber of cases needed for Sem, 5 to 10 cases per with the final model will indicate how much
parameter to be estimated, suggests consid- “trimming” has taken place. In addition,
erably larger samples than usually needed the values and signs of the parameters are
for multiple regression; thus, samples of 100 evaluated. The signs (positive or negative)
for a very modest model to 500 or more for of the parameters should be in the expected
more complex models are often required. direction. parameters on the paths between
Despite the advantages of Sem, these larger the latent variable and its indicators should
samples can result in complex and costly be >.50 but <1.0 in a standardized solution.
studies. The lower the unexplained variance of the
Sem is generally a multistage procedure. endogenous variables, the better the model
First, the Sem implied by the theoretical performed in explaining those endogenous
model is tested and the fit of the model to the variables (similar to the 1–R value in mul-
2
observed data is evaluated. A nonsignificant tiple regression). Results that are consistent
χ indicates acceptable fit, but this is diffi- with a priori expectations and findings from
2
cult to obtain because the χ value is heavily previous research increase one’s confidence
2
influenced (increased) by larger sample sizes. in the model.
Thus, most analytic programs provide other In summary, Sem is a powerful and flex-
measures of fit. A well-fitting model is nec- ible analysis technique for testing models of
essary before the parameter estimates can be cause, for investigating specific cause-and-
evaluated and interpreted. effect relationships, and for exploring the
In most cases, the original theoretical hypothesized process by which specific out-
model does not fit the data well, and modi- comes are produced. With Sem programs,
fications must be made to the model in order the researcher has greater control over the
to obtain a well-fitting model. Although dele- analyses than with other factor analysis
tion of nonsignificant paths (based on t val- and multiple regression programs. model
ues) is possible, modifications generally focus respecification is usually necessary, but the
SUBSTAnCe USe DISORDeRS In RegISTeReD nURSeS n 497
role of theory in selecting appropriate modi- professional ethical code and standards of
fications is crucial. nursing practice because cognitive, inter-
personal, and/or motor skills of the practi- S
JoAnne M. Youngblut tioner are impaired by psychiatric illness or
excessive use of alcohol and/or other drugs.”
The 1982 AnA house of Delegates passed a
resolution on impaired practice, and a pol-
SubStance uSe diSorderS in icy statement, Addictions and Psychological
Dysfunctions: The Profession’s Response to
regiStered nurSeS the Problem, followed (AnA, 1984). The eco-
nomic consequences of substance-related
disability, risk management, and contin-
Addiction, a health problem for registered uing quality assurance still make substance
nurses and other health professionals, came dependence in health professionals an
to the attention of nurse researchers in the important policy issue.
1980s. Social stigma, denial in the profession, The prevalence of substance depen-
and a dearth of willing research subjects are dence in nurses and health professionals
all reasons for a paucity of research in this as compared with the public was among
area. In framing a research review and the the first research questions addressed.
scope of this professional issue, the term Approximately 9% of Americans abuse or
“substance dependence” is recommended are dependent on alcohol and 2% abuse or
over “addiction.” Substance dependence is are dependent on other drugs (grant et al.,
a maladaptive pattern of substance use with 2004). The recognition of nicotine addic-
a cluster of cognitive, behavioral, and phys- tion and efforts to limit its prevalence have
iologic symptoms, outcomes of neurologic resulted in female nurses’ decreased rates
adaptation. An individual continues use of smoking (8.4% in 2003 from 33.2% 1976)
despite significant impairment in social, pro- (Sarna et al., 2004), significantly lower than
fessional, and/or legal function. “Substance the public’s 20.6 % prevalence (Centers for
abuse” has as its essential feature, this mal- Disease Control and prevention, 2010a).
adaptive pattern of use along with “recurring Because the majority of nurses are women
and adverse consequences” without phys- and the prevalence for alcohol dependence
iologic dependence (American psychiatric is 3 to 1, m/F, and because illicit drug use is
Association, 2000). These disorders result in lower in women, the prevalence of depen-
significant disability and death for nurses dence on alcohol, nicotine, and illicit drugs
and can contribute to below-standard nurs- was estimated to be lower in nurses than
ing practice (impaired practice), endangering in American women in general (Clark &
public health and safety. Farnsworth, 2006; Trinkoff & Storr, 1998a,
Substance dependence in registered 1998b; West, 2003). The findings of Trinkoff,
nurses challenges the profession to regu- eaton, and Anthony (1991) provided sound
late its practitioners’ delivery of high qual- epidemiologic data about prevalence
ity care. In 1982, a climate of social concern based on a small sample of nurses in the
and the visibility of substance-related prob- epidemiologic Catchment Area Study
lems in nurses led to the American nurses (national Institute of mental health). This
Association (AnA) and several specialty was a multisite, probability sample of 142
nursing associations, support of research nurses and suggested that nurses and con-
and development of organizational posi- trol group members had similar rates of
tions about impaired practice, defined as illicit drug use—marijuana, cocaine, heroin,
“nursing practice which does not meet the psychedelics, tranquilizers, amphetamines,
498 n SUBSTAnCe USe DISORDeRS In RegISTeReD nURSeS
and other opiates—which were nurses and mansfield compared 920 nurses with
(32.9%) and controls (31.5%). other female employees and found low use
S Anecdotal and survey findings in levels for illicit drugs and alcohol in all sub-
the 1980s sought the etiology of addiction jects. nurses had the lowest prevalence of
in nurses in small, convenience samples. smoking and 79% of them reported moderate
Although critical to motivating further alcohol use. The nurses’ Worklife and health
research, they generally provided little reli- Study, an anonymous, national survey of a
able data. In Bissell and haberman’s (1984) stratified sample (78% response), reported
research about recovering nurses in an smoking rates of 14% and cocaine/marijuana
Alcoholics Anonymous sample, Bissell and use at 4%, lower than in the general popula-
Jones (1981), Sullivan, Bissell, and leffler tion; binge drinking rates were comparable
(1990), and Sullivan and hale (1987) described (Trinkoff & Storr, 1998a, 1998b).
the characteristics of recovering nurses, seek- This study was the most comprehen-
ing to identify the nature and outcomes of sive in validating higher prescription drug
their dependence. newer theoretical and use rates for nurses. The prevalence of past-
scientific findings on the heritability, genetic year substance use for all substances was
and environmental etiologies, pathophysiol- 41%; for marijuana/cocaine, 4%; prescription
ogies, and responses to addiction treatment drugs, 7%; cigarette smoking, 14%; and binge
support their observations of addiction as a drinking, 16%. male nurses were more likely
complex, chronic, and treatable medical ill- to misuse prescription drugs, with opiates
ness (mclellan, lewis, O’Brien, & Kleber, abused most frequently (60.3%) followed by
2000). There is now strong scientific evidence tranquilizers (44.6%). The findings support
that the same factors that predispose the the link between ease of workplace access
general population to addiction also predis- and higher rates of prescription drug abuse
pose nurses. These include family history of and provided direction for further analyses
substance abuse, stress and trauma, or sex- of substance use by nursing specialty.
ual and/or emotional abuse, some of which The investigations of Trinkoff, geiger-
were noted in the above reports. Research by Brown, Brady, lipscomb, and muntaner
Burns (1998) and hutchinson (1986) mapped (2006) and Trinkoff and geiger-Brown (2010)
the trajectories of recovery for nurses with of workplace factors contributing to sub-
an eye toward understanding the origins of stance dependence continued on observed
their disorders. differences in substance use across spe-
professional risk factors for substance cialties providing statistical insights. later
use in nurses first emerged in the work of analyses suggest that nurses in certain spe-
haack’s (1988) on stress in nursing students. cialties were more likely to use substances.
Although recognizing that stress does not It was reported that critical care and emer-
precipitate substance dependence on drugs, gency nurses had higher rates of marijuana
a research trend has continued on work- or cocaine use, oncology nurses had higher
place and occupational factors that can pose rates of binge drinking, and psychiatric,
challenges in coping for practitioners with gerontology, and emergency nurses had the
established alcohol, tobacco, and other drug highest rates of smoking. little evidence
use patterns. Blazer and mansfield’s (1995) exists to support an increased prevalence of
randomized descriptive survey (N = 1,525) substance dependence among nurse anes-
and the nurses’ Work life and health Study thetists, although 10% of Certified Registered
(4,438 registered nurses) both explored how nurse Anesthetists in a small survey admit-
workplace factors, including stress, might ted to diverting controlled substances (Bell,
contribute to substance use and abuse. Blazer 2006, as cited in Wilson & Compton, 2009).
