518 n TRANSLATIONAL RESEARCH
it is interpreted in a range of ways (Levine, the ability to control the intervention versus
2007; Newby and Webb, 2010). Translational an inconsistent or convenient application of
T research is often referred to as “bench-to- the intervention, the identification and mea-
bedside” and further explained in several surement of outcomes, the choice of statis-
ways: using new knowledge produced as a tical analyses, and the ability to generalize
part of the science of discovery and applying findings.
that knowledge to improve health and health In an attempt to address methodological
care, or the application of new and unproven issues and to improve translational research
laboratory discoveries to improve health, or methods, glasgow (2009) discussed the need
research that explores and develops potential for translational research designs to consider
treatments and tests the safety and efficacy of four critical research issues that relate to the
those treatments in randomized control trials. ability to generalize findings from transla-
These definitions of translational research tional research:
are referred to as T1 translation (Agency for
Healthcare Research and Quality, 2000). 1. use of a heterogeneous population—
However, a second definition or type of samples must be purposively selected to
translational research, referred to as T2 trans- represent the real world and include rep-
lation (Agency for Healthcare Research and resentativeness of age, gender, ethnicity,
Quality, 2000), investigates how the newly and health literacy that have all been asso-
discovered science can be applied to real- ciated with inequity in health care.
world clinical settings. Even when a drug, 2. use of multiple settings—the research
test, or treatment is found safe and effica- must include a range of settings that repre-
cious in the randomized control trial, further sent a typical practice.
research on the use of that drug or treatment 3. use of comparison—well-designed com-
in a typical clinical practice or setting is nec- parisons that include the current standard
essary. The setting for this type of transla- of care to an alternative rather than pla-
tional research is the organization, clinical cebo or no treatment.
practice, or community, and it requires a dif- 4. use of multiple outcomes—include mul-
ferent set of research skills. Sometimes now tiple outcomes that are relevant to deci-
referred to as implementation science (Titler, sion makers and policy makers including
2004a), this translational research evaluates cost, benefit, quality of life, and impact
interventions in the clinical setting using measures.
information technology, epidemiology, orga-
nizational theory, change theory, adult learn- It is widely recognized that the gap
ing theory, behavioral science, marketing between research findings and practice is a
theory, social cognitive theory, social ecolog- concern for all health care practitioners, and
ical theory, and social influence/communica- many countries are investing in providing
tion theory to further a better understanding resources to increase and support transla-
of organizational variables that affect the tional research (Canadian Institutes of Health
translation of evidence into practice. Research, 2009; Cooksey, 2006; National
Calling both T1 and T2 programs of Institutes of Health, 2009; Woolf, 2008). At a
research “translational research” has been a time when experts warn of the fragmented
source of confusion to many. T1 and T2 face health care system and a widening “chasm” in
different research challenges including the access, quality, and disparities, interventions
recruitment of subjects, homogeneous sam- to close these gaps—the work of T2—may
ples versus diverse samples/populations, do more to improve outcomes than the dis-
rigor of the research methods particularly covery of yet another new imaging device
TRANSLATIONAL RESEARCH n 519
or additional drug (Institute of Medicine, at least neutralized external environment. To
2003; Mcglynn et al., 2003; Woolf, 2008). The move from single studies to broader impact,
Clinical and Translational Science Awards therefore, one will need to increase synergies T
program, a part of the National Institutes for across studies, bring in the organizational
Health’s effort to catalyze the development of component, consider and potentially mod-
clinical and translational science, was devel- ify the impact of reimbursement, regulation,
oped to assist institutions take a unique, and other environmental factors, and look at
transformative, and integrative academic ways to take findings to scale” (Fraser, 2004).
approach to translational research (National This is still our challenge today in transla-
Institutes of Health, 2010). Focusing on the tional research.
second area of translational research, these A third type of translational research,
programs seek to close the gap and improve or T3, has been described in the literature
quality by improving access, reorganizing and is necessary to evaluate the ongoing
and coordinating systems of care, helping and complex environmental and policy
clinicians and patients to change behaviors measures that affect sustainability of clin-
and make more informed choices, providing ical strategies that have been found safe
reminders and point-of-care decision sup- and efficacious and have successfully been
port tools, and strengthening the patient- implemented (Lean, Mann, Hoek, Elliott, &
clinician relationship (National Institutes of Schofield, 2008). The Agency for Healthcare
Health, 2010). Research and Quality developed the
In October 2003, a 2-day invitational con- partnerships for Quality program to accel-
ference was held at the university of Iowa to erate the translation of research findings
discuss the future of translation science in into practice on a broad scale through pub-
advancing systems to support quality nurs- lic/private partnerships led by organiza-
ing care called “Advancing Quality Care tions well-positioned to reach end-users
through Translation Research.” The confer- and maintain the consistency of emerg-
ence used a definition of translation research ing evidence across the health care system
that has since been used in nursing research: (Donaldson et al., 2007).
“the scientific investigation of methods, There are interesting examples of
interventions, and variables that influence translational research in the literature, but
adoption of evidence-based practices (EBps) most focus on only one type of transla-
by individuals and organizations to improve tional research discussed above. To further
clinical and operational decision making in understand the continuum of translational
health care. This includes testing the effect research, the following example will show
of interventions on promoting and sustain- how an innovation in health care, a scien-
ing the adoption of EBps” (Titler, 2004b). The tific discovery, can be applied and evaluated
conference developed a consensus around to improve outcomes in the care of a patient
the importance of translation of evidence with congestive heart failure (CHF). A T1
and in the summary article of the conference, translation research study would first test a
Fraser (2004) captured the discussion: “The new drug or treatment that has been found to
successful impact requires, at a minimum, a be safe and efficacious in previous discovery
strong evidence base, a well-designed inter- and design a randomized control trial to test
vention and implementation strategy that that drug or treatment in a specific popula-
takes into account the structure, culture, and tion/sample, for example African American
capacities of the organization itself and, if male CHF patients between 40 and 50 years
necessary, succeeds in modifying these as of age in one clinic in a large suburban pri-
part of the intervention, and a supportive or mary care practice. If the drug was found to
520 n TRIANguLATION
be effective, the research team would eval- triangulation has its roots in surveying and
uate the effectiveness of implementing this navigation, and describes the idea of using
T drug or treatment for a broader population, known points and angles in a triangular
such as all CHF patients in that practice and fashion to locate an unknown point.
several other practices around that city who There are four different approaches to
admit their patients to a similar hospital. triangulation: methodological, data, theoret-
The T2 translational research study would ical, and investigator. Methodological trian-
be designed to determine the best strategies gulation, currently the most commonly used
(educational, marketing, e-mail, phone, mail- triangulation approach in nursing research,
ings, and meetings) to communicate the suc- involves the use of two or more different meth-
cess of this drug or treatment in CHF to all ods within a single study. This approach can
practitioners in the area and to increase the involve within-method or between-method
practitioners’ compliance implementing the triangulation. Within-method triangulation
new evidence, theoretically, to close the qual- refers to the use of several different instru-
ity chasm. Finally, a T3 translational research ments to measure a construct, for example, the
study would be designed to study how the use of the peabody picture Vocabulary Test-
inclusion of this new drug or treatment in Revised as well as the Kaufman Assessment
CHF guidelines of care could be sustained Battery for Children to measure different
and become a nationwide standard of care dimensions of child development. Between-
for all CHF patients. A program, such as the method (also known as across-method) tri-
American Heart Association’s Get with the angulation refers to the use of more than one
Guidelines, is a prefect example of a program research method to study a phenomenon, for
to use to disseminate the new evidence. The example, the use of a qualitative approach
T3 research would focus on the strategies to such as phenomenology in concert with a
implement the program to sustain compli- quantitative approach such as a descriptive
ance nationwide using the new drug or treat- survey. Between-method triangulation can
ment as part of the coronary artery disease be accomplished simultaneously or sequen-
secondary prevention treatment guidelines to tially. A second type of triangulation, theo-
be implemented for CHF patients by the time retical triangulation, involves the analysis of
of hospital discharge. What is often referred data using several related yet perhaps con-
to as “distilling evidence” through the imple- tradictory theories or hypotheses. This type
mentation of guidelines for care helps take of triangulation can be used within a quan-
evidence to all practitioners to improve the titative or a qualitative methodology; it seeks
outcomes of care. to avoid a narrow, specialized interpretation
of the data. A third type, data triangulation,
Kathleen M. White involves data collected from different sources.
A fourth type of triangulation is investigator
triangulation. The use of more than one data
collector helps to ensure the reliability of the
TriangulaTion data and the use of multiple analysts to inter-
pret the data guards against the risk of bias
associated with only one point of view.
Triangulation, as it is most commonly used Originally, triangulation was carried
in nursing research, refers to the combina- out mainly for purposes of confirmation.
tion of qualitative and quantitative research Confirmation is analogous to convergent
methods within a single study. There are a validity and refers to the idea that through
number of approaches to triangulation, and the use of multiple methods, data sources, or
it can serve a number of purposes. The term investigators, a single, obvious conclusion or
TRIANguLATION n 521
representation of reality can be researched. Despite these challenges, triangulation
Recently, triangulation has been conducted of method, data, theories, or investigators
to achieve completeness. This approach can can be an important tool in developing nurs- T
illuminate many of the individual facets of a ing science. The concepts of interest to nurs-
multidimensional construct. These research- ing are generally complex, multidimensional
ers used qualitative and quantitative meth- human constructs and are difficult to exam-
ods as they sought both confirmation and ine by means of a singular research approach.
completeness in their study of families with Triangulation is a means to a deeper under-
a critically ill child. However, not all schol- standing of these constructs.
ars agree with the notion of triangulation for
completeness. Theresa Standing
U
of uncertainty in chronic illness. This classic
Uncertainty in illness qualitative study on living with uncertainty
brought home the invasion of uncertainty
into multiple aspects of life and some strate-
Uncertainty in illness has been defined by gies to tolerate the uncertainty.
Mishel (1988) as the inability to determine Since the publication of the Uncertainty
the meaning of illness-related events; this in Illness Theory and the scales to measure
occurs in situations in which the decision uncertainty: Mishel Uncertainty in Illness
maker is unable to assign definite value Scale (Mishel, 1981), the Parents Perception
to objects and events or is unable to accu- of Uncertainty Scale (Mishel, 1983b), the
rately predict outcomes because of a lack of exploration of uncertainty scales for spe-
sufficient cues. The uncertainty theory by cific populations (Mishel, 1983a), along with
Mishel explains how uncertainty develops early conceptualization of the uncertainty
in patients with an acute illness and how it within illness (Mishel, 1981), the study of
is proposed that patients deal with uncer- uncertainty has expanded considerably. Both
tainty. Mishel further defined the original qualitative and quantitative work in nursing
theory to refer to chronic illness in 1990, and in other fields added to the knowledge
building the extended theory on chaos the- on uncertainty in illness. The research has
ory and presenting a new model. spread to practice through clinical publica-
Uncertainty regarding an illness has been tions (Hilton, 1992; Righter, 1995; Wurzbach,
identified as the greatest single psychological 1992). A second instrument on uncertainty in
stressor for the patient with a life-threatening illness has been developed by Hilton (1994).
illness (Koocher, 1985). Uncertainty is not the This instrument is based on the stress and
total experience in acute and chronic illness, coping framework by Lazarus and Folkman
yet it is a constant occurrence from diagno- (1984) and is not derived from a nursing the-
sis through living with a long-term illness ory of uncertainty in illness.
or condition. The study of uncertainty dates A number of reviews of the research on
back to some of the early work by Davis (1960), uncertainty in illness have been published.
