18 n ALZHEiMER’S DiSEASE
and African Americans more than 31% com- cognitive, and functional ability and the every-
pared with a 15% increase in Anglos, these day lives of individuals. in addition, the theo-
A projections of cognitive decline are alarming. retical paradigms that investigators choose to
of those adults 65 years and older enrolled guide their inquiries also systematically neces-
in the Health and Retirement Study, 12.7% of sitate ongoing evaluation (McDougall, 1995a,
both sexes had moderate or severe memory 1995b; McDougall, & Becker, Arheart, 2006).
impairment defined as four or fewer words in addition, understanding the impact of cul-
recalled out of 20 on combined immediate ture and social class on cognitive function
and delayed recall tests (Federal interagency and other important health outcomes requires
Forum of Aging-Related Statistics, 2006). research that takes a broader perspective and
Unknown from this longitudinal data was identifies intervening factors that affect mem-
the source of the memory impairment. What ory performance.
is known is that racial and ethnic minorities, Ethnicity, race, and culture are impor-
females, older persons, and persons with tant considerations in cognitive aging. After
limited education are at higher risk for both examining the relationship between memory
obesity and cognitive decline. performance and SES, a positive correlation
Despite uniform detection methods and between memory performance and SES
controlling for reported duration of dementia was observed, although there was no suf-
symptoms, measured cognitive impairment ficient evidence to show that SES is not dif-
is significantly more severe when AD is rec- ferentially related to memory performance
ognized in Blacks compared with Whites (Espino, Lichtenstein, Palmer, & Hazuda,
(McDougall, vaughan, Acee, & Becker, 2007). 2001; Herrmann & Guadagno, 1997).
in a sample of Black and White community older Latinos had a mean age at Alzheimer
elderly, age and race were statistically signifi- symptom onset 6.8 years earlier than did
cant predictors of memory performance in the Anglos. of 89 Mexican American elders who
multiple regression analysis, even accounting were seen in an outpatient memory evaluation
for education, depression, gender, and mem- clinic, they had greater than expected mod-
ory complaints (Shadlen, Larson, Gibbons, erate and severe memory impairment, high
McCormick, & Teri, 1999). The rate of decline levels of instrumental activities of daily living
in Blacks with AD may be slower than that impairments (83%), and high levels of depres-
in Caucasians. Researchers from the Chicago sive symptoms (63%). older Mexican-origin
Health and Aging Project demonstrated that cohorts have very low levels of education, a
greater social resources, as defined by social risk factor for AD. in the Hispanic Established
networks and social engagement, were associ- Populations for Epidemiological Studies of
ated with reduced cognitive decline in old age the Elderly study, only 35.6% of the Mexican
among 6,102 Black elderly (Barnes, Mendes de American elderly sample were not cognitively
Leon, Wilson, Bienias, & Evans, 2004). These impaired by passing both the Mini-Mental
relationships remained after controlling for State Examination (MMSE) and the execu-
socioeconomic status (SES), cognitive activity, tive clock-drawing task. in the Sacramento
physical activity, depressive symptoms, and valley epidemiological study of older Latinos,
chronic medical conditions. Education has dementia prevalence was 4.8% but reached 31%
particular relevance for Black and Hispanic in those 85 years and older (Black et al., 1999;
elderly, who often have less formal education Espino et al., 2002; Haan et al., 2003; Royall,
than their White counterparts and are partic- Espino, Polk, Palmer, & Markides, 2004).
ularly afraid of cognitive or mental disorders. The Duke Established Populations for
Nursing research investigates not only the Epidemiological Studies of the Elderly study
screening, assessment, and diagnosis of AD but noted that cognitive problems were diffi-
also the impact of the disease on the affective, cult to recognize in Hispanic families. When
APPLiED RESEARCH n 19
informants reported memory loss, 30% of with Alzheimer pathology plus clinical diag-
participants were found not to have a cogni- noses of dementia.
tive loss. Among participants in whom fam- A review of 23 studies of alcohol use A
ily informants reported no memory loss, 75% found that alcohol use during adulthood in
were diagnosed with dementia or cognitive moderation may protect the individuals from
impairment. Mexican Americans were 2.2 developing dementia in later life (Peters,
times more likely than European Americans Peters, Warner, Beckett, & Bulpitt, 2008).
to have MMSE scores less than 24, indicat- in conclusion, the findings from a state
ing cognitive impairment (Watson, Lewis, & of the science consensus conference on AD
Fillenbaum, 2005). convened by the National institutes of Health
Prevention of cognitive decline has was recently published (Daviglus et al., 2010).
ongoing merit for health promotion research. The risk factors identified were current
Aspects of lifestyle and SES, including diet, tobacco use, apolipoprotein E ε4 genotype,
emotional state, and use of drugs, are of high and certain medical conditions, which were
interest to nurse scientists (Karlamangla associated with increased risk (Plassman,
et al., 2009). Williams, Burke, Holsinger, & Benjamin,
Whether or not diabetic Hispanics are at 2010). Although the identification of protec-
an increased risk for cognitive impairment tive factors was limited, as reported by the
is uncertain. Cognitive aging studies have authors, the quality of research from obser-
failed to assess the overall health and phys- vational studies (N = 122) was low.
ical functioning in older subjects. Recently, The major outcome from the conference
investigators found decreasing serum anti- was a change in the criteria for diagnosing AD
oxidant levels to be negatively associated toward an earlier diagnosis using biomarkers,
with memory performance in a multiethnic such as brain scans and spinal taps. Another
sample of elderly (N = 4,809). Hispanic elders’ change is categorizing AD into three stages:
memory complaints may be misclassified as preclinical disease, mild cognitive impair-
cognitive impairment or dementia with the ment, and Alzheimer’s dementia. Complaints
MMSE if other sociodemographic and med- and problems with everyday memory are
ical conditions such as diabetes are ignored primary determinants of whether an individ-
(Perkins et al., 1999; Wu et al., 2003). ual seeks medical attention or is motivated
Data from the Baltimore Longitudinal to participate in cognitive aging research
Study on Aging illuminated the association and/or engage in activities such as mental
between depression and cognitive decline stimulation, social engagement, or lifestyle
(Bierman, Comijs, Jonker, & Beekman, 2005). adjustment. The AD research funding at the
Four groups of individuals were compared: (1) National institutes of Health for fiscal year
cognitively normal controls with no Alzheimer 2011 is estimated at $480 million.
pathology, (2) cognitively normal individu-
als with Alzheimer pathology, (3) individu- Graham J. McDougall Jr.
als with mild cognitive impairment plus
Alzheimer pathology, and (4) individuals with
clinical diagnoses of dementia plus Alzheimer
pathology. Depressive symptoms were APPlied reSeArch
assessed using the Center for Epidemiologic
Studies Depression Scale. individuals with
Alzheimer pathology but no cognitive decline in an attempt to differentiate between vari-
before death had significantly lower rates of ous types of research, the scientific commu-
depression than cognitively normal controls nity uses a myriad of terms, which, however,
with no Alzheimer pathology and individuals tend to fall into a discrete classification. on
20 n APPLiED RESEARCH
the one end, terms such as basic, fundamental, Applied research in nursing, then, refers
and theoretical research are used to refer to to research aimed at concrete and practi-
A research focused on discovering fundamen- cal issues and questions of concern to the
tal principles and processes governing phys- delivery of nursing care. The most evident
ical and life phenomena. on the other end, type of applied research is intervention
we find such terms as applied, clinical, practical, research—from exploratory investigations
and product research. These refer to the appli- to randomized controlled trials. This type
cation of the findings of basic/fundamental/ of applied research is aimed at providing
theoretical research to generate research answers to questions about the effectiveness,
aimed at answering focused and problem- efficacy, and safety of nursing interventions.
specific questions. Although it is the subject yet nonintervention (or descriptive)
of ongoing debate, it is assumed that there research may be categorized as applied
are fundamental principles and processes research as well if it meets the general crite-
that are core to the nursing discipline and its rion of being focused on concrete and practi-
central tenets of health, patient, nurse, and cal issues and questions about nursing care.
environment. in addition, it is assumed that other types of applied research in nursing
nursing draws on fundamental principles include studies on models of care, research
and processes discovered in other disciplines on organizational or other systems-level
to generate new knowledge about nursing determinants of care, analyses of the nurs-
and patient care. ing work force, and studies on the economic
Under these assumptions, applied aspects of nursing care.
research in nursing can be defined. The
etymology of applied goes back to the Latin Ivo Abraham
ad-plicare, meaning to put something (a Sabina De Geest
law, a test, etc.) into practical operation. Karen MacDonald
B
States. This educational path is used more
Basic ReseaRch often in countries where doctoral programs
in nursing are not available. Another link
between the basic sciences and nursing has
Basic research includes all forms of scholarly evolved as a result of doctoral students in
inquiry for the purpose of demonstrating nursing pursuing a graduate minor in a basic
the existence or elucidation of phenomena. science or a postdoctoral fellowship in a basic
Basic research is conducted without intent science. These basic research programs for
to address specific problems or real-world nurses with doctoral degrees in nursing are
application of knowledge. As a discipline and facilitated by nurses with doctoral degrees
a science, nursing is informed by knowledge in basic research disciplines. Nurse research-
from basic and applied research, and nurs- ers often engage in basic research to generate
ing disciplinary knowledge is integrated into knowledge that may lead to new perspectives
the broader context of the whole of human for applied research in nursing.
knowledge.
The origins of nursing research trace Sue K. Donaldson
back to Florence Nightingale. Over time, the
majority of the scholarly work is best catego-
rized as applied rather than basic research
in that nursing research has been con- BehavioRal ReseaRch
ducted for the primary purpose of solving
problems related to human health. Nursing
seeks knowledge from the perspective of the An examination of behavioral research is
human experience of health. Human percep- best begun by examining what it is and dif-
tions and experiences of health are studied ferentiating it from related areas of research.
with the intent to generate knowledge to Behavioral research within nursing generally
solve problems through nursing care and refers to the study of health-related behaviors
practice. of persons. Studies may include the following
There is a cadre of nurses who were areas: (a) health-promoting behaviors such as
doctorally prepared in the basic sciences, exercise, diet, immunization, and smoking
both social and biological, as part of the cessation; (b) screening behaviors such as
U.S. Public Health Service Nurse Scientist mammography, breast self-examination, and
Training Program from 1962 until the late prostate examinations; and (c) therapeutic
1970s. Nurses with doctoral degrees in basic behaviors such as adherence to a treatment
sciences were prepared to contribute as basic regimen, blood glucose monitoring, partic-
researchers, and then they adapted their ipation in cardiac rehabilitation programs,
knowledge and skills to conduct nursing and treatment-related appointment keep-
research. Despite the growing number and ing. The research spans medical and psychi-
popularity of doctoral programs in nursing, atric populations. It is directed toward an
small numbers of nurses continue to pursue understanding of the nature of behavior and
degrees in the basic sciences in the United health relationships and to the modification
22 n BeHAvIOrAl reSeArcH
of behaviors that affect health. It has been economies, which have been used in stud-
estimated that over half of premature deaths ies on unit management with the mentally
B could be prevented if health behaviors were ill or developmentally delayed; and contin-
altered. gency management, which has been used in
Behavioral research has its roots in the promotion of treatment behaviors such as
learning theories that arose in the early part exercise.
of the 20th century. classical or respondent As the operant model has expanded over
conditioning was followed by instrumental time, self-management or self- regulation
or operant conditioning and evolved into the has evolved as a special case of contingency
cognitive–behavioral theories that dominate management. With self-management, the
the field today. In classical conditioning, an individual is responsible for establishing
unconditioned stimulus is paired with a con- intermediate goals, monitoring progress
ditioned stimulus, resulting in the develop- toward those goals, and administering self-
ment of a conditioned response. Much of the reinforcement for success. Self-management
research emphasizes conditioned physiolog- has been studied particularly for chronic,
ical responses. An example is found in the long-term regimens such as those for diabe-
study of anticipatory nausea and vomiting tes, asthma, and cardiovascular disease.
during chemotherapy. In this case, chemo- In both of these models, there is an
therapy (unconditioned stimulus) may induce emphasis on behavior rather than motivation
nausea and vomiting. After several expo- or personality or relationships, beyond that
sures to chemotherapy in a particular setting of the reinforcing behaviors of significant
(conditioned stimulus), the setting itself may others. The history of the behavior is of less
induce nausea and vomiting (conditioned interest than the factors that currently sus-
response) prior to and independent of the tain the behavior. An empirical model is used
actual administration of the chemotherapy with an assessment of the frequency or inten-
(unconditioned stimulus). Another example sity of the behavior over time, the stimulus
is reciprocal inhibition or desensitization in conditions that precede the behavior, and the
which anxiety is viewed similarly as a condi- consequent or reinforcing events that follow
tioned response to stimuli. An incompatible the behavior. Intervention is then directed
response (relaxation) is paired with progres- to the specific areas targeted by the initial
sively stronger levels of the conditioned stim- assessment. Detailed assessment continues
ulus to inhibit anxiety responses. through the course of intervention and often
With instrumental or operant condition- through a period following intervention to
ing, behavior is seen as arising from environ- assess maintenance or generalization.
mental stimuli or random exploratory actions, each of the cognitive–behavioral mod-
which are then sustained by the occurrence els identifies a cognitive feature as a major
of positive reinforcement following the motivational determinant of behavior. Self-
behavior. laws have been established that efficacy theory postulates the role of per-
address the identification of reinforcers, the ceived capability to engage in a behavior
schedules of administration of reinforcers for under various conditions. The theory of
initiation and maintenance of behavior, and reasoned action postulates that intention
the strategies for the extinction of behavior. to engage in a behavior is significant and is
In this model, motivation is seen as a state of influenced by beliefs regarding behavioral
deprivation or satiation with regard to rein- outcomes and attitudes toward the behav-
forcers. Numerous strategies have evolved ior. The health belief model postulates that
from this work, including but not limited to one’s perceptions about the illness in terms
contracting and tailoring, which have been of its threat (severity and susceptibility) as
used in studies of patient adherence; token well as the perception of the benefits and
BIOFeeDBAck n 23
barriers to engaging in the behavior influ- field has come to be known as biobehavioral
ence intentions and subsequently behavior. research.
The common sense model of illness pro- Given the prevalence of lifestyle behav- B
poses that the individual’s own model of the iors that adversely affect health and the man-
illness influences his or her illness or treat- agement of illness, research to understand
ment-related behaviors. and modify those behaviors would benefit the
Behavioral research can be distin- individual as well as the population. There is
guished from psychosocial research, which a need for nursing research to expand into
tends to emphasize adjustment and coping the interdisciplinary arenas, particularly in
as well as predictor and moderator variables the examination of health behavior change
arising from the psychological state or the in the community, the studies within multi-
social environment of the person. Behavioral center clinical trials, and the etiological rela-
research, including cognitive–behavioral tionship between behavior and health and
studies, emphasizes behavior. In the classical illness. Further, many of the studies in nurs-
and instrumental models, observable behav- ing have been descriptive in nature or have
ior is stressed. In the cognitive–behavioral focused on the development of assessment
model, both observable and covert behaviors instruments. Few of the studies have exam-
are stressed. Within nursing, much of the ined how to intervene with behaviors that
behavioral research has addressed participa- contribute to the development or progression
tion in treatment, exercise, sexual behaviors, of illness. This research, however, would be
health promotion, breast self-examination and useful to better direct interventions with
mammography utilization, childbirth and patients.
maternal behaviors, behavioral symptoms
of dementia, self-management in chronic This paper was supported in part by a National
conditions, management of alcohol or drug Institute of Nursing research grant (5 P30
dependency, and role of biofeedback in such Nr03924) and a National Heart, lung, and Blood
behaviors as pelvic floor muscle exercise Institute grant (1 UO1Hl48992).
in incontinence and heart rate variability. Jacqueline Dunbar-Jacob
Unlike psychosocial studies, factors such as
personality, coping strategies, and socioeco-
nomic status are not primary interests; how-
ever, they may be of interest in determining
reinforcers and stimulus conditions. BiofeedBack
There is an additional body of behav-
ioral research that tends to be interdisciplin-
ary in nature and is of relevance to nursing. Biofeedback is a training program in which
There are studies in the community to mod- individuals are provided with visual or audio
ify health behaviors within populations and information about their physiological state.
studies within multicenter clinical trials that The most commonly indexed physiologi-
attempt to influence the health behavior or cal states include heart rate, heart rate vari-
protocol-related behaviors of research par- ability (Hrv), respiration, blood pressure,
ticipants. Also there is a broad set of studies body temperature, peripheral sweating level
to identify the relationship between behavior (also known as galvanic skin response, elec-
and disease etiology, such as studies of the trodermal response, or skin conductance),
role of exercise on the maintenance of func- brainwave electroencephalogram (eeG), and
tion in the older adult, mechanisms of addic- muscle activity electromyography. The phys-
tion in smoking behavior, and effect of iological data are measured using noninva-
neurotransmitters on eating behaviors. This sive sensors, and the data are processed and
24 n BIOFeeDBAck
displayed through a computerized device. Diamond et al. stimulated brain growth in
Through the feedback training, individuals older rats by enriching the environment.
B learn techniques to consciously regulate invol- From this study were derived the studies
untary bodily functions such as balancing by Budzynski (1996) and Budzynski and
the autonomic nervous system. Psychological Budzynski (2000) to improve cognitive func-
responses often co-occur with the change tioning of elderly humans by enhancing the
of physiological and emotional states. With brain with neurofeedback and light–sound
repeated practices, individuals often become stimulation. results of studies on cellular res-
mindful about the self- regulation technique toration of nerve tissue together with reports
and may achieve the desired physiological of improvement of body functioning through
and psychological states without the assis- neurofeedback suggested that changes in
tance of external devices. bodily functioning can be reached through
The goal of biofeedback is to enable the the brain.
process of self-regulation for health promo- By managing appropriate change in
tion and peak performance (Association for the eeG or the brain’s electrical activity,
Applied Psychophysiology and Biofeedback, the body not only can rid itself of chronic
2008). symptoms but also can heal itself. In addi-
Although in the past biofeedback for tion to augmenting neurological function,
chronic symptom patterns has been thought the technique of self-regulation has also been
to be simply training muscles and body exploited to promote cardiovascular health.
functioning through operant condition- The most easily accessed method of change
ing, now it is more common to consider is the use of selected sounds to alter both
the brain and the central nervous sys- brain and cardiovascular function. Studies
tem as the central focus of treatment. It is, have shown that brainwave entrainment
after all, the electrical- biochemical systems using audio-guided relaxation training effec-
through which all bodily activity is finally tively reduced the blood pressures in groups
determined. To focus on the brain–neural of elderly (Tang, Harms, Speck, vezeau,
pathway, it acknowledges the mind–body & Jesurum, 2009; Tang, Harms, & vezeau,
interface and the centrality of the brain in 2008). These new directions for intervention
the disease process. are reaching consumers of health care.