SUBSTAnCe USe DISORDeRS In RegISTeReD nURSeS n 499
The nurses’ Worklife and health Study they “knew too much to become addicted”
findings link scheduling patterns with (Burns, 1998). These rationalizations extend
the prevalence and odds of substance use. as far as to reason that addiction is not S
Working overtime, working shifts longer possible so long as a chemical is being
than 8 hours, and working one or two week- injected intramuscularly, not intravenously
ends per month all increased the likelihood (hastings & Burn, 2007).
of alcohol use. In addition, smoking was The limited and dated research on
more prevalent among night-shift work- addictions/substance dependence in nurses
ers and those working several weekends suggests that nurses share risk factors with
per month, a factor also associated with the general population but that workplace-
increased drug use. related factors, such as access to controlled
West’s (2002) research suggests that substances and pharmaceutical knowledge,
nurses with high numbers of early risk indi- increase the risks for misuse and dependence
cators (psychological stress, low self-esteem, for some. Of concern are the 60,010 disciplin-
low religiosity, distance in family, higher ary cases (27.53%) reported by the national
sensation seeking scores and family sub- Council of State Boards of nursing (1996–
stance use histories) are at higher risk for 2006; http://www.ncsbn.org/index.htm) for
alcohol and drug dependence which results alcohol and other drug incidents, and the
in impairment. Attitudes about the benefits 16,268 cases categorized as drug diversion by
of medications and their ability to control the nurse for his or her own use. Clearly, sub-
use have also been identified as risk factors. stance abuse and dependence remain health
nurses who routinely administer medica- problems for nurses and self-regulatory chal-
tions believe them to be “safe.” Familiarity, lenges for the profession. most cases of alco-
then, precedes self-medication, which pre- holism and many cases of drug diversion are
cedes abuse (Trinkoff & Storr, 1994). not reported, suggesting a greater problem
Brown, Trinkoff, and Smith (2003), than the data support. There is a need for fur-
Burns (1998), and hutchinson (1986) ther research to explore the risk factors that
described nurses’ experiences of depen- might be influenced by professional educa-
dence and recovery as different from those tion, workplace factors, and the development
of the general population but similar to of substance dependence in nurses, the man-
other health professionals. A noteworthy agement of such problems in employment
fact is the use of prescription medications settings, and the access of nurses to “best
as opposed to street drugs, more frequently practices” addiction treatment. Findings sug-
accessed in employment settings (Clark & gest that nurses generally receive less treat-
Farnsworth, 2006). Additionally, it has been ment and return to longer working hours
shown that traditional predictors of alco- than substance-dependent physicians, plac-
hol abuse, such as age, gender, and income, ing them at high risk for relapse. nurses have
present little benefit in discovering alcohol- less economic independence than physicians,
ism in health care professionals (Kenna & which may explain shorter courses of treat-
Wood, 2004), who are generally well edu- ment. They are also more likely to face sanc-
cated and steady income earners. The role of tions which more severe on return to work
intellectualization and denial in supporting (Shaw, mcgovern, Angres, & Rawal, 2003).
use and abuse cannot be over emphasized. The differences in how addiction is per-
Despite the aforementioned prevalence of ceived and treated in physicians and nurses,
abuse and dependence in the profession, all and limitations to access to high-quality
of the nurses in one study described their treatment as a function of economic status
health as “excellent to good,” and often felt remains areas for exploration for nurses and
500 n SySTemATIC ReVIeW
the public. Further study of successful recov-
ery by nurses could help design more effec- SyStematic review
S tive return-to-work programs and underscore
the economic argument for policies that sup-
port rehabilitation and retention, which have The volume of information and data avail-
demonstrable financial benefits. Although able for consideration when making a clinical
significant numbers of nurses are enrolled decision is increasing at unprecedented rates.
in monitoring and peer assistance associated It has become impossible for nurses to keep
with alternative to discipline programs, there up with the literature in their field on a regu-
is little research to support outcomes. This is lar basis. Systematic reviews summarize evi-
in contrast to findings supporting some of the dence across relevant studies, published and
highest long-term addiction recovery rates unpublished. This scholarly integration of
recorded for physicians; one study reported research findings and other evidence forms
that 78% of 904 recovering physicians tested the foundation for evidence-based practice
regularly (mean = 83 tests) over a period of allowing the practitioner to make up-to-date
four 1/2 years had negative results on every decisions.
single test (Dupont, mclellan, White, merlo, A systematic review involves the identi-
& gold, 2007). Such evidence on recovery fication, selection, appraisal, and synthesis of
in nurses could promote healthy lifestyles the best available evidence for clinical deci-
among nurses and encourage the pursuit of sion making. A properly conducted system-
better treatment outcomes for health profes- atic review uses reproducible, preplanned
sionals, typically seen as health role models strategies to reduce bias and instill rigor
by the public (Smith & leggat, 2007). The and pools information from both published
retention of educated and experienced nurses and unpublished sources. The inclusion of
contributes to alleviating the nursing short- unpublished studies and reports is necessary
age, improves patient care, and strengthens to avoid, to the extent possible, a publication
professional resources (Trinkoff, 2006). bias. The holistic understanding provided
The growing evidence on risk factors by a systematic review negates the reduc-
suggests that early intervention with vulner- tionist view provided by a single study and
able nursing students and nurses could deter allows the researcher to make sense of grow-
the prevalence of substance dependence. ing bodies of information (Cook, mulrow, &
education about these and policies that pro- haynes, 1997).
mote healthy work environments should also Systematic reviews are conducted
be evaluated. Unfortunately, little research to answer specific, often narrow, clinical
exists on relationship of increased addictions questions. These questions are formulated
education in medical or nursing programs according to the mnemonic pICO address-
on improved personal outcomes. Despite ing: a specific population (p) (such as peo-
a 47% increase in the hours dedicated to ple traveling long distance), the intervention
drug abuse education in anesthesiology pro- of interest (I) (e.g., preventive measures for
grams, for example, addiction rates remained deep vein thrombosis), an optional com-
largely unchanged (Booth, grossman, moore, parison (C) (such as the standard of care,
lineberger, Reynolds, Reves & Sheffield, which may be no intervention), and one or
2002). educational interventions in nursing more specific outcomes (such as prevention
curricula have yet to be evaluated beyond of deep vein thrombosis). An example, then,
the outcomes of small addictions specialty of a question for systematic review would be,
programs (naegle, 2002). In long-distance travelers, what is the most
effective method of preventing deep vein
Madeline A. Naegle thrombosis?
SySTemATIC ReVIeW n 501
A quantitative systematic review uses to approach the question differently, or a
statistical methods to combine the results new question must be considered.
of two or more studies, where appropriate. 2. Formulation of a pICO-based research S
The review may or may not be a meta-anal- question.
ysis. A meta-analysis involves the pooling of 3. Development of a review protocol that
results from comparable randomized con- includes specific aims and objectives,
trolled trials. The focus of a meta-analysis clear inclusion and exclusion criteria,
is on therapy and interventions. Its purpose and an explicit search strategy developed
is to provide a single estimate of effect of an with the assistance of a medical librarian.
intervention or treatment from the combined Consideration needs to be given to the
results of included studies. When the results importance of the problem addressed. The
of qualitative studies are synthesized, the databases and other sources of evidence to
review may be called a qualitative systematic be searched need is a prestudy decision.
review, or meta-synthesis. economic system- 4. Criteria for considering studies for
atic reviews compare both the costs and the review must include a description of the
consequences of different courses of action. types of participants, types of interven-
By quantitatively combining the results of tions (if applicable), types of outcome
several studies, meta-analyses create more measures, and types of studies (study
and convincing conclusions, meta-synthesis designs).
illuminates and expands the understanding
of processes and meaning, and economic The stages associated with conducting
systematic review quantifies attributable cost the review are as follows:
and cost effectiveness. examples of these are
recent reviews highlighting nursing inter- 5. Identification of research studies and
shift reports in acute care hospitals (poletick other evidence for possible inclusion in
& holly, 2010), outcomes of magnet designa- the review.
tion (Salmond, Begley, Brennan, & Saimbert, 6. Assessment of methodological quality
2009), an examination of factors that contrib- using a standardized critical appraisal
ute to nursing leadership, the effectiveness of instrument and conducted by at least
educational interventions in developing lead- two reviewers working independently.
ership behaviors among nurses (Cummings 7. Determination of studies for inclusion
et al., 2008), and an economic analysis of based on the quality assessment.
hospital-acquired infections (Stone, Braccia, 8. Data extraction involved.
& larsen, 2005).