in which he detailed the difference between The first review by Mast (1995) used the
clinical and functional uncertainty and tied uncertainty in illness theory as the frame-
the experience to the delivery of care and work for the review of research on uncer-
the agenda of health care providers. From tainty. Similarly, the two reviews by Mishel
1960 through 1974, other early perspectives in the Annual Review of Nursing Research
on uncertainty emerged, which included the (1997, 1999) also used the Uncertainty in
work by McIntosh (1974, 1976) on the desire Illness theory published in 1988 as the frame-
for information among patients with cancer. work for review, although Mishel (1999) also
This work provided some of the first ideas included the uncertainty theory published
about the ambiguity surrounding diagnosis in 1990 to evaluate the qualitative work done
and prognosis and the impact of this ambi- on uncertainty in chronic illness. Stewart
guity on the patient’s psychological state. and Mishel (2000) reviewed the research on
Work by Wiener in 1975 explored the topic parent and child uncertainty. Other recent
UnceRTAInTy In ILLneSS n 523
reviews of the research and theory on uncer- in this area, it should be focused on building
tainty include the review by neville (2003), on what is known instead of repeating simi-
with a focus on application to orthopedic con- lar findings. U
ditions, and the chapter by Barron (2000), on concerning the role of personality dis-
stress, uncertainty, and health. Mishel’s work positions as antecedents or modifiers of
on uncertainty has lead to stimulating fur- uncertainty, the evidence is not solid. In acute
ther work within nursing and related fields. illness, there is some support for mastery in
Work on the concept of uncertainty has been a mediating role, but the study of personality
published by Mccormick (2002), Brashers dispositions related to uncertainty has been
(2003, 2004), and by Babrow (2001) from the limited to a small number of studies, all with
field of health communication. Discussion cancer patients receiving treatment. Other
of the theory of uncertainty as conceptual- acute illnesses require study to see which
ized by Mishel has appeared in two sources personality dispositions are associated with
on nursing theory (Alligood & Tomey, 2002; uncertainty and at which phase in the illness
Smith & Liehr, 2003, 2008). experience. Further research is necessary to
As noted by Barron (2000) and Mishel determine if the acuity of illness immobi-
(1997), there has been a strong interest in lizes personality variables and whether they
the study of uncertainty; however, most of come into play during the recovery phase or
it has been atheoretical. Most of the quanti- during the management of continual uncer-
tative studies of uncertainty in illness have tainty in chronic illness.
used one of Mishel’s uncertainty scales, but In chronic illness, interesting findings
the selection of variables had not been tied to are emerging from quantitative studies of
the theory of uncertainty in illness. Most of perceived personal control as a personality
the research has been on uncertainty in spe- disposition for influencing uncertainty and
cific clinical populations, with the predom- the relationship between uncertainty and
inance of the quantitative research on acute mood state. Likewise, spirituality is also
illness and with more qualitative work on being studied for its potential in modifying
chronic illness. This may be due to the focus the impact of uncertainty in mood. Both of
of the uncertainty scales on acute illness and these avenues of study are important and
hospitalization, with less use of the Growth point out that in a long-term illness, person-
through Uncertainty Scale, which was devel- ality dimensions may come into play for their
oped to address the chronic enduring illness ability to reduce uncertainty or to reduce the
conditions. negative impact of uncertainty.
In the study of uncertainty, most of the Studies of coping with uncertainty in
descriptive studies are cross-sectional and persons with acute illness have resulted
the findings are associative, although the in consistent findings for the relationship
analyses in many studies are often consid- between uncertainty and emotion-focused
ered predictive when causal modeling is coping. To determine if a broader range of
used. At this time, some consistent findings coping strategies exists, attention needs to
have emerged. Across all illnesses studied be given to developing instruments that are
to date, uncertainty decreases over time and related to the problem under study. If coping
returns upon illness recurrence or exacerba- strategies were derived from the setting and
tion, and uncertainty is highest or most dis- population, results may differ from those
tressing while awaiting a diagnosis. current consistently accrued from global measures of
evidence is strong for the role of social sup- coping.
port in reducing uncertainty among those There is sufficient evidence that uncer-
with an acute illness. Because of the consen- tainty has a negative impact on quality of life
sus of the findings, if further research is done and psychosocial adjustment in acute illness
524 n UnLIcenSeD ASSISTIve PeRSOnneL
populations. Uncertainty has consistently across studies so that support for particular
been found to be related to depression, anxi- strategies can emerge.
U ety, poorer quality of life, less optimism, and In conclusion, the research on the con-
negative mood states. Because the evidence cept of uncertainty continues to spread across
is consistent and strong, it provides direction disciplines and countries. Today, the uncer-
for interventions to target outcome variables. tainty in illness scales have been translated
There is growing evidence in support of the into more than 15 languages and the research
effectiveness of supportive educational inter- continues across all continents.
ventions in modifying the adverse outcomes
from uncertainty. Recently, interventions for Merle H. Mishel
managing uncertainty in breast and prostate
cancer have been published and reported
strong intervention effects (Braden, Mishel,
Longman, & Burns, 1998; Mishel et al., 2002, Unlicensed assistive
2003, 2005, 2009). Recent publication of the
intervention work in Advancing Oncology Personnel
nursing Science (2009) has presented
the interventions to a broader audience.
Furthermore, the recent ncI monograph Unlicensed assistive personnel (UAP), func-
(epstein & Street, 2007) on Patient-centered tioning in an assistive role to the registered
communication in cancer care includes nurse (Rn), providing specific kinds of
uncertainty as conceptualized by Mishel as direct and indirect care pursuant to dele-
a central issue in doctor–patient communica- gation of such tasks by an Rn and in accor-
tion. The research needs to expand with the dance with the respective state’s nurse
use of the theory. In other disciplines, a the- Practice Act, are a safe, appropriate, and
ory such as the uncertainty theory would be efficient use of resources to provide nursing
used and expanded. However, in nursing, the care (AnA Position Statement, 2007). They
theory is dissected and not built on except for are known by a variety of names in differ-
the work of a few. Repeated testing of these ent care/ service settings, including patient
interventions, and the development of theory care assistant, nurse extender, nurse part-
and research-based interventions that build ner, patient care technician, or nursing assis-
on the body of existing descriptive and inter- tive personnel in acute care; certified nurse
vention research, should be the direction of assistant (cnA) in nursing homes; resident
future research. assistant in assisted living; personal care
In chronic illness, the work on manage- attendant or home care aide in home care;
ment of uncertainty has been advanced by aide; orderly; and so forth. Job qualifications,
qualitative investigations in which a variety training, and nursing activities vary widely.
of management methods have been found nursing home (nH) cnAs are the subject of
across a number of chronic illnesses. The more intervention and descriptive studies
findings from qualitative studies indicate than any other UAPs.
that people are very resourceful in finding Most state boards of nursing indicate
approaches for living with enduring uncer- what nursing processes/tasks can and can-
tainty. However, there is an absence of con- not be delegated. Tasks can be assigned if the
sistent findings. This may be because of the care task is routine, low risk, unlikely to need
variation in the qualitative methods applied to be modified, has a predictable outcome,
and how uncertainty is defined in such stud- and does not require assessment, interpre-
ies. More solid research is needed in this tation, or decision making. In general, tasks
area, with an attempt to replicate findings cannot be delegated to UAPs if the patient
UnLIcenSeD ASSISTIve PeRSOnneL n 525
is “medically fragile.” Ultimate responsibil- cnA work experience and why they chose to
ity and accountability bears on the Rn who work in long-term care (i.e., a nursing home);
needs to be aware of the education, training, (2) changes needed in wages, benefits, and U
and experience of the UAP and periodically career opportunities that would make the
assesses the UAPs performance of the spe- cnA job more attractive and retain current
cific task. A qualitative analyses of narra- workers; and (3) to develop a framework for
tives (based on the Five Rights of Delegation) evidence-based research and practice initia-
about a delegated task that resulted in pos- tives that would address workforce issues.
itive and negative outcomes—revealed that Key subject areas were recruitment, educa-
nurses attributed negative outcomes to UAPs tion (initial and ongoing), job history, family
performing nursing activities that had not life, quality of management and supervision,
been delegated to them (e.g., administering work load and recognition for value of the
a tube feeding) and their failing to receive cnAs work, growth opportunities within
or follow directions or established policy the organization, job satisfaction, workplace
(Standing, Anthony, & Hertz, 2001). A nurse’s attitudes and environment, on-the-job inju-
experience and longevity in practice is more ries, and demographics. Interviewees who
associated with their readiness for, and com- no longer worked at the nH were asked why
fort with, delegation than with their being they left, current work arrangements, and if
educated on how to delegate. A facility’s job they would recommend the nH to a fam-
description for UAPs constitutes “implicit” ily or friend. Data from the nnHS, nnAS,
delegation but is not always recognized as and the minimum data set will be combined
such by nurses. explicit delegation is more to look at associations between facility and
concretized by nurses and constitutes more worker characteristics, perceptions, experi-
than just the patient assignment. ences, and resident care outcomes (Squillace,
A growing number of states permit spe- Remsburg, Bercovitz, Rosenoff, & Branden,
cially trained UAPs to administer some types 2007). Analysis of nnAS, nnHS, and Area
of medications (generally, oral medications), Resource File data revealed that economic fac-
in which case the UAP is certified as a “med tors (i.e., wages and benefits) for low-income
tech” or “med aide.” There is no difference nH workers was significantly associated
in the medication error rate between assisted with turnover as are job security and other
living community (ALc) med techs/aides opportunities for employment in the geo-
and licensed nurses with regard to errors graphic area (Weiner, Squillace, Anderson, &
with potential moderate-to-significant harm Khatusky, 2009).
(center for excellence in Assisted Living/ Studies indicate that UAPs working
University of north carolina, 2009). Most in long-term care (i.e., nH, ALc, and home
errors were errors of time, that is, outside the care) want, above all, respect and recogni-
2-hour administration window. Medication tion from their supervisors/superiors for the
errors of any kind were associated with poor work they do (Barry, Brannon, & Mor, 2005;
scores on a written test of medication admin- Kemper et al., 2008; Pennington, Scott, &
istration and knowledge. Magilvy, 2003). Regardless of setting, UAPs
The national nursing Assistant Survey want a leadership style that is trusting and
(nnAS) was first conducted in 2004 as a supports teamwork (Pennington et al., 2003),
supplement to the national nursing Home management practices that support empow-
Survey (nnHS). Designed as a probabil- erment and input into care decisions to effec-
ity study, nnAS data were collected via tuate quality outcomes (Barry et al., 2005;
computer-assisted telephone interview from Pennington et al., 2003), and better commu-
slightly over 3,000 cnAs. The three main nication (Kemper et al., 2008). empowerment
purposes of the nnAS were (1) to describe variables include nurse aides working on
526 n UnLIcenSeD ASSISTIve PeRSOnneL
committees, job enhancement opportunities, self-direction, and an enhanced relation-
extent and kind of delegation, and the degree ship with the resident, the absence of fair
U of influence that aides have regarding res- wages and personal growth opportunities
ident care (Barry et al., 2005). Interestingly, could mute the presumed attractiveness of
there is a positive association between the a restructured job in keeping with culture
influence a nurse aide brings to the develop- change principles (Bishop et al., 2008).
ment of a resident’s plan of care and the level Individualized care, a precursor to the
of social engagement of the resident in facil- concept and practice of person-centered care
ity life (Barry et al., 2005). (Pcc)—a hallmark of the culture change
As part of the Better Jobs Better care movement—requires organizational struc-
demonstration project, a survey of almost tures and supports to be realized. nursing
3,500 UAPs working in home care, ALcs, home cnA’s perceptions about facilitators of
and nHs found that the recommendation for individualized care include supervisor sup-
increased compensation was statistically sig- port of cnA suggestions, their interest and
nificant for all three groups (n = 1,091; Kemper willingness to assist a cnA in trying a new
et al., 2008). Recommended improved work approach to care, and their being a resource for
relationships were statistically significant resident care issues (curry, Porter, Michalski,
with regard to communication, apprecia- & Gruman, 2000). Being able to provide indi-
tion, and supervision. When nH cnAs per- vidualized care also means that the cnAs
ceive that their job affords them autonomy, have to have the flexibility to change their
the opportunity to use their knowledge, and assignment or schedule and to fully partic-
work as a team, they are more committed to ipate in the development of the plan of care.