The use of biofeedback and its accompa- There are three major organizations for
nying belief in helping individuals master biofeedback professionals: the Association for
self-regulation of body function and optimum Applied Psychophysiology and Biofeedback,
states has been greatly impacted by the cellu- the Biofeedback certification Institution
lar research in the recent years. Some groups of America, and the International Society
of neuroscientists have explored the progress for Neurofeedback and research. There
of using stem cells as a way of repairing are more than 100 nurse professionals in
organs. Other movements in research have the Biofeedback certification Institution of
realized exciting possibilities in tracing evi- America, the certifying body for biofeed-
dence of the capability of the body to perform back or neurofeedback. Untold other nurses
repair by means of neurogenesis and neuro- are practicing without current certification.
plasticity (eriksson et al., 1998; kempermann Many of these practitioners are performing
& Gage, 1999; kempermann, kuhn, & Gage, exciting biofeedback or neurofeedback work
1997; Magavi, leavitt, & Macklis, 2000). with target chronic problems, such as lack
early evidence of the possibility of gener- of urinary control, attention deficit disorder,
ating growth or regrowth in neural tissue epilepsy, stroke, mild head injury, migraines,
was reported by Diamond, Johnson, Protti, and other symptom patterns. However, they
Ott, and kajisa (1985). In these early studies, practice outside the mainstream of nursing’s
BIOFeeDBAck n 25
institutions of care, privately alongside mul- have ventured forth using validated skills
tiple other health disciplines. Other schisms and techniques to treat patients with these
are that these practitioners are not inclined problems although the skills and the tools B
to undertake research. Those who are doing for practice are accessible and clearly in the
research tend to be faculty in universities realm of nursing practice. The following are
who have little access to practice settings. some of the examples:
The nursing biofeedback field could advance
markedly if these activities and profession- 1. Advanced heart failure, even after open
als could merge, as has medicine, to develop heart surgery and multiple stent proce-
research-based programs for specific target dures, chronic obstructive lung disease,
clinical problems. and diabetic complications such as reti-
Nursing biofeedback research has nopathy can actually be reversed by offer-
shown effective changes in patient symp- ing compressed O (through closed mask
2
toms through application of complementary administration) while exercising (linke
techniques. A review of biofeedback or self- et al., 2005; Moreno de Azevedo et al., 2010;
management training research by nurses Nguyen et al., 2004; Tsutsui et al., 2001;
before 1997 indicated favorable patient out- ventura-clapier, Mettauer, & Bigard, 2007).
comes when performing management of Oxygen starvation is well known to form
stress symptoms, progressive relaxation, the basis of death of cells through inability
reduction of tension with electromyography of cells to obtain nourishment as a result
training, hand warming, training during of reduced blood flow. The oxygen under
childbirth, respiratory training, and Hrv pressure opens the arteries and capillar-
training (Nakagawa-kogan, 1994). These ies and detoxifies the system through a
publications predominantly indicated indi- broader and greater force of blood to the
vidual efforts to inform the field of their extremities of the body. This static would
respective specialized treatments. Over the require a prescription by advanced regis-
years, there is very little shift to indicate that tered nurse practitioners.
programs of care by nurses have proliferated.
Although few biofeedback studies have been In lieu of compressed O while exercising,
2
generated in nursing publications, there is the advanced registered nurse practitioner
evidence that more biofeedback research may prescribe the hyperbaric chamber for
methods and physiological measurement patients who cannot exercise. This chamber
feedback research articles have proliferated can infuse concentrated O into various parts
2
by faculty in nursing teaching programs, of the body to heal diabetic ulcers, general-
which are competitive in nonnursing jour- ized infections such as psoriasis, and chronic
nals. An example is the edited handbook of lung problems, to name a few conditions.
neurofeedback, with one of the authors as
a second editor: Introduction to Quantitative 2. chronic pain and nonhealing ulcers or
EEG and Neurofeedback: Advanced Theory and wounds are treatable with many of the
Applications (Budzynski, Budzynski, evans, & self-help microcurrent instruments that
Abarbanal, 2008). are currently available on the market.
It is informative to point out the follow- The current, issued at a microcurrent
ing: chronic symptom patterns such as in level of microamperes, provides a gentle
advanced heart failure, sudden cardiac arrest, but powerful change of polarity in tis-
incontinence following surgery, chronic pain, sues damaged and scarred by accidents,
nonhealing wounds, and elderly cognitive infections, toxicity, or aging. The small
decline are symptoms that are frequently in current, when applied to damaged areas,
the domain of care by nurses. Yet few nurses heals by opening the ion channels of the
26 n BOYkIN AND ScHOeNHOFer
cells, releasing the toxins and restoring The pivotal role of nursing is to nurture
the adenosine triphosphate for the cells’ the developmental process of caring as growth
B nourishment. The science of microcurrent toward self-actualization. concepts central to
action is well documented in two research- the theory include the following: caring, char-
grounded energy medicine books: Energy acterized by recognition of value and con-
Medicine: The Scientific Basis, by James l. nectedness between the nurse and the nursed
Oschman (2000), and The Body Electric: (person who is cared for and about), pro-
Electromagnetism and the Foundation of Life, moting mutual respect and altruistic actions
by robert Becker and Gary Selden (1985). (Boykin & Schoenhofer, 2001); caring between
a personal encounter connection between the
Physiological indicators with a psychologi- nurse and the nursed “within which person-
cal self-care orientation are used to demon- hood is nurtured” (p. 14); and nursing situa-
strate change. These previously mentioned tion, “a shared lived experience in which the
studies are few in number, but recently the caring between nurse and nursed enhances
kinds and quality of noninvasive instrumen- personhood” (p. 13).
tation on the market are allowing researchers The visual synthesis of the theory
to trace change in bodily and psychological of nursing as caring, the Dance of Caring
processes—eeG, Hrv, blood sugar levels, Persons, represents the active and the circu-
blood flow, cO 2 , and respiratory activity, lar “dance-like” nature of caring grounded
to name a few. The stage is set for offering in respect for one another (the nurse and
feedback to any number of chronic problems the nursed) as unique caring individu-
heretofore neglected. als in the process of growth (Boykin &
Schoenhofer, 2001; Boykin, Schoenhofer,
Helen Kogan Budzynski Smith, St. Jean, & Aleman, 2003). valuing
Hsin-Yi (Jean) Tang of all persons connecting within the dance
inform ways of communicating and relat-
ing effectively with others (Boykin &
Schoenhofer, 2001). The Dance of Caring
Boykin and schoenhofeR: Persons was developed as a model for build-
The TheoRy of nuRsing as ing organizational effectiveness through
enhancing collaboration, respect, and satis-
caRing faction of nurses and the nursed (health care
customers; Boykin & Schoenhofer, 2006).
The development of caring health care
Boykin and Schoenhofer’s theory of nursing practice environments is enhanced through
as caring defines the essential nature of the the application of nursing as caring through
discipline of nursing as “nurturing persons story. The use of story provides a vehicle
living caring and growing in caring” (2001, for the art of nursing to inform its practice.
p. 12). Fundamental assumptions include the Sharing nursing situation through story
following: persons are caring by virtue of reminds nurses of the richness of living car-
their humanness; persons are caring, moment ing within nursing practice and promotes the
to moment; persons are whole and complete realization of self and others as “persons liv-
in the moment; personhood is a process of ing caring and growing in caring” (Boykin &
living grounded in caring; personhood is Schoenhofer, 2001, p. 12).
enhanced through participating in nurturing The theory of nursing as caring is
relationships with caring others; and nursing described by Boykin and Schoenhofer (2001)
is both a discipline and a profession (Boykin as a general (grand) theory. The broad concep-
& Schoenhofer, 2001, p. 1). tual framework of nursing as caring serves
BreASTFeeDING n 27
as a catalyst for the development of middle- recognition that breastfeeding is a health care
range theories addressing more specific phe- behavior. National and international policies
nomena of nursing as caring in the realms of and recommendations from nongovernmen- B
nursing administration, practice, and edu- tal organizations, national governments, and
cation. examples of middle-range theories medical organizations have been developed
on the basis of nursing as caring include the on the basis of compelling research and
theory of technological competence as car- include the U.S. Department of Health and
ing in the critical care nursing (locsin, 1998), Human Services (2000) Healthy People 2010
Dunphy’s (1998) “circle of caring” model for goals, the U.S. Surgeon General’s “Blueprint
advanced practice nursing, an acute care for Action on Breastfeeding” (Satcher, 2001),
model grounded in the perspective of nurs- and the World Health Organization’s Global
ing as caring (Boykin et al., 2003), a model of Strategy for Infant and Young child Feeding
nursing education with application to online (World Health Organization/United Nations
education grounded in caring (Purnell, 2006), children’s Fund, 2003).
and the innovative approach of eggenberger Historically, a large discrepancy exists
and keller (2008) developing a nursing as car- in the United States between breastfeeding
ing model for nursing simulations. rates, especially according to income, educa-
tion, race, and ethnicity (Ahluwalia, Morrow,
Mary Angelique Hill Hsia, & Grummer-Strawn, 2003; Watkins &
Dodgson, 2010). Nursing research has focused
on meeting the needs of these vulnerable
populations, recognizing that continuity of
BReasTfeeding care and support systems, including health
care professional support play a large role in
women’s success to breastfeed, their intended
Breastfeeding provides nutritional, immuno- duration.
logical, cognitive, and psychological benefits Major areas studied by nurse scholars
for young children. A burgeoning body of include breastfeeding interventions (Ahmed
research has identified the unique properties & Sands, 2010; Pate, 2009; Spiby et al., 2009;
and unreplicable living tissue transferred to Watkins & Dodgson, 2010), support for breast-
infants and children through breastfeeding feeding mothers (Declercq, labbok, Sakala, &
and the effect on health outcomes. A report O’Hara, 2009; kearvell & Grant, 2010; Nelson,
from the Agency for Healthcare Quality and 2007), maternal self-confidence (Hauck, Hall,
research screened 9,000 studies in devel- & Jones, 2007; Mccarter-Spaulding & Gore,
oped countries with a meta-analysis of the 2009; Pollard & Guill, 2009), effect of pacifier
health impact of breastfeeding on infants use (chapman, 2009; Declercq et al., 2009;
and women. According to this report, infants kronborg & væth, 2009), effect of the Baby-
who are breastfed had a reduced risk of Friendly Hospital Initiative on breastfeeding
acute otitis media, atopic dermatitis, gas- (Bartick, Stuebe, Shealy, Walker, & Grummer-
trointestinal infections, lower respiratory Strawn, 2009; Duyan Çamurdan et al., 2007;
tract disease, asthma, obesity, type 2 diabe- Hannula, kaunonen, & Tarkka, 2008; Merten,
tes, childhood leukemia, and sudden infant Dratva, & Ackermann-liebrich, 2005; reddin,
death syndrome (SIDS). Mothers who breast- Pincombe, & Darbyshire, 2007), postpartum
feed had a reduced risk of type 2 diabetes, depressions effect on infant feeding (Dennis
breast cancer, and ovarian cancer (Ip et al., & kingston, 2008; Dennis & McQueen, 2009;
2007). Documentation of the superiority of Henderson, evans, Straton, Priest, & Hagan,
breastfeeding to the health and well-being of 2003), and ethnic diversity and low-income
infants, children, and women has led to the effect on breastfeeding (Bulk-Bunschoten,
28 n BreASTFeeDING
Pasker-de Jong, van Wouwe, & de Groot, 2008; of self-efficacy, and the social-ecological
cricco-lizza, 2006; Gill, 2009; kelly, Watt, & frameworks. Nurses have conducted many
B Nazroo, 2006; Mccarter-Spaulding & Gore, meta-analyses of both quantitative and qual-
2009; racine, Frick, Guthrie, & Strobino, 2009; itative research in the area of breastfeeding.
ryan & Zhou, 2006). researchers have demonstrated the impor-
Nurses need updated education on the tance of peer and social support, the effect
basis of research to provide support to breast- of hospital interventions, the need for com-
feeding mothers at critical times (Dennis & prehensive breastfeeding education and sup-
kingston, 2008; Hannula et al., 2008; port, the communication-related barriers, the
Johnson, Mulder, & Strube, 2007; kearvell & socioeconomic issues, the effect of values and
Grant, 2010; McInnes & chambers, 2008; practice, and most importantly the culturally
Nelson, 2007; rêgo et al., 2009) and to iden- relevant issues that influence infant-feeding
tify women at risk for complications early choices.
on, for example, obesity as a risk factor in clinical issues being explored by nurse
the mother or infant admission to the neona- scientists include the following: biological
tal intensive care unit (Amir & Donath, 2007; benefits of breastfeeding to the mother and
cohen et al., 2009; cricco-lizza, 2009; Jevitt, infant, HIv and breastfeeding, lactation mas-
Hernandez, & Groër, 2007), so that interven- titis, breastfeeding in special circumstances,
tions can be initiated and referrals made in and positioning and attachment. The influ-
a timely fashion to preserve the breastfeed- ence of the health care delivery system,
ing relationship. Nurses need to be aware community, and society/culture cannot be
of new developments on breastfeeding in ignored.
areas such as breast reduction/augmenta- challenges related to the study of breast-
tion surgery (chamblin, 2006; Hurst, 2003; feeding include three major areas: the lack of
Souto, Giugliani, Giugliani, & Schneider, consistency in the definition of breastfeed-
2003), HIv status (Jackson, Goga, Doherty, ing (e.g., exclusivity) making comparison of
& chopra, 2009; kuhn, reitz, & Abrams, studies tedious if not impossible; the diffi-
2009), and drugs (Fortinguerra, clavenna, & culty measuring cross-cultural effects (lack
Bonati, 2009; Howland, 2009). careful assess- of reliability and validity studies of major
ment of the benefits and risks of not breast- breastfeeding instruments with various cul-
feeding should be in the forefront of nursing tures); and the development of prospective
research. In addition, new growth charts designs and randomized controlled trials.
provide more accurate data on breastfeeding We have made strides with meta-analyses,
infants’ expected growth patterns, and clini- more theory-focused research, and better
cians have new resources in planning their effort at defining breastfeeding and separat-
care (vesel et al., 2010). ing out the effects of exclusivity.
Nurse scientists continue to use different Although breastfeeding is now recog-
methodologies to study breastfeeding and nized as a right of mothers, a health care
to identify some of the reasons for discrep- behavior contributing to the reduction of
ancies in initiation, duration, and support, infant and maternal morbidity and mortal-
including ethnographies, phenomenological ity rates, less expensive than artificial milk
studies, historical-cultural approaches, and supplementation and more environmentally
ecological perspectives. Theoretical frame- friendly, the national breastfeeding goals
works used to explore the health behav- are far from being met. Federal funding for
ior of breastfeeding include the theory of breastfeeding research in the United States
planned behavior, the health belief model, continues to demonstrate an incongruity
the social cognitive theory using the concept with the national priorities for breastfeeding.
BreASTFeeDING n 29
Only 13.7% ($5.6 million out of $40.4 million artificial milks (Brown, Bair, & Meier, 2003).
available) of federal research funds from recent cost analyzes demonstrate that if 90%
1994 to 1996 were awarded to projects having of U.S. families with children were success- B
an impact on the Healthy People 2000 goals ful at exclusively breastfeeding for 6 months,
for increasing the incidence and duration of the cost saving would be $13 billion per year
breastfeeding. In contrast, 27 projects (7.5% or (Bartick & reinhold, 2010).
$4.1 million) involved the use of human milk
composition and technologies to improve Suzanne Hetzel Campbell
C
is associated with an increased incidence of
CanCer in Children congenital anomalies. Children with syn-
dromes caused by abnormal numbers of
chromosomes (i.e., Down syndrome) have an
Pediatric oncology represents only a small increased incidence of cancer (Lightfoot &
fraction of the discipline of oncology. Roman, 2004). Children with immune defi-
Although relatively rare, childhood cancer ciencies are at greater risk for developing
causes considerable morbidity among those cancer. Some viruses have been linked to
affected and is the leading cause of disease- childhood cancer, such as hepatitis B virus
related death among children ages 1 to 19 associated with hepatocellular cancer in chil-
years (Martin et al., 2008). Yet the numerous dren and Epstein-Barr virus associated with
advances in the diagnosis and treatment of the development of lymphoma. Despite the
childhood cancer have resulted in significant lack of knowledge about the origin of cancer,
improvements in survival. Approximately there is some information on risk factors that
81% of all children diagnosed with malignant increase the likelihood of children develop-
neoplasms will survive more than 5 years ing cancer. Environmental agents such as
(Jemal, Siegel, Zu, & Ward, 2010). exposure to ionizing radiation have been
The annual incidence of childhood can- found to cause cancer in children (Lightfoot
cer is 16.6 per 100,000 children ages 0 to 19 & Roman, 2004).
years (U.S. Cancer Statistics Working Group, The major focus of pediatric oncology
2010). There is a slightly higher incidence nursing research includes symptom assess-
in men (17.5 per 100,000) compared with ment and management, end-of-life care,
women (15.3 per 100,000). There are approx- quality of life, and long-term survivorship
imately 13,100 children and adolescents less issues (Hockenberry & Kline, 2010). Although
than 20 years of age diagnosed each year increased attention on nursing research has
with cancer (U.S. Cancer Statistics Working occurred over the past 10 years, many areas
Group, 2010). For children of all ages, leu- of pediatric oncology nursing have yet to be
kemia is the most frequent type of cancer, explored. There is a significant need for fur-
followed by brain tumors and lymphomas. ther clinical research with a cultural and
Tumors of the kidney are more common communication focus (Hare & Hinds, 2004).
in African Americans, whereas tumors of Qualitative research has been used more
the brain and bone are more common in frequently to allow children with cancer to
Caucasians. describe phenomenon that is not well under-
The cause of childhood cancer is not stood; however, incorporating the pediatric
known. Some childhood cancers, in particu- patient as an active participant in all research
lar retinoblastoma, Wilms tumor, and neuro- studies is an important consideration for pedi-
blastoma, demonstrate patterns of inheritance atric oncology nursing research (Hare, 2005).
that suggest a genetic basis for the disorder. Symptom assessment and management
Chromosome abnormalities have been found has been a focus of pediatric oncology nursing
in acute leukemia and lymphoma as well as research for many years. In the 1980s, nursing
other pediatric solid tumors. Wilms tumor research focused on procedure-related pain,
CAnCER In CHILDREn n 31
treatment-related nausea and vomiting, and As survival for childhood cancer con-
emotion-related symptoms (Hockenberry, tinues to improve, nursing investigations
2004). To evaluate the status of the current are focusing on survivorship issues and C
research on symptom management in indi- quality of life after the diagnosis and treat-
viduals with cancer, the national Institutes ment of cancer. A review of childhood can-
of Health (2002) held a State of the Science cer survivor studies showed that childhood
on Symptom Management in Cancer: Pain, cancer survivors who underwent radiation
Depression, and Fatigue. The review of exist- therapy reported more psychological dis-
ing research revealed that efforts to man- tress, those who underwent chemotherapy
age symptoms of cancer and its treatments treatment with anthracyclines or alkylating
have not kept pace with new advances in the agents experienced more physical impair-
causes and cures for cancer. ments, and those who had limb-sparing
Priority areas of symptom management procedures reported more anxiety and more
research include longitudinal and multidi- functional impairment than those who had
mensional studies to evaluate symptom dis- an amputation (Zelter et al., 2009). Childhood
tress, patient and parent studies to identify cancer survivor studies have also docu-
expectations of cancer-related symptoms, mented the adverse effects of central nervous
evaluation of pain management effective- system treatment on cognitive, academic,
ness, and evaluation of the presence of symp- and psychosocial functioning. Interventions
tom clusters (Hockenberry, 2004). Hedstrom designed to minimize the adverse effects
et al. (2003) discovered that the most common of central nervous system therapy are now
causes of distress in a group of 121 children being conducted.
with cancer were treatment-related pain, nau- Docherty (2003) completed a review of
sea, and fatigue. Woodgate and Degner (2003) the published literature on symptom experi-
evaluated expectations about childhood can- ences of children and adolescents with cancer.
cer symptoms in a group of 39 children and This review revealed no longitudinal symp-
their family members and found that these tom management study designs, limited use
individuals expected to experience suffering of conceptual models or theories, frequent
as part of the cancer treatment. The families adaptation of adult instruments as symptom
felt that unrelieved or uncontrolled symp- measures, and no attention to the impact of
toms were necessary for cure. Studies evalu- these symptoms on the children’s lives.
ating pain management now focus on various It is evident from the recent childhood
pharmacological and nonpharmacological cancer literature that there is still much to be
interventions; however, longitudinal studies gained from continued research. The impor-
evaluating the effectiveness of pain interven- tance of striving for symptom relief in chil-
tions over time are lacking. A relatively new dren cannot be overemphasized. Recognition
area of symptom assessment research is the and acknowledgment of the beliefs and expec-
evaluation of symptom clusters and research tations of children and their parents regard-
efforts are initially focusing on identifying ing cancer-related symptoms (Woodgate &
clinically significant symptom clusters and Degner, 2003) should continue to be a major
their prevalence rates (Miaskowski, Dodd, & research focus. Longitudinal studies evalu-
Lee, 2004). A recent study of 67 children and ating the trajectory of symptom occurrence
adolescents receiving chemotherapy found and symptom management over time are
that when fatigue, sleep disturbance, nau- not found. Continued exploration of the most
sea, and vomiting were present, depressive effective management and coping strategies
symptoms and behavior changes occurred should be pursued for children experiencing
among the adolescents after chemotherapy all types of cancer or treatment-related symp-
treatment (Hockenberry et al., 2010). toms. Finally, utilization of research findings
32 n CARDIovASCULAR RISK FACToRS: CHoLESTERoL
in the clinical setting is lacking. More innova- Panel (ATP) issued the first guidelines for
tive, creative methods for dissemination of our identifying and managing hypercholester-
C knowledge of symptom occurrence and symp- olemia in adults. Since that time, results of
tom management must be explored. Evaluating numerous randomized controlled trials con-
feasibility and fidelity along with the effective- firmed that lowering LDL-C was important
ness of an intervention during a study will in the primary and secondary prevention
allow for a more successful transition to real of CHD. The most recent revision of these
life settings (Breitenstein et al., 2010). guidelines (Executive Summary of the Third
An ongoing effort to strengthen collabo- Report of the national Cholesterol Education
ration among staff nurses, advanced practice Program, 2002), referred to as ATP III, con-
nurses, and nurse researchers is a priority. tinues to focus on LDL-C as the primary tar-
Designing and maintaining joint research get of risk reduction therapy, considers other
relationships with other disciplines is essen- lipid and nonlipid risk factors, and empha-
tial to facilitate the development of scien- sizes therapeutic lifestyle change (TLC) and
tific credibility of nurse-initiated protocols pharmacological therapies for reducing indi-
and pediatric oncology nurse investigator vidual risk and the public health burden of
studies. CHD. With continued emphasis on identifica-
tion of individuals at risk and more attention
Marilyn Hockenberry to adherence-enhancing strategies, ATP III
Cheryl Rodgers incorporates numerous roles for nurses and
nursing across health care settings where lipid
abnormalities are diagnosed and treated.