A systematic review involves several The stages associated with interpreting
discrete steps. Decisions at each step of the the review are:
process are accomplished through the use of
at least two reviewers. The steps associated 9. Data synthesis, which involves rea-
with planning, conducting, and interpreting soning from the general to the partic-
findings follow. ular whereby a new interpretation is
The stages associated with planning the presented. If heterogeneity is found,
review are as follows: approaches to finding the reason need to
be specified.
1. Identification of the need for a review. 10. Recommendations for best practice.
This can be accomplished through “scop- 11. Recommendations for further research.
ing,” searching the literature to see if a
review has been done already. If a review While systematic reviews are regarded
has been done, a determination is needed as the strongest form of evidence, a review
502 n SySTemATIC ReVIeW
of 300 studies found that not all systematic provide peer review of systematic review
reviews were equally reliable and that their protocols against particular guidelines,
S reporting could be improved by a universally which further increases scientific rigor.
agreed upon set of standards and guidelines In summary, a systematic review is a
(moher, Tetzlaff, Tricco, Sampson, & Altman, research method conducted by at least two
2007). Consequently, several international people, working independently and then
initiatives have evolved to help prepare, to combining their independent results. The
maintain, and to disseminate the results review is guided by a question, with spe-
of systematic reviews of health-related cific aims and objectives, and conducted in
interventions. notably are the Cochrane accordance with a predefined strategy, with
Collaboration (www.cochrane.org), which an overall intent to identify and recommend
reviews randomized trials of the effects best practice. In particular, researchers per-
of treatment; the Campbell Collaboration forming a systematic review must make
(www.campbellcollaboration.org), which every effort to identify and report research
focuses on reviews that address issues of that both supports and does not support
policy making, specifically related to crime, their preferred research position. It is this
justice, social welfare, and education; and the unbiased approach that makes a review
Joanna Briggs Institute for evidence Based systematic.
nursing and midwifery (www.joannabriggs. Investigation into the science of system-
edu.au), which focuses on reviews that sup- atic review is among the necessary future
port the translation, transfer, and utilization initiatives for this research method. In addi-
of feasible, appropriate, meaningful, and tion, it is not unusual now to find more than
effective healthcare practice. In addition, the one systematic review addressing the same
evidence for policy and practice Information or similar questions paving the way for
Center at the University of london (http:// meta-summary or meta-study, a systematic
eppi.ioe.ac.uk/cms) has been influential in review of systematic reviews, which further
developing methods for combining both supports the growing need for investigation
qualitative and quantitative research in sys- into the science of systematic review.
tematic reviews for social science, public
policy, and health promotion. These groups Cheryl Holly
T
or to assist nursing care at distant sites. This
TelehealTh broad definition includes several means of
transmission, including telephone and fax
transmissions, interactive video and audio,
Telehealth is defined as the use of interac- store-and-forward technology, patient mon-
tive technology for the provision of clinical itoring equipment, electronic patient records,
health care, patient and professional educa- electronic libraries and databases, the
tion, public health, and health care admin- Internet and intranet, World Wide Web, elec-
istration over small and large distances tronic mail systems, social media, decision
(American Nurses Association, 1999; Chaffee, and care planning support systems, and elec-
1999). The defining aspect of Telehealth is tronic documentation systems. When used
the use of electronic signals to transfer var- optimally, telehealth can be used to leverage
ious types of personal health information limited health care resources to better meet
from one site to another. Information ranges the needs of patients (Bendixen, Levy, Olive,
from clinical records to health promotion Kobb, & Mann, 2009; Lillibridge & Hanna,
instructions to still-images of wounds and 2009; Malacarne et al., 2009; Rajasekaran,
motion-images demonstrating exercise rou- Radhakrishnan, & Subbaraj, 2009).
tines. Throughout the published literature Most nurses have been already been
relevant to the health sciences, telehealth is involved in telehealth without realizing it.
used interchangeably with telemedicine, and Examples include telephoning or faxing a
every so often the term telenursing will sur- patient status report, telephone triage, home
face. The term telehealth is embraced as the health visits via telecommunication for mon-
more encompassing concept, descriptive of itoring, participation in social media, and
the state of technology used in the provision designing Web sites for educating patients.
of health care; telemedicine and telenursing Although much attention has been paid to
are subsets of telehealth. technology and innovative equipment as a
Telehealth has tremendous potential for potential to enhance the access and availabil-
nursing, both as a means of communication ity of health care services for patients, regard-
among nurses, patients, and their caregiv- less of where they live, very little work has
ers, and as a way to deliver tailored nurs- been accomplished in the area of systemati-
ing services. Telehealth can serve in nearly cally reviewing the efficiency and effective-
every area of nursing care, from emergency ness of its applications. Numerous studies
response systems to hospital, home, and have shown that telehealth can produce clin-
community care. Telehealth has the poten- ically similar care to face-to-face visits with
tial of expanding health care services beyond health practitioners, that it can improve
traditional geographic boundaries and patients’ access to care, and can reducehospi-
enabling access to a broader range of care tal and patient travel costs (Rheuban, 2006).
options in previously underserved areas, However, studies on the clinical outcomes
and at times in which health care providers of care have focused on different patient
commonly are not accessible. It can be used populations,different disease categories, and
for bedside nursing care, patient education, different telehealth technologies, making it
504 n TELENuRSINg/TELEpRACTICE
difficult to assess the overall effect of tele- health outcomes. However, across all of the
health on clinical outcomes of care resulting studies, a persistent theme emerges: the
T in mixed findings and some unanswered telehealth innovations that work the best are
questions (Bensink, Hailey, & Wootton, 2006; those that complement the existing nursing
Dansky, Vasey, & Bowles, 2008; DelliFraine & approaches. Importantly then, this finding
Dansky, 2008). calls for an end to isolated telehealth appli-
Research examining telehealth in sup- cation evaluation and an initiation of more
port of clinical nursing is still maturing. With studies in which the telehealth innovation is
some projects, say Brennan’s ComputerLink examined as a component of, not apart from,
work (Brennan, Moore, & Smyth, 1991), the the nursing intervention (Barnason et al.,
acceptance of telehealth for clinical nursing 2009; Kleinpell & Avitall, 2007; Moore &
was realized only in the last decade (Heisler, primm, 2007).
2007, 2009; Mohr, Vella, Hart, Heckman, &
Simon, 2008; Nahm et al., 2008; Sorensen, Josette Jones
Rivett, & Fortuin, 2008; Zolfo, Lynen,
Dierckx, & Colebunders, 2006). This rela-
tively slow growth is a consequence both
of the state of telehealth applications and Telenursing/TelepracTice
the expectations of nurses regarding the
nature of appropriate interventions. The
World Wide Web is now several decades old Telenursing is defined as the use of telecom-
and the penetration of information technol- munication technology to provide nursing
ogy into daily life, although accelerating, services to clients at a distance. Telenursing,
has yet to touch the lives of more than 80% a subset of telehealth (see Telehealth), com-
of the American public. Additionally, the bines information technology to support and
nursing discipline initially concentrated its expand professional nursing practice from
professional and scientific attention on face- its traditional borders by removing time
to-face encounters with patients (Dansky, and distance barriers to nursing care (Jones,
Yant, Jenkins, & Dellasega, 2003; Darkins, 2001). Telenursing is an expanding part of
Fisk, garner, & Wootton, 1996; gardner health care mainly used to assess care needs,
et al., 2001; Johnson-Mekota et al., 2001; provide advice, support and information,
Wakefield, Flanagan, & pringle Specht, 2001; and recommend and coordinate health care
Whitten, Cook, & Doolittle, 1998). Nursing resources (Holmström & Höglund, 2007).
is now moving toward embracing informa- Although typically associated with the
tion technology to support and expand the use of the telephone or facsimile, telenurs-
delivery of care (Heisler, 2007; Lillibridge & ing provides other potentials for the nurs-
Hanna, 2009; Rajasekaran et al., 2009; ing practice. A small but persuasive set
Sorensen et al., 2008). Investigations into of research projects (Beebe et al., 2008;
the use of telehealth for the delivery of pro- Ernesäter, Holmström, & Engström, 2009;
fessional nursing interventions (Brennan & Hagan, Morin, & Lepine, 2000; Hanson &
Ripich, 1994; Brennan, Moore, & Smyth, 1995; Clarke, 2000; Hanson, Tetley, & Shewan,
Brennan et al., 2001; Cady, Finkelstein, & 2000; Hayes, Duffey, Dunbar, Wages, &
Kelly, 2009; Fincher, Ward, Dawkins, Holbrook, 1998; Jerant, Azari, Martinez,
Magee, & Willson, 2009; Heyn Billipp, & Nesbitt, 2003; Johnson-Mekota et al.,
2001; Wakefield et al., 2008; Zimmerman & 2001; Kaminsky, Carlsson, Hoglund, &
Barnason, 2007) demonstrate the feasibil- Holmstrom, 2010; Schlachta-Fairchild,
ity of the approach and the potential for Elfrink, & Deickman, 2008; Whitten, Mair, &
not only social benefits but also improved Collins, 1997; Wootton et al., 1998) identified
TELEpRESENCE n 505
the important components of nursing care communication and interaction, or to
that could be delivered via telecommunica- become electronically present in a distant
tions applications, demonstrated the equiv- real-world environment for the purposes of T
alence of technology-mediated assessment remote-controlled action and/or observation
with face-to-face approaches, and illustrated (Ballantyne, 2002; Hamit, 1993).