their job. This, in turn, has a positive effect on Barriers to individualized care are similar to
resident well-being and satisfaction (Bishop factors in cnA job dissatisfaction and turn-
et al., 2008). The quality of the relationship over: insufficient staff, inadequate education
between a UAP and his or her supervisor in clinical care, negative attitude, and poor
affects commitment. Having control over team communication.
their work and being able to use their knowl- A researcher-developed instrument to
edge can, however, be mishandled and per- assess the kind and amount of time cnA
ceived by the cnA as job expansion rather students spent providing Pcc—the Patient-
than job enhancement (Bishop et al., 2008). centered Behaviors Inventory (PcBI)—found
empowered cnA work teams—one of no difference between cnA students in the
the operational principles of culture change— intervention group (i.e., received special
can increase individual empowerment, instruction in Pcc) versus those in the con-
improve performance (and cooperation), trol group (i.e., no Pcc instruction; Grosch,
reduce sick calls and turnover, and improve Medvene, & Wolcott, 2008). Using trained
resident care and choices (yeatts & cready, coders and another researcher-developed
2007). cnAs in an empowered team gained instrument—the Global Behavior Scale—
decision-making skills and competence, as intervention cnA students were slightly
well as having the opportunity to provide more likely to be in a Pcc mode, but not sig-
feedback to their colleagues. The influence of nificantly. Residents were more satisfied with
empowered cnA work teams on job attitude their interactions with the intervention cnA
is mixed, however. nurse managers need students than with the control group stu-
education about team empowerment; what dents. The PcBI, drawing on the literature,
it means, what it does, communication and operationalized Pcc to include communica-
feedback, and the nature of accountability for tion that conveyed interest in the resident’s
team decisions. Given the positive potential of comfort, explaining the nursing task to be
culture change that includes empowerment, performed and asking permission to begin,
UnLIcenSeD ASSISTIve PeRSOnneL n 527
offering choices about the care options, pro- and lower educational achievement (high
viding feedback to the resident about their school or less) are likely to disagree with eBP
participation in the task, engaging in social recommendations. These UAPs do not want U
conversation, and respectfully responding to care for demented or agitated residents
to the resident’s questions and concerns. The and, in fact, have a sense of helplessness
reliability and validity of the PcBI were not when trying to do their work and complete
reported nor were the statistical significance their assignments (Ayalon, Arean, Bornfeld,
of the findings. The guidelines to adminis- & Beard, 2009). Ayalon et al. (2009) examined
tering the PcBI, prepared by the researchers, three major beliefs about eBP with regard
can move forward further development and to Alzheimer’s disease and agitation: beliefs
testing of this instrument. about the use of isolation and intense super-
As has been reported by others, nH vision of residents with Alzheimer’s disease,
cnAs are subject to pejorative name-calling beliefs about the effectiveness of pharmaco-
by residents (Berdes & eckert, 2001; Ramirez, logical versus nonpharmacological/behav-
Teresi, & Holmes, 2006). In some cases, the ioral interventions, and beliefs about the
name-calling lacks specific racial references nature and intensity of family involvement.
(known as “anachronistic racism”); in other Significant differences between the UAPs
cases, it is targeted and meant to be offen- and health care professionals (i.e., admin-
sive (known as “malignant racism”; Berdes istrators, nurses, social workers, and thera-
& eckert. 2001). Support groups did not peutic recreation staff) were reported. More
improve the cnA’s feelings of worthlessness so than health care professionals, UAPs had
and demoralization. However, in-service great faith in the use of physical or chemical
education about confusion and dementia restraints to control agitation and dementia
behavior reduced the cnA’s perception of behavior, felt that the family’s role in manag-
racism and improved their attitudes towards ing the resident’s behavior was limited, and
such residents. believed that isolation and intense supervi-
As many as 65% of nH and ALc resi- sion were effective interventions. educational
dents have some kind of dementia in varying interventions have to start with preparing
stages and intensities. Interviews conducted for receptivity of eBPs and then move on
with 154 UAPs in nHs and ALcs revealed to actual findings and guidelines. nursing
that those with 1 to 2 years work experience assistants collect data and interpret what
had a higher stress level but more positive they see for use in rating scales, the mini-
attitude about Pcc in comparison with those mum data set, and in construction of the plan
who had been working longer (Zimmerman of care. Quality of life rating for persons with
et al., 2005). Patient-centered attitude was dementia by UAPs in nHs and ALcs seems
consistently associated with dementia-sensi- to be associated with their attitudes about
tivity, job satisfaction, and perceived compe- dementia, training, and their confidence in
tence in providing dementia care. identifying and attending to their residents’
Although education has been put forward care needs (Winzelberg, Williams, Preisser,
as the best way to help staff, especially direct Zimmerman, & Sloane, 2005).
care workers like UAPs, understand, man- An instrument developed in collabora-
age, and feel confident about care of persons tion with cnAs was able to identify change
with dementia, drawing on evidence-based in nH residents’ behaviors such that it pre-
practice (eBP) as the goldstone to guide prac- dicted the development of an acute illness
tice might not be appreciated or valued by within 7 days in comparison to residents
some health care workers. UAPs belonging to with no observed change (Boockvar, Brodie,
minority ethnic groups, with fewer years of & Lachs, 2000). Documentation of change
acculturation, english-language proficiency, on the “Illness Warning Instrument”
528 n UnLIcenSeD ASSISTIve PeRSOnneL
preceded licensed nurse documentation of low among residents who were experiencing
change in the medical record by an aver- unreported pain.
U age of 5 days. The 10-item instrument asks Professional nursing supervision of the
if the resident is the same or different daily care delegated to nH UAPs requires
“today” with regard to, for example, food organizational systems and resources to fully
intake, watching Tv, confusion, or needing operationalize the supervisory role (Siegel,
help with personal care. young, Mitchell, & Shannon, 2008). There
A comparison of resident self-reported appears to be a direct relationship between
and cAn report of the presence, location, turnover and informal supervisory systems
and intensity of pain revealed that more resi- and processes. In spite of nurses’ recognition
dents than cnAs reported pain (Horgas & that they have received little formal training
Dunn, 2001). Severity reports of pain by resi- for their supervisory role, they do not per-
dents and cnAs were similar. The cnAs ceive a need for such training. The mediating
were underdetecting pain in some cases and effect (and efforts) of management are effec-
overreporting pain in other cases. Depression tive in crisis intervention but fail to address
was clinically present among residents whose the larger issue of the need for a valued, pre-
pain was not reported by cnAs. conversely, pared, and robust UAP workforce.
feelings of well-being were high among resi-
dents whose cnAs reported their pain and Ethel L. Mitty
V
Content validity determines whether
Validity the items sampled for inclusion adequately
represent the domain of content addressed
by the instrument. The assessment of con-
Validity refers to the accuracy of responses tent validity spans the development and
on self-report, norm-referenced measures of testing phases of instrumentation and super-
attitudes and behavior. Validity arises from sedes formal reliability testing. Examination
classical measurement theory, which holds of the content focuses on linking the item
that any score obtained from an instru- to the purposes or objective of the instru-
ment will be a composite of the individu- ment, assessing the relevance of each item,
al’s true pattern and error variability. The and determining if the item pool adequately
error is made up of random and systematic represents the content. This process is typ-
components. Maximizing the instrument’s ically done by a panel of experts, which
reliability helps to reduce the random error may include professional experts or mem-
associated with the scores (see Reliability), bers of the target population. Lynn (1986)
although the validity of the instrument helps has provided an excellent overview of the
to minimize systematic error. Reliability is judgment- quantification process of having
necessary but not a sufficient requirement judges assert that each item and the scale
for validity. itself is content-valid. The results of the pro-
Validity and theoretical specification cess produce a content validity index, which
are inseparable, and the conceptual clari- is the most widely used single measure for
fication (see Instrumentation) performed in supporting content validity. Content valid-
instrument development is the foundation ity should not be confused with the term
for accurate measurement of the concept. face validity, which is an unscientific way of
Broadly stated, validity estimates how well saying the instrument looks as if it measures
the instrument measures what it purports to what it says it measures. Although content
measure. Underlying all assessment of valid- validity is often considered a minor compo-
ity is the relationship of the data to the con- nent for instrument validation, researchers
cept of interest. This affects the instrument’s have repeatedly found that precise attention
ability to differentiate between groups, pre- to this early step has dramatic implications
dict intervention effects, and describe the for further testing.
characteristics of the target group. Criterion validity is the extent to which
Literature usually describes three forms an instrument may be used to measure an
of validity: content, criterion, and construct. individual’s present or future standing on
These forms vary in their value to nursing a concept through comparison of responses
measurement, and unlike reliability, singu- to an established standard. Examination of
lar procedures are not established that lead to the individual’s current standing is usually
one coefficient that gives evidence of instru- expressed as concurrent criterion valid-
ment validity. Instead, validity assessment ity, although predictive criterion validity
is a creative process of building evidence to refers to the individual’s future standing. It
support the accuracy of measurement. is important to note that rarely can another
530 n VALIdITy
instrument be used as a criterion. A true cri- analysis and related factor analytic proce-
terion is usually a widely accepted standard dures, such as latent variable modeling. Factor
V of the concept of interest. Few of these exist analysis has become one of the major ways in
within the areas of interest to nursing. which nursing researchers examine the con-
Construct validity has become the central struct validity of an instrument. It is impor-
type of validity assessment. It is now thought tant to note that this approach addresses
that construct validity really subsumes all only the second aspect of construct validity
other forms. In essence, construct valida- testing and in itself is insufficient to support
tion is a creative process that rarely achieves the validity of an instrument. Factor analysis
completion. Instead, each piece of evidence simply provides evidence that the underly-
adds to or detracts from the support of con- ing factor structure of the instrument is in
struct validity, which builds with time and line with the theoretically determined struc-
use. Nunnally (1978) proposes three major ture of the construct.
aspects of construct validity: (a) specifica- The third aspect of construct validation
tion of the domain of observables; (b) extent provides an opportunity for more creative
to which the observables tend to measure approaches to testing. Hypotheses proposed
the same concept, which provides a bridge have to do with the relationship of the con-
between internal consistency, reliability, and cept being measured with other concepts that
validity; and (c) evidence of theoretically have established methods of measurement.
proposed relationships between the measure These hypotheses deal with convergent and
and predicted patterns. The first aspect is discriminate construct validity, subtypes
similar to content validity and is essentially that examine the relationship of the concept
handled through formalized concept clarifi- under study with similar and dissimilar
cation in instrument development. The inclu- concepts. If data shows a strong relationship
sion of this specification of the domain under with similar concepts and no relationship
construct validity supports the contention with dissimilar concepts, evidence is built
that construct validity is the primary form, for the construct validity of the instrument.
with other types forming subsets within its Should data not support similarities and
boundaries. differences, several options are possible: (a)
The other two aspects of construct valid- the instrument under construction may not
ity are examined formally through a series be accurately measuring the concept, (b) the
of steps. These steps form a hypothesis- instruments for the other concepts may be
testing procedure in which the hypotheses faulty, or (c) the theory on which the test-
are based on the theoretical underpinnings ing was based upon may be inaccurate. The
of the instrument. Hypotheses can relate multitrait–multimethod matrix has been pro-
to the internal structure of the items on the posed as a way to formally test convergent
instrument. Hypotheses can also refer to the and discriminate construct validity.
instrument’s anticipated relationship with Another approach to examining the
other concepts, based on a theoretical formu- relationship among concepts involves a
lation. The first set of hypotheses fall into the known group technique. In this method,
second aspect of construct validity testing; the researcher hypothesizes that the instru-
the latter relate to the third aspect. ment will provide a certain level of data from
Although there are no formalized groups with known levels on the concept the
ways to examine the hypothesis proposed instrument has been designed to measure.
for construct validity testing, some typical The above approaches to testing con-
approaches have been identified in nursing struct validity are only samples of tech-
research. Primarily, the internal structure niques that can be used. As previously
of an instrument is tested through factor mentioned, construct validity testing is
VIoLENCE n 531
creative. Researchers can design unique Nursing scholarships related to violence rec-
ways to support the validity of their instru- ognize the complex interaction of commu-
ments. The important point is that whatever nity and societal factors, individual factors, V
is designed must be based in theory and and familial risk factors that include, but are
must be intuitively and logically supported not limited to, inequality, marginalization,
by the investigator. disparity, residential mobility, poverty, unem-
ployment, lack of education, lack of career
Joyce A. Verran opportunities, housing, social and cultural
Paula M. Meek norms, stigmatization and bias, population
density, history of violence, psychological
conditions, alcohol or drug use, presence
of mental illness, dependency, and attach-
Violence ment disorders, which require evidence and
research-based preventive measures.