ATP III continues to define hypercholes-
CardiovasCular risk terolemia as TC 240 mg/dl or greater (6.21
mmol/L) for individuals 20 years and older;
FaCtors: Cholesterol TC levels of 200 to 239 mg/dl are considered
borderline high, and less than 200 mg/dl is
considered desirable. LDL-C levels are cat-
Cardiovascular disease (CvD) is a major egorized as follows: very high (≥190 mg/
cause of disability and premature mortality dl), high (160–189 mg/dl), borderline high
in men and women in the United States, in (130–159 mg/dl), above optimal (100–129
the industrialized world, and in the major- mg/dl), and optimal (<100 mg/dl). Results of
ity of developing countries. Atherosclerotic- several clinical trials suggested that LDL-C
CvD processes begin early in life and are lowering beyond 100 mg/dl in secondary
influenced over time by the interaction of prevention (after an acute coronary event)
genetic and potentially modifiable envi- was associated with improved cardiovas-
ronmental factors including health-related cular outcomes, raised questions regard-
lifestyle behaviors. Hypercholesterolemia— ing the established cut points for LDL-C,
elevated serum total cholesterol (TC)—is and prompted a modification to the ATP III
recognized as an independent risk factor for treatment algorithm (Grundy et al., 2004).
coronary heart disease (CHD). Low-density Specifically, an LDL-C goal of less than
lipoprotein cholesterol (LDL-C), the major 70 mg/dl is now considered a therapeutic
atherogenic lipoprotein, typically constitutes option for patients at very high risk.
60% to 70% of serum TC and is the primary ATP III recommends a fasting lipopro-
target of cholesterol-lowering therapy. In tein profile (TC, LDL-C, high-density lipopro-
1988, on the basis of available epidemiologi- tein cholesterol, and triglyceride) should be
cal and clinical data, the national Cholesterol obtained once every 5 years in adults 20 years
Education Program (nCEP) Adult Treatment or older. A basic principle of prevention is
CARDIovASCULAR RISK FACToRS: CHoLESTERoL n 33
emphasized throughout ATP III: the intensity adherence over time to the prescribed die-
of risk-reduction therapy should be adjusted tary regimen. The first priority of pharmaco-
to an individual’s absolute risk. logical therapy is to achieve the appropriate C
The Framingham projections of 10-year LDL-C goal (as defined by the individual’s
absolute CHD risk (i.e., the percent proba- category of risk). ATP III recommends the use
bility of having a CHD event in 10 years) are of HMG-CoA reductase inhibitors (statins) as
used to identify and risk stratify individu- first-line therapeutic agents. In a meta-anal-
als. In addition to LDL-C, risk determinants ysis of clinical trials, the average reduction
include presence or absence of CHD and in TC in more than 30,000 middle-aged men
other clinical forms of atherosclerotic dis- followed for more than 5 years was 20%, the
ease, cigarette smoking, hypertension (blood average reduction in LDL-C was 28%, and the
pressure ≥ 140/90 mm Hg or on antihyperten- decline in triglyceride averaged 13% (LaRosa,
sive medication), low high-density lipopro- He, & vupputuri, 1999). Results of a landmark
tein cholesterol (<40 mg/dl), family history secondary prevention trial suggested that
of premature CHD, and age (men ≥ 45 years, early and continued lowering of LDL-C with
women ≥ 55 years). The category of highest an intensive lipid-lowering (statin) regimen
risk (10-year risk > 20%) includes CHD and provides greater protection against death or
CHD risk equivalents (other clinical forms major cardiovascular events than a standard
of atherosclerotic disease, diabetes) and has regimen (Cannon et al., 2004). other pharma-
a goal of LDL-C defined as less than 100 mg/ cological agents currently used in treatment
dl. The intermediate risk category (10-year of dyslipidemia in adults include bile–acid
risk ≤ 20%) includes multiple (2+) risk factors binding resins, niacin, and fibrates. The
and has a goal LDL-C as 130 mg/dl; the low- decisions to initiate LDL-C-lowering drug
est risk category (10-year risk < 10%) includes therapy, the type and dosage of agent to be
0 and 1 risk factors with an LCL-C goal of used, and the schedule for monitoring indi-
160 mg/dl. vidual response to therapy are based on the
The cornerstone of treatment for hyper- individual’s baseline risk status. normally,
cholesterolemia and other lipid abnormalities the patient’s response is evaluated approxi-
is TLC, with emphasis on dietary modifi- mately 6 weeks after starting drug therapy.
cation, increased physical activity, and nor- Relatedly, TLC continues throughout (and
malization of body weight. The important beyond) the duration of pharmacotherapy.
components of the TLC diet are saturated fat Consistent with recommendations of
(<7% of total calories), polyunsaturated fat the 33rd Bethesda Conference on preventive
(up to 10% of total calories), and monounsat- cardiology (ockene, Hayman, Pasternak,
urated fat (up to 20% of total calories). Less Schron, & Dunbar-Jacob, 2002), ATP III iden-
than 200 mg/day of dietary cholesterol, 50% tifies and targets adherence-enhancing inter-
to 60% of total calories from carbohydrates, ventions that consider the characteristics of
and approximately 15% of total calories the individual patient, the provider, and the
from protein are recommended. other key systems of health care delivery. Case man-
components of the TLC diet include viscous agement by nurses within the context of mul-
fiber, plant stanols/sterols, and soy protein. tidisciplinary team approaches is considered
Considerable variation in response to dietary an integral component of increasing adher-
modification has been observed in males and ence to therapeutic regimens for hypercho-
females across the life span. variations in lesterolemia and other lipid abnormalities.
serum TC, for example (ranging from 3% to The nCEP has not revised the 1991
14%), are attributed to individual differences definitions and guidelines for management
in biological mechanisms, baseline TC levels, of hypercholesterolemia in children and
nutrient composition of baseline diets, and adolescents in the United States; however,
34 n CAREGIvER
the American Heart Association’s (AHA) cornerstone of treatment. Therapeutic regi-
guidelines for primary prevention (Kavey mens including pharmacotherapy and TLC
C et al., 2003) and the American Academy of are based on the individual’s risk status;
Pediatrics (AAP) recent recommendation treatment outcomes are optimized with case
(Daniels & Greer, 2008) are consistent with management by nurses within the context of a
nCEP definitions: acceptable TC (<170 mg/dl; multidisciplinary team approach. Directions
4.4 mmol/L), borderline TC (170–199 mg/dl), for future research build on and extend cur-
and elevated TC (≥200 mg/dl). Similar to rent programs of nursing and multidisciplin-
adults, both lipid and nonlipid risk factors ary research focused on innovative models
are addressed, LDL-C levels are targeted as for primary and secondary prevention of
the basis for treatment decisions, and TLC is CvD across the life span and with emphasis
the cornerstone of treatment. LDL-C levels on both quality and cost as outcomes (Allen
110 mg/dl or less are considered acceptable & Dennison, 2010; Berra, Miller, & Fair, 2006;
for children and adolescents without comor- Fletcher et al., 2005; Ma et al., 2009). In addi-
bidities; LDL-C less than 100 mg/dl is recom- tion, current recommendations emphasize
mended for children and adolescents with family-based approaches to CvD risk reduc-
diabetes. An important pharmacological tion (Hayman et al., 2007); however, minimal
modification in treatment recommended by data exist regarding strategies for effective
AAP (Daniels & Greer, 2008) and the AHA implementation in clinical practice.
(McCrindle et al., 2007) focuses on timing of
initiation and class of lipid-lowering agents. Laura L. Hayman
Specifically, current recommendations
emphasize TLC as cornerstone of treatment;
however, if an adequate trial of TLC does not
result in target goals (LDL-C is persistently Caregiver
>190 mg/dl with no other risk factors; LDL-C
is persistently >160 mg/dl with family his-
tory of premature heart disease or ≥2 other Caregiver is defined as an individual who
risk factors; and LDL-C ≥130 mg/dl in the set- assists ill person(s), often helps with a patient’s
ting of diabetes), pharmacological treatment physical care, typically lives with the patient,
beginning at 8 years and older should be con- and does not receive monetary compensation
sidered. on the basis of accumulated safety for the help. Also, a caregiver is a person who
and efficacy data, the AHA recommends that not only performs common caregiver respon-
statins be considered as the first line of drug sibilities (i.e., providing physical, social, spir-
treatment. itual, financial management, and complex
Assessment and management of hyper- home care) but also advocates for the ill
cholesterolemia and other lipid abnormal- person within health care systems and soci-
ities is an important component of both ety as a whole (national Family Caregivers
individual/high risk and population-based Association, 2009). The caregiver’s role is
approaches to CvD risk reduction. Current often expected in relation to one’s elders, yet
evidence-based guidelines, including ATP rarely is there preparation for caregiving for
III, the AHA primary prevention guidelines one’s child or one’s spouse.
for children and youth, and the AAP recom- Direct patient care encompasses much
mendations for lipid screening and cardio- more than physical care; it also necessitates
vascular health in childhood, consider both learning an extensive amount of informa-
lipid and nonlipid risk factors, target LDL-C tion about illness, symptoms, medications,
in algorithms for assessment and treatment technological treatments, and how to relate
considerations, and emphasize TLC as the to health care professionals (Smith, 1995;
CAREGIvER n 35
Wilkins, Bruce, & Sirey, 2009). Caregivers mortality, and cardiovascular disease;
also must be prepared for emergencies and be Beach, Schultz, Yee, & Jackson, 2000; Federal
capable of responding appropriately. Usually, Interagency Forum on Aging, 2000; Given & C
the caregiver must also manage their personal Given, 1998; Schulz & Sherwood 2008; Silver
responsibilities, whether as a breadwinner, a & Wellman, 2002; Silver, Wellman, Galindo-
housekeeper, or both. The caregiver’s rela- Ciocon, & Johnson, 2004). In addition, the
tionship with the patient, the caregiver’s age majority of caregivers experience depression,
and life developmental stage, the patient’s social isolation, financial strain, sleep depri-
illness severity, and the suddenness and vation with daytime sleepiness, and ineffi-
amount of the change in the patient’s need for cient use of family resources (Smith, 1996).
caregiving have been predictive of caregiver Smith’s (1994) research indicated care-
burnout in various illness populations, such givers’ motives for helping consistently
as chronic obstructive pulmonary disease explain the variance in their depression, cop-
(Caress, Luker, Chalmers, & Salmon, 2009), ing, and quality of life (Smith, Kleinbeck,
kidney disease (Tong, Sainsbury, & Craig, Boyle, Kochinda, & Parker, 2002). In another
2008), heart failure (Bakas, Pressler, Johnson, clinical trial (Smith, 2006), Smith et al. (2010)
nauser, & Shaneyfelt, 2006; Molloy, Johnston, reported significant relationships among
& Witham, 2005; Pressler et al., 2009), and family income adequacy and patients’ and
stroke survivors (Rigby, Gubitz, & Phillips, caregivers’ quality of life as well as patients’
2009). The indirect familial caregiver tasks clinical outcomes and caregivers’ mental
include designating others to assist with health. Qualitative data supported these
patient care, exchanging information, main- findings that economic stress was the stron-
taining decision making among appropriate gest factor affecting quality of life of patients
persons, and coping with psychosocial stres- and caregiver (Smith et al., 2010). This find-
sors (Whitlatch, 2008). ing was consistent and confirmed the Smith’s
Because the caregiver by definition (1994) family home caregiving model, which
is laden with tasks and expectations, the was replicated across two decades (Smith,
major area of research has been caregiver 1999; Smith et al., 2002; Winkler, Ross,
burden and negative outcomes on care- Piamjariyakul, Gajewski, & Smith, 2006).
givers’ physical, mental, and financial In each model, caregiver characteristics of
health (Piamjariyakul et al., 2010; Schulz & esteem, depression, and physical and men-
Sherwood, 2008; Smith, Piamjariyakul, tal health and in the context of caregiving
Yadrich, Ross & Gajewski, 2010). The majority (e.g., family income adequacy) have pre-
of burden studies have been descriptive and dicted patient outcomes (Smith, 2007; Smith,
correlational and have resulted in identifica- Leenerts, & Gajewski, 2003).
tion of multiple factors recognized as being Problem-solving ability is lauded as
significant problems: complexity of the care essential and the caregiver’s ability to
needed by the patient that is often measured solve problems can avert patient problems
as illness demands. numerous variables (national Family Caregivers Association,
(e.g., demographic information, develop- 2002; Schulz, 2000), yet only a handful of
mental stage, social support) that have been studies on problem solving in caregiving
studied in relation to caregiver experience were found. Unique research on the posi-
are influential yet not universally predictive tive aspects of caregiving is being conducted
of caregiver burden (Biegel, Sales, & Schulz, by Smith (2007) under the concept of care-
1991). Research across disciplines identifies giving effectiveness. Effective caregiving
significant negative health outcomes of care- is defined as family provision of technical,
giving (reduced physical function, immune physical, and emotional care that results
status, wound healing, greater fatigue, in optimal patient health and quality of
36 n CAREGIvER
life and minimal technological side effects et al., 2010). The state of the science report on
while maintaining the caregiver’s health computer-based algorithms that aid patients
C and quality of life (Smith, 1994). nursing to make step-by-step decisions about treat-
interventions have been found efficacious ment options concluded that improved knowl-
for caregiver problems of depression, sleep edge, attitudes, and lower health services
deprivation, social isolation, and lack of used resulted from patients’ use of algorithms
access to evidence-based information, care- (Agency for Healthcare Policy and Research,
giving, and complex technology problem 1998; Agency for Healthcare Research and
solving (Smith, Curtas, et al., 2003; Smith, Quality, 2010). The Cochrane review and the
Dauz, Clements, Werkowitch, & Whitman, randomized trial results concur, adding that
2009; Smith et al., 2006). These interventions patients with step-by-step decision aids had
include counseling, peer support, high- realistic treatment expectations, satisfaction
quality Internet information, and contacts with care, and lowered anxiety (o’Connor
with experts. There is a dearth of research on et al., 2002). The more successful problem-
caregiving with lifelong technology depen- solving algorithms included logical, easily
dence that begins unexpectedly in middle remembered steps, multiperspective (psycho-
life (when teenagers and elder family mem- logical and physical) information, long-term
bers also need assistance) and continues on access, and booster repetition, all tailored
a trajectory of intermittent disease exacerba- to a specific group with common problems
tions and slow, progressive decline (Winkler (Piamjariyakul et al., 2006; Smith, Koehler,
et al., 2006). Moore, Blanchard, & Ellerbeck, 2005).
Traditional education such as verbal Research should continue on the cultur-
instruction at discharge does not ensure that ally related aspects of caregiving strategies
caregivers will be able to understand and used in various ethnic groups (Dilworth-
integrate home care management activities Anderson et al., 2005; Dilworth-Anserson,
into daily routines (Albert, 2008; Clark et al., Williams, & Gibson, 2002; Evans, Crogan,
2009). Telehealth and Web-based support Belyea, & Coon, 2009). Another contempo-
in the homes are other interventions pro- rary focus in caregiving research should be
viding caregivers support (Piamjariyakul, the caregiving family, as research has clearly
Schiefelbein, & Smith, 2006; Piamjariyakul & indicated that multiple members of families
Smith, 2008; Smith, 2007). In two recent stud- are involved in providing direct and indirect
ies, family caregivers requested information care, both to the patient and in support of
on the most challenging aspects of providing the primary caregiver (Smith, 1996). In addi-
home care for chronically ill patients: dealing tion to the caregiving family, the caregiving
with patients’ dietary restrictions, monitoring neighborhood or parish should be a focus of
signs and symptoms, and obtaining infor- study. With appropriate outreached inter-
mation from health care providers (Pressler vention program, the “out-of-home caregiv-
et al., 2009; Wilkins et al., 2009). The most ers” can help provide a low-cost health care
widely recommended clinical yet unverified support to the patients such as monitoring
approach is to provide guidelines to manage symptoms, improving treatment adherence,
specific caregiving problems (Schulz, Lustig, prescribed diet, and lifestyle changes (Kalra
Handler, & Martire, 2002). Step-by-step guide- et al., 2004; Piette et al., 2008).
lines (including computer algorithms) can Historically, research on the topic of
guide systematic thinking and develop skills caregivers has come from the literature
for solving stressful caregiving problems and on aging in which burden and support-
communicate with their health care provid- ive interventions have been studied (Tong
ers (Given, Sherwood, & Given, 2008; Smith, et al., 2008). Interventions tested include
2010a, 2011; Smith & Blanchard, 2011; Smith teaching mastery of caregiving tasks, social
CARInG n 37
interventions such as support groups or trait, a moral imperative, an affect, an inter-
telephone contacts, and direct clinical ser- personal interaction, and a therapeutic inter-
vices such as counseling and respite care. vention. In another analysis of caring theory, C
outcomes of many of these intervention Boykin and Schoenhofer (1990) argued for a
studies indicated that in the short term, the multidimensional approach integrating onto-
interventions may reduce caregiver stress in logical (meaning of caring), anthropological
a limited way but the burden returns when (meaning of being a caring person), and onti-
the interventions cease (Smith, 2008). Given cal (function and ethic of caring) perspectives.
the escalating involvement of informal care- Watson (2005) defined caring as an ontology,
givers and high costs of chronic illness care, a way of being, or a quality of consciousness
interventions with the potential for improv- that potentiates healing. She also defined car-
ing caregiver daily home care management ing as an ethic or moral imperative for relat-
and improving patients’ outcomes (i.e., reduc- ing with the other in which the humanity
ing rehospitalizations) must be tested. of the person is preserved. Swanson (1991)
defined caring as “a nurturing way of relat-
Ubolrat Piamjariyakul ing to a valued other toward whom one feels
Carol E. Smith a personal sense of commitment and respon-
sibility” (p. 165). She identified five processes
by which caring is enacted: knowing, being
with, doing for, enabling, and maintaining
Caring belief. Smith (2001) argued that the meaning
of caring as a concept is defined by the theory
in which it is situated. She described a uni-
Caring has been identified as a central con- tary view of caring as manifesting intentions,
cept in the discipline of nursing (Cowling, attuning to dynamic flow, appreciating pat-
Smith, & Watson, 2008; newman, Sime, & tern, experiencing the infinite, and inviting
Corcoran-Perry, 1991; newman, Smith, creative emergence.