the feasibility and potential health benefits In health care, a more restrictive defini-
of information technology designed to inter- tion of telepresence is applied and is based
vene in significant health problems. on robotic technology. A teleoperator with
The use of telecommunication appro- the dexterity matching that of a bare-handed
aches for clinical assessment, although operator can fully perform in a distant envi-
accepted in northern Europe for wide scale ronment without a physical presence. The
clinical deployment (Ernesäter et al., 2009), sensory information generated by and within
shows great promise in assisting nurses in the computer compels a feeling of being pre-
important components of the nursing pro- sent in the distant real world. Throughout the
cess, such as assessment, diagnosis, and published literatures relevant to the health
intervention (Snooks et al., 2008). Telenursing sciences, the terms virtual presence and tel-
also expanded the practice of nursing across erobotics are used interchangeably.
state and international borders, challenging The venue of the robotic technology,
many of the assumptions that have created combined with advances in computer tech-
a state-based system of nursing practice acts nology, have broadened the scope and
and licensing (Holmström & Höglund, 2007; ability of surgery, especially stereotactic
Schlachta-Fairchild, Varghese, Deickman, neurosurgery and laparoscopy (Ballantyne,
& Castelli, 2010). In response to telepractice, 2002; Ballantyne, Hourmont, & Wasielewski,
the creation of a new mechanism for licen- 2003; gandsas, parekh, Bleech, & Tong, 2007;
sure and practice are warranted (American Vespa et al., 2007) as well as truama care in
Nurses Association, 1998; Miller & Morgan, emergency rooms (Daruwalla, Collins, &
2009). The guiding framework critical to pro- Moore, 2010). In addition, robotic surgery
viding safe, competent, and ethical nursing lends itself to telesurgery, in which surgeons
telepractice services is based on the nursing and patients are in remote geographic loca-
process, and targets improving the nurse- tions. Nurses have assisted in those surgeries
patient connection while embracing the ben- (DeKastle, 2009; Eckberg, 1998; peck, 1992).
efits of health care technology innovations. More recently, a shift from a traditional
In sum, the fields of telehealth, telenurs- hospital-centered model of care in geriatrics
ing, and telepractice are not mixing infor- to a home-based model has created oppor-
mation technology and the nursing practice; tunities for using telepresence with mobile
however, they are incorporating electronic robotic systems in home telecare (Boissy,
correlates with all professional dimensions Corriveau, Michaud, Labonte, & Royer, 2007;
of the nursing practice. Michaud et al., 2010). Teleoperated mobile
robotic systems in the home were found
Josette Jones to be useful in assisting multidisciplinary
patient care through improved communica-
tion between patients and health care profes-
Telepresence sionals, and offering respite and support to
caregivers under certain conditions.
The ability of telepresence in health
Telepresence is the use of virtual real- care is a reality, although it is still evolving.
ity to enter a shared cyberspace graphic The ultimate use of telerobotics remains
environment for the purposes of human uncertain; and to date, no nursing practice
506 n TERMINAL ILLNESS
applications involving human touch have cure. Furthermore, unlike hospice or end-of-
occurred using robotic technology (DeKastle, life care, palliative medicine is recognized as
T 2009; Eckberg, 1998; peck, 1992). The ability a medical specialty. As such, the likelihood
to touch patients, change dressings, perform that this service will be incorporated into
wound care, or hug an elderly patient remain treatment is enhanced.
a distant possibility. Research in the area of terminal illness
Telepresence is a new and challenging has focused on the individual (patient needs,
aspect being added to the nursing practice. symptom management, and holistic care),
Nurses are expected to take an active role, family needs (meaning-making, empower-
embrace this technology, and work to max- ment, anticipatory grief, managing time, and
imize its potential for patient care. the impact of terminal illness on the family),
and system issues (adequacy of care, ethical
Josette Jones issues, impact of ethnicity on care, terminally
ill patients and research, transfer to hospice
and palliative are, and incarcerated termi-
nally ill patients).
Terminal illness A continuing question in the care of
those with a terminal illness is the role of
food and hydration. For relatives and signif-
What is a terminal illness? The term gener- icant others, food has a symbolic value, con-
ally is applied to a person with a degenerative noting nurturing and life and the hope that
process rather than an episode engendered death will be forestalled. “What if my loved
by trauma sustained as a result of some exter- one stops eating/Will my loved one starve”
nal force. “A person may be regarded as hav- was one of a number of questions that fam-
ing a terminal illness when broad agreement ily caregivers wanted to discuss with health
has been reached among health professionals care professionals in a study of 33 current and
that there is no longer the possibility of cure bereaved health caregivers (Herbert, Schulz,
and that life-expectancy is limited” (Hughes Copeland, & Arnold, 2008). Nurses in Taiwan
& Neal, 2000, p. 4). also were influenced by the cultural maxim
“When is an illness terminal?” is still of “food comes first for people” and thus con-
a question that both providers and patients sidered artificial nutrition and hydration as
may be reluctant to discuss. The emphasis basic care for terminally ill persons (Ke, Chui,
on curative treatment, no matter the dimin- Lo, & Hu, 2008). plonk and Arnold (2005) dis-
ishing chances for prolonged life, abets the aggregate nutrition and hydration, noting
reluctance to label a condition as terminal. that the consensus is that the former is not
Failure to do so, however, may result in dying beneficial to dying persons whereas the lat-
persons not having the time to attend to the ter is controversial. Also controversial is the
tasks they would wish to, were the reality use of palliative sedation when other means
of their condition openly shared (gawande, of pain relief are ineffective to relieve intrac-
2010). Interestingly, nurses were more likely to table suffering (De graeff & Dean, 2007).
be willing to disclose “bad” news to patients Although the previous studies focus on the
than were physicians (Ben Natan, Shahar, & needs of the dying person, the needs of the
garfunkel, 2009). At the same time, with the families of those who are terminally ill also
new emphasis on palliative care at the diag- have been of concern to health care practitio-
nosis of a life-threatening illness, the poten- ners and of interest to researchers.
tial for such discussions may be enhanced. The quality of life of the informal care-
And unlike hospice care, there is no require- giver is predicted by their physical health
ment to forego aggressive treatment aimed at and spirituality (Tang, 2009). Consequently,
TERMINAL ILLNESS n 507
it is recommended that health care provid- when used to indicate the satisfaction with
ers pay more attention to the health status of care of the terminally ill person. At the same
the informal provider. In a grounded theory time, there is no easy answer as to how satis- T
investigation of the nurse-facilitated empow- faction with care of terminally ill persons is
ering intervention of 24 family caregivers to be measured, given the fragile condition of
of terminally ill patients, it was found that persons nearing the end of their lives.
information, education, encouragement, and Research with the terminally ill, as
support were required by these caregivers with other patients, demands the calcu-
(Mok, Chan, Chan, & Yeung, 2002). The role lation of a risk/benefit ratio. In this case,
of communication is underscored in numer- the research may not benefit the individ-
ous studies (Marco, Buderer, & Thun, 2005). ual participant but it may be of benefit to
Caregivers of terminally ill children, future terminally ill persons. given the
usually parents, present both similar and condition of terminally ill persons, qualita-
distinctive issues. Factors that influence how tive research has been favored as a method
families navigate this terrain include the of inquiry. That leaves the question of the
relationship with health care providers, the generalizability of the results; quantitative
availability of information, and the effec- methods are important for future studies.
tiveness of communication between parents Kirchhoff and Kehl (2007) and Schulman-
(Steele, 2002). Being a good parent by making green, McCorkle, and Bradley (2009) dis-
unselfish decisions for the child was under- cuss some of the challenges in patient
scored in a recent study (Hinds et al., 2009). recruitment and research methodology for
Repeatedly, in the research on caregivers end-of-life research As the research results
of terminally ill persons, the need for infor- accumulate, the translation of the research
mation, communication, and good listen- findings into practice will enhance the care
ing has been stressed (Andershed, 2006). In of the terminally ill.