Violence and abuse against women
Violence is an intentional public health prob- (VAAW) has been recognized globally as
lem of epidemic proportions that impacts a public health problem affecting women
individuals, families, and communities. regardless of age, culture, or socioeconomic
More than 1.6 million people worldwide status. VAAW consists of physical, psycho-
lose their lives to violence each year (Centers logical, and sexual types; various control-
for disease Control and Prevention, 2010c). ling behaviors by perpetrators; stalking; and
Violence is the leading cause of death for indi- workplace violence. A silent phenomenon
viduals between the ages of 15 and 44 years is violence and abuse against men, which
(Centers for disease Control and Prevention, is also considered a public health problem.
2010c). Since the early 1980s, public health Violence against men occurs through male
practitioners and researchers have responded and female perpetrators in a variety of set-
to violence in an attempt to understand the tings. The types of violence against men are
roots and strategies for the prevention of the same as that experienced by women.
violence. Violence is a preventable prob- Nursing research evolved from concern
lem. The World Health organization (2002) for the victim of abuse and focused on risk
defines violence as “the intentional use of factors, battering syndrome, intimate part-
physical force or power, threatened or actual, ner violence, children of battered women,
against oneself, another person, or against a consequences of abuse, relationships of HIV
group or community, that either results in or infections and violence, and abuse during
has a high likelihood of resulting in injury, pregnancy. Ethical conduct and safety issues
death, psychological harm, maldevelopment, in VAAW research are critical. Campbell,
or deprivation” (p. 5). However, this defini- Harris, and Lee (1995) published a violence
tion of violence is not universally accepted review that highlighted significant findings
as a result of cultural influences. The World in the area of VAAW. Manfrin-Ledet and
Health organization, developed a three-level Porche (2003) published a meta-analysis of
violence typology of violence that includes the state of the science in the intersections of
self-directed, interpersonal, and collective violence and HIV infection.
violence. Contributions by nurse researchers
Violence affects victims physically, emo- related to the study of child abuse have
tionally, psychologically, spiritually, econom- focused on shaken baby syndrome, the bat-
ically, and socially. Nurses are engaged in tered child, health and sociological conse-
providing care to victims and perpetrators of quences of child abuse, risk factors, child
violence in a variety of health care settings. sexual assault, and neglect. Clements and
532 n VIoLENCE
Burgess (2002) conducted research to under- Adolescent violence is preventable behav-
stand children’s responses to family member ior that needs to be understood and treated.
V homicide and associations with complicated However, nursing research related to adoles-
bereavement, including childhood post- cent violence has been rather limited. Vessey,
traumatic stress disorder. duffy, o’Sullivan, and Swanson (2003) have
Elder abuse and neglect are significantly studied teasing, a precursor to bullying, and
underdiagnosed and underreported. The developed the Physical Appearance Related
National Center on Elder Abuse (n.d.) defines Teasing Scale-Revised instrument to assess
seven different types of elder abuse: physi- teasing in school-aged children. Future
cal, sexual, and emotional abuse; financial research should take into account risk and
exploitation; neglect; abandonment; and self- protective factors among the biological, psy-
neglect. Elder abuse is largely hidden under chological, and social-contextual aspects of
a shroud of family secrecy, in addition to the adolescent violence.
problem of not being recognized by health Violence is a ubiquitous problem that
care providers. A nursing scholarship by affects the health of individuals, families,
Fulmer and Gurland (1996) addressed elder and communities. Historically, within nurs-
mistreatment and elder abuse assessment. ing’s evolution as an applied science ser-
Phillips and Rempusheski (1985) studied vice profession, nurses have recognized a
diagnostic and intervention decisions in professional responsibility to care for those
elder abuse and neglect. affected by violence. Thus, nursing research
Researchers have developed valid and focuses on primary, secondary, and tertiary
reliable instruments to identify elders at intervention.
risk of abuse. Instruments include screen- Nursing research and evidence-based
ing tools for elder abuse or tools whose pur- practice focused on victims, survivors, and
pose is to assess existing cases of elder abuse perpetrators of violence provide the nec-
for future risk. Two elder abuse screening essary scientific foundation for improving
tools are the Hwalek-Sengstock Elder Abuse quality of life, safety, and other health inter-
Screening Test and the Indicators of Abuse ventions related to violence and recovery.
Screen. Risk assessment tools for future developing knowledge about the myriad
abuse generally contain a list of indicators of human, social, structural, and environ-
or conditions which are rated with regard mental factors associated with violence
to the elder’s risk for future victimization. requires theoretical and research perspec-
Typical indicators include client characteris- tives to guide practice so that the health and
tics, environmental risk factors, support ser- well-being concerns of those individuals,
vices, historical abuse factors and patterns, families, and communities affected by vio-
and abuse factors (Wolf, 2003). There is a lence are appropriately addressed. Within a
paucity of male violence assessment instru- broad ecological-theoretical perspective that
ments specific to men. addresses human, social, developmental,
The epidemic of adolescent violence and environmental factors associated with
forces millions, including youth, families, violence and health, various topics have been
and communities, to cope with injury, dis- explored throughout the history of nursing
ability, and fatality. Homicide is a leading research on violence, including risk factors,
cause of death for adolescents. Two general battering, intimate partner violence, abuse
trajectories have been proposed to explain during pregnancy, hate crime, dating vio-
the development of adolescent violence. lence, child maltreatment, type and severity
one is the development of violence before of violent attacks, psychological and psycho-
puberty and another is violence beginning social characteristics, health consequences,
in adolescence. coping, and many others.
VIRTUAL NURSE CARING n 533
For example, Campbell, Abrahams, and (2008) used qualitative descriptive methods
Martin (2008) have indicated that structural- to describe the childhood remembrances of
based and gender-based violence needs to be adult women who experienced their mothers V
addressed by researchers from a standpoint being murdered by their fathers (based on
of intersectionality. Scholars have examined interviews with the women). draucker et al.
published research literature on perinatal (2009) conducted a qualitative metasynthesis
home visitation intervention for evidence of to determine the essence of healing from sex-
intimate partner violence assessment and ual violence for adults, in which the violence
intervention, and found that no interventions was from childhood. Thomas and Hall (2008)
were designed to address intimate partner conducted narrative research to determine
violence within the context of home health how women who experienced child abuse as
visits to pregnant and postpartum women children are able to thrive and achieve suc-
(Sharps, Campbell, Baty, Walker, & Merritt, cess. Wei and Brackley (2010) used phenome-
2008). Fredland, Campbell, and Han (2008) nological research to understand the violence
investigated relationships among young experiences of adult men in childhood and
urban youth’s exposure to different forms of their influences on mental health and use of
violence (community, home, and personal), violence in intimate relationships.
stress, coping, and health outcomes (physi- Nursing research, practice, health policy,
cal, behavior, and mental). Humphreys and and political activism have all been instru-
Lee (2009) investigated relationships among mental in addressing violence as a health
violence exposure, social support, depres- phenomenon. Nursing research on violence
sion, and health outcomes with three ethni- has advanced the science of violence preven-
cally diverse community-dwelling midlife tion and treatment. Recommendations for
women. Amar and Gennaro (2005) conducted future research need to focus on understand-
research to examine relationships among ing violence in the context of cultural con-
dating violence, mental health symptoms, siderations. School-related violence must be
health care–seeking, and physical injury. addressed by understanding the complexity
Burgess and Clements (2006) used retro- and extent of this increasing phenomenon.
spective record review of reported cases of Also, there is a need to document the efficacy
elder sexual abuse (60 and older) to identify of violence prevention programs and poli-
mental health symptoms and found that lim- cies through nursing research. Research data
ited data was documented on posttraumatic about human responses to violence should
stress disorder in 284 case records. Burgess provide direction for improved health care,
and Clements have called for research on nursing care outcomes, and policy.
information processing and health outcomes
associated with elder sexual abuse. Linda Manfrin-Ledet
Qualitative research on experiences of Danny G. Willis
hate crime, interparental homicide (uxori- Demetrius J. Porche
cide), healing from sexual violence, thriv-
ing after child abuse, and violent men who
experienced childhood violence are recent
advancements in violence research within Virtual nurse caring
nursing science. Willis (2008) utilized a
phenomenological perspective to discover
meanings in adult gay men’s experiences of The innovative concept of virtual nurse car-
hate crime and its aftermath related to acts of ing (VNC) was operationally defined and
physical, psychological, and verbal violence. measured by Smith (2005, 2008) as commu-
Laughon, Steeves, Parker, Knopp, and Sawin nication of nurses’ concern, expertise, and
534 n VIRTUAL NURSE CARING
advocacy via the Internet in the form of Chee, 2002; Piamjariyakul, Scheifelbein,
accurate science-based health care informa- Smith, 2006; Smith, 2008; Smith et al., 2005).
V tion and guidance that maintains patients’ Web site content that is comprehensive
and family members’ sense of connection and has evidence-based interventions can
with health professionals from a distance provide specific visuals and prompts for
(Smith, 2010a, 2010b). The literature on car- managing complex health care treatments
ing is diverse, with several distinct theoreti- (Fitzgerald, yadrich, Werkowitch, & Smith,
cal perspectives ranging from interpersonal in press). Scientifically based Internet linked
interaction, communicating respect, and algorithms and illustrations can guide
nurses providing families information patients and family caregivers through step-
needed to accurately anticipate their health by-step to solutions for the most common
care challenges (Glasgow et al., 2006; Im & home treatment and health care problems
Chee, 2002; Piamjariyakul, Scheifelbein, (Smith, Puno, & Werkowitch, 2005).