Dexheimer-Pharris, & Jones, 2008; Smith, Several trends have accelerated inter-
2010a, 2011; Smith & Blanchard, 2011). These est in the phenomenon of caring in nursing.
authors have asserted that the discipline of Hospitals with or seeking Magnet ™ status
nursing focuses on the study of the relation- have adopted caring-based frameworks to
ship of caring to human health. Caring is also guide nursing practice. The International
essential to nursing practice, for without car- Caritas Consortium has been developed
ing, true nursing practice does not exist. In the as a network of hospitals and practitioners
past 30 years, theory and research on caring committed to advancing Watson’s theory-
have grown significantly, contributing to the based model in practice (http://www.watson
emergence of a substantive body of knowledge caringscience.org/icc/index.html). Several
referred to as caring science. Although criti- hospitals in South Florida are implementing
cism has been levied against this body of lit- Boykin and Schoenhofer’s (2001) nursing as
erature for its lack of conceptual clarity (Paley, caring model. The importance of caring to a
2001), there is growing international consen- culture of safety is being explored by some
sus in the discipline that knowledge about scholars (Swanson & Wojnar, 2004). others
caring is the key to understanding human (Duffy & Hoskins, 2003; Ray, 1989; Turkel,
health, healing, and quality of life (Watson & 2001; valentine, 1997) have examined the
Smith, 2002). on the basis of an analysis of the relationship between economics and caring,
literature, Morse, Solberg, neander, Bottorff, asserting and supporting that caring and
and Johnson (1990) elaborated five perspec- attention to the economics of healthcare are
tives of caring in nursing as follows: a human not mutually exclusive and that caring-based
38 n CARInG
nursing practice can result in positive eco- down. Haldorsdottir’s (1991) research led to a
nomic outcomes. Theoretical and empirical classification of levels of caring relationships
C work in caring is expanding. Grand theories related to a continuum of health or vitality;
(Boykin and Schoenhofer, 2001; Leininger & abusive relationships were classified as bio-
McFarland, 2006; Watson, 2008a, 2008b) and cidic, cold and detached as biostatic, apa-
middle-range theories (Duffy & Hoskins, thetic ones as biopassive, benevolence and
2003; Locsin, 2001; Ray, 1989; Smith, 2010; kindness as bioactive, and transpersonal car-
Swanson, 1991) are focused on explicating ing relationships as biogenic or life giving.
the nature and dynamics of care and caring. Sherwood’s (1997) meta-synthesis of 16
Three reviews of the research literature qualitative studies revealed four patterns
on caring have been published. Swanson of nurse caring: interaction, knowledge,
(1999) summarized and categorized the intentional response, and therapeutic out-
research related to caring in nursing science, comes. Caring was defined within content,
and Sherwood (1997) reported a meta-syn- context, process, and therapeutic or healing
thesis of the qualitative research on caring. outcomes. Two types of caring knowledge
Smith (2004) reviewed the research related and skills were identified as person-centered
to Watson’s theory of human caring. Many and technical-physical.
different designs and methods have been Smith (2004) reviewed 40 studies pub-
used to investigate caring, including descrip- lished between 1988 and 2003 that focused
tive qualitative designs, surveys, phenom- specifically on Watson’s theory of transper-
enology, and quasi-experimental designs sonal caring. Four major categories of research
using standardized scales and physiological were identified: nature of nurse caring, nurse
measurement. caring behaviors as perceived by clients and
Swanson (1999) reviewed 130 data-based nurses, human experiences and caring needs,
articles, chapters, and books on caring pub- and evaluating outcomes of caring in nursing
lished between 1980 and 1996. The studies practice and education. The largest number
were categorized into five levels: capacity for of studies focused on nurse caring behaviors
caring (characteristics of caring persons), con- as perceived by clients or nurses. An expand-
cerns and commitments (beliefs or values that ing area of research related to evaluating
underlie nursing caring), conditions (what outcomes of caring. Research supports that
affects, enhances, or inhibits the occurrence of caring-based activities impact mood follow-
caring), caring actions (what caring means to ing miscarriage, patient satisfaction, pain
nurses and clients and what it looks like), and and symptom distress in patients with can-
caring consequences (outcomes of caring). In cer, well-being, and even blood pressure.
her summary of 30 qualitative studies that Watson’s (2008a, 2008b) compendium
described outcomes of caring and noncaring of instruments to assess and measure car-
relationships, Swanson found that outcomes ing is an important contribution toward the
of caring for the recipients of care were emo- advancement of research. This text provides
tional and spiritual well-being (dignity, self- background on more than 20 instruments,
control, and personhood), enhanced healing, citations of work in which they were used,
and enhanced relationships. Consequences and a copy of them. Some of these tools are as
of noncaring were humiliation, fear, and feel- follows: (a) Larson’s CARE-Q to measure per-
ing out of control, desperate, helpless, alien- ceptions of nurse caring behavior, (b) Wolf’s
ated, and vulnerable. nurses who care report Caring Behaviors Inventory to measure the
a sense of personal and professional satisfac- process of caring, (c) Cronin and Harrison’s
tion and fulfillment, whereas noncaring is Caring Behavior Assessment Tool and
related to outcomes of becoming hardened, Duffy’s Caring Assessment Tool to measure
oblivious, depressed, frightened, and worn patient perceptions of nurse caring behaviors,
CASE STUDY AS A METHoD oF RESEARCH n 39
(d) nyberg’s Caring Attribute Scale to mea- trials to test the effectiveness of caring-based
sure caring attributes, and (e) Coates’ Caring therapeutics in promotion of health and well-
Efficacy Scale to measure the belief in the being. Different designs and methods must C
ability to express a caring orientation and to be used to capture the emerging questions
develop caring relationships. in the field. Multiple ways of knowing from
The future of research in caring is prom- empirics to aesthetics are required to explore
ising. An international community of schol- all dimensions of caring phenomena. A
ars is actively building knowledge in caring model of research that integrates these mul-
science. The International Association for tiple perspectives and ways of knowing may
Human Caring meets annually to disseminate be the preferred epistemological model for
the work of its members, and the International studying caring (Quinn, Smith, Ritenbaugh,
Journal in Human Caring publishes research Swanson, & Watson, 2003).
and scholarship that expands caring science.
The Watson Caring Science Institute and the Marlaine C. Smith with contributions
Anne Boykin Institute for the Advancement from Sally Phillips (volume 1)
of Caring in nursing have been established
to support the scholarly development, dis-
semination, and application of knowledge
related to caring. Scholars are examining the Case study as a Method
transtheoretical linkages between caring the-
ories and other nursing conceptual systems oF researCh
(Watson & Smith, 2002). Important research
questions center on the relationship between
caring and healing outcomes, the qualities Although case study as a research approach
of a caring consciousness, the ontological has been used in nursing and the social sci-
competencies and types of nursing therapeu- ences for decades, there is little clarity about
tics that are caring based, and the types of case study methodology. It is described
environments and communities that facili- by some as a research method or strategy
tate caring. nursing is the discipline that is (Jones & Lyons, 2004; Yin, 2003), a method
studying the relationship between caring of data collection (Gangeness & Yurkovich,
relationships and healing. Research needs 2006; Lincoln & Guba, 1985), a research design
to move beyond examining caring in nurse– (Bergen & White, 2000), and a technique for
patient relationships to caring relationships teaching (Henning, nielsen, & Hauschildt,
with family, friends, animals, nature, and the 2006). Stake (1995) considers the case as the
Divine and how these relationships affect unit of study rather than a methodologic
health outcomes. It will be important to study choice. Although there is lingering confusion
both caregiver and recipient outcomes of car- about case study, most experts agree that
ing theory-based models of practice in differ- case study is a way to describe, to explore,
ent settings. Swanson (1999) offered several to understand, and to evaluate a phenom-
suggestions for future research related to enon within the context in which it occurs
caring: developing measures of caring capac- (Anthony & Jack, 2009; Stake, 1995; Yin, 2003).
ity, examining the effects of nurturing and In addition, it is a valuable tool to explore the
experience on caring capacity, identifying transition between theory and practice.
and measuring the competing variables The earliest use of case study was as
that may confound the links between car- a teaching technique reported in 1870 at
ing actions and their outcomes, moving from Harvard Law School (Garvin, 2003). From
studying the individual as unit of analysis to there, it spread to other disciplines such as
studying aggregates, and developing clinical business, medicine, and nursing. Case study
40 n CASE STUDY AS A METHoD oF RESEARCH
as a teaching technique used problem solv- Case study is used to expand under-
ing in the transition between theory and standing of phenomena about which little
C practice and has been used in nursing since is known. The data can then be used to for-
the early 1900s (Parsons, 1911). Case studies mulate hypotheses and plan larger studies.
were commonly reported in nursing 40 to 50 other purposes of case study include the-
years ago (Burns & Grove, 2007) but fell out of ory testing, description and explanation. For
favor as nursing struggled to be recognized example, the intensive analysis involved in
as a science. There has been renewed interest case study is appropriate to answer ques-
in case study as an approach to constructivist tions of explanation, such as why partici-
inquiry (Anthony & Jack, 2009). pants think or behave in certain ways. The
Case study research design can be quan- case study approach can also be used when
titative; but because of the narrative nature a problem has been identified and a solution
of the case study itself, it is most often used needs to be found all within the context of
as a qualitative research method. Case stud- the current “real-life” situation.
ies can be as simple as a single, brief case The research process for case study
or very complex, examining a large num- design is similar to the techniques used
ber of variables. Case study is also used for in other designs. First, the purpose, the
theory generation and hypothesis testing. research questions, and the propositions
Qualitative case study method is often used are developed. Questions of what, how, and
as an adjunct method in an otherwise quanti- why are appropriate for case study designs.
tative study. It is used this way for “in-depth The propositions of the study are often state-
study of meaningful characteristics of real- ment of expected outcomes that resemble a
life events” (Anthony & Jack, 2009, p. 1175). hypothesis. The propositional statements are
Case study is a method that is appropriate supported or rejected after the data are ana-
with research that is flexible in epistemol- lyzed (Gangeness & Yurkovich, 2006). A the-
ogy, ontology, methodology, and strategies of oretical framework may be used to guide the
inquiry (Denzin & Lincoln, 2000). case study. This will help to identify assump-
In nursing, case study design is used tions that the researcher may have about the
to study the complexities of nursing prac- phenomenon at the beginning of the study.
tice (Casey & Houghton, 2010). Case study At the outset of the study, the unit of
is an intensive systematic study of an entity analysis must be clearly delineated. The unit
or entities about which little is known and of analysis can be an individual, a family, an
conducted within the context of the real-life organization, or an event. Clearly identify-
situation. The common characteristics of case ing the unit of analysis has implications for
studies include the following: the use of the- the data collection and the study protocol.
ory to guide data collection and analysis; the The protocol should list how participants
use of multiple sources of data and triangula- will be recruited and what constitutes data
tion, applicable when the boundaries between (documents, letters, interviews, field observa-
context and phenomenon are unclear; and tions, etc.). The protocol should also identify
there are more variables than data points what resources will be needed and a tentative
(LoBiondo-Wood & Haber, 2006). Case stud- time line for data collection. Modifications
ies can be exploratory, descriptive, interpre- can be made in the protocol as the study pro-
tive, experimental, or explanatory (Yin, 2003). gresses and the problems emerge. The pro-
The level of analysis also varies from factual tocol should also identify the plan for data
or interpretive to evaluative (Lincoln & Guba, analysis and how the data will be reported.
1985). The unit of analysis is the case, which Case study design can be a single-case
can be a single person, family, community, or design or a multiple-case design. Single-case
institution (Burns & Grove, 2007). designs are used when a case represents a
CASE STUDY AS A METHoD oF RESEARCH n 41
typical, extreme, critical, unique, or revela- context and processes surrounding the phe-
tory case (Yin, 2003). When the purpose of the nomenon under investigation. A discussion
study is theory generation, a multiple-case of the results is also included in the reports, C
design is appropriate. Multiple-case design which can contain inferences about how
draws inferences and interpretations from a these results fit with the existing literature
group of cases. The multiple-case design is and practice implications.
also useful to add depth to explanatory and The standard measures of reliability and
descriptive studies. validity apply to case studies that are quanti-
Data for case study can be qualitative tative. The criteria developed by Lincoln and
or quantitative and often includes both in Guba (1985) are used to evaluate qualitative
the same study depending on the research case studies. When a study meets the criteria
question. Data from multiple sources, archi- for credibility, transferability, dependabil-
val data, field notes, interview tapes (audio ity, and confirmability, it is considered to be
or video), direct observation, participant trustworthy (reliable and valid). Credibility
observation, logs, documents, and narra- of the interpretations is supported by tech-
tives generate a comprehensive and rich case niques such as triangulation of data collec-
study. Every source of data has strengths and tion methods, negative case analysis, and
weaknesses, but when used together the ben- checking the interpretation with the par-
efits of each combine to diminish the weak- ticipants themselves. Transferability (gener-
nesses and strengthen the outcome. alizability) is an indication of whether the
Data analysis in case study is guided findings or conclusions of the study fit in
by the propositions and the type of data. other contexts and fit with the existing liter-
Qualitative data analysis techniques, content ature. When another person is able to follow
analysis, analytic induction, constant com- the researcher’s audit trail or the process and
parison, and phenomenological analysis are procedures of the inquiry, then the study is
used in case study depending on the type considered to be dependable. Confirmability
of data and research question. Planned case is achieved when the results, conclusions,
studies are generally analyzed using pat- and recommendations are supported in the
tern matching because the multiple sources data and the audit trail is evident.
of data contribute to similar phenomena Case study method is a comprehensive
(Gangeness & Yurkovich, 2006). Because research strategy used to examine phenom-
there are no fixed formulas for analyzing ena of interest to nursing within the real-life
qualitative data, the researcher’s own rigor- context. As a method, it has survived the pos-
ous thinking is paramount, giving consid- itivist debate and is being used more often in
eration to alternative interpretations (Yin, nursing. on the basis of the fact that case stud-
2003). If data are quantitative in nature, anal- ies are reported almost exclusively in peer-
ysis is similar to any quantitative study and reviewed journals (benchmarks of quality),
is dependent on the research question. it can be stated that case study is an accepted
Case study reports are presented in a research method/design in nursing. An ongo-
variety of ways, from formal written narra- ing challenge to the utility of case study as a
tives to creative montages of photographs, research method in nursing is the continued
videotape, and arts and craft work. Most case debate and lack of clarity in what case study
study reports in nursing are formal written actual is. Case study method fits with the cur-
narratives appearing in peer-reviewed jour- rent trend in inquiry that supports flexibility
nals. There are no rules or standardized in epistemology, ontology, methodology, and
ways to write a report, but most case stud- research strategy (Denzin & Lincoln, 2000).
ies include an explanation of the problem
or issue and a detailed description of the Debera Jane Thomas
42 n CAUSAL MoDELInG
are used to describe the latent variables.
Causal Modeling Exogenous variables are those whose causes
C are not represented in the model; the causes
of the endogenous variables are represented
Causal modeling refers to a class of theo- in the model.
retical and methodological techniques for Causal models contain two different
examining cause-and-effect relationships, structures. The measurement model includes
generally with nonexperimental data. Path the latent variables, their empirical indicators
analysis, structural equation modeling, (observed variables), and the associated error
covariance structure modeling, and LISREL variances. The measurement model is based
modeling have slightly different meanings on the factor analysis model. A respondent’s
but often are used interchangeably with the position on the latent variables is consid-
term causal modeling. Path analysis usu- ered to cause the observed responses on the
ally refers to a model that contains observed empirical indicators, so arrows point from
variables rather than latent (unobserved) the latent variable to the empirical indica-
variables and is analyzed with multiple tor. The part of the indicator that cannot be
regression procedures. The other three terms explained by the latent variable is the error
generally refer to models with latent vari- variance generally due to measurement.
ables with multiple empirical indicators that The structural model specifies the rela-
are analyzed with iterative programs such as tionships among the latent concepts and is
LISREL or EQS. A common misconception is based on the regression model. Each of the
that these models can be used to establish endogenous variables has an associated
causality with nonexperimental data; how- explained variance, similar to R in mul-
2
ever, statistical techniques cannot overcome tiple regression. The paths between latent
restrictions imposed by the study’s design. variables represent hypotheses about the
nonexperimental data provide weak evi- relationship between the variables. The mul-
dence of causality regardless of the analysis tistage nature of causal models allows the
techniques applied. researcher to divide the total effects of one
A causal model is composed of latent latent variable on another into direct and
concepts and the hypothesized relationships indirect effects. Direct effects represent one
among those concepts. The researcher con- latent variable’s influence on another that is
structs this model a priori on the basis of the- not transmitted through a third latent var-
oretical or research evidence for the direction iable. Indirect effects are the effects of one
and sign of the proposed effects. Although latent variable that are transmitted through
the model can be based on the observed cor- one or more mediating latent variables. Each
relations in the sample, this practice is not latent variable can have many indirect effects
recommended. Empirically derived models but only one direct effect on another latent
capitalize on sample variations and often variable.
contain paths that are not theoretically defen- Causal models can be either recursive or
sible; findings from empirically constructed nonrecursive. Recursive models have arrows
models should not be interpreted without that point in the same direction; there are no
replication in another sample. feedback loops or reciprocal causation paths.
Most causal models contain two or more nonrecursive models contain one or more
stages; they have independent variables, one feedback loops or reciprocal causation paths.
or more mediating variables, and the final out- Feedback loops can exist between latent con-
come variables. Because the mediating vari- cepts or error terms.
ables act as both independent and dependent An important issue for nonrecursive
variables, the terms exogenous and endogenous models is identification status. Identification
CEREBRAL ISCHEMIA n 43
status refers to the amount of information the complexities of the phenomenon, to test
(variances and covariances) available com- theoretical models specifying causal flow,
pared with the number of parameters that and to separate the effects of one variable C
are to be estimated. If the amount of infor- on another into direct and indirect effects.
mation equals the number of parameters to Although causal modeling cannot be used
be estimated, the model is “just identified.” If to establish causality, it provides information
the amount of information exceeds the num- on the strength and direction of the hypoth-
ber of parameters to be estimated, the model esized effects. Thus, causal modeling enables
is “overidentified.” In both cases, a unique investigators to explore the process by which
solution for the parameters can be found. one variable might affect another and to iden-
With the use of standard conventions, recur- tify possible points for intervention.
sive models are almost always overidentified.