Norway and Sweden, using 45 forced choice, With the introduction of palliative care
open-ended questions, researchers found earlier in the disease process, questions of
that respondents supported ongoing disclo- compensation inevitably occur (De Fanti,
sure of information to terminally ill patients 2010). As with hospice care, the question
(Lorensen, Davis, Konishi, & Haugen Bunch, arises as to whether the organization of the
2003). This contrasts sharply with the parts care is directed to containing the costs of care
of Europe and Japan where it is the custom or meeting the needs of the patient and fam-
to speak with the family rather than the ily. If the latter is not achieved, there will be
patient. Clearly assessing patient and family reluctance to accept such services.
preferences with regard to communication is Finally, is palliative care beneficial for the
essential. patient? A study by McKechnie, MacLeod,
In research on the subject of the experi- and Keeling (2007) explored the dying pro-
ences of the terminally ill person, caregiv- cess of seven women with carcinoma receiv-
ers often serve as the source of information ing palliative care using qualitative research
about the end-of-life experience of their fam- methodologies. uncertainty throughout the
ily member. Quality of care and satisfaction diagnostic and treatment process as well as
with care are measured by reports of family their freedom from distressing symptoms
members regarding the patient’s experience. marked their experience. “Living until you
Hinton’s (1996) reinterview of 71 relatives die” was not achieved for these research par-
showed that there is variable agreement ticipants. In addition, with withdrawal from
with earlier statement made by these same usual activities, dying persons experienced a
individuals. This raises a question about the form of “social death.” The authors conclude
validity and reliability of such measurement that “whether one has a ‘good death’ or not is
508 n THEORETICAL FRAMEWORK
determined not only by the progression and theoretical world and the empirical world to
management of the disease process by health which it applies are made through the formu-
T professionals, but also by the way in which lation and testing of hypotheses. Theoretical
one is perceived by self and others” (p. 264). frameworks are developed and tested through
With social death, the terminally ill will be theory-linked research. Theory-generating
dead to themselves and others prior to their research is designed to discover and describe
physical death. If such is the case, caregivers, concepts and relationships for the construc-
both informal and professional, will have tion of theory. Once theory is constructed,
failed in their care of the terminally ill. theory-testing research is used to validate
how accurately the theory depicts empirical
Inge B. Corless phenomena and their relationships.
generation of theoretical frameworks in
nursing has followed an evolutionary pro-
cess. Initially, nursing grappled with defin-
TheoreTical Framework ing theory for a developing discipline. In
the 1960s and 1970s, early nurse theorists
attempted to answer questions, such as (a)
A theoretical framework is a group of state- around what phenomena do nurses develop
ments composed of concepts related in some theory? (b) What are the things nurses think
way to form an overall view of a phenome- about and take action on? (c) What are the
non. As constructions of our mind, theoret- boundaries of the discipline? In response to
ical frameworks provide explanations about these questions, a proliferation of concep-
our experiences of phenomena in the world. tual models and philosophies of practice of
The explanations provided by theoretical nursing were developed. These nursing con-
frameworks are of two types: descriptive ceptual models are considered at the grand
(understanding the interaction among a set theory level, examples of which are the the-
of variables) or prescriptive (anticipating a ories of Johnson, Roy, Neuman, Rogers, and
particular set of outcomes; Dubin, 1978). The Watson.
term theoretical framework often is used inter- The discipline also addressed the ques-
changeably with the terms theory, theoretical tion of how to develop theory for nursing
model, and theoretical system. and proposed definitions emphasizing the
Theoretical frameworks consist of the structure, purpose, and use of theory. Nurse
following components: (a) concepts that are scientists and theorists debated methods of
identified and defined, (b) assumptions that developing theory, including reformulation
clarify the basic underlying truths from of borrowed theories and development of
which and within which theoretical reason- unique nursing theories based on quanti-
ing proceeds, (c) the context within which tative and qualitative research. These dis-
the theory is placed, and (d) relationships cussions led to the acceptance of multiple
between and among the concepts that are approaches to theory development in nurs-
identified. Theoretical frameworks serve as ing, including both inductive and deductive
guides for practitioners and researchers in methods. Recent attention has focused on the
that they organize existing knowledge and need to develop knowledge about the sub-
aid in making new discoveries to advance stance of nursing. Middle range theories that
nursing practice. focus on the clinical processes in nursing are
The scientist focuses on making the being developed. Examples of middle-range
empirical world and the theoretical world theoretical frameworks are Mishel’s theory
(represented by theoretical frameworks) as of uncertainty in illness, pender’s theory of
congruent as possible. Linkages between the health promotion, Smith’s story theory, and
THERMAL BALANCE n 509
Lenz and colleagues’ theory of unpleasant vasoconstriction, shivering, and increased
symptoms. metabolic activity. Each physiological
response augments or inhibits the transfer T
Shirley M. Moore of heat by affecting the thermodynamics
of conduction, convection, radiation, and
evaporation. Vasodilation warms the skin
where heat is more easily lost to air, contact
Thermal Balance surfaces, or liquids. Vasoconstriction creates
a poorly perfused insulative layer of tissue
that conserves heat. In infants, cold expo-
Thermal balance is defined as a thermal sure causes metabolic breakdown of brown
“steady state” in which the loss of body heat fat to generate heat. In older children and
is equal to the heat gain. In health, this bal- adults, the primary means of heat genera-
ance produces a thermoneutral state, opti- tion is shivering.
mal for cellular function. In humans, this Nurses have recognized the impor-
state averages about 37°C ± .05 for inter- tance of assessing thermal balance as a
nal temperatures and 33.5°C ± .05 for skin. vital health indicator for as long as the
Variations in body temperature respond to profession has existed. Body temperature
both homeostatic and circadian influences provides an important vital sign of meta-
(Holtzclaw, 2001). Circadian rhythm of bolic, neurological, and infectious activity.
core temperature is regulated by a remark- Circadian rhythms, monthly cycles, and
ably stable endogenous “clock,” which has daily body temperature ranges are assur-
helped to make it the most widely used ances of healthy variations. The pregnant
circadian indicator. There is evidence that mother provides heat exchange both for
circadian rhythms begin in fetal develop- herself and the fetus; therefore, high mater-
ment but there is also research support for nal body temperatures, from fever, hyper-
maternally derived prenatal and postnatal thermia, or prolonged “hot tub” use, put the
influences on rhythm (Weinert, 2005). The unborn infant at risk for neurological dam-
tendency of older people to go to bed and age. Temperature elevations in the acutely
wake up earlier than younger people has ill and injured may indicate either fever or
generated studies with a lack of consensus hyperthermia. Each has its own dynamics
about whether a phase advance (shifted ear- and treatment. Fevers are manifestation of
lier) of circadian rhythms occurs in later life the host response to pyrogens and are usu-
(Yoon et al., 2003), Hypothalamic thermo- ally self-limiting. By contrast, thermoregu-
regulatory controls keep internal tempera- latory control is lost during hyperthermia
tures fairly stable, despite environmental and requires aggressive cooling treatment.
changes and the propensity of heat to escape Temperatures above 42°C can cause irre-
to cooler regions. Metabolic and physical versible neural cellular damage. Conductive
activity continually generates heat, even cooling blankets, ice packs, and cooling
as it is constantly lost to the cooler envi- fans are used to lower core temperatures.
ronment. Current theory is that elaborate In immunosuppression associated with
thermoregulatory control systems maintain cancer treatment, fevers may indicate ful-
temperatures within the optimal set point minating systemic infection. However, the
range. Compensatory cooling or warming immunosuppressed HIV-infected patient
mechanisms respond to deviations above or may become febrile from high cytokine lev-
below this range. Temperatures rising above els, without obvious secondary infection. In
this range evoke vasodilation and sweat- both groups, constant assessment of other
ing, whereas falling temperatures cause indicators is necessary to rule out infection.