Smith, 2006; Smith, 2008; Smith et al., 2005). Across previous studies, data themes
Watson (2003) emphasizes that nurse caring have found that families recognize caring
is not defined by doing but rather by creating in nurses who communicate detailed and
a connection and conveying an “authentic timely information (d’Alessandro & dosa,
presence” whereby families feel supported 2001; White & dorman, 2000). other con-
to share their experiences and health care sistent themes found that patients describe
stories. Watson (2000) states that caring can a caring nurse as one who “honestly”
be sustained through communications from describes the details about health care man-
a distance using the telephone, Internet or agement difficulties, including the physical
telehealth (picture phones), and that Internet challenges (lack of energy and sleep dis-
connection can encompass the essential turbances), assists them with managing the
“carative” factors of transpersonal teaching- depression associated with chronic illness
learning and sense of presence (Finfgeld- (Smith, Leneerts, & Gajewski, 2002), and
Connett, 2006). guides daily treatment complexities (Czaja
The concept of VNC has been tested & Schultz, 2006; Morris, Bottoroff, Neaderf,
on Web sites to ascertain patient and fam- & Solberg, 1991). Families felt cared for
ily members’ sense of being cared for via when nurses had prepared them for the
Internet-based nursing care (Smith, 2011). typical but also the uncommon occurrences,
The VNC questionnaire has reliable sub- including “all the information” about the
scales that measure patients’ and family “intensity, difficulty,” and the “daily work
caregivers’ perceptions of nurse caring; needed” from caregivers to support the
detected after then use of Web sites contain- patients’ recovery and long-term function-
ing nursing guidance for managing complex ing (Smith, 2009).
health care (Smith, 2010). Connections in vir- The societal and economic perspectives
tual environments (Internet sites, second life on nursing practice via the Internet are cur-
platforms) can increase perceptions of nurse rently being studied. An HHS national study
presence Thus, Web sites can provide VNC found that chronically ill persons of all ages,
in the form of detailed health and treatment ethnic and economic groups, and surpris-
guides, health and illness management infor- ingly, those with depression consistently
mation, to prompts for participation in health used and highly rated the Internet for health
care activities and sharing of care experiences information (Wagner & Hibbard, 2001). There
(Smith, 2008). Web sites can contain nursing was a drastic increase in blue collar (52%),
interventions that help maintain individu- elderly (47%), and caregiver (70%) Internet
al’s quality of life and connection to health use from 2004 to 2006 (Fox, 2009; PEW
professionals (Glasgow et al., 2006; Im & Internet and American Project, 2006). daily,
VIRTUAL NURSE CARING n 535
6 million people log on to health sites (PEW of information, patient confidentiality, and
Foundation, 2003). The few Internet interac- the site’s technical reliability (Smith et al.,
tive programs tested in inner city/rural and 2002). V
low socioeconomic status groups, includ- Smith’s Web sites incorporates “user-
ing our studies, found patient outcomes friendly” designs with information as easy to
improved (Locsin, 2005; Smith, 2007a, 2007b). find as it would be in a newspaper (Brennan
Thus, the Internet can overcome problems et al., 2001). There are common graphics,
of disparity, distance, and health care access simple written instructions, defined medi-
(Fox, 2005; Glasgow et al., 2006). cal terms, and automatic information links.
There are historical examples of pio- For example, users do not have to know the
neering Internet nursing care. Such Web medical term “hyperglycemia” to find infor-
sites have paved the way for contemporary mation on high blood sugar. Training for
practice (Brennan, 1998; Brennan, Anthony, patient/caregivers on their home computer
Jones, & Kahana, 1998; Brennan, Moore, & includes the illustrated and practice session
Smyth, 1992; Piamjariyakul, Schiefelbein, & that was successfully used by the older adults
Smith, 2006). Notably, Smith’s Web sites pro- in Smith’s Internet trial (dauz, Moore, Smith,
vide specific information for the illness being Puno, & Schaag, 2004).
addressed on the site (Smith, 2011; ybarra & Content themes from evaluation of
Bull, 2007). All content is based on the crite- Smith’s Web sites studies were that “the
ria of providing specific evidence that has Internet fixed the need for detailed infor-
been reviewed by health experts to ensure mation on homecare,” the Web site helped
educative quality and clinical accuracy, and with “depressed moods,” and “overcom-
nursing interventions with everyday appli- ing home care related family disruptions.”
cation shown in simple logic tested for ease Furthermore, it was found that the algo-
of use (Smith, 2007a). Each site answers com- rithms guided problem solving. Lastly, (the
mon questions provides decision-making Web sites) “let us know we are not alone.”
guides and online health assessments using Unlike read-only Web sites, Smith’s nursing
an interactive game format—all with imme- Web sites contain unique nursing interven-
diate feedback (Brennan & Aronson, 2003; tions that engage the patient and caregiver in
Wilson, 2007). applying the information in their everyday
Web site formats should all incorpo- management of health or illness (Gustafson
rate the National Institutes of Health Web et al., 2008). Thus, several studies found
Literacy and National disabilities Act stan- that following the use of nurse-developed
dards, including text in large font, simple Internet interventions, nurse caring was
graphics, and easy-to-locate straightforward readily conveyed after the use of the Web
navigation symbols as well as being compat- sites (Smith, 2011).
ible with public library Internet connections New research includes one study of
and basic home personal computers (yadrich photographs and video recordings of surgi-
& Smith, 2008). Also, these Web sites use cal incisions and wounds sent from patients’
geragogy education principles so that infor- mobile phones (Martinez-Ramos, Cerdan, &
mation is given in large font type and sim- Lopez, 2009). other visuals (x-ray, EKGs) are
ple illustrations with repetition and multiple being sent directly to Md’s computer screens
examples (Smith, 2007b). Smith’s Web site has for evaluation and reporting to patients by
certification from the international consumer nurse practitioners (Cisco, 2009). Mobile
advocacy professional group, Health on the phones also expand access to social support
Net (2003). Health on the Net Certification from peers. The current, third-generation eas-
includes multidisciplinary review and then ier-to-use mobile phones meet stringent pri-
continuous random monitoring for credibility vacy standards and Internet access reliability
536 n VULNERABLE PoPULATIoNS
(Glasglow et al., 2006). other reviewers found
effective chronic disease management on the Vulnerable PoPulations
V Internet (Fry & Neff, 2009; Nelson, Barn, &
Cain, 2003).
overall, the Internet allows the patient More than 717,000 unduplicated articles
and caregiver to choose when and what infor- spanning the years 1982 through 2010 were
mation to access when needed. Furthermore, identified via www.scholar.google.com
results from the VNC questionnaire found using the key terms “vulnerable” and “popu-
nurse Web sites provided patients and care- lations.” The most frequently cited authors
givers with interactive anticipatory guid- were Gelberg, Anderson, and Leake (2000;
ance, scientifically based information, and a n = 250) and Aday (2001; n = 302). A surfeit
sense of nurse caring from a distance (Smith, of research has examined vulnerable popu-
Kochinda, yadrich, & Gajewski, 2010). lations (VPs) over this past decade (2000–
Notably, insurers will reimburse three 2010). A search through Elton B. Stephens’
times as many distant contacts versus Company (EBSCohost) for electronic jour-
in-home traditional visits because of the nals using the same parameters generated
lower travel and personnel costs (National 4,922 articles. An advanced search through
Association for Home Care and Hospice, EBCSo set for “research” and “nursing”
2009). Millions of dollars are spent annually resulted in 345 studies. The focus of these
on morbidities-associated chronic illnesses studies were veterans, cultural approaches,
and on preventable home care complications, social justice using human subjects, global
such as IV infections. Reducing IV infections, populations and disasters, and the reduc-
one of the top 25 research priorities (Institute tion of health disparities. A search through
of Medicine, 2009), can be accomplished by the Cumulative Index to Nursing and Allied
Internet instructions and prompts (Smith, Health Literature database using the search
2005, 2007a, 2007b). However, of the 557 selection terms “vulnerable,” “populations,”
peer-reviewed articles on distant nursing and “research” between the years 2000 and
(none on cell phones or the Internet), only 2010 resulted in 266 studies. The focus of these
55 included costs and only 24 of those used articles were gang youth, prisoners, interna-
standardized cost measurement as used in tional populations and settings, the effective-
this study (Whitten et al., 2002). There is a ness of nursing interventions, system-related
need to determine the cost-efficiency and delivery of care structures and values on
clinical effectiveness of mobile phone ver- impact of care (i.e., ER use and primary care
sus Internet nursing interventions guides vs. faith-based nursing settings and school-
(Smith, 2007a, 2007b). based clinics), the development of theory and
Future directions of research are to test science, measurement issues and instrument
new technologies to convey VNC. Specifically, development, and policy. In essence, earlier
research must test if mobile telephones can research focuses on identifying populations
access the Internet, illustrate health care most at-risk and later research focuses on
treatment, answer common illness questions, methods for improvement in research and
and provide decision-making guides and outcomes.
automated symptom or health assessments. VPs in reference to human beings are
Also, research on the impact of VNC on clin- those identified as being at-risk for health
ical outcomes and privacy in relation to using problems, harm, or neglect (Aday, 2001;
the Internet should be undertaken (dilworth- Leight, 2003). Most often, these humans
Anderson et al., 2005; Im & Chee, 2002). are referred to as “the poor and those with
chronic illnesses” or people who are less for-
Carol E. Smith tunate than others due to low socioeconomic
VULNERABLE PoPULATIoNS n 537
variables (Lexchin & Grootendorst, 2004). opportunities as well as Healthy People 2010’s
The term is derived from a combination goals (Shi & Stevens, 2005; National Institutes
of Latin words: vulnerare (verb) meaning of Health, 2000; National Institute of Nursing V
“wound” and populatio meaning “wasting Research, 2000; U.S. department of Health
or devastation” as well as populous meaning and Human Services, 2000). The national
“specific members of a region.” Aday (2001) attention was in direct response to the World
referred to VPs as societal subgroups in Health organization’s Health for All and
the position of being hurt, ignored, and/or Millennium Development Goals. The American
helped by others. She claimed all members of Nurses’ Association defended the relevance
human communities are potentially vulner- of VPs for nursing research. The notion of
able. Flaskeraud and Nyamanthi (2002) con- equality and health presents an overlap in
tend that VPs have increased susceptibility defining “health disparities” (among various
to health adversities due to discrimination populations) and “vulnerable populations”
and marginalization. A summary of those as applied to elimination of health dispari-
most at-risk include, but are not limited to, ties using social determinants of health
women, pregnant women, infants, children, (Guthrie, 2005; U.S. department of Health
teenagers and young adults, the economi- and Human Services, 2000). As a result, the
cally or educationally disadvantaged, ethnic Institute of Medicine (2002) report reframed
people of color, immigrants, prisoners, inter- national focus that VPs experience health
national groups living in poverty condi- disparities especially in the unequal receipt
tions, people living in disaster and war-torn of health care, specifically, in the quality
areas, homosexuals, HIV infected, chemi- and access of services (Nyamathi, Koniak-
cally addicted, mentally impaired, homeless, Griffin, & Greengold, 2005). The signing of
elderly, and those living in rural and urban the National Health Care Reform Bill in 2010
settings (Flaskerud & Nyamanthi, 2002; has changed the face of health care receipt.
Flaskerud et al., 2002; Leight, 2003). When The principles of social and distributive jus-
coupled into subgroups, the appellation is tice, as it relates to resource allocation, are of
“doubly” VPs (Liamputtong, 2007; Moore & debate. For example, Frolich and Potvin (2008)
Miller, 1999). The impact on health of being proposed an inequality paradox for decreas-
doubly vulnerable is not well defined, but ing health inequities between socially defined
legal and ethical implications for research groups. They explained an inverse care law:
and intervention are presented (Fleischman those with the most resources at hand dur-
& Wood, 2002). This has been most evident ing crisis adapt more readily and are first to
in studies pertaining to the effect of disas- derive maximum benefit from interventions.
ters on victims (Gershon, Rubin, Qureshi, The end result may lead to positive discrim-
Canton, & Matzner, 2008). An interna- ination, stigmatization, and inefficient public
tional legal definition of VPs is found in the health. The debate has not been entertained by
Safeguarding Vulnerable Populations’ Act leading agencies. In fact, Healthy People 2020’s
of 2006 (Griffith & Tengnah, 2009; Schwehr, national goals have not been released to date.
2010). An interpretation of the United States’ The focus of the National Institutes of Health
legal definition relates to susceptible individ- is on genomics as related to health differences
uals within specific subgroups and has not among various populations (Collins, 2010).
changed since 2003 (Stone, Horton, Pestronk, National Institute of Nursing Research and
& Ransom, 2003). American Nurses Association remain focused
Early in this decade, national attention on the art and science of nursing as it relates to
has focused on VPs, as evidenced by National positively influencing the health of VPs.