When the amount of information is less than JoAnne M. Youngblut
the number of parameters to be estimated,
the model is “underidentified” or “unidenti-
fied,” and a unique solution is not possible.
nonrecursive models are underidentified Cerebral isCheMia
unless instrumental latent variables (a latent
variable for each path that has a direct effect
on one of the two latent variables in the recip- Cerebral ischemia is defined as inadequate
rocal causation relationship but only an indi- blood flow to the brain to meet meta-
rect effect on the other latent variable) can be bolic and nutritive needs of the brain tis-
specified. sue (Edvinsson, MacKenzie, & McCulloch,
Causal models can be analyzed with 1993). The severity of ischemia depends on
standard multiple regression procedures or the severity and duration of the reduction in
structural equation analysis programs, such cerebral blood flow (CBF) adversely affecting
as LISREL or EQS (see Structural Equation various functional and metabolic processes
Modeling). Multiple regression is appropriate as CBF decreases (Heiss & Rosner, 1983). The
when each concept is measured with only one brain stores no oxygen and little glucose and
empirical indicator. Path coefficients (stan- is thus dependent on a constant supply of
dardized regression coefficients, β ) are esti- oxygen and glucose from the blood.
mated by regressing each endogenous variable Cerebral ischemia may be focal or
on the variables that are hypothesized to have global, depending on whether a part of the
a direct effect on it. The fit of the model is cal- brain or the entire brain is ischemic. Focal
culated by comparing total possible explained cerebral ischemia occurs when a major cere-
variance for the just identified model with bral artery becomes occluded or constricted
the total explained variance of the proposed from arterial spasm, emboli, or thrombo-
overidentified model. Data requirements for sis. Global ischemia occurs from an overall
path analysis are the same as those for mul- decrease in CBF, for example, after cardiac
tiple regression: (a) interval or near-interval arrest. Global oxygen deprivation of the
data for the dependent measure; (b) interval, brain may also occur as a result of asphyxia,
near-interval, or dummy-coded, effect-coded, anemia, hypoxia, or near drowning. nurses
or orthogonally coded categorical data for the are responsible for identifying individuals
independent measures; and (c) 5 to 10 cases at risk for focal or global cerebral ischemia.
per independent variable. Assumptions of nursing assessment of early symptoms of
multiple regression must be met. cerebral ischemia can allow for intervention
In summary, causal modeling tech- and minimize the probability of permanent
niques provide a way to more fully represent damage.
44 n CEREBRAL ISCHEMIA
Spielmeyer first described “ischemic production of “heat” or energy. Adolf Fick
cell change” in 1922 (Spielmeyer, 1922), and (1870) defined blood flow as the quantity of
C Brierley presented the time course for neu- a substance, such as oxygen, that is taken up
ronal change during a low-flow state and by a specific organ over a unit of time (obrist,
provided evidence of the threshold for cere- 2001). The first “measures” of CBF involved
bral anoxic ischemia (Brierley, Brown, & direct and indirect observations of intra-
Meldrum, 1971; Chiang, Kowada, Ames, cranial vessels (Roy & Sherrington, 1890). It
Wright, & Majno, 1968). He observed and was not until 1945, when Kety and Schmidt
described in further detail the process of applied the Fick principle to diffusible gas,
ischemic cell change (Brierley, 1973). With the nitrous oxide, that one was able to estimate
initial decrease in blood flow, oxygen, and/ CBF (Kety, 1950; Kety & Schmidt, 1948).
or glucose to the brain, the contour of cells, Kety was the first person to measure
nucleus, and nucleolus remain unchanged. global CBF in humans using vascular transit
There is disruption of mitochondria and an time. The technique was modified by Lassen
increase in the astrocyte processes surround- and Ingvar (1972) when Xe-133, a highly dif-
ing the neurons. As the ischemic process con- fusible gas, was injected into the internal
tinues, there is neuronal shrinkage, changes carotid artery. Multiple extracranial detectors
within organelles in the cytoplasm, and the traced the transit time of the radiation from
cell is further surrounded by astrocytic pro- the Xe-133 as it flowed through the brain,
cesses. As the nucleus continues to shrink providing focal CBF measures. Diffusible
and the cytoplasm becomes more amor- tracers are now combined with tomographic
phous, incrustations begin to form. Finally, reconstruction such as computed tomog-
as the incrustations disappear and the cyto- raphy (CT), positron emission tomography,
plasm becomes increasingly homogeneous, or magnetic resonance imaging to calculate
astrocytes proliferate and lipid phagocytes vascular transit time. For example, stable
form in preparation for removal of the now xenon-enhanced CT scanning measures CBF
“ghost cell.” As the flow lowers and the mito- via conventional scanner interfaced with
chondria fail, energy sources change from computer hardware and software and directs
an aerobic to an anaerobic pathway, with a the delivery of xenon gas transit throughout
corresponding increase in lactic acid produc- brain regions. Serial CT scans are conducted
tion, metabolic derangement, and loss of ion during the inhalation of a gas mixture con-
and transmitter homeostasis. If this process taining 30% xenon, 30% to 60% oxygen, and
continues unchecked, there will be inade- room air. The serial images are stored and
quate energy to maintain the sodium potas- regional flows are calculated.
sium pump across the cell membrane (Jones CBF is also estimated from measure-
et al., 1981). Researchers have increasingly ment of cerebral blood volume. one way to
detailed the process in an attempt to identify estimate cerebral blood volume is using a
and improve the brain’s tolerance to recover gradient echo planar system on MR systems.
from an ischemic challenge. The dynamic contrast-enhanced susceptibil-
Servetus, in the sixteenth century, first ity-weighted perfusion imaging technique
presented the idea that blood flowed through involves giving a bolus of paramagnetic con-
the lungs; he was burned at the stake for his trast material (i.e., gadolinium). The contrast
efforts. William Harvey (1578–1657) sup- media are traced, and the amount of signal
ported Servetus’ findings by describing attenuation is proportional to the cerebral
the flow of blood through the body. nearly blood volume. With a series of multislice mea-
200 years later, oxygen was discovered by surements, one may generate a time–density
Priestley, and Steele and Lavoisier made the curve, and the area under the curve provides
connection that oxygen contributed to the an index of relative blood volume (Grandin,
CHILD DELInQUEnTS n 45
2003). Similar techniques are adapted to CT infarct such as blood–brain barrier disrup-
scanners with the capability for rapid sequen- tion (Barr et al., 2010).
tial scanning. Future directions in cerebral ischemia C
The threshold for irreversible brain include more specific and sensitive clinical
damage from cerebral ischemia is generally criteria for stages of cerebral ischemia and
defined as below 20 ml/100 g of tissue/minute infarction, noninvasive techniques to mea-
(Jones et al., 1981; Yonas, Sekhar, Johnson, & sure regional blood flow, and the develop-
Gur, 1989). CBF below this level alters the ment of assays of ischemia and/or infarct. As
functioning of the mitochondria to produce techniques become increasingly more por-
energy. Studies show that the threshold for table and useable, there will be a translation
irreversible brain damage is volume and from the radiology department to application
time dependent. Global brain ischemia that is by nurses in the community or at the bedside
sustained for longer than 4 to 5 minutes will to assess, to predict, to identify, and to moni-
result in permanent brain damage (Brierley, tor patients at risk for cerebral ischemia.
Meldrum, & Brown, 1973). The majority
of studies show that above 23 ml/100 g/ Mary E. Kerr
minute, little impairment occurs; however,
below 20 ml/100 g/minute, symptoms of
neurologic impairment develop (Branston,
Symon, Crockard, & Pasztor, 1974). Below 18 Child delinquents
to 20 ml/100 g/minute, evidence of dimin-
ished electrical activity by evoked poten-
tials or electroencephalogram occurs (Sundt, Child delinquents, those children who
Sharbrough, Anderson, & Michenfelder, 1974). become delinquent at a young age, are two
Below 15 ml/100 g/minute is considered to to three times more likely to become seri-
be a threshold for synaptic transmission ous, violent, and chronic offenders (Loeber,
(Astrup, Siesjo, & Symon, 1981). In addition, Farrington, & Petechuk, 2003). Because of
factors including temperature, drug admin- their early entry into the criminal system,
istration, and individual variation contribute these children have longer offending careers
to the complexity of defining this threshold. and, as a result, are perceived to constitute a
Recent work focuses on methods that “non- threat to public safety and property (Loeber &
invasively” detect, track changes in, or treat Farrington, 2001) as they consume a dispro-
cerebral ischemia. portionately large amount of educational,
The determination and prediction of social, child welfare, mental, and health
cerebral ischemia is subject to the strengths care resources. Following a report by Snyder
and limitations of the technique used to (2001) noting a 33% increase in the number of
detect low-flow states. As dynamic perfu- juveniles between the ages of 7 and 12 years
sion CT imaging (Kim et al., 2010) and diffu- handled by U.S. juvenile courts, attention on
sion-weighted magnetic resonance imaging the problem of child delinquency and chronic
(Chalela et al., 2007; Totaro et al., 2010) evolve, criminality dramatically increased. The clin-
they improve a clinician’s ability to differen- ical impact nurses can make in health, social,
tiate between cerebral infarct and ischemia education, and legal systems can signifi-
(Saver, 2008). To date, there are no serum bio- cantly alter the life course trajectory of child
markers or assays available that can detect delinquents.
the presence of cerebral ischemia; however, Child delinquents are not legally
advances are being made in the identifica- defined in the same way across the United
tion of serum biomarkers associated with States (Wiig, 2001). only 14 states have a
complications of cerebral ischemia and legally defined minimum age of criminal
46 n CHILD DELInQUEnTS
responsibility, ranging from 6 to 10 years. (Snyder, Espiritu, Huizinga, Loeber, &
These states have established a presumption Petechunk, 2003), and risk factors operate in
C of incapacity for children under the estab- multiple domains: the individual child, the
lished minimum age, declaring that they are child’s family, the peer group, the school, the
incapable of understanding the wrongful- neighborhood, and the media. It is generally
ness of their behaviors. The other states that agreed that early on in a child’s life, the most
have not set a minimum age for delinquency important risks stem from individual fac-
rely on the common law definition to estab- tors (e.g., birth complications, temperament)
lish 7 years of age as the minimum age for and family factors (e.g., parental antisocial
delinquency. The root of this common law or criminal behavior ,poor child-rearing
presumes incapacity to protect children from practices). As the child moves through to
criminal prosecution. Known as the infancy adolescence, risk factors related to peer influ-
defense, this presumption can be rebut- ences, school, and community begin to play
ted by proof that the child understands the a larger role.
act and knows that it was wrong (Kaban & Large national specialized studies of
orlando, 2008). child delinquency in the United States are
A Study Group on very Young offenders lacking (Snyder et al., 2003). The data that are
convened by the office of Juvenile Justice and reported on child delinquents rely on self-
Delinquency Prevention defined child delin- report data from three longitudinal studies of
quents as children between 7 and 12 years the causes and correlates of delinquency: the
who had committed a delinquent act (an Denver Youth Survey, the Rochester Youth
act that would be a crime if committed by Development Study, and the Pittsburgh
an adult). This was differentiated from dis- Youth Study (Loeber, Wei, Stouthamer-
ruptive nondelinquent behavior, which Loeber, Huizinga, & Thornberry, 1999). The
was defined by the American Psychiatric analyses of these data reveal some interesting
Association (2000) as a recurrent pattern of findings critical to our understanding about
negativistic, defiant, disobedient, and hos- these child delinquents. Among both sam-
tile behavior toward others lasting at least ples, some forms of aggressive behavior (hit-
6 months during childhood and adolescence. ting, fighting, and physical attacks) appeared
The study group then classified child delin- to be normal before the age of 13 years. Initial
quents into three categories: serious child involvement in serious violence generally
delinquents who had committed one or more did not occur until ages 11 years or later, and
criminal acts—homicide, aggravated assault, prevalence rates declined as the seriousness
robbery, rape, or serious arson; other child of the violence increased (Snyder et al., 2003).
delinquents—all other children excluding These children reported substantially less
the serious delinquent group; and children involvement in other types of offenses, par-
showing persistent disruptive behavior ticularly for females.
(including truancy and incorrigibility) who Self-report information from childhood
are at risk of offending (Loeber et al., 2003). through adolescence indicated that much of
It has long been known that aspects of the involvement in delinquent behaviors was
childhood coupled with children’s exposure limited to childhood. For those involved in
to certain risk and protective factors influ- serious violence, most (40%) were involved for
ence the likelihood of children becoming 2 years or less. only a few (25%) were involved
delinquent at a young age. Most profession- for 5 years or more. violence and drug use
als agree that no single risk factor leads a was among the most common offense pattern
young child to delinquency. There is a devel- (Huizinga, Loeber, Thornberry, & Cothern,
opmental aspect to childhood delinquency 2000). Similar findings held for most other
CHILD DELInQUEnTS n 47
offenses, with the exception of status offenses and early intervention (71%) was endorsed
and drug use for 75% or more of juveniles. as an effective method to reduce the risk
Interestingly, contact with police increased of future offending (Farrington, Loeber, & C
with age, and boys were more likely than Kalb, 2001).
girls to be contacted by the police for delin- Contemporary theoretical contributions
quency. Children ages 7 to 10 years contacted recognize the complexities surrounding
by police were commonly taken home or to child delinquency and call upon frameworks
a social services agency. However, more than in which multiple factors can be accounted
half of children ages 11 to 12 years contacted for as contributors to outcomes. The world
by police for delinquency appeared in court, of children and adolescents is complex, and
with court dispositions commonly involv- bringing prevention, youth development,
ing fines, community service, restitution, or treatment, and social rehabilitation models
probation. to the interface of the juvenile justice sys-
An approach to treatment has been to tem is challenging. The contributions of the
focus on the needs of children with con- varied models reflect the expertise and per-
duct disorder (CD) or CD symptoms (Burns spectives of individuals, but the most signif-
et al., 2003). CD symptoms include aggres- icant and difficult to achieve are integration
sion toward people and animals, destruction and implementation within the community,
of property, deceitfulness or theft, and seri- which is generally agreed to be the environ-
ous violations of rules (American Psychiatric ment where youth and their families achieve
Association, 2000, p. 98). The focus has been best outcomes.
on children who exhibit CD symptoms The development and testing of
because they are prone to other conditions approaches for translating research findings
such as attention deficit/hyperactivity disor- into effective community prevention ser-
der, anxiety, depression, and substance abuse vice systems is important to achieve reduc-
(Angold, Costello, & Erkanli, 1999), and the tions in the prevalence of youth health and
behavior problems associated with CD are behavior problems (Wandersman, 2003).
often delinquent in nature. The Community Youth Development Study
Lipsey and Wilson (1998) reviewed (Hawkins et al., 2008) is a large-scale com-
200 studies published between 1950 and munity-randomized trial of 24 communities
1995 on the treatment of juvenile offend- across seven states nationally. Referred to
ers and found that the most effective inter- as Communities That Care (CTC), this coali-
ventions for serious and violent juvenile tion-based prevention-operating system uses
offenders were interpersonal skills train- a public health approach to prevention and is
ing, individual counseling, and behavioral designed to increase communication, collab-
programs. Brestan and Eyberg (1998) also oration, and ownership among community
conducted a review of 82 studies of inter- members and service providers. CTC’s prin-
ventions for children and adolescents with cipal strategy focuses on strengthening pro-
CD and found parent–child treatment pro- tective factors that can buffer young people
grams for pre-school-age youth and pro- from problem behaviors and promote posi-
grams that focus on the development of tive youth development (Hawkins & Weiss,
problem-solving skills and anger coping 1985). CTC’s theory of change hypothesizes
among school-age children most effective. that it takes from 2 to 5 years to observe com-
Community care, specifically multisystemic munity-level effects on risk factors and 5 or
system approaches, was at least as effective more years to observe effects on adolescent
as inpatient treatment (Burns, Schoenwald, delinquency or substance use. Early findings
Burchard, Faw, & Santos, 2000). Prevention suggest a slowing of the usual developmental
48 n CHILD–LEAD EXPoSURE EFFECTS
increase in adolescents’ risk exposure.
Longitudinal study is needed to determine Child–lead exposure eFFeCts
C if effects (reduced youth delinquency and
substance use) will hold over time. A second
study phase is in place currently. Childhood lead poisoning is recognized as
Research has been making incremental the most important preventable pediatric
steps toward unraveling the complexities environmental health problem in the United
resulting in outcomes of youthful offend- States, and the adverse health effects of lead
ing. Research has clearly demonstrated that exposure in early childhood are well docu-
youth are developmentally different than mented. Lead poisoning is defined as expo-
adults. Brain imaging research revealed sure to environmental lead that results in
that the brain systems that govern impulse whole blood lead concentrations ≥10 μg/dl
control, planning, and thinking ahead are (Centers for Disease Control [CDC], 1991,
still developing well beyond age 18 years 2005). However, there is no safe level of lead
(MacArthur Foundation, 2008). Behavioral exposure because factors such as age dur-
studies confirm that youth are less able to ing exposure, environmental characteristics
gauge risks and consequences, to control of the home, and duration of exposure need
impulses, to handle stress, and to resist peer to be considered, and adverse neurological
pressure than adults (Malbin, Boulding, & effects can occur at blood lead levels (BLLs)
Brooks, 2010). Research also reveals that well below the 10-μg/dl mark (Bellinger,
most young offenders will cease lawbreak- 2004). Exposure to environmental lead
ing as part of the normal maturation process begins in the prenatal period when physio-
(Elliott, 1994), and for the few children with logic stress mobilizes lead from its storage in
long-term pathways through delinquency, maternal bone into the blood, where it eas-
assessment and prevention strategies are ily crosses the placenta and is deposited in
even more important. The implications are to fetal tissue (Cleveland, Minter, Cobb, Scott, &
implement developmentally appropriate pol- German, 2008a, 2008b). Depending on the
icies and interventions to address our under- level of lead present in the environment, the
standing of these research findings. exposure can continue as infants and chil-
Research has also shown that a reduc- dren develop. Absorption of lead is depen-
tion of secure confinement and an increase dent on age and nutritional status; young
in reliance on effective community-based children and those who have diets high in
services have better outcomes (Holman & fats are most susceptible, as are those who
Ziedenberg, 2006), but implementation and are poor and live in deteriorating housing
sustainability of this approach have yet to (American Academy of Pediatrics Committee
be achieved (Annie E. Casey Foundation, on Environmental Health, 2005). Lead is
2008). As evidenced by the growing focus most commonly ingested through exposure
on implementation science, fidelity strate- to lead- contaminated paint and the resulting
gies, and community-based methodologies, dust, soil, and paint chips. once ingested,
the future lies in science translation. Most lead is distributed in the blood and eventu-
aptly stated in a recent report by the Annie E. ally is deposited in bone and teeth.