510 n THERMAL BALANCE
Situations that promote heat loss or inter- linked disorder occurring when suscepti-
fere with heat generation put patients at risk ble persons receive anesthetic agents, led
T for hypothermia. The neonatal nurse must be to closer surveillance of perioperative body
extremely sensitive to the low-birthweight temperature. This precaution reduced mor-
infant’s need for external heat source. unable tality from hyperthermia in this uncommon
to shiver, the neonate expends oxygen to condition, but also brought to awareness the
metabolize brown fat and can easily become high incidence of low body temperatures in
hypoxic from cold exposure. Declining met- most surgical patients. Increased survival of
abolic and vasomotor activity makes older preterm infants in the 1970s created increased
persons particularly susceptible to heat loss concern for thermal balance of vulnerable
during surgery, trauma, or outdoor exposure. infants. Studies of environmental influences,
Hypothermic states can destabilize thermo- warming devices, and skin-to-skin contact
regulatory function further, eventually lead- were made possible by sophisticated contin-
ing to death. uous skin temperature monitors.
Since early times, fever patterns have Temperature measurement issues con-
provided a key indicator for detecting the tinue to dominate clinical nursing research,
onset and progress of infections. Concern stimulated by the commercial development of
that high temperatures could cause irrevers- new technologies in thermometers. Erickson
ible brain damage led nurses to routinely cool (1999) and McKenzie and Erickson (1996)
patients with rising body temperature using were among the first to compare oral, skin,
ice packs, cooling sponge baths, or circulating rectal, and tympanic membrane measure-
fans, regardless of the temperature elevation’s ment sites as well as methods of thermome-
cause. In the 1970s, nurses used conductive try in children and adults. Findings reassure
cooling blankets with refrigerated circulat- nurses that oral measurement provided reli-
ing coolant to appropriately treat refractory able intermittent thermal assessment in afe-
hyperthermia in which thermoregulatory brile patients. Newer research studies have
cooling responses are impaired. However, reaffirmed this in community-dwelling older
in treating fever, in which thermoregulation adults (Lu, Dai, & Yen, 2009). Although place-
remains intact, sharp gradients between skin ment site and method of insertion yield statis-
and core temperatures stimulated vigorous tically significant differences, they are of less
and distressful shivering. Interventions to importance clinically. Erickson’s work was
prevent shivering were among the earliest to set apart from other contemporary studies by
be tested by nurses. Interest in and awareness her appropriate statistical treatment beyond
of temperature variations became more acute simple correlations and by meaningful inter-
among nurse researchers when advanced pretation of device reliability, accuracy, and
technology in thermometry was introduced linearity. In the past decade, nurse research-
to clinical settings. Hemodynamic monitor- ers began drawing inferences from observed
ing systems with thermistor probes first made relationships between thermal changes and
pulmonary artery temperature measurement other variables. gradients between skin
possible in critical care settings in the 1970s. and core temperatures initiate thermoreg-
The availability of clinically made bladder, ulatory responses (see entry on Shivering).
tympanic membrane, and skin temperature Studies have shown the importance of ther-
probes led to numerous studies of gradients mal gradients and rate of cooling in initiating
between body regions and measurement shivering in a comparison of cooling blan-
sites. Variation in quality and precision of ket temperatures (Caruso, Hadley, Shukla,
instruments made studies of reliability and Frame, & Khoury, 1992; Sund-Levander &
accuracy important. Recognition of malig- Wahren, 2000). Nursing research has also
nant hyperthermia, a rare but lethal genetically tested methods to alleviate adverse effects of
TIME SERIES ANALYSIS n 511
warming and cooling in patients of all ages. to thermal balance are studies using ani-
particularly vulnerable are the preterm infant, mal models to demonstrate the effects of
the elderly, and patients recovering from exercise on thermoregulatory responses T
surgery, cardiopulmonary bypass, or trau- (Rowsey, Metzger, & gordon, 2001) and fever
matic injury. Research-active members of the (Richmond, 2001; Rowsey et al., 2009), and
American Society of periAnesthesia. Nurses circadian influences on thermoregulation in
improved nursing standards and policy rec- obesity (Jarosz, Lennie, Rowsey, & Metzger,
ommendations through their research efforts 2001) As more nurses enter the fields of genet-
to promote normothermia in the periopera- ics, immunology, and molecular biology,
tive area (Hooper, 2009; Hooper et al., 2009; they will play important roles in seeking
pikus & Hooper, 2010). Anderson et al. (2003) origins and mechanism of thermoregulatory
pioneered “kangaroo care” as a method of responses. New avenues for nursing research
maintaining thermal balance in preterm and in thermal balance emerge as new situations
term infants. Drawn from perinatal practices of vulnerability develop and measurement
in Western Europe, this method uses skin- techniques are advanced. At particular risk
to-skin care for infants held against the skin is the rapidly growing population of the frail
under the mother or father’s clothing. Self- elderly who are at risk of heat-related ill-
demand breast-feeding and lactation were nesses in extremely hot weather and hypo-
promoted by close constant maternal con- thermia associated with cool climates and
tact (Hake-Brooks & Anderson, 2008). The exposure. Declining metabolic rate, lower
method was found feasible and beneficial, vasomotor sensitivity and diminishing insu-
even in infants that were mechanically ven- lation from body fat contribute to vulnerabil-
tilated (Swinth, Anderson, & Hadeed, 2003). ity to extremes in heat or cold. The existence
Relationships between the infant’s body tem- and treatment of thermoregulatory failure in
perature and environment, circadian rhythm, home-bound patients is an area that nursing
and parental co-sleeping have been investi- has not yet systematically studied. Improved
gated (Thomas & Burr, 2002). Several studies survival of individuals with neurological,
have compared the effectiveness of cooling vasomotor, and endocrine impairments and
interventions in febrile adults with similar with extensive burns creates new situations
findings (Caruso et al., 1992; Henker et al., in which thermal balance is altered. Only
2001). Most concluded that antipyretic drugs recently have nurses begun to investigate
are as effective as cooling without inducing the relationships between the circadianicity
distressful shivering. In a controlled trial of body temperature and the effectiveness of
with febrile patients with HIV disease, insu- other therapies. Study and intervention are
lating skin against heat loss actually kept needed in addressing thermal balance, ther-
peak febrile temperatures lower (Holtzclaw, mal perception, and thermal comfort during
1998). Although numerous small studies in a variety of life events and health alterations.
nursing have tested various products that
cool febrile patients or restore heat loss in Barbara J. Holtzclaw
perioperative patients, they are often empir-
ical in nature. By contrast, the investigations
mentioned above are theoretically based on
the principles of thermodynamics and phys- Time series analysis
iological responses. They seek to explain
mechanisms, predict consequences, and alle-
viate the hazards of altered thermal balance. Time series analysis and statistical time series
Some of the newer areas of investiga- models are basic to describing and studying
tion conducted by nurse scientists related change in human responses and behavior.
512 n TIME SERIES ANALYSIS
They are appropriate to cyclical patterns as response patterns of individuals, families,
well as periodic or systematic variance across communities, health care systems, or politi-
T time. Outcomes of nursing care are generally cal institutions.
quantified by measures of response changes The characteristic feature of time series
across specified periods of time: improve- analysis is that the phenomenon to be stud-
ment or declines in health status, increase or ied has a distinctive temporal component—
decrease in strength or endurance are a few the behavioral state will vary predictably
examples. Although these changes are often with the passage of time. Obviously, the pas-
treated as simple, linear processes, the rate sage of time cannot be manipulated, thus,
and degree of linear variation in outcome differences in patterns of change are not a
variables are often confounded by related direct function of time. Instead, time is the
or underlying predicable patterns of fluctu- necessary temporal frame or marker in any
ation, Thus, whereas time series statistical time series analysis study. Although not
models are an appropriate and powerful conceptually an independent variable, time
methodology for analysis of intraindividual assumes that role in univariate time series
differences in predictable patterns of change, statistical models. Time series studies can be
they can also be used to identify recurring either univariate or multivariate. However, a
patterns of variation that are confounding time series variable always consists, by defi-
the rate and degree of intervention success. nition, of a series of observations that occur
In contrast with inferential statistical in temporal order. Thus, multivariate time
models, in which aggregate data are general- series analysis is accomplished by identify-
ized to describe changes in human behavior, ing the relationship between or among two
time series analysis uses individual patterns or more pairs of univariate time series.
of change to predict future behavior. Thus, unlike inferential statistical models,
the subject is a unitary entity or system time series data points are not intended to
whose behavioral state can be isolated within be independent of one another. Each value
a given point and measured through a speci- is highly correlated with every successive
fied window of time. Allowing subjects to act value. Thus, any observation in a time series
as their own controls eliminates the random has significantly less individual predictive
heterogeneity of response threat to infer- significance than its inferential counterpart.