Institutes of Health and National Institute of Theoretical perspectives of VPs are
Nursing Research’s missions and funding rooted in the fundamental tenet of defining
538 n VULNERABLE PoPULATIoNS
and describing VPs as related to health risk specific to working with VPs are two-fold:
and time across life course (Aday, 2001). That ethics and measurement.
V is, risk to health is directly related to the Since the 1970s the organizational-based
amount of time a person or group is exposed human ethics and research committees have
to health threats as well as the length of been required to provide ethical approval for
time it takes for disease to develop. The research. With regard to ethics in research-
VPs conceptual model (VPCM) for health ing VPs, study design, setting, and situation
and research developed by Flaskerud and are key factors (Perez & Treadwell, 2009).
Winslow (1998) postulates interrelationships When multicentered designs are used, it is
between resource availability, relative risk, imperative that review boards consider the
and health status mediated by access to care local impact of the study on VPs (McCauley-
(Aday & Andersen, 1974). The University of Elmson et al., 2009). Palliative care patients
California, Los Angeles School of Nursing, are considered vulnerable. Ethical consider-
Center for Vulnerable Populations Research ations involve benefit and risk of interrupt-
faculty are experts in the area and have ing natural death experiences, pain, and
explored the health behaviors of many sub- offering false hope to a defined end. Mental
groups in terms of health behavior outcomes health patients are considered VPs. Ethical
using the VPCM as a guide in answering considerations involve risk of further psy-
research questions. Another model that chological distress, exacerbation of illness,
has been used to guide research is the risk of exploitation, and/or coercion. General
Comprehensive Health-Seeking and Coping considerations are more comprehensive than
Paradigm, which explores environment, attaining written approval, but in spending
behavior, social demographics, and health extra time with patients to protect vulnera-
outcomes (Nyamathi, 1989). The focus of the bility (McCauley-Elmson et al., 2009). Prisons
Comprehensive Health-Seeking and Coping and schools require strict adherence to fed-
Paradigm is more on the individual than in eral guidelines for including prisoners and
the population; yet, the model has a research- school children in research (IoM, 2004, 2006;
practice paradigm (Nyamathi et al., 2005). Lerner, 2007). Community-based participa-
Receipt of care has been explored using the tory research offers a conduit for considering
Behavior Model for Vulnerable Populations VPs’ perspectives (McCauley-Elmson et al.,
(Gelberg et al., 2000). The model served to 2009) and can allow for participants to a voice
determine predictors of health service uti- and representation, thus promoting equality.
lization and behavior change (Nyamathi UyBico, Pavel, and Gross (2007) emphasized
et al., 2005). that regardless of study design, recruitment
Each concept of the VPCM uses empir- of VPs need ethical review because financial
ical indicators to predict health status. This reward can represent coercion and payment
model has been fundamental to design- can invoke bias (Bentley & Thacker, 2004;
ing descriptive studies to enhance under- Emanuel, 2004; Halpern, Karlawish, Casarett,
standing and knowledge about VPs. The Berlin, & Asch, 2004).
University of California, Los Angeles, determining bias and valid results in
School of Nursing, Center for Vulnerable relation to VPs was the charge of Strickland,
Populations Research’s contributions to sci- diLorio, Coverson, and Nelson (2005). They
entific literature have been extremely pro- completed a research review on studies
ductive in terms of developing collaborative (n = 133) published in selected nursing jour-
partnerships, multisites for data collection, nals (n = 4) in 2004. About 62% of studies
and timely publications. The current issues involved VPs. When quantitative designs
in developing the nursing science of nursing were used, survey research focused on
VULNERABLE PoPULATIoNS n 539
nursing care (38%) and most often validity research involving VPs. There is a new focus
and reliability were lacking because most to make sure certain measurement concerns
instruments were developed and tested on are addressed (Strickland et al., 2005). V
nonvulnerable samples. In essence, poor mea-
surement practice has been common among Ann M. Stalter
W–Z
The etiology of wandering remains a
Wandering topic of debate. Proposed explanations range
from physical discomfort, boredom, seeking
a familiar place or person, and unmet needs
Since 1980, when Irene Burnside expressed to right parietal lobe dysfunction. Positive
dismay at the lack of a suitable definition correlations have been found between wan-
of wandering as well as the lack of nursing dering and cognitive impairment, spatial
articles or research on the topic, thousands disorientation, stress, unmet needs, reduced
of journal articles have addressed the topic. higher order cognitive and planning abili-
Although numerous definitions have been ties, and circadian rhythm disturbances. The
proposed since 1980, the common threads possibility that wandering is an extension of
are (1) locomotion and (2) cognitive impair- a person’s premorbid activity level or means
ment. One of the more comprehensive modern of reducing stress has been examined with
definitions was proposed by the International inconsistent results. One study in long-term
Consortium for Research on Wandering. It care facilities identified low extroversion
defines wandering as “a syndrome of demen- scores and negative verbalization in response
tia related locomotion behavior having a fre- to stress as two premorbid factors that pre-
quent, repetitive, temporally disordered, and/ dicted greater wandering behavior (Song
or spatially disoriented nature that is mani- & Algase, 2008). The need-driven behavior
fested in lapping, random, and/or pacing model has been used to explain wandering
patterns, some of which are associated with as the result of the interplay of background
eloping, eloping attempts, or getting lost unless (relatively fixed variable such as general
accompanied” (Algase, Moore, Vandeweerd, & health status and neurocognitive status)
Gavin-Dreschnack, 2007, p, 696). and proximal factors (dynamic individual
The prolific work of Dr. Donna Algase or environmental variables such as physio-
has illuminated the complexity of wander- logical needs) (Algase, 1999a). Aspects of the
ing behavior. Since the early 1990s, numer- physical environment that have been exam-
ous nursing studies have used observational ined include lighting, noise level, home-like
techniques to document characteristics of arrangements, and furnishings.
wanderers as well as the frequency, dura- Wandering can be viewed as meaning-
tion, and patterns of wandering. Studies of less or as an effort to fulfill felt needs that
personal characteristics of wanderers have the patient may or may not be able to com-
produced variable results. Algase’s (1999b) municate. Cohen-Mansfield and Werner
review reported no consistent relationships (1998) asserted that wandering could be both
between wandering and gender, education, adaptive and appropriate for the cognitively
or race. Factors that correlated positively with impaired elder. Despite general agreement
wandering included general health, appetite, that activity has physical benefits, wander-
fewer medications and medical diagnoses, ing is treated as a problem because of the risk
and other “agitated” behaviors. Factors that for harm from falls or becoming lost in dan-
correlated negatively with wandering were gerous places. Therefore, most intervention
pain and eating impairment. studies focus on structuring the physical or
WATSOn’S TheORy OF huMAn CARInG n 541
psychosocial environment to prevent unsafe neuroleptics (American Geriatric Society
wandering. Areas of study have included Clinical Practice Committee, 2003). One
environmental modifications, exercise pro- comparative study found slightly fewer side W–Z
grams, and medication reviews. The use of effects with risperidone than with olanzap-
physical restraints is universally labeled an ine in a sample of 730 adults with dementia
unacceptable strategy because of the poten- (Martin, Slyk, Deymann, & Cornacchione,
tial for harm by the restraints and the ethi- 2003). Cholinesterase inhibitors are reported
cal issues raised by their use. environmental to improve function for some persons with
strategies have included the creation of safe Alzheimer’s disease, especially in the early
walking areas that offer sensory stimulation, stage, and may also reduce behavioral dis-
the use of visual illusions to discourage walk- turbances (Daly, Falk, & Brown, 2001).
ing beyond certain limits, concealment of In summary, research on wandering
exits, doorknobs, and so forth, and the use of continues to elucidate variables and char-
alarms and tracking devices. Assuming that acteristics associated with wandering.
wandering might represent a need for more Common acceptance of a single definition
physical activity, some investigators have of wandering is needed to allow evidence
implemented regular exercise programs. of best practices to accumulate. emphasis
Despite the array of studies, it remains dif- on interventions to maintain safety with-
ficult to generalize findings because of the out undue restrictions is receiving increased
variations in definitions, measurement attention. Continued efforts to identify and
instruments, and samples studied. meet underlying needs are warranted. Other
The limited intervention studies located suggested topics for future studies might
focused on environmental adaptations, focus on (a) assessment and management in
caregiver approaches, and pharmacologic various settings including acute care, tran-
management. In relation to environmental sitional settings, assisted living, and private
conditions, wandering was found to increase residences, and (b) strategies for locating lost
in the presence of a low noise level and with wanderers.
normal lighting and temperature (Cohen-
Mansfield & Werner, 1995; Cohen-Mansfield, Adrianne D. Linton
Werner, Marx, & Freedman, 1991). Limited
research on visual illusions shows that they
work with some, but not all, patients (Price,
hermans, & Grimley, 2001). Differences in Watson’s theory of
patient responses to specific adaptations
could be attributed to differences in cog- human Caring
nitive skills that characterize each stage of
dementia among study subjects.
Increased tolerance of wandering, mea- Watson’s Theory of human Caring has its
sures to create safer wandering environ- origins in 1975 through 1979 (Watson, 1979)
ments, and caregiver education have made as an “attempt to bring meaning and focus
drug therapy a last resort in most cases. to nursing as an emerging discipline and dis-
When wandering is accompanied by agi- tinct health profession with its own unique
tation, neuroleptics sometimes are used. A values, knowledge, and practices, with its
major adverse effect with neuroleptics is own ethic and mission to society” (Watson,
orthostatic hypotension. The atypical antip- 2001, p. 344). Watson (1996, p. 142) proposed
sychotics such as risperidone and olanzap- that her early work could be viewed as a
ine are preferred for older adults because “philosophy, ethic, or even a paradigm or
they have fewer side effects than most older worldview” that embraces the art and science
542 n WeIGhT MAnAGeMenT
of nursing. Watson proposed an integrated (Watson, 2008b), in which the nurse is cen-
view of personhood, life, health and heal- tered on consciousness, intentionality, and
W–Z ing (p. 141) with an emphasis on the spiritual presence for the purpose of transformational
nature of the human being and the transper- caring. The transpersonal caring relationship
sonal caring relationship that is the basis of provides unitary caring approach to transfor-
nursing practice. mational caring–healing that recognizes the
Watson embraces caring science as spiritual nature and dignity of humanity.
necessary for the survival of nursing and Watson’s Theory of human Caring pro-
humanity. Caring science is described as “a vides a philosophical and theoretical foun-
deep moral-ethical context of infinite cosmic dation for nursing science, practice, and
love” (Watson & Woodward, 2010, p. 353). education. human caring is in fact a world-
Further, Watson believes that caring science view that encompasses a way of being awake
allows nursing’s caring–healing core to be to oneself and others, being intentional in
both discipline specific and transdisciplin- one’s life and work, being genuinely present
ary (Watson & Woodward, 2010). Specifically, for self and other, and embracing the caring–
Watson (2005a, 2008b) has introduced the healing transformational process. Watson’s
term caritas to further explicate the relation- theory has been widely disseminated glob-
ship between caring and love in the context ally in scholarly works, served as a guide for
of human caring philosophy and theory. The master’s and doctoral student research, pro-
definition of caritas used by Watson is from vided a foundation for theory-based practice
the Latin and means “to cherish and appre- and curriculum development, and has framed
ciate, giving special attention to, or loving” the development of research in human car-
(Watson & Woodward, 2010, p. 353). Thus, this ing and methods. At the Watson Caring
represents an evolution in language from the Science Institute, work is being engaged in
concept of carative (Watson, 1979) to the use of and disseminated to address resources and
caritas for the theory of transpersonal caring, research models for nursing education, clin-
the use of clinical caritas process rather than ical practice, and administration. The theory
carative factor, and the transpersonal cari- of human caring has made a significant on
tas energy field for the context of the heart- nursing science and caring science. The work
centered transpersonal caring moment. continues as clinicians, theorists, research-
The Theory of human Caring embraces ers, and educators engage in diverse ways
the values of the reverence and sacredness of of knowing to generate greater understand-
life and humanity. Through the art and the ing of the unitary, human caring–healing
science of human caring, humanistic care experience.