Casey Foundation (2008), “. . . juvenile justice Whole BLLs greater than 10 μg/dl put
has probably suffered the most glaring gaps children at risk for developing a variety of
between best practice and common practice, health problems. At high-level exposures
between what we know and what we most (BLL > 20 μg/dl), damage to the nervous,
often do” (p. 1). hematopoietic, endocrine, and renal systems
can occur. At lower level exposures, these
Deborah Shelton health problems include altered cognitive and
CHILD–LEAD EXPoSURE EFFECTS n 49
neurobehavioral processes including learn- Lanphear, 2009). Until recently, lead exposure
ing disabilities, intellectual impairment, and was thought to be a problem only for poor
antisocial behavior. Researchers have dem- inner city minority populations, and parent- C
onstrated that some of these effects may be ing practices were thought to contribute to the
seen in children with BLL as low as 3 μg/dl problem. Also, many considered the elimina-
(Bellinger, 2004; Canfield et al., 2003; Chiodo, tion of lead in gasoline and paint sufficient to
Jacobson, & Jacobson, 2004; Lanphear, 2005; eradicate the problem of lead poisoning. The
Lanphear, Deitrich, Auinger, & Cox, 2000; CDC, in 1991, issued comprehensive guide-
needleman & Landrigan, 2004). lines for preventing and treating the problem
Direct results of primary and second- of childhood lead exposure. These guide-
ary efforts at prevention of lead toxicity have lines were issued after the CDC accumulated
significantly reduced BLL among young U.S. large amounts of scientific evidence from
children within the last 30 years. The major animal and human studies that supported
sources of environmental lead exposure have the hypothesis that the deleterious effects
been greatly decreased through the elim- of lead exposure occur at levels previously
ination of lead in gasoline, the banning of thought to be harmless. The guidelines were
lead-based paint for residential use, and the updated in 2005 and emphasize the need for
elimination of lead solder from food and effective strategies to eliminate environmen-
beverage cans. Despite the success of these tal lead hazards. Despite warnings about the
efforts, lead poisoning continues to occur in known hazards of lead exposure, no policy
approximately 5% of children 5 years of age for universal screening of BLLs for infants,
and younger, and much higher levels of lead children, adolescents, and pregnant women
poisoning have consistently been documen- has been established.
ted among low-income, urban, minority, and Childhood lead poisoning was first
immigrant woman and children (olympio, described in the late 1800s by Gibson, Love,
Goncalves, Gunther, & Bechara, 2009). Hardie, Bancroft, and Turner (1892), who
Although few nurse researchers have encountered a case of peripheral paralysis
investigated the effects of low-level lead expo- in a young child and described the similar-
sure on the neurobehavioral development of ities of the case to that of chronic lead poi-
children, low-level lead exposure certainly soning in adults. Gibson speculated that the
falls within the realm of the phenomena of source of the lead poisoning was paint, and
concern to the discipline. Lead exposure he described the long-lasting effects of the
is unquestionably of clinical significance; exposure. Unfortunately, most of Gibson’s
until all lead is abated from the environ- observations were ignored, as the prevailing
ment, clinicians will be faced with screen- view of the time was that once a child sur-
ing children for lead exposure, preventing vived lead poisoning, there were no lasting
exposure through educational efforts, and effects. It was not until the early 1970s that
treating the effects of this preventable pub- cross-sectional and longitudinal studies of
lic health problem. The deleterious effects of low-level lead exposure were conducted.
lead exposure have been known for a hun- These early studies of lead exposure
dred years; however, progress in prevention involved comparisons of a lead-exposed
has been slow. Some of the reasons for this group and a comparison group on intelligence
are related to society’s indifference to prob- test measures. As knowledge accumulated
lems of poor and vulnerable populations and and research strategies became more sophisti-
a lack of household educational and environ- cated, researchers began to assess the influence
mental interventions that have demonstrated of covariates, such as parental intelligence,
effectiveness at reducing BLLs in children socioeconomic status, and parental education
(Yeoh, Woolfenden, Wheeler, Alperstein, & level (Gatsonis & needleman, 1992). Although
50 n CHILDBIRTH EDUCATIon
conflicting results were common, lead expo- concentrations. Research with lead-exposed
sure and neurobehavioral deficits remained primates strengthened the consensus, and
C significantly associated. the toxic level of lead was redefined by the
The earliest studies of lead poisoning CDC as a BLL ≤ 10 μg/dl.
were conducted on children who had BLL Recently, nurse researchers have used
≥ 60 μg/dl and were symptomatic. During the Dixon’s Integrative Environmental Health
1970s, researchers focused on asymptomatic Model (Dixon & Dixon, 2002) to identify knowl-
children who had BLL in the range of 40 to 50 edge gaps related to public policy that have
μg/dl. Conclusions about the effects of lead prevented the development of effective strat-
exposure were difficult to make from these egies to create environmental lead- exposure
studies because of their methodological short- policy change (Perron & o’Grady, 2010).
comings. In 1979, researchers conducted a Researchers continue to study the effects
major investigation of large cohorts of asymp- of low-level lead exposure on the develop-
tomatic children and used shed deciduous ment of infants, children, and adolescents.
teeth rather than BLL to measure lead expo- Longitudinal studies involving large and
sure (needleman et al., 1979). These research- diverse populations that involve standard-
ers controlled for major confounding variables ized measurement and control of known
and concluded that BLL was associated with confounders will need to be undertaken.
lower IQ, decreased attention span, and poor Although these efforts are worthwhile,
speech and language skills in the children future efforts also could focus on (1) iden-
studied. Long-term follow-up of these chil- tifying mediators of lead exposure effects,
dren lead the researchers to conclude that the (2) investigating the effects of strategies to
effects of low-level lead exposure (equivalent lower BLLs (chelation and environmental lead
to BLL ≤ 25 μg/dl) persisted throughout young abatement) on the neurobehavioral outcomes
adulthood; failure to complete high school, of children, (3) investigating the synergistic
reading disabilities, and delinquency were effects of other environmental exposures on
behaviors exhibited by children who had ele- neurocognitive development, and (4) investi-
vated BLL at age 7 years (needleman, Riess, gating the effects of educational strategies to
Tobin, Biesecker, & Greenhouse, 1996). inform parents about preventing or reducing
Scientists criticized the work done by environmental lead exposure. Furthermore,
needleman et al. (1979) because the study investigations of the effectiveness of early
lacked baseline data about early cogni- intervention strategies for children identi-
tive abilities of the subjects. For instance, fied with elevated lead levels need to be con-
it was proposed that the affected children ducted. Any efforts that address the primary
may have had neurological deficits at birth prevention of the problem would help to
that would lead them to certain behaviors protect millions of children against the long-
(increased mouthing) that predisposed them lasting effects of lead exposure.
to be lead exposed. To address this issue,
subsequent studies were designed to follow Heidi V. Krowchuk
large numbers of subjects from birth through
early school age, and major outcomes
(e.g., IQ level, motor development, cogni-
tive development) were measured whereas Childbirth eduCation
large numbers of covariates were controlled.
numerous investigators using comparable
designs reported similar findings; thus, a Childbirth education focuses on the learn-
solid consensus among investigators began to ing needs of expectant families and covers a
emerge that lead was toxic at extremely low broad range of topics from the physical care
CHILDBIRTH EDUCATIon n 51
needs of expectant women to the psycho- “natural childbirth.” Although philosophi-
socio-cultural needs of the new family. The cal differences still exist among childbirth
goal of childbirth education is to assist fam- education methods, common aspects of all C
ilies in acquiring the knowledge and skills programs include education on (a) the phys-
necessary to achieve a healthy transition ical process of labor, (b) the physical and
through the childbearing process and initial psychological conditioning methods, and
phases of parenthood. Classes range from (c) the supportive assistance during the birth-
courses designed for those considering preg- ing process.
nancy through courses dealing with infant A number of organizations have affected
care needs and early parenting skills. the progress of childbirth education in the
nurses are the professional practitioners United States. Lamaze International, formerly
who assume the primary responsibility for the American Society of Psychoprophylaxis
teaching childbirth education classes within in obstetrics, was organized in 1960. The
the United States. nurses are in a unique posi- American Society of Psychoprophylaxis in
tion to serve as childbirth educators because obstetrics began certifying childbirth educa-
of their broad knowledge base, including tors in 1965 and was one of the first attempts
both the biological and the behavioral sci- to provide consistency in quality of child-
ences. In addition, nursing’s focus on car- birth education. The International Childbirth
ing and emphasis on client education enable Education Association was also founded in
nurses to guide families toward their child- 1960 as a consumer group in new York City.
birth goals with sensitivity using appropriate It was devoted to a philosophy of consum-
educational methods. nurses are the health ers working with health professionals for the
professionals within the hospital environ- benefit of the laboring family (ondeck, 2002).
ment who provide the majority of hands-on The American Academy of Husband Coached
care and labor support. Thus, nurses are in Childbirth was established in 1970 to certify
a strategic position to act as patient advocate childbirth educators in the Bradley method
and to provide anticipatory guidance regard- of childbirth. Bradley method educators are
ing birth decisions that are often required proponents of unmedicated childbirth with
within an increasingly complex health care significant husband/partner involvement
system. (Monto, 1996).
Formal childbirth education in the A number of related keywords were
United States began with classes in hygiene, used to search databases for nursing research
nutrition, and baby care provided by the articles published between 2005 and 2010,
American Red Cross. During the early twen- including “childbirth education,” “prepared
tieth century, classes on childbirth and fam- childbirth,” “childbirth classes,” and “child-
ily care became increasingly available to birth education classes.” A total of 186 nurs-
American women. As society’s view of child- ing research articles were identified through
birth shifted from the female-controlled CInAHL, PubMed, and PsychInFo. Almost
social model to the medical-illness model 50 topics were identified; however, little depth
during the first half of the twentieth century, was found for the majority of the topics. The
the focus of classes turned to the manage- range of topics relate to (a) postpartum skills
ment of childbirth pain (ondeck, 2000). such as parenting and breastfeeding, (b) clas-
Contemporary childbirth education ses for special populations such as fathers,
dates back to the work of Dick-Read, Lamaze, (c) examination of the benefits of childbirth
and Bradley. The notion of pain during labor education for parents, (d) self-care measures
as secondary to fear and the use of psycho- during pregnancy and labor, (e) effects of
logical conditioning methods to reduce both childbirth education on the need for medi-
the fear and the pain became the basis for cal interventions such as cesarean deliveries,
52 n CHILDBIRTH EDUCATIon
(f) caregiver perceptions of childbirth edu- The benefits of childbirth education con-
cation, (g) teaching strategies, and (h) use tinue to be a focus for nurse researchers.
C of the media (Internet, videos, and Tv) for Malata, Hauck, Monterosso, and McCaul’s
childbirth education. (2007) quasi-experimental study found pos-
A mix of both quantitative and quali- itive benefits for a childbirth education pro-
tative articles was identified. Quasi- gram designed for the needs of Malawian
experimental and correlational methods women. Artieta-Pinedo et al. (2010) reported
predominated in the quantitative studies, reduced anxiety among Spanish women
and phenomenology was the preferred qual- who attended childbirth education classes
itative research method. In addition, a num- when compared with women not attend-
ber of mixed method studies were identified. ing the classes. ngai, Chan, and Ip’s (2009)
very few authors identified a theoretical longitudinal study found support for the
framework for the study. Several frame- effectiveness of childbirth psychoeduca-
works noted were Roy’s adaptation model, tion for improving learned resourcefulness
Bandura’s self-efficacy model, Rosenbaum’s and decreasing depression outcomes among
learned resourcefulness model, and Dona- Chinese women. Childbirth education clas-
bedian’s structure, process, and outcomes ses were reported to improve antenatal adap-
framework. tation for a Turkish population (Serçekus &
There is a rise in the number of research Mete, 2010).
articles focusing on expectant fathers. Familiar topics showing a decline in
Erlandsson and Häggström-nordin’s (2010) nursing research studies include child-
phenomenological study found that Swedish birth education for teens and the effect of
fathers attending childbirth education dis- childbirth education on pain control during
cussions focused on the normalcy of birth, labor. This raises interesting questions. Has
the father’s role, infant behaviors, the need teen pregnancy become so normalized in
for information on complicated births, gender American culture, as well as worldwide, that
roles, and parenting. The benefits of a male- there is less emphasis on attending to the
facilitated, all-male discussion group for developmental needs of teens during preg-
expectant fathers in Australia were reported nancy? or do researchers believe we know all
by Friedewald, Fletcher, and Fairbairn (2005). that is necessary about the care of pregnant
Those fathers discussed topics such as their teen families? Has the marked acceptance of
role as fathers, coping, relationships, and pharmaceutically managed pain control in
communication. labor decreased the interest of both families
The use of electronic sources for child- and nurses in studying alternate options? or
birth education is becoming a focus of have nurses become discouraged in promot-
research. A research brief reporting on the ing the concepts of “natural” childbirth?
effects of a popular Tv reality show geared The increase in the global nature of
to childbirth states the media uses a medical nursing research on childbirth education is
model to depict childbirth, portraying inter- evident. A wide variety of countries on six
ventions for labor progression and pain as continents are represented in the nursing
normal, and a lack of information on birth literature. Topics show a wide conceptual
alternatives (vandevusse & vandevusse, scope of interest but little depth of study.
2008). Swedish women are reported to use These studies use a wide variety of methods
the Internet extensively to seek pregnancy- but have refrained from stating a theoretical
related information (Larsonn, 2007). These perspective for the studies.
women perceived the information to be reli- Although mother-friendly and baby-
able, and only about half discussed the infor- friendly initiatives continue to spread
mation with their health care provider. through maternity services, a large number
CHRonIC ILLnESS n 53
of research studies are being generated at least one chronic illness (ogden, Carroll,
related to the postpartum hospitalization McDowell, & Flegal, 2007).
experience. However, there seems to be a Chronic illness includes a broad spec- C
disconnect between studies focusing on the trum of diseases that differ significantly
antenatal childbirth education experience from one another in their underlying causes,
and those focusing on the in-patient hospital- modes of treatment, symptoms, and effects
ization experience. nursing is in an optimal on a person’s life and activity. Chronic ill-
position to make this logical and vital con- ness is usually an unexpected and long-
nection. Also, examination of the impact of lasting condition of health that often cannot
childbirth education on vulnerable popula- be cured: It affects all, regardless of gender,
tions has declined in recent years despite the age, and economic interest. It usually persists
continued discrepancies noted in pregnancy for an indefinite period of time, making it
outcomes for minority groups. If these poor impossible to predict its course and outcome.
outcomes are to be effectively addressed, Chronic illness usually requires long-term
the childbirth education needs of vulnerable surveillance and sometimes leaves residual
populations require the continued attention disability (Lubkin & Larsen, 2009). Families
of nurse researchers. are drained physically, emotionally, and
financially. There is often upheaval of rela-
Bobbe Ann Gray tions among the patient, family, and other
members of society. overall, chronic ill-
nesses vary greatly in their developmental
course. Some conditions improve over time,
ChroniC illness some stabilize, and others are progressively
degenerating and debilitating.
Chronic illness has a huge negative eco-
The practice of nursing has long been identi- nomic impact (Suhrcke, nugent, Stuckler, &
fied with the care and comfort of the chron- Rocco, 2006). noncommunicable chronic dis-
ically ill. However, the health care delivery eases—including cardiovascular diseases,
system has not adequately responded to the some cancers, chronic respiratory diseases,
needs of the increasing numbers of chroni- and type 2 diabetes—are the major health
cally ill adults (Frieden & Henning, 2009; problems facing the world, and they are a
Yach et al., 2010). Until recently, communica- barrier to development and alleviating pov-
ble diseases were the leading cause of death erty in countries of the global south (Daar
worldwide. new medical discoveries and et al., 2007). In a 2007 study, it was estimated
the evolution of public health have improved that over the next decade, China, India, and
the ability to survive acute threats, and thus the United Kingdom were projected to lose
life expectancy has lengthened, changing $558 billion, $237 billion, and $33 billion,
the course of diseases from acute to chronic respectively, in national income as a result
(World Health organization, 2005). Chronic of heart disease, stroke, and diabetes, partly
illnesses cause the greatest share of death as a result of reduced economic productivity
and disability. of 58 million deaths world- (Lopez, Mathers, Ezzati, Jamison, & Murray,
wide in 2005, 35 million were due to chronic 2006). In the United States, expenditures
illness, with 80% of those deaths occurring in for health care for people with chronic ill-
countries of the global south in equal propor- nesses exceed billions of dollars every year
tions among men and women (World Health and are associated with 75% of the nation’s
organization, 2005). In the United States in $2 trillion health care costs each year (Centers
2005, an estimated 133 million people, that is, for Disease Control and Prevention, 2009).
one out of every two adults, are living with Health care utilization seems to be associated
54 n CInAHL DATABASE
®
with access and income; in Russia, for exam- Nursing and Healthcare of Chronic Illness, pub-
ple, those with chronic illness with health lished by Wiley-Blackwell and edited by
C care insurance and higher average educa- Kralik, is devoted entirely to the nursing care
tion were associated with higher health care of those with chronic illness. other impor-
expenditures (Abegunde & Stanciole, 2008). tant contributions have shown that nursing-
Beyond its economic impact and strain led interventions among those with chronic
on health care systems, chronic illness causes illness improve quality of life and mood
psychological strain on individuals and (Bakitas et al., 2009). Internationally, nurses
physical and mental health effects on those can use behavioral and clinical interven-
who care for them, placing burdens on fami- tions to reduce the risk for many of the prob-
lies (Schulz & Sherwood, 2008). lems that lead to chronic illness and death
The traditional approach to studying (Besdine & Welte, 2010).
chronic illness has been limited, focusing on The landscape of chronic illness is
the medical model. Research has focused on diverse and complex, presenting a vast range
risk factors, prescriptions, and adherence to of symptoms and trajectories, accomplished
treatments (Canadian nurses Association, by a variety of demands over the natural his-
2005). However, a new health paradigm—a tory of the diseases. The impact of chronic
care-oriented model of illness—has emerged. illness on the patient, well family members,
The concept of health is more readily mea- and key caregivers differs and depends on
sured in terms of maximizing physical, psy- when an illness strikes in the family and on
chological, social, and spiritual well-being. In each member’s individual development. As
this paradigm, a holistic health-focused model chronic illness continues to advance through-
has become accepted with a resulting change out the world, it pushes individuals, families,
toward care of the whole person as well as and countries into poverty. nurses can be the
the family. In addition, in chronic disease bridge between those affected by chronic ill-
management, all clinical decisions need to be ness and health care services by promoting
individualized because they usually involve health, by preventing disease, and by caring
choices between possible outcomes that may for people (del Pilar Camargo Plazas, 2009).
be viewed differently by different patients.
The self and family management in chronic Ruth McCorkle
illness framework was developed to engage Mark Lazenby
individuals and families in the management
of their chronic conditions according to their
abilities and preferences (Grey, Knafl, &
®
McCorkle, 2006). Building on the self and Cinahl database
family management framework, Whittemore
and Dixon (2008) have described how adults
with chronic illness can, through self- In the late 1940s, while Index Medicus existed
management interventions, integrate their for the biomedical literature, there was no
illnesses into their life contexts. De Ridder, index to the few nursing journals published
Geenen, Kuijer, and van Middendorp (2008) at the time. Individual librarians took it
have described how those with chronic con- upon themselves at their particular hospi-
ditions who are engaged in self-management tal or school of nursing to index the journals
strategies have the best chance to adjust to the they received for their own population, a tre-
challenges posed by their chronic illness. mendous “duplication of effort and expendi-
Pollock (1986) provided an initial review ture” as well as “waste on a national scale”
of nursing research related to adaptation to (Grandbois, 1964, p. 676). one such librarian
chronic illness. More recently, the Journal of in Los Angeles, Ella Crandall, used 3 × 5
CINAHL DATABASE n 55
®
index cards to meet the needs of the nurses design, methodology, analysis, and data col-
on the staff of White Memorial Hospital and, lection have been added, as have the names
later, Los Angeles County Hospital. This of nursing specialties, organizations, and C
index which began as an internal project was classification systems.
published as The Cumulative Index to Nursing Aside from the terms used, the mate-
Literature in 1961, a cumulation of indexing rials indexed are different from those in
covering the period 1956 to 1960. Seventeen indexes of the biomedical and other litera-
journals were included in this publication— ture. Books and book chapters, pamphlets,
from the American Journal of Nursing and pamphlet chapters, dissertations, audiovisu-
Nursing Research to the American Association als, consumer health, and patient education
of Industrial Nurses Journal. The “red books” materials are just a few of the other types of
as this publication became known were well materials indexed. Because of the difficulty
received in the nursing community (Raisig, in obtaining these materials, they are often
1964) and became a familiar part of nursing defined as elusive or fugitive literature.
education throughout the United States. other changes have also taken place over
over the next four decades and more, these years. Recognizing that the boundaries
the index grew and changed, reflecting the of nursing intersect with many other health
changes taking place in the profession itself. care disciplines, allied health was added
Although, as would be expected, many index- to the index title in 1977, resulting in the
ing terms are similar or identical to those Cumulative Index to Nursing and Allied Health
®
used in the indexing of biomedical journals, Literature (CInAHL ). There are 17 such dis-
there are some important differences, and ciplines covered, including physical therapy,
the many terms added to the thesaurus dem- occupational therapy, and communicative
onstrate the development and growth of the disorders. In 1983, the CInAHL electronic
nursing profession, both as a practice and as a database became part of several online ser-
science. The thesaurus is composed of a hier- vices and was released as a CD-RoM in 1989.
archical tree structure that is used to index Recent years have seen the development
to the most specific focus of the material. of CInAHL-created documents as part of the
Broad categories include anatomy, diseases, database. These include research instrument
and health care, among others. An example descriptions, clinical innovations, accredita-
of this hierarchy would be as follows: tion materials, and legal case descriptions.