ential statistical validity; but limits statisti- In time series analysis, predictive power is
cal external validity. generalization of time not a direct function of sample size. Instead,
series findings requires repeated replications predictive power depends on an accurate
in conceptually congruent others. hypothesis of the internal temporal structure
For the purpose of time series analysis, of the phenomenon, selection of a sampling
the singular system can be defined at many time window of sufficient length to capture
different levels of complexity and inclu- multiple expressions of the change being
siveness. However, because 50 observations studied, and identification of a sampling fre-
across the specified time period is the con- quency that will adequately capture all criti-
ventional minimal number of observations cal phases of the evolving pattern.
necessary for the accurate identification of Although change in behavior is an essen-
predictable patterns of behavior, pragma- tial characteristic of many of the phenomena
tism often limits subjects for time series of interest to nursing science, the use of statis-
nursing research to the often more reliable tical time series models is not always appro-
physiological and directly observed behav- priate or feasible. However, although time
iors of individuals, for example, cardiovas- series analyses are complex and costly, they
cular responses to a cardiac stressor, rather permit nurse scientists to more completely
than equally legitimate, social or behavioral examine and evaluate trends, cycles, and
TRANSITIONAL CARE n 513
patterns of change that are framed within are at risk for adverse events and, thus, will
predictable spaces of time or could affect be the focus of this entry.
rates and degree of treatment effectiveness. In 1981, a team at the university of T
pennsylvania School of Nursing recognized
Bonnie L. Metzger the need to develop a multidisciplinary
model of transitional care led by master’s
prepared advanced practice nurse special-
ists (clinical nurse specialists or nurse prac-
TransiTional care titioners) to meet increasing health care
costs, decreasing acute care length of stay,
and increasing fragmentation of health
Changes in health care delivery and aging care (Brooten et al., 2002). This model was
of the population during the past 30 years initially designed to deliver care to vulner-
have placed patients increasingly at risk for able low–birth weight premature infants.
adverse events during transitions in care. As The quality cost model of advanced practice
a result of decreased length of stay during nurse transitional care, herein termed TCM,
acute care episodes, changes to payment sys- was subsequently tested with other vul-
tems, and fragmentation among providers nerable populations including women who
across settings, u.S. health care has developed had unplanned cesarean births, pregnant
into an overly complex system. Additionally, women with hypertension and diabetes,
patients are living longer, have increased inci- and the elderly. The elderly, who represent a
dence and prevalence of chronic conditions, high-cost, complex population with multiple
and require more complex care (Institute of chronic illnesses, is a vulnerable population
Medicine, 2001; pham, grossman, Cohen, who has demonstrated the potential to bene-
& Bodenheimer, 2008). Transitional care, fit from transitional care (Murtaugh & Litke,
defined as a set of actions to ensure the coor- 2002; Naylor, 2000, 2004; Naylor et al., 1999;
dination and continuity of health care as Naylor & Van Cleave, 2010).
patients transfer between different locations Research has helped to define and iden-
or different levels of care within the same tify the core components of effective transi-
location, is essential to ensure the coordina- tional care. These evidence-based practices
tion and continuity of health care. Locations include screening for high-risk patients in
for transitional care may include hospitals, need of transitional care services, elucidat-
subacute and postacute nursing facilities, ing patients’ and caregivers’ goals and pref-
the patient’s home, primary and specialty erences, facilitating communication among
care offices, and assisted living and long- providers and across settings regarding the
term care facilities (Coleman & Boult, 2003). essential components of the plan of care,
Studies investigating nurse-directed, multi- educating patients and caregivers regard-
disciplinary, multidimensional interventions ing prevention, early identification, and
have demonstrated the potential for effec- response to worsening health problems,
tive transitional care to improve quality and and placing highly skilled nurses through-
decrease health care costs for older adults at out the transitions to address patients’ com-
risk for poor outcomes (Harrison et al., 2002; plex needs and promote continuity of care
Naylor et al., 1994, 1999, 2004; Schnipper et al., (Naylor, 2006, 2010).
2009; Stewart, Marley, & Horowitz, 1999). The By incorporating these core components,
transitional care model (TCM), developed the TCM has thus demonstrated effective-
at the university of pennsylvania School of ness in three randomized trials for older
Nursing, has demonstrated effectiveness in adults who are at risk for adverse events.
three randomized trials for older adults who These three studies have generated results
514 n TRANSITIONAL CARE
showing reductions in preventable hospital- intervention group (intervention = $642,595
izations for primary and coexisting illnesses, vs. control = $1,238,928; p < .001). Time to first
T improvement in health outcomes after dis- readmission for any reason was increased in
charge, enhanced patient satisfaction, and the intervention group (log-ranked χ 1 = 11.1,
2
reduction in total hospital costs. p < .001; Naylor et al., 1999).
The first randomized clinical trial, con- The third clinical trial demonstrated
ducted in 1994, demonstrated that transitional potential for the TCM to decrease readmis-
care has the potential to decrease rehospital- sions or death, decrease mean total costs,
izations, number of hospital days, and total increase quality of care, and increase patient
charges among 276 older medical and surgi- satisfaction in 239 patients, ages 65 years and
cal cardiac patients aged 70 and older (Naylor older, hospitalized with heart failure (Naylor
et al., 1994). patients were randomized to et al., 2004). patients were randomized to
receive either a comprehensive discharge receive a 3-month advanced practice nurse–
planning protocol specifically developed for directed intervention or control group who
elders and implemented by geriatric clinical received routine patient management, dis-
specialists, or to a control group who received charge planning, and standard home agency
the hospital’s routine discharge plan. The care if referred. Time to first readmission or
results demonstrated that the intervention death was longer in intervention patients
medical patients had significantly decreased (log-ranked χ = 5.0, p = .026, Cox regression
2
readmissions during the first 6 weeks (95% incidence density ratio = 1.65, 95% confidence
confidence interval [CI] = 25% to –1%, p = .04). interval = 1.13–2.40). At 52 weeks, intervention
Total rehospitalization days were fewer for patients had fewer readmissions (104 vs. 162,
the medical intervention group than for p = .047) and lower mean total costs ($7636 vs.
the control group 2 weeks after discharge $12,481, p = .002). The intervention group also
(p = .002) and between 2 and 6 weeks after reported short-term improvements in over-
discharge (p = .01). Total charges for health all quality of life (2 weeks, p < .01; 12 weeks,
care services after discharge for the medical p < .05) and patient satisfaction (2 and
intervention patients were $295,598 less than 6 weeks, p < .001; Naylor et al., 2004).
the control group at 6 weeks (p = .02; Naylor Ongoing research is directed toward
et al., 1994). translating evidence into practice and extend-
Results generated from the second clini- ing transitional care into other populations.
cal trial suggested that the TCM significantly The team at the university of pennsylvania
decreased readmissions, hospital days, and has formed a partnership with leaders of the
costs among 363 medical or surgical hospi- Aetna Corporation to translate and integrate
talized elders ages 65 and over (Naylor et al., the TCM for use in everyday practice and
1999). patients were randomized to either promote widespread adoption of the model
an advanced practice nurse–centered dis- by demonstrating its effectiveness with a
charge planning and home follow-up inter- high-risk Medicare managed-care popula-
vention, or to a control group who received tion in the mid Atlantic region. The evidence
routine discharge planning. At 24 weeks, the from this partnership is currently in analysis.
intervention resulted in fewer total hospital The key lessons, however, from translating
readmissions after the index hospitalization research to practice, are the need to identify
(intervention = 49 vs. control = 107; rank sum strong champions, fit with the organization,
test, p < .001), decreased hospital days (inter- engage key stakeholders, remain flexible,
vention = 270 days vs. control = 760 days; assess and know the external climate, strat-
p < p < .001), and lower reimbursement costs egize the marketing of the innovation to
for readmissions, acute care visits, and home others, establish milestones, and measure
visits were significantly decreased in the success (Naylor et al., 2009).
TRANSITIONS AND HEALTH n 515
Other ongoing work involves testing
the efficacy and effectiveness of transitional TransiTions and healTh
care among other older vulnerable popula- T
tions. The university of pennsylvania team
is exploring the TCM among hospitalized, Nursing has had a sustained and ever-grow-
cognitively impaired elder adults (National ing interest in transitions and health for more
Institute on Aging, R01Ag023116; Marian S. than 40 years. During this time, conceptual
Ware Alzheimer’s program, 2005–2010). The models have been developed, elaborated, and
primary goal of this project is to assess the refined (Chick & Meleis, 1986; Schumacher &
clinical and economic outcomes achieved by Meleis, 1994). Middle-range and situation-
nurse-led interventions of varying intensi- specific theories have been developed (Im &
ties, each designed to improve transitions in Meleis, 1999; Meleis, Sawyer, Im, Messias, &
care for these patients and their caregivers. Schumacher, 2000). Research-based evidence
Another ongoing study, Health Related Quality has demonstrated the benefits of transitional
of Life: Elders in Long-term Care, (National models of care for individuals and health
Institute on Aging and the National Institute systems (Naylor, 2002). Increasingly, theory,
of Nursing Research, R01Ag025524, Marian research, policy, and practice are integrated
S. Ware Alzheimer’s program, 2006–2011), is into a comprehensive scholarship of transi-
the first attempt to document the experiences tions and health. The establishment of the
of frail elders, including those with cognitive New Courtland Center for Transitions and
impairment, as they meet very challenging Health at the university of pennsylvania
care transitions in long-term settings, for School of Nursing is a milestone in this
example, community-based (participant’s regard.
homes) assisted living facilities or in nursing Transition is defined as a passage
homes (Naylor & Van Cleave, 2010). between two relatively stable periods of time.