in which both the nurse and the individual
receiving the care are affected, resulting in a Diana Lynn Morris
more humanistic, holistic self-transcendence Updated by Kristen S. Montgomery (1998)
(Watson, 1996). The original carative factors Updated by Diana Lynn Morris (2010)
that “actually potentiate therapeutic healing
processes for both the one caring and the one
being cared for” (Watson, 1996, pp. 154–155)
are now emerging as the clinical caritas pro- Weight management
cesses. Through the transpersonal caring
relationship, one seeks to embrace the soul
(spirit) of the other (Watson, 2002; Watson & Weight management, defined as deliberate
Woodward, 2010). Transpersonal caring cre- actions to reduce and maintain healthy body
ates a heart-centered transpersonal caring weight, is classified as formal and infor-
moment within the Caritas energetic field mal. Formal weight management consists of
WeIGhT MAnAGeMenT n 543
paying for organized services to assist indi- were obese—a 1 in 6 incidence. Overweight
viduals with weight reduction, such as health and obesity have a greater effect on minori-
center-based and commercial programs. ties; Blacks had 51% and hispanics had 21% W–Z
Informal weight management includes per- higher obesity prevalence compared with
sonal weight-loss methods without pro- Whites. national study of costs attributed to
fessional assistance. Weight management overweight and obesity revealed that medi-
usually is targeted at reducing weight (ver- cal expenses accounted for over 9% of total
sus gaining) because of societal pressures to u.S. medical expenditures in 1998 or approx-
be thin and growing epidemic incidences of imately $78.5 billion (Finkelstein, Fiebelkorn,
overweight, obesity, and comorbidities. For & Wang, 2003). In 2002, expenses rose to $92.6
adults 20 years or older, overweight is defined billion, half of which were paid by Medicaid
as having a body mass index (BMI) of 25 to and Medicare.
29.9 kg/m and Class 1 obesity is defined as Overweight and obesity are multifacto-
2
having a BMI of 30 to 34.9 kg/m (national rial conditions. etiological influences include
2
heart, Lung, and Blood Institute [nhLBI], bio-psycho-sociocultural factors and toxic,
1998). Class 2 obesity is defined as having a obesogenic environmental factors (Apovian,
BMI of 35 to 39.9 kg/m , and Class 3 is hav- 2010; Blackburn et al., 2010). experts agree
2
ing a BMI of greater than 40 kg/m (World that obesogenic environmental factors, more
2
health Organization expert Committee on than biological reasons, explain the obesity
Physical Status, 1995). epidemic over the past four decades. Four
Overweight and obesity are a grave conditions account for the environmental
health care epidemic despite efforts and stimulus–response nature of the rise in obe-
national initiatives to abate this growing sity in the united States: (1) a fast-paced eat-
dilemma. Progress in the past 10 years toward ing style consisting of fatty, glycemic “fast
healthy People 2010 objectives for overweight foods” and super sizing; (2) excessive calorie
and obesity was of little consequence, thus intake; (3) reduced physical activity and tech-
requiring retention and revision for the new nological dependency; and (4) heightened
healthy People 2020 objectives for healthy responsiveness to food as a stimulant (hill,
weight and obesity (Sondik, haung, Klein, Wyatt, Reed, & Peters, 2003).
& Satcher, 2010). According to the national unfortunately, failure rates for weight
health and nutrition examination Survey loss treatments in the united States, once
(nhAneS) u.S. data from 2007 to 2008, over- estimated to be as high as 90% to 95%, have
all prevalence of overweight and obesity for not improved. Long-term habits of overeat-
adults was 68% (approximately 72% among ing without hunger and with minimal reg-
men and 64% among women; Flegal, Carroll, ular physical exercise in a fast-paced society
Ogden, & Curtin, 2010). Overall, obesity have been described as chronic and refrac-
prevalence was 35.5% for women and 32.2% tory with high recidivism for treatment
for men. Class 3 obesity was reported to have (Wadden, Brownell, & Foster, 2002). Most
increased at greater rates than any other class weight-loss treatments in the united States
of obesity in the united States (Blackburn, have not helped reduce weight over the long
Wollner, & haymsfield, 2010). term and have even contributed to the over-
Over the past three decades, childhood weight problem (hill & Wyatt, 2005). As
obesity has more than doubled among chil- obesity increased, so did many associated
dren ages 2 to 5 years, has tripled among comorbid conditions, including hyperten-
youth ages 6 to 11 years, and has more sion, dyslipidemia, type 2 diabetes, coronary
than tripled among adolescents ages 12 to heart disease, stroke, gallbladder disease,
19 years (Flegal et al., 2010). Approximately osteoarthritis, sleep apnea and respiratory
17% of American children ages 2 to 19 years problems, and endometrial, breast, prostate,
544 n WeIGhT MAnAGeMenT
and colon cancers. Insulin resistance syn- Treatments that do not permit individuals to
drome (metabolic syndrome) is positively tailor weight management to their prefer-
W–Z correlated with excess weight and lack of ences and lifestyles cannot be lasting. Weight
physical activity and affects approximately loss treatments fail when program directives
24% of American adults (Ford, Giles, & Dietz, are too stringent for individuals to feel own-
2002; national Institute of Diabetes and ership and acceptance of weight management
Digestive and Kidney Diseases, 2010). The strategies as a way of life (hill et al., 2003).
safest, most effective way to reverse insulin The 2009 ADA position statement defined
resistance and most obesity comorbidities multidimensionality for long-term weight
is through physical activity, dietary intake management. Comprehensive programs
(less glycemic, more fiber), and weight loss should make maximum use of multiple
(national Institute of Diabetes and Digestive cognitive–behavioral strategies (self-moni-
and Kidney Diseases, 2010). toring, stress management, stimulus control,
The challenge that continues to face problem solving, contingency management,
America is not so much achievement of cognitive restructuring, and social support)
weight loss but rather weight loss maintenance. in addition to dietary and physical activity
The most known unidimensional physical strategies to lose and maintain weight loss.
strategies for losing weight have been suc- Successful weight management programs,
cessful, including reduced dietary volume, therefore, are multidimensional, flexible,
calories, fat, and carbohydrates and increased and also focus on internal motivations for
energy expenditure through physical exer- overeating and not exercising regularly.
cise. Medicines to reduce fat metabolism Behavioral strategies have gained rec-
(orlistat) and suppress appetite (sibutramine, ognition as being important to promote
phentermine, and herbal preparations) have long-term weight management, such as the
been found to be effective, especially com- PReMIeR, Diabetes Prevention Program,
bined with lifestyle modifications (American Finnish Diabetes Prevention, and Look
Dietetic Association [ADA], 2009). Bariatric AheAD studies (ADA, 2009). Confusion,
surgical treatments for obese individuals that however, exists in recognizing differences
reduce intake volume (vertical banded gas- between behavioral strategies and cognitive–
troplasty) and reduce food absorption (gas- behavioral strategies. Behavioral strategies
tric bypass) have been found to successfully use behavior modification, which focuses on
reduce comorbidities (Buchwald et al., 2004). changing individuals’ behaviors with little
These unidimensional strategies are consis- or no concern for their underlying reasons
tently based on energy balance theory, as it for overeating, not exercising, and unhealthy
stresses the physiological balance between coping behaviors (Popkess-Vawter, 2008).
energy in and energy out needed for weight Behavioral weight management strategies
loss, maintenance, and gain (hill & Wyatt, emphasize stimulus control of intake and
2005; nhLBI, 2010). output by dieting and weight-related behav-
Few weight management programs use ior modification, which are unidimensional
a holistic, multidimensional approach to life- and focus mainly on calorie reduction. A
style changes with strategies that address and stimulus response mentality (emphasis on
correct underlying overeating, lack of exer- overweight behaviors) without regard for
cise, and poor self-esteem (Popkess-Vawter, individuals’ beliefs, thinking, feelings, and
yoder, & Gajewski, 2005). Often, weight related behaviors (cognitive–behavioral the-
management strategies used in clinical tri- ory) may be partly responsible for continued
als research place greater emphasis on eat- escalation of the overweight–obese epidemic.
ing, exercise, or psychosocial aspects rather Dietary, pharmacological, and surgical treat-
than holistic emphasis on all three dimensions. ments that reduce intake and restrict calories,
WeIGhT MAnAGeMenT n 545
choices, and when to eat offer temporary minutes daily difficult and unrealistic over
modifications that are unrealistic for the long the long term. Jakicic, Winters, Lang, and
term and often are accompanied by rebound Wing (1999) found that 10-minute exercise W–Z
weight gain and detrimental psychological bouts done three to six times daily can be
consequences (Popkess-Vawter et al., 2005). effective for weight management and more
Strategies that concentrate on modifying practical for busy people’s lifestyles. Small
behavior by differentiating stimuli before, targeted behavioral changes (e.g., walking
during, and after eating are a healthy start 15–20 minutes daily) can significantly con-
toward lasting weight management (i.e., tribute toward sustained weight loss. There
identifying stimuli other than hunger that is growing evidence that 5% to 7% of max-
trigger eating, monitoring amounts and con- imum weight lost is associated with lower
ditions during eating, and rewarding appro- incidence of diabetes, reduced blood pres-
priate actions). One reason why behavioral sure, and improved dyslipidemia (yanovski
techniques have limited success is because & yanovski, 2002). Modest weight loss and
they seek to control the diet and environ- improved fitness can lower comorbidity risk
ment without considering eating as a coping and ultimately lead to sustained weight man-
mechanism to manage unpleasant feelings agement (Blackburn et al., 2010).
(Popkess-Vawter, Brandau, & Straub, 1998). Convenient and practical means to
Few current weight management behav- offer multidimensional weight management
ioral approaches, cognitive restructuring, or approaches include use of telehealth video-
combinations thereof directly address how conferencing, telephone, and the Internet,
negative beliefs about self and irrational per- which in turn offer greater access for study
ceptions of the world can trigger negative self- participants and future applications for for-
talk with resultant responses of overeating, mal programs (enwald & huotari, 2010; Kim
skipping regular exercise, and feeling bad et al., 2010). Research is needed to develop and
about self (Popkess-Vawter, 2008). Increasing test community-structured and work-related
numbers of researchers have reported find- multidimensional programs (Apovian, 2010;
ings from weight management studies based Greener, Douglas, & vanTeijlingen, 2010).
on psychosocial theories such as self-efficacy, Collaboration among researchers, health pro-
transtheoretical model, self-determination fessionals, policy makers, and community
theory, and health belief model, which sug- leaders is essential for tailoring meaningful
gest progress in using holistic strategies for research (Flegal et al., 2010).
eating, exercise, and psychosocial aspects. The ultimate goal of weight manage-
Stringent recommendations of the past ment is to prevent obesity and its comorbidi-
have only fueled the obesity epidemic (hill ties (Serdula, Khan, & Dietz, 2003). Research
et al., 2003). nhLBI weight management pro- agendas must include the refractory nature
grams like “America on the Move” and the and high recidivism to assure long-term
2005 Dietary Guidelines for Americans are weight management. Primary care clinics
national initiatives that have accommodated are frontline settings to approach people
people’s busy lives by suggesting “real world, about weight management, but structured
do-able” eating and exercise goals for revers- and practical treatments are still lacking.
ing the obesity epidemic. Consistent research Providers may not be aware of their power-
findings have shown that 60 to 90 minutes ful influence in helping patients with weight
per day of moderate intensity physical activ- management (Clark et al., 2010; heintze et al.,
ity is needed to maintain a significant weight 2010). health professionals and patients need
loss (hill & Wyatt, 2005). Despite these prom- to be educated about the benefits of modest
ising findings, most people, normal weight weight loss using evidence-based methods
or overweight, will find exercising 60 to 90 (Phelan, nallari, Darroch, & Wing, 2009). To
546 n WeLLneSS
promote healthy weight among Americans, athleticism, and liberty (p. 3). Ardell pro-
long-term, lifestyle-change intervention duces a weekly wellness report and is active
W–Z studies are vital, using qualitative and quan- in helping people to age without becoming
titative measurements of physical and psy- old prematurely (Ardell, n.d.).
chosocial weight management strategies. The topic of wellness has been discussed
for the past 50 years with great strides being
Sue A. Popkess-Vawter made. There is a great need for further
research as our health industry is changing.