The database can no longer be viewed as
Social control only a bibliographic database although that
Human rights continues to be its primary function. Like
Patient rights Index Medicus, the print index is no longer
Treatment refusal published in printed form; the database is
now available only electronically.
An article specifically concerning a patient Throughout the nearly 50 years of its
who was unwilling to accept care would be existence, the primary goal of CInAHL
indexed with the most specific term: “treat- Information Systems, as publisher of the
ment refusal.” A more general article might index and now the database, has been to
be indexed using the “patient rights” term. connect nursing and later allied health pro-
Increased emphasis on nursing research, fessionals with materials written about and
specialty and advanced practice, or managed for them. The basic premise underlying the
care has resulted in indexing terms such as existence of this tool is that effective and
phenomenology, survival analysis, family knowledgeable practice depends on access
nurse practitioners, case management, and to materials describing or studying that
nursing intensity. Research terms describing practice. These materials may be present
56 n CLInICAL CARE CLASSIFICATIon SYSTEM
in a variety of formats and from a variety and designed for measuring outcomes
of sources. Whereas indexing began with and determining care costs, workload, and
C fewer than 10 journals, the current journal resources in any health care information
list includes more than 3,000 titles. Content technology (HIT) system. The CCC System
other than that listed above includes practice version 2.1 is based on a coded, standard-
guidelines, practice acts, standards of prac- ized, and unified framework for electronic
tice, critical pathways, and even full text of documentation, processing, retrieval, and
some journal articles. This is far too much analysis following the conceptual frame-
material for any individual to subscribe to work of the American nurses Association
or otherwise acquire randomly, making an (AnA) six nursing process standards (2003)
index to the material essential. “Increased (assessment, diagnosis, outcome identifica-
emphasis on professionalization of nursing tion, planning, implementation, and evalua-
and clinical competence” (Pravikoff, 1993, tion) to assess, to document, and to evaluate
p. 33), changes in health care delivery, and a patient holistically.
ever-increasing time pressures make any tool The CCC System is the first national
that assists in gathering information critical nursing Standard accepted by the Depart-
to practice. Searching this material on a reg- ment of Health and Human Services as a
ular basis should be a professional obligation coded interoperable terminology for the
of members of all health care disciplines for information exchange of health data in the
the duration of their careers. Evidence-based electronic health record through the office
nursing practice requires access to the best of the national Coordinator for Health
available information to “provide the most Information Technology and the office
consistent and best possible care to patients” of the national Coordinator Healthcare
(Pravikoff, Tanner, & Pierce, 1994, p. 40). Information Technology Standards Panel
Biosurveillance Technical Committee in
Diane Shea Pravikoff the first set of approximately 55 standards
adopted by the Department of Health and
Human Services Secretary in 2007 and 2008.
The CCC System is free with permission,
CliniCal Care consists of atomic-level concepts and open
source/open architecture for documenta-
ClassiFiCation systeM tion of patient care in the electronic health
record systems. The CCC is interoperable
with the American national Standards
The Clinical Care Classification (CCC) Institute, Health Level Seven, integrated
System, previously known as the Home in Logical observations Identifiers names
Health Care Classification System (version and Codes, meets the Cimino criteria for
1.0), is a standardized, coded nursing termi- a standardized terminology, is an AnA
nology system that identifies discrete atomic- recognized terminology, and conforms
level concepts and data elements of nursing to ISo Reference Terminology Model for
practice. The CCC System provides a unified nursing (ISo-18104). The CCC System is
framework and coding structure for nurses also indexed in the Metathesaurus of the
and allied health professionals to electroni- Unified Medical Language System and
cally capture and document the “essence Cumulative Index of nursing and Allied
of care” in all health care settings. The Health Literature.
CCC System is a clinical decision- support The CCC System was developed as part
terminology developed empirically from of a federally funded research study by
research of live patient care data records the Health Care Financing Administration
CLInICAL CARE CLASSIFICATIon SYSTEM n 57
(1988–1991) to develop a methodology for elec- major and 126 subcategories] and 4 action
tronically assessing and classifying Medicare qualifiers: assess/monitor, perform/care,
patients to predict nursing resources and teach/instruct, and manage/refer). CCC of C
evaluate outcomes. The research study was nursing outcomes consists of 546 nursing
conducted by Dr. virginia K. Saba, Rn, EdD, diagnosis outcomes (182 diagnoses and 3
FAAn, FAMCI, LL, and her colleagues at the outcome qualifiers: improve, stabilize, and
School of nursing, Georgetown University, deteriorate) to code expected and actual
Washington, DC. The research study con- outcomes.
sisted of a national sample of almost 650 The CCC System consists of a four-level
health care facilities, which collected data framework that allows data to be coded at
on approximately 9,000 newly discharged multiple levels of abstraction and analyzed
Medicare cases representing each patient’s at multiple levels of granularity. The highest
entire episode of care from admission to level is four health care patterns: health behav-
discharge. The CCC System (version 2.1) ioral, functional, physiological, and psycho-
provides the documentation of nursing care logical, each of which represents a different
by linking nursing diagnoses, interventions, number of care components. The health care
and outcomes using the six standards of the patterns provide the framework for the third
nursing process recommended by the AnA level of the 21 care components—a cluster of
(2003). elements that depicts a holistic approach to
The CCC System was empirically devel- patient care. The care components are as fol-
oped from the computer processing of lows: activity, bowel/gastric elimination, car-
approximately 40,000 textual phrases rep- diac, cognitive, coping, fluid volume, health
resenting nursing diagnoses and/or patient behavior, medication, metabolic, nutritional,
problems and 72,000 phrases depicting physical regulation, respiratory, role rela-
patient care services and/or actions collected tionship, safety, self-care, self-concept, sen-
on the research study cases from live patient sory, skin integrity, tissue perfusion, urinary
records. The textual phrases were processed elimination, and life cycle. The 21 care com-
by computer using keyword sorts, statisti- ponent nursing classes were found to be
cal analyses, and other computerized tech- clinically relevant and the best predictors
niques, which provided the framework for of health care resources (Holzemer et al.,
classifying, coding, and indexing the textual 1997).
phrases to create the one system known as The next level consists of two interre-
the Home Health Care Classification version lated terminologies: (1) the CCC of nursing
1.0. It was revised in 2003–2004 from research Diagnoses and outcomes and (2) the CCC
study and feedback from “live” HIT systems of nursing Interventions and Actions. The
to form version 2.0 and the current CCC CCC of nursing Diagnoses and outcomes
System version 2.1. depicts patient conditions and/or problems
The CCC System, version 2.1, consists requiring clinical care by nurses and allied
of two terminologies: the CCC nursing health professionals. The definition of a nurs-
Diagnoses and outcomes and the CCC ing diagnosis is based on the definition used
nursing Interventions/Actions. Together, the by the north American nursing Diagnosis
two interrelated terminologies form one sin- Association (1992). An example of CCC
gle system classified by 21 care components nursing Diagnosis is Activity Alteration
and organized by 4 health care patterns. CCC (A01). Each nursing diagnosis is also paired
of nursing Diagnoses consists of 182 code with three outcome qualifiers (improve, sta-
concepts (59 major and 123 subcategories). bilize, and deteriorate) to depict an expected
CCC of nursing Interventions consists of 792 and an actual outcome representing the 546
nursing interventions (198 interventions [72 CCC outcomes. The qualifier digit represents
58 n CLInICAL DECISIon MAKInG
the lowest level of the framework and pro- action. This coding structure facilitates the
vides the codes for expected outcomes (goal design of clinical care pathways as well as
C of care) and actual outcomes (goal resolu- other plans of care applications.
tion); for example, Expected outcome (Goal) The CCC System has been implemented
to Improve Activity Alteration (A01.0.1), by numerous HIT vendor systems: Siemens
whereas Actual outcome Activity Alteration Medical Solutions integrated the CCC into
Stabilized (A01.0.2). Sorian©, which is distributed around the
The CCC of nursing Interventions and world. It has also been implemented in hospi-
Actions is the terminology used to docu- tals, for example, Rush Presbyterian Hospital
ment the “essence of nursing care” deter- (Chicago, IL), Southeast Hospitals Group
mined to treat the diagnosis, problem, or (Fall River, MA), orton Hospital (Helsinki,
condition. The definition of a nursing inter- Finland), Kupio Hospital (Kupoi, Finland),
vention is “A single nursing action designed Hospital Corporation of America (HCA), and
to achieve an outcome for a nursing or medi- numerous others. Further, it is translated into
cal diagnosis for which the nurse is account- Dutch, Portuguese, Spanish, Finnish, Korean,
able” (Saba, 2007, p. 328). An example of CCC Turkish, and so forth.
nursing Intervention is Cast Care (A02.1). In summary, the CCC System version
Each nursing interventions is always mod- 2.1 documents nursing practice follow-
ified by one of four Action qualifiers: (1) ing the nursing process. It is being used
assess/monitor, (2) perform/care, (3) teach/ in nursing research for the design of deci-
instruct, or (4) manager/refer. The quali- sion support systems, in nursing education
fier digit also represents the lowest level of by incorporating it in PDAs for electronic
the framework, which expands the nursing documentation, and as a simulated system
intervention, service, activity, and so forth, using a PC to enhance the learning of the
and provides the codes for the four action nursing process. The CCC System validates
types. Examples of intervention actions are the documentation of nursing practice
as follows: assess cast care (A02.1.1), perform makes nursing visible, provides the data for
cast care (A02.1.2), teach cast care (A02.1.3), the “essence of nursing” care, and contrib-
and manage cast care (A02.1.4). The four utes to patient care while advancing nurs-
codes make the intervention action data eas- ing science.
ier to process, retrieve, and analyze; that is,
the four intervention actions require differ- Virginia K. Saba
ent services, skills, and time, making it pos-
sible to measure outcomes, determine cost,
workload, and resources.
The CCC System coding structure is CliniCal deCision Making
based on the structure of the International
Classification of Diseases and Health Related
Problems, Tenth Revision (Who, 1992). Each Clinical decision making is a process that
diagnostic and intervention concept is involves the interaction among the knowl-
assigned a unique five alphanumeric charac- edge of preexisting pathological conditions,
ter code: first position, an alphabetic charac- patient data, clinical experience, and judg-
ter for the care component; second and third ment (Banning, 2008). Clinical decision-
positions, a two-digit code for a core data ele- making ability is defined as the ability by
ment (major category) followed by a decimal which a clinician identifies, prioritizes, estab-
point; fourth position, a one-digit code for a lishes plans, and evaluates data. Decision
subcategory (if needed); and fifth position, making is central to professional nursing
a one-digit code for a qualifier outcome or and has vital links to patient care outcomes
CLInICAL DECISIon MAKInG n 59
(Catolico, navas, Sommer, & Collins, 1996). aspect of understanding the significance of
Researchers have investigated the process, the data acquired and in making the cor-
types, and quality of clinical decision mak- rect decision. nurses gain a sense of saliency C
ing. Catolico et al. (1996) studied decision in clinical decision making with increased
making of practicing staff nurses. It was experience (Banning, 2008). In a study of
demonstrated that nurses with better com- novice and expert nurses in an intensive care
munication skills had a greater frequency of unit, it was demonstrated that expert nurses
actual decision-making practices. Intuition used a wider range of cues, and more cues
was a critical component of clinical decision that identified impending problems, in their
making in a qualitative study of novice nurse clinical decision making (Hopkins, Aitken, &
practitioners (Kosowski & Roberts, 2003). Duffield, 2009).
Some researchers have looked at approaches When investigating the decision- making
such as informatics or algorithms to aid deci- process, researchers have used simulations,
sion making. Gillespie and Peterson (2009) together with interviews regarding the
showed that that the use of a decision-making thought processes individuals use to reach
framework to guide clinical decision making decisions. The quality of decision making
by novice nurses fostered the development of is defined as having the ability to make fre-
their knowledge, skill, and confidence. quently required decisions (Catolico et al.,
A critical issue in clinical decision mak- 1996). That aspect of decision making has
ing is the educational level, preparation, and been studied by using computer-assisted
experience of the nurses who are formulat- simulations requiring nurses to make deci-
ing decisions. Studies have explored the sions in controlled clinical situations. To
decision-making process of student nurses, investigate clinical decision making by nurse
staff nurses, and nurse practitioners. A group practitioners, the nurses care for patients via
of nursing students were given didactic and computer and interactive videos. Decision
interactive teaching sessions on clinical deci- support technology serves as an adjunct
sion making. Students’ decision making was to, not as a replacement for, actual clinical
in accordance with the decision making of decision making. Advanced practice nurses
experts significantly more often than that of integrate clinical decision systems into their
the student nurses who did not receive the practices is to provide more objective, scien-
decision-making content (Shamian, 1991). A tifically derived, technology-based data for
study in the United Kingdom demonstrated their patient care decisions (Traynor, Boland,
that nurses having a college education were & Buus, 2010). There are some inherent diffi-
significantly better at decision making than culties with technology-based decision sup-
their colleagues educated in diploma pro- port systems. nurses who are unfamiliar or
grams (Girot, 2000). Advanced practice uncomfortable with the technology are less
nurses in specialty practices tend to generate likely to value the utilization of the systems
fewer hypotheses in their clinical decision (Weber, Crago, Sherwood, & Smith, 2009).
making. Those nurses must be aware that nurses have a professional responsibil-
formulating a diagnosis too early in the data- ity to provide patients with opportunities
gathering phase precludes the possibility of to participate in clinical decision making.
considering all options (Lipman & Deatrick, However, patients’ preferences to partici-
1997). nurses with case-related experiences pate vary greatly. Patient participation in
are more likely to choose appropriate inter- clinical decision making has been studied
ventions. A study of nurse practitioners by from a variety of perspectives. In a study of
White, nativio, Kobert, and Engberg (1992) more than 400 patients, it was shown that
concluded that case content expertise is cru- females, those with a high school or college
cial for clinical decision making from the education, and those with previous hospital
60 n CLInICAL JUDGMEnT
experience are significantly more likely to concerned and involved ways. Clinical judg-
prefer an active role in clinical decision mak- ment occurs within a framework of clinical,
C ing (Florin, Ehrenberg, & Ehnfors, 2008). It legal, ethical, and regulatory standards and
is also crucial for nurses to have knowledge is closely aligned with phenomena such as
of ethical issues related to clinical decision critical thinking, decision making, problem
making. This is particularly important when solving, and the nursing process (Benner,
the decision process is regarding end-of-life Tanner, & Chesla, 1996).
care (Mahon, 2010). Expert clinical judgment is held in high
nurses’ decision making has been regard by nurses as it is generally viewed as
shown to be affected by the sociodemograph- essential for provision of safe, effective nurs-
ics of the patient. Age, sex, race, religion, and ing care and the promotion of desired out-
socioeconomic status can impact on decision comes. nursing research has been conducted
making. Racial disparities in health care may on the processes of clinical judgment with
be due to racial biases when formulating the intent to better understand how nurses
clinical decisions. Interviews with African identify relevant information from the vast
American patients with diabetes revealed amounts of information available and then
that they believed that shared decision mak- use that information to make inferences about
ing was offered more often to White patients patient status and appropriate interventions.
(Peek et al., 2010). non-White patients pre- The complexity of the clinical judgment pro-
senting to the emergency department with cess has brought about collaboration of nurse
chest pain are hospitalized less frequently researchers with multidisciplinary experts
than White patients (Pope et al., 2000). There from a broad array of scientific backgrounds
was a significant difference in reports of sus- including cognitive psychology, informatics,
pected abuse after the evaluation of fractures phenomenology, and statistics.
between minority and nonminority children The body of research on clinical judg-
(Lane, Rubin, Monteith, & Christian, 2002). ment generated by interdisciplinary collabo-
Competent clinical decision making by ration has been categorized into two distinct
nurses requires being cognizant of potential theoretical classifications: the “rationalistic”
biases. Decision making is critical to nurs- and the “phenomenological” perspectives. In
ing practice. Gathering, organizing, and pri- this context, the term “rationalistic” describes
oritizing data are major components of the scientific inquiry into the deliberate, con-
process. Continued research in this area can scious, and analytic aspects of clinical judg-
foster the development of decision-making ment (Benner et al., 1996). Examples include
skills in novice nurses and cultivate high research on the role of information process-
clinical decision-making ability in expert ing, diagnostic reasoning (Tanner, Padrick,
nurses. Westfall, & Putzier, 1987), and decision
analysis (Schwartz, Gorry, Kassirer, & Essig,
Terri H. Lipman 1973) in the clinical judgment process. The
term “phenomenological” refers to research
on the skill-acquisition component of clinical
judgment as advanced by Benner and Tanner
CliniCal JudgMent (1987) and Benner et al. (1996) in the novice
to Expert Model.
Information processing theory and diag-
Clinical judgment has been defined as the nostic reasoning are based on the work of
process by which nurses come to understand Elstein, Shulman, and Sprafka (1978) and
problems, issues, or concerns of patients, newell and Simon (1972) and collectively
attend to salient information, and respond in describe problem-solving behavior and the
CLInICAL JUDGMEnT n 61
effect of memory and the environment on reasoning used by nursing students and
problem solving. These theories hold that practicing nurses. They found that practicing
human information processing capacity is nurses were more likely to use a systematic C
restricted by short-term memory, and effec- approach and to be more accurate in diag-
tive problem-solving ability is dependent on nosis than the students. Henry (1991) exam-
adoption of strategies to overcome human ined the effect of patient acuity on clinical
limitations. Information processing theory decision making of experienced and inex-
and diagnostic reasoning have been applied perienced critical care nurses using comput-
widely to the study of clinical judgment and erized simulations. Findings suggest that
the use of information in the clinical judg- inexperienced nurses collected more data
ment process. The literature suggests that and had poorer patient outcomes than expe-
nurses and physicians use a similar process rienced nurses.
for clinical judgment, which involves infor- Salantera, Eriksson, Junnola, Salminen,
mation gathering, early hypothesis gen- and Lauri (2003) used simulated case descrip-
eration, and then additional information tions and the think-aloud method to compare
gathering to confirm or rule out a suspected and describe the process of information gath-
diagnosis or clinical problem. According to ering and clinical judgment by nurses and
the “rationalistic theories,” early hypothesis physicians working with cancer patients. The
generation “chunks” data and is an effective authors found that while nurses and physi-
strategy for conserving short-term memory cians identify similar problems, they use
(Corcoran, 1986; Elstein et al., 1978; Tanner divergent approaches to information gather-
et al., 1987). Although knowledge generated ing and knowledge base application for the
from work completed in the fields of infor- purposes of clinical judgment. They found
mation processing and diagnostic reasoning that nurses rely more on personal knowl-
has been descriptive in nature, decision anal- edge, whereas physicians rely more heavily
ysis is a prescriptive approach to decision on theory.
making and involves the process of weighing Unlike the objective, detached approach
cues and using mathematical models (gener- to the study of clinical judgment charac-
ally made possible through expert systems) teristic of the rationalistic perspective, the
to determine the course of action most likely phenomenological perspective holds that
to produce desired outcomes. intuition is a legitimate and essential aspect
Corcoran (1986) used an information of clinical judgment and is the feature that
processing approach and verbal protocol distinguishes expert human judgment from
technique to compare care-planning strate- that of expert systems (Benner & Tanner,
gies used by hospice nurses. She found that 1987). Benner’s work is based on the skill-
unlike novice nurses, the overall approach acquisition model advanced by Dreyfus and
of expert nurses differed by case complex- Dreyfus (1980). According to this model,
ity with a systematic method used for less there are six key aspects of intuitive judg-
complex cases and an exploratory approach ment: pattern recognition, similarity recog-
for cases of greater complexity. In addition, nition, commonsense understanding, skilled
expert nurses generated more alternative know-how, sense of salience, and deliberative
actions during the treatment planning pro- rationality (Benner & Tanner, 1987). Much of
cess, were better able to evaluate alternative the research related to Benner’s work and the
actions, and developed better care plans than novice to Expert Model relates to the rela-
did novices. tionships that exist between nursing knowl-
Tanner et al. (1987) used verbal responses edge, clinical expertise, and intuition.