In conclusion, the growing complexity In this passage, an individual moves from
in both the patient population and health one life phase, situation, or status to another
system will continue to challenge u.S. (Chick & Meleis, 1986; Schumacher, Jones, &
health care delivery, necessitating a con- Meleis, 1999). The need for nursing care is so
tinued need for transitional care services. often precipitated by a transition that transi-
The patient protection and Affordable Care tion is a concept central to the discipline of
Act, signed into law by president Obama nursing (Meleis & Trangenstein, 1994; Kralik,
in March 2010, contains a provision for Visentin, & van Loon, 2006).
community-based care transition programs Transitions are processes that occur over
targeting high-risk Medicare patients with time. They are initiated by significant marker
cognitive impairment, depression, history events or turning points that require new
of multiple readmissions, and unspecified patterns of response. Transition processes
chronic illnesses to be determined as the encompass the period of time from the first
law is implemented (u.S. Congress, 2010). anticipation of transition until a new iden-
Continuing research efforts, identifying tity is formed at the conclusion of the tran-
community settings and partnerships, and sition. Transitions often are conceptualized
translating evidence into practice, there- in terms of stages in order to capture their
fore, must continue to advance the science movement and direction as they evolve over
of quality, affordable transitional care for time. A classic description of transition stages
vulnerable populations. is found in Bridges (1991) work. He identified
three stages: (a) a period of ending or discon-
Janet H. Van Cleave nectedness from what had been there before,
Mary D. Naylor (b) a neutral period characterized by a sense
516 n TRANSITIONS AND HEALTH
of disruption and disorientation as well as students, and practicing nurses (Meleis, 2010).
discovery, and (c) a period of new beginnings An increasing emphasis on transitions in cul-
T in which the individual finds new mean- turally diverse populations is evident as well,
ings and a sense of control and challenge. including Chinese, Mexican, Taiwanese, and
Transitions also can be conceptualized in Saudi Arabian populations. The rapidly
terms of critical periods. Critical periods are growing scholarship on diverse interna-
turning points that can lead to either healthy tional populations experiencing transitions
or unhealthy outcomes. demonstrates the centrality of the concept of
The transition process takes place within transition for nursing worldwide.
the context of an individual’s history, present underlying the current interest in transi-
circumstances, and future possibilities. A tions and health are global societal changes
sense of disconnectedness from one’s famil- occurring with unprecedented rapidity
iar world may occur during transitions. A (Meleis, 2010). Some are the result of tech-
sense of loss or alienation from what had nological developments, such as the ease
been familiar and valued may also occur, with which information and communica-
along with fundamental changes in one’s tion flows around the world. Others are the
view of self and the world. ultimately, indi- result of wars, disasters, recessions, and dis-
viduals experiences changes in identity, location. These events precipitate transitional
roles, and patterns of behavior during a tran- processes that reach well beyond the individ-
sition. New knowledge and skills, new roles, uals directly experiencing them. global tran-
new relationships, and new coping strategies sitional processes may last for an extended
must be developed. period of time and impact health and well-
Nursing scholarship focuses on many being on a long-term basis. Far-reaching
types of transitions, including develop- changes during global societal transitions
mental, situational, health/illness, and have profound effects on organizations and
organizational transitions (Meleis, 2010). populations alike.
Developmental transitions that nurses fre- persons in transition experience a wide
quently encounter include the transition into range of health-related responses. They
motherhood, the menopausal transition, and may experience losses or gains, be more
the aging transition, among others. Situational or less aware of being in transition, suffer
transitions include hospital discharge, relo- from physical debilitation, have lower or
cation, immigration, and education. Health/ higher immune responses, feel an emer-
illness transitions include movement from gence or loss of spirituality, discover new
one phase of a health and illness trajectory to meanings, or experience traumatic stress
another, such as diagnosis, recovery, rehabil- symptoms. Outcomes indicating healthy
itation, lifestyle change, and development of responses to transitions include a sense of
self-care abilities. Organizational transitions meaning, subjective well-being, the devel-
include changes in environments for nurs- opment of a new identity, mastery of new
ing, initiated by changes in leadership, poli- roles, well-being in relationships, harmony
cies, procedures, practices, and technologies. with the environment, renewed energy,
Structural reorganization and new programs optimal physical and mental health and
also initiate transitional processes within functioning, and positive quality of life.
organizations. Adverse outcomes include marginalization,
Nurse researchers have investigated inability to separate from past identities
these types of transitions in an ever-increas- and ways of functioning, inability to make
ing range of populations, including women, decisions, ongoing role insufficiency, isola-
older adults, individuals living with heart fail- tion, and protracted duration of the tran-
ure, diabetes, cancer or rheumatoid arthritis, sition process. previous life patterns may
TRANSLATIONAL RESEARCH n 517
be maintained that are incongruent with A new direction for scholarship on tran-
the demand for new identities and life pat- sitions and health is translational research.
terns (Chick & Meleis, 1986; Schumacher & Translational research is needed to move T
Meleis, 1994). knowledge from the controlled environment
A primary goal of nursing is to facilitate of research to the real-world environment of
healthy transition processes and outcomes clinical practice. Collaboration on many fronts
(Meleis & Trangenstein, 1994). Ongoing will best facilitate this work. For example,
knowledge development focuses on strat- collaboration with health care administrators
egies that nurses use to prevent unhealthy and advanced practice nurses is needed to
transitions, to support individual and fam- effect changes in health care delivery across
ily well-being during transitions, and to pro- the continuum of care, ranging from large
mote healthy outcomes at the conclusion of health systems to long-term care to home
the transition process. Models of care devel- care and nurse-managed community clinics.
oped by nurses to assist clients during a Collaboration with experts in policy develop-
transition include transitional care, role sup- ment is needed to align clinical practice pat-
plementation, and debriefing (Meleis, 2010). terns and reimbursement mechanisms with
The transitional care model is a model of nurse-led transition interventions. Such col-
choice for older adults and those with chronic laborations provide opportunities for link-
conditions. Nursing strategies include ongo- ing research with improvements in health
ing assessment, coaching, and interdisci- care quality. For example, Naylor et al. (2009)
plinary collaboration (Naylor, 2002; Naylor are collaborating with a large u.S. insurance
et al., 2009). The role supplementation model organization to develop policies, procedures,
involves a partnership in which a nurse with and reimbursement mechanisms to give
knowledge, skill, and experience with a role patients access to a transitional care model
(e.g., parenting, caregiving, or chronic ill- that was developed and tested in a large,
ness management) assists an individual new long-standing program of research.
to the role in acquiring the necessary knowl- In summary, more than 40 years of the-
edge, skill, and experience. This is a dynamic ory development and research about transi-
partnership in which the nurse steps in when tions and health has resulted in an extensive
supplementation is needed and steps back as knowledge base, which provides a founda-
the partner becomes able to manage inde- tion for future intervention and translational
pendently (Meleis, 1974). Debriefing includes research. Emerging new directions include
reflection, dialogue, recreating situations, integrating theory, research, policy, and prac-
and reminiscing. It is a strategy to enhance tice into a comprehensive approach to schol-
awareness of the meaning of a transition arship with global, real-world applications.
and to cope with its implications (Steele &
Beadle, 2010). Afaf Ibrahim Meleis
Despite progress in developing and Karen L. Schumacher
testing nursing interventions to assist indi-
viduals during transitions, much additional
knowledge development is needed in this
area. For example, identification of transition TranslaTional research
outcomes most sensitive to nursing inter-
ventions is needed. Interventions specific
to different transition stages, critical peri- The wonderful thing about translational
ods, and milestones need to be developed. research is that everyone knows exactly
Interventions tailored to the needs of specific what it means—the only trouble is that
populations are also needed. none of them have the same definition and
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