Wellness has become an important focus and
the illness challenge has changed to staying
Wellness healthy.
The Internet has opened up the arena
to research, to evaluate, and to understand
The definition of wellness dates back to the the topic of wellness. Travis who was a pio-
time of hippocrates and the definition con- neer of wellness has his own websites that
tinues to be revised. early definitions were are devoted to wellness as well as many oth-
focused on wellness as freedom from disease ers. Today Travis states that you have view
processes. Current understandings of well- the consciousness of the world if you address
ness are influenced by changes in society. wellness (Travis, n.d.). how a person views
From a nursing perspective, wellness the world determines their experience with
can be viewed as a progression to better wellness (Travis, n.d.).
health, including encouraging activities that The Medical home Model is the start of
promote health. you have to feed the body the new wellness revolution. There will be
correct nutrition, to exercise to improve the a need for studies in the future to see if the
body, and to spiritually connect to the body Medical home Model works. This is a new
to engage in the outcome of wellness. nurses arena that will demand research to validate
have always had an impact on influencing and find new areas that will improve health
patients to make lifestyle changes that can and wellness.
improve wellness.
Dunn in the late 1950s was one of the Joyce Johnston
first to use the term wellness. Wellness was
described by Dunn as a complex state that is
a combination of different levels of wellness
(Dunn, 1959). In the 1970s emerged others WidoWs and WidoWers
like Ardell, hettler, and Travis who was also
interested in wellness. In the 1980s, Smith,
Laffrey, Walker, Sechrist, and Pender were Between 2003 and 2010, nurse researchers
all instrumental in the wellness movement. expanded knowledge about widows and
hettler cofounded the national Wellness widowers, especially particular subgroups.
Institute in 1975. In 1976, hettler developed however, the main focus remained on
the 6 Dimensional Model of Wellness (hettler, bereavement rather than longer term circum-
n.d.). This model also became known as the stances of widowhood. Of the 30 full-length
hexagonal model (hettler, n.d.). reports retrieved from CInAhL and PubMed,
Ardell (2010) has developed numerous only 1 was an intervention study. Qualitative
wellness models since the 1970s. The ReAL methods were used in 27 of 29 descrip-
wellness model was developed by Ardell in tive studies. The work clustered around
2010; ReAL stands for reason, exuberance, four themes: (a) retrospective reflections on
WIDOWS AnD WIDOWeRS n 547
bereavement, (b) pre- and post-bereavement 24 Iranian widows with children sought to
experiences, (c) concepts and variables per- continue bonds with their husbands even
tinent to widowhood, and (d) health-related as they experienced overwhelming hope- W–Z
experiences of older widows. lessness and marked lifestyle changes
Of the eight qualitative cross-sectional (Khosravan, Salehi, Ahmadi, Sharif, &
studies including diverse subgroups of wid- Zamani, 2010). Doherty and Scannell-Desch
ows and widowers, the only one involving (2008) did a phenomenological study of wid-
widowed persons of both genders was done owhood during pregnancy with 10 women
in Korea, with five women and five men whose husbands had died in the 2001 ter-
whose spouses had died from cancer. There rorist attacks or while serving in the Armed
were gender differences in grief responses Forces in Iraq or Afghanistan. As in findings
and influences on grieving (Lee, Lee, Kim, & of the study with lesbian widows (Bent &
Kang, 2005). In the only study pertaining only Magilvy, 2006), positive and negative fac-
to widowers, Rushton (2007) interviewed 14 ets of support were presented. “navigating
middle-aged and older men and some of their pregnancy: flying solo while running on
adult children 2 to 15 years after the death of empty” and “re-creating home: a new nor-
the spouse/mother. Family communication mal” were two of the emergent themes.
problems associated with the loss were para- Steeves and Kahn (2005) used a longi-
mount pre- and post-bereavement. tudinal design and recruited widowed per-
Bent and Magilvy (2006) described sons of both genders. using a hermeneutic
experiences of six widowed lesbians, noting approach, they interviewed 10 older women
political, social, and familial matters that pos- and 5 older men before and after the spouse’s
itively and negatively affected participants’ death and compared findings by gender.
experiences and called for nursing inter- Their interpretation highlighted metaphors
ventions to preclude “complicated bereave- associated with grieving, grief work, home-
ment” (p. 456). Stigmatization and isolation related concerns, and getting on with one’s
also were features of life for 10 barren, life. Although all participants were rural,
older rural widows in nigeria (Fajemilehin, implications of rurality relative to findings
2003). harrison, Khan, and hsu (2005) and were not addressed.
Rodgers (2004) explored bereavement expe- In two descriptive phenomenological
riences with samples of 11 middle-aged and studies from the same project with 10 mid-
older African American widows. Rodgers life widows, Scannell-Desch (2005a, 2005b)
incorporated observations of nonverbal isolated two sets of concepts for study,
behaviors and gestures of participants and contrasting struggles with triumphs and
recommended that nurses allow African comparing “experiences of support and non-
American widows opportunities to tell their support” (p. 43). Similarly, Shih, Turale, Shih,
stories of bereavement. Otherwise, the find- and Tsai (2010) considered the influence of
ings of the two studies were similar with religiosity on the bereavement adjustments
regard to the importance of (a) being with of 20 older Taiwanese widows in a mixed-
the dying spouse, (b) feeling minimal guilt methods study, classifying participants’
about events associated with the death, (c) religious beliefs as extrinsic or intrinsic and
drawing support from various sources, and comparing problems and coping strategies
(d) retaining bonds with the spouse while of the two groups. In the only intervention
learning to let go. study retrieved for review, Korean middle-
Several authors explored bereavement aged women who took part in a bereavement
experiences with subgroups of younger wid- program (including the meditative practice
ows. As detailed in a grounded theory study, of Dan-jeon) had lower grief levels and fewer
548 n WIDOWS AnD WIDOWeRS
stress symptoms than the control group formal–informal dichotomy of home-care
(Kang & yoo, 2007). Kowalski and Bondmass helpers, four categories of standby helpers
W–Z (2008) surveyed 173 women (aged 30–91years) emerged (Porter, Ganong, Drew, & Lanes,
who had been widowed less than 5 years. 2004). The women were not passive care
They found “moderate … correlations” (p. 27) recipients; the experience was one of sort-
between the number of self-reported phys- ing, protecting, and mobilizing standbys and
iological grief symptoms and scores on working with them on tasks associated with
the Revised Grief experience Inventory. living alone (Porter, 2005b). Markers of trust
however, values for r were reported rather were discerned relative to nonprofessional
than values for r , so correlations actually providers (Porter & Lasiter, 2004), as were
2
were modest. Compared with women who speculations about actions of professional
had been widowed less than a year, women providers (Porter & Ganong, 2005b) and
in the second year of widowhood reported expectations of home-care nurses (Porter,
fewer physical symptoms of grief. 2005a). Intentions included deciding whether
The first anniversary of the spouse’s a nonprofessional helper could be trusted
death has long been viewed as a stressful (Porter, Lasiter, & Poston, 2005) and taking
time. Correlations among psychological actions to allow providers access to the home
stress, physiological stress, well-being, opti- (Porter, 2007a). A data-based perspective on
mism, and life satisfaction were explored 12 home-care satisfaction was offered (Porter,
and 13 months after bereavement with 47 2008b). The complexity of the home-care
widows 65 years or older (Minton, hertzog, experience was illustrated in a case study
Barron, French, & Reiter-Palmon, 2009). At with one widow (Porter, 2008a). Some expe-
both data points, patterns in rates of phys- riences with personal emergency response
iological and psychological stress varied systems were detailed (Porter, 2003, 2005d),
without clear evidence of an anniversary as were problems with food preparation
reaction. Minton et al. (2009) noted that stress (Porter, 2007c), difficulties with daily activi-
might have peaked prior to the anniversary ties (Porter, 2007b), and incidents with trou-
but that supposition could not be verified. blesome visitors (Porter & Lasiter, 2007). In
The positive correlation between measures of a report on transitions of widows who had
optimism and life satisfaction was consistent lost a standby helper, Porter and Ganong
with prior gerontological research. (2005a) concluded that continuity of care
Drawing on interviews with 16 widows must extend beyond the home-care agency to
about the experience of living alone at home, the community.
Porter (2005c) described sources of satisfac- Three main implications for nursing
tion in daily life and the phenomenon called practice result from the research literature.
savoring satisfactions. The essence of the com- First, nurses should teach clients and families
ponent phenomenon, bowing to no one, was communication skills to promote productive
similar to autonomy, a common concept in dialogue about pre- and post-bereavement
gerontology. Other component phenomena, issues. nurses also should consider that
such as marking the milestones, were new to although widows and widowers have suf-
the literature. Sources of satisfaction varied, fered a loss, the overall impact of bereave-
suggesting that nurses should explore such ment varies with the individual just as it
sources in individualized assessment with varies for each individual over time. nurses
clients. should carefully assess widowed persons for
Porter studied the experience of home stressors, coping strategies, and risk factors
care related to widows, engaging in inter- for complicated bereavement while recogniz-
views over 3 years with 25 widows (aged ing that intentions about continuing one’s life
81–96 years). In contrast to the typical are also basic. Finally, regardless of practice
WIDOWS AnD WIDOWeRS n 549
setting, nurses should engage widowed cli- those two objectives. nurse researchers must
ents in dialogue about their intentions vis- continue to approach recruitment creatively
à-vis health-related experiences and make while restricting enrollment to inclusion cri- W–Z
every effort to align plans of care with those teria that emanate directly from the research
unique intentions. problem.
Little methodological diversity was evi- nurse researchers have focused on older
dent in this set of research reports about widowed persons, primarily women. The
widowed persons. nurse researchers should increasing interest in younger and midlife
explore associations among variables asso- widows, widowed persons of both genders,
ciated with bereavement and widowhood and diverse u.S. and international subgroups
and test interventions to enable adjustment is encouraging. Researchers should continue
to bereavement and to promote health dur- to illuminate needs of vulnerable subgroups,
ing widowhood. Although qualitative work including parents of young children and
is still warranted on many topics, we offer persons at-risk for age-related conditions.
several recommendations as to approach. Although widows outnumber widowers, the
First, researchers should propose aims that dearth of research with widowers remains
are consistent with the discovery thrust of problematic; more studies yielding gender
qualitative work. The aim to compare facets comparisons are needed.
of a dualism, such as supportive and non- With regard to research topics, scholars
supportive experiences (Scannell-Desch, must reveal variations in experiences among
2005a, 2005b), is more consistent with verifi- widowed persons due to demographic char-
cation than discovery. Second, rigor could be acteristics. Given the recent understanding
enhanced by adopting and reporting detailed of family as broader than kin, some per-
strategies for collecting, managing, and ana- sons might