to videotape vignettes to describe and com- The novice to Expert Model was devel-
pare the cognitive strategies of diagnostic oped using a phenomenological approach to
62 n CLInICAL JUDGMEnT
interview and observe nurses with varying Table 1
degrees of clinical expertise. In the inter- Four Phases of the Tanner CJM
C view process, nurses were asked to describe
outstanding clinical situations from their CJM Aspect Description
practice. Benner found that a holistic grasp noticing Perceiving the situation based
of clinical situations is a necessary precur- on clinical knowledge, clinical
experience, and knowing the patient
sor to expert clinical judgment (Benner, Interpreting Developing a deep understanding of
1984). Subsequent research supports these the situation
findings and discriminates between differ- Responding Intervening based on clinical
ences in clinical judgment among clinicians reasoning
with varying levels of experience (Corcoran, Reflecting Reading the patient response to
1986). In a 6-year interpretive study of nurs- interventions and making
adjustments to care based on that
ing practice, Benner et al. (1996) identified response; ongoing deliberation of
five interrelated aspects of clinical judg- practice to secure lessons learned
ment: (1) disposition toward what is good From Tanner, 2006.
and right, (2) extensive practical knowledge,
(3) emotional responses to the context of a
clinical situation, (4) intuition, and (5) role of Using the CJM as a conceptual frame-
narrative in understanding a patient’s story, work, Lasater (2007) developed the Clinical
meanings, intents and concerns. The authors Judgment Rubric to provide a means to
suggested that these aspects play a signifi- describe and quantify levels of performance
cant role in clinical judgment and deserve in clinical judgment. neilson further devel-
equal consideration along with the aspects oped this work though development of the
arising from the “rationalistic” perspective CJM study guide that uses the phases of
of clinical judgment. Tanner’s model to assist students in appli-
on the basis of a critical review of liter- cation of the model to assigned patients in
ature published through 2004, Tanner (2006) clinical practice (nielsen, Stragnell, & Jester,
proposed an alternative model of clinical 2007). Together, the Clinical Judgment Rubric
judgment. The Tanner Clinical Judgment and the study guide provide an evaluation
Model (CJM) represents the complexity of framework to assist faculty and preceptors
the construct including its interrelation with in recognizing and evaluating clinical judg-
the nurses’ background, the situational con- ment skills in more novice nurses. In addi-
text, and the degree to which knowing the tion, these tools provide guiding principles
patient influences interpretation of findings, and a standardized language for offering
response, and reflection on that response feedback to students as they work to develop
(Tanner, 2006). The CJM proposes a nonlinear clinical judgment skills.
process that characterizes the clinical judg- Although early research on clinical judg-
ment skills used by expert nurses. However, ment identified two divergent but legitimate
the model supports the diagnosis of break- perspectives of rationalistic and phenome-
down in clinical judgment with novice nurses nological approaches, the more recent work
by faculty members and preceptors. The CJM (Lasater, 2007; neilson 2007; Tanner, 2006)
also supports self-diagnosis of lapses in clin- indicates signs of convergence. The challenge
ical judgment by more experienced nurses for future research is continued integration
through self-reflection on practice. The CJM of these perspectives to apply what is known
includes four distinct yet iterative phases: (1) and to study the impact of integrated models
noticing, (2) interpreting, (3) responding, and on clinical reasoning and patient outcomes.
(4) reflecting. A description of each phase is Tanner’s CJM provides a framework that
included in Table 1. holds promise not only for supporting the
CLInICAL nURSInG RESEARCH n 63
skill-acquisition component of clinical judg- degrees, doctoral education with a major
ment but also for guiding research on clinical in nursing finally became a reality, and the
reasoning patterns, associated actions, and focus of nursing research shifted more firmly C
practice outcomes. away from nurses and nursing education to
the practice of clinical nursing. The broad
Patricia C. Dykes definition of clinical nursing research, then,
Moreen Donahue was originally formulated to differentiate
between the research conducted by nurses
before the 1960s, which focused on nurses,
and the major shift in focus on practice.
CliniCal nursing researCh Strongly influenced by the establish-
ment of the Center for nursing Research (at
present the national Institute of nursing
Clinical nursing research is both broadly Research) in the national Institutes of Health,
and narrowly defined. Broadly, it denotes clinical nursing research has recently taken
any research of relevance to nursing prac- on a narrower definition, modeled after the
tice that is focused on care recipients, their definition of clinical trials (large-scale exper-
problems and needs. This broad definition iments designed to test the efficacy of treat-
stems from the 1960s, when a major change ment on human subjects) used at national
occurred in nursing science. Before the 1960s, Institutes of Health. This narrow definition
the research of nurses had focused on nurses limits clinical nursing research to only those
and the profession of nursing including studies that focus on testing the effects of
major questions of interest related to nurs- nursing interventions on clinical or “nurse
ing education and the way in which nurses sensitive” outcomes.
practiced within care delivery structures In addition to an evolution in definition,
(i.e., hospitals). The reasons for these foci are clinical nursing research also has changed in
many, but for the most part they stem from form and complexity over time. Early clini-
the dearth of nurses with advanced degrees cal nursing research was characterized by
at that time and the fact that nurses with a focus on circumscribed areas of inquiry
advanced degrees were educated in other using experimental and quasi-experimental
disciplines (e.g., education). methodologies. Investigators were few and
In the late 1950s and 1960s, a major shift tended to work in isolation. often an inves-
occurred, driven by three factors. First, lead- tigator conducted single studies on different
ers in nursing successfully lobbied for the problems rather than series of studies focused
institution of the nurse scientist program on different aspects of the same problem.
through the federal government, which pro- As a result, study results tended to be con-
vided financial support for nurses to be edu- text bound and limited in generalizability
cated in the sciences (e.g., physiology, biology, to other settings, samples, or problems. The
anthropology, psychology). Second, nurse relationship between theory development
theorists such as Faye Abdellah, virginia and research was discussed abstractly but
Henderson, Imogene King, Ida orlando, not explicitly operationalized, and a philoso-
Hildegard Peplau, and Martha Rogers began phy of knowledge building rather than prob-
to formulate conceptual models to direct lem solving had not yet developed.
nursing practice, and attention was focused The next stage in the evolution occurred
on designing research that more or less was with the realization that little was known
guided by those models (or at least the sub- about many of the phenomena of concern to
stantive areas circumscribed by the models). nurses. This heralded a period during which
Third, as more nurses attained advanced emphasis shifted away from experimental
64 n CLInICAL nURSInG RESEARCH
methods to exploratory/descriptive methods, change also may be required. This has
such as grounded theory. Guided by the resulted in the need for many investigators
C meta-paradigm of nursing (person, nursing, to incorporate techniques such as time series
health, and environment), nurse scientists analysis and individual regression into their
began focusing on discovering and naming research.
the concepts of relevance for study in nursing, Understanding the human responses of
delineating the structure of these concepts, concern to nurses can also require an under-
and hypothesizing about the relationships of standing of cellular mechanisms that are best
these concepts in theoretical systems. studied in animal models and a coupling of
More recently, clinical nursing research biological techniques such as radioimmu-
has become clearly defined as a cumula- noassay and electron microscopy, with psy-
tive, evolutionary process. Investigators are chosocial techniques such as neurocognitive
still advised to derive questions from clini- assessment or self-report of psychological
cal problems, but the focus is on knowledge states. In addition, measurement of differ-
generation, specifically the generation and ent units of analysis (e.g., individual, family,
testing of middle-range theory (a theory organization) may be required, along with
that explains a class of human responses), strategies for understanding the effect of care
for example, self-help responses, symptom contexts (e.g., social, physical, organizational
experience and management, and family environments) on the human response of
responses to caregiving. Because knowledge concern. needless to say, single investigators
is viewed as cumulative, investigators usu- rarely have all the skills needed to advance
ally study various aspects of one particular the understanding of a particular concept.
concept or response; studies build on one As a consequence, single investigators are
another, and each study adds a new dimen- becoming more and more a thing of the past
sion of understanding about the concept of as teams of scientists, including nurses and
interest. This approach to clinical nursing individuals from other disciplines, collabo-
research requires investigators to use mul- rate in the knowledge-building endeavor.
tiple methodologies in their programs of nursing is concerned with human
research, including (a) inductive techniques responses and is based on the assumption
to discover knowledge from data, (b) deduc- that humans are holistic and embedded in
tive techniques to test hypotheses that are history and various environments. Clinical
either induced or deduced, and (c) instru- nursing research is about generating a body
mentation to increase the sensitivity, reliabil- of knowledge on which nurses can base prac-
ity, and validity of the measurement system tice. It is about assuring the efficacy and safety
designed for the concept. of nursing actions, substantiating the effect
The methodologies being used include of nursing actions on patient outcomes, and
qualitative methods such as ethnometh- conserving resources (costs, time, and effort)
odology, grounded theory, and phenome- while effecting the best possible results. It is
nology and quantitative methods, ranging about identifying strategies for improving
from traditional experimental methods and the health of the population and promoting
designs to less traditional methods, such as humanization within a health care environ-
path analysis and latent variable modeling. ment that has a natural tendency to be mech-
Because human responses change over time anistic, compartmentalized, and focused on
on the basis of contextual factors or treat- short-term rather than long-term gain. It is
ments (independent variables) applied by the about client advocacy, client protection, and
nurse investigator and because understand- client empowerment. The challenge of clini-
ing the nature of change often is at the crux cal nursing research is to develop an under-
of the theory building, skills in measuring standing of human response through theory
CLInICAL PREvEnTIvE SERvICES n 65
generation and testing while developing Meissner, 2004; Lopez-de-Munain, Torcal,
measurement systems and using research Lopez, & Garay, 2001; Ma, Urizar, Alehegn, &
methods that capture the holism of the cli- Stafford, 2004; natarajan & nietert, 2003; C
ent and the holistic nature of the health care nelson et al., 2002; Solberg, Kottke, & Brekke,
experience. 2001; Stange, Flocke, Goodwin, Kelly, &
Zyzanski, 2000; USPSTF, 2000). A number of
Linda R. Phillips variables influence the delivery of clinical
preventive services primary care providers.
Research has shown that lack of the provision
of preventive services included clinicians’
CliniCal preventive report lack of time (Ayres & Griffith, 2007a,
2007b, 2008; Frame, 1992; Jackson, 2002), lack
serviCes of commitment to prioritize preventive ser-
vices, inadequate reimbursement for clinical
preventive services, lack of adequate clini-
Clinical preventive services are screenings, cian training, and the lack of a system to inte-
vaccinations, counseling, or other preventive grate clinical preventive services into regular
services delivered to one patient at a time by patient care (Ayres & Griffith, 2006, 2007a,
a health care practitioner in an office, clinic, 2007b, 2008; Cornuz, 2000).
or health care system (Centers for Disease Attributes of primary care such as
Control and Prevention, 2010). Timely receipt patient preference for their regular physi-
of clinical preventive services (nelson et al., cian, interpersonal communication, and
2002; Taylor-Seehafer, Tyler, Murphy-Smith, coordination of care influence the delivery
Hitt, & Meier, 2004; United States Preventive of clinical preventive services. In addition,
Services Task Force [USPSTF], 1996) can personal factors have also been found to
reduce premature mortality and morbidity. influence the delivery of clinical preventive
Evidence suggests that screening for colo- services. Clinician failure to use recommen-
rectal and breast cancer can reduce morbid- dations in the form of clinical guidelines
ity and mortality for many older patients has been explained by a perceived lack of
(Holmboe et al., 2000; Pignone, Rich, Teutsch, effectiveness, lack of familiarity with the
Berg, & Lohr, 2002; Smith et al., 2001). There content of published recommendations, the
is strong consensus that screening for colo- belief that some forms of recommended
rectal, breast, and cervical cancer, screening care do not apply in ones’ own practice,
for high blood cholesterol levels, and timely the reduced confidence that screening
receipt of adult immunizations can reduce will lead to expected outcomes, and the
the risk of premature death (Apantaku, 2000; uncertainty about which preventive ser-
Lawvere et al., 2004; nelson et al., 2002) and vices to provide to their patients (Ayres &
that tobacco use, excessive alcohol use,physi- Griffith, 2006, 2007a, 2007b; Lawvere et al.,
cal inactivity, obesity, and failure to use safety 2004; Litaker, Flocke, Frolkis, & Stange,
belts increase mortality risk (Kerlikowski 2005; Tudiver et al., 2001; USPSTF, 2000;
et al.; nelson et al., 2002; Shapiro, Seeff, & Zitzelsberger, Grunfeld, & Graham, 2004;
nadel, 2001). Zoorob, Anderson, Cefalu, & Sidani, 2001).
Although scientific evidence exists for Primary care practices are strategic
emphasizing prevention within clinicians’ avenues for initiating clinical preventive
practices, studies have shown that clinicians services. Yet, although visits to the doctor’s
often fail to provide recommended clini- office are appropriate times to advise patients
cal preventive services (Ayres & Griffith, on health behaviors, these opportunities are
2007a, 2007b, 2008; Finney Rutten, nelson, & often missed (Woolf & Atkins, 2001). Studies
66 n CLInICAL PREvEnTIvE SERvICES
have reported that nurse practitioners (nPs) therapeutic services, and played a larger role
provide more preventive care than do phy- in ob-gyn clinics than Pas.
C sicians (Hooker & McCaig, 2001); however, Studies using other techniques, such
no studies to date have solely investigated as chart review and vignettes, have also
the factors that may influence the delivery revealed differences between MDs and nPs
rates of clinical preventive services provided in the practice characteristics carried out
by nPs based on the theoretical literature. during patient encounters. In a chart review
Studies that examined the delivery of clini- study comparing nPs and MDs in the pri-
cal preventive services have been conducted mary care of adults with type 2 diabetes,
exclusively with physicians or have included nPs were found to be more likely than MDs
nPs under an umbrella term of “clinicians” to document the provision of general diabe-
dominated by physicians and examined tes education and education about nutrition,
under a medical practice model. weight, exercise, and medications (Lenz et al.,
There is a growing body of evidence that 2002). In a review of 10 health maintenance
nPs and physicians differ in the preventive items, relatively poor overall compliance was
and treatment strategies they use during found with rectal examinations, pneumococ-
patient encounters and in the populations cal vaccinations, and fecal occult blood tests.
served (Aparasu & Hegge, 2001; Hopkins, Better performance was seen for cholesterol
Lenz, Pontes, Lin, & Mundinger, 2005; Lenz, screening and mammography. Patients in
Mundinger, Hopkins, Lin, & Smolowitz, this study who were followed by nPs experi-
2002; Lin, Hooker, Lenz, & Hopkins, 2002; enced better rates of adherence to prevention
Moody, Smith, & Glenn, 1999; Pieper & measures than patients followed by nP-MD
Dinardo, 2001). For example, the process of teams, or MDs alone, although all groups had
nP and MD patient encounters and the pop- relatively low adherence to prevention guide-
ulations these providers tend to serve have lines (Pieper & Dinardo, 2001). Inconsistent
been examined in several studies using data adherence to diabetes guidelines has been
from the national Ambulatory Medical Care found for nPs studied in isolation (Fain
Survey (nAMCS). one study found that nPs & Melkus, 1994) as well as MDs (Puder &
directly supervised by MDs saw younger Keller, 2003).
patients than MDs and provided counseling A study by the national Alliance of
and education during a higher proportion of nurse Practitioners was conducted in 1992
visits (Crabtree et al., 2006; Hooker & McCaig, to evaluate nPs’ performance in the deliv-
2001; Hung et al., 2006). Another study exam- ery of clinical preventive services (Martin,
ined patient encounters of nPs combined 1992). Two journal articles reported conflict-
with physicians’ assistants (PAs) and found ing results of the national Alliance of nurse
that nP/PA patients were more likely to be Practitioners study. one study reported that
65 years or older, female, Black, and from the nationally nPs were meeting or exceed-
northeastern United States when compared ing most of the preventive service objec-
with MD patients (Aparasu & Hegge, 2001). tives (12 out of 17) recommended in Healthy
Another study that used nAMCS data found People 2000, with progress needed in only
nPs to have younger clients who were more a few areas (Lemley, o’Grady, Raukhorst,
often female. nPs also tended to provide Russell, & Small, 1994).
more health counseling interventions and Another study suggested that nPs
to perform fewer office surgical procedures have not been as consistent or as frequent
(Moody et al., 1999). Lin et al. (2002) used in providing preventive services as recom-
nAMCS data to compare nP with PA prac- mended by Healthy People 2000 and major
tice and found that nPs saw a larger propor- authorities (Griffith, 1994). In fact, a later
tion of visits, provided more preventive and study reported nPs devoted less than 1% of
CLInICAL TRIALS n 67
patient encounter time to health promotion to improve the delivery of clinical preventive
(Courtney & Rice, 1997). Given the empha- services among clinicians, once again inclu-
sis on health promotion and disease preven- sive of nPs, have been developed empirically C
tion in nP clinical practice, little research rather than being based on a sound theoret-
has occurred since 1992 regarding nP per- ical understanding of underlying cognitive
formance in these areas of clinical preven- processes that may influence the extent to
tion. Since 1992, pressure on nPs to see which clinicians deliver clinical preventive
more patients in a given amount of time has services to their patients. Examining the
increased, and there may be a gap between variables that may influence nurses’ deliv-
what nPs believe to be the ideal and what is ery of clinical preventive services based on
actually practiced (Birkholz & viens, 2001). theory has the potential to inform the design
Although physician adherence to clini- of theory-based interventions to improve the
cal preventive services guidelines has been delivery rates among the patient populations
found to be uneven (Finney Rutten et al., nPs typically serve, the diverse and chron-
2004; Gottlieb et al., 2001; Kiefe et al., 2001; ically underserved populations such as the
Lopez-de-Munain et al., 2001; Ma et al., 2004; elderly, the poor, and those in rural areas.
natarajan & nietert, 2003; nelson et al., 2002;
Solberg et al., 2001; Stange et al., 2000; USPSTF, Cynthia G. Ayres
2000), nPs and their adherence to guidelines
have not been as closely examined. Studies
that have specifically examined nPs to gain
a better understanding of their delivery CliniCal trials
of clinical preventive services are few and
far between. Furthermore, there has been
very little research conducted to assess the A clinical trial is a prospective controlled
knowledge and behaviors specific to nPs experiment with patients. There are many
in the area of delivering clinical preven- types of clinical trials, ranging from studies
tive service based on USPSTF guidelines. to prevent, detect, diagnose, control, and treat
Additionally, the nPs’ attitudes, beliefs, and health problems to studies of the psycholog-
behaviors about preventive care activities ical impact of a health problem and ways to
have not been fully examined using a theo- improve people’s health, comfort, function-
retical framework from which effective, the- ing, and quality of life.
ory-based interventions could be developed The universe of clinical trials is divided
and tested. differently by different scientists. Clinical
Although the goal to improve the deliv- trials are often grouped into two major clas-
ery of clinical preventive services in primary sifications, randomized and nonrandom-
care is undisputed, progress in this area is ized studies. A randomized trial is defined
slow. Studies that have examined primary as an experiment in which therapies under
care practice to improve the delivery of clin- investigation are allocated by a chance mech-
ical preventive services have included nPs anism. Randomized clinical trials are com-
under an umbrella term of “clinicians” dom- parative experiments that investigate two
inated by physicians and examined under or more therapies. nonrandomized clinical
a medical practice model. However, nurses, trials usually involve only one therapy, on
particularly nPs, by virtue of their nursing which information is collected prospectively
philosophy and education as well as their and the results compared with historical
scope of practice, may be unique in their data. Comparing prospective data with his-
attitudes, beliefs, and behaviors about pre- torical control data introduces biases from
ventive care. Moreover, strategies designed many sources. These potential biases are
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Encyclopedia of Nursing Research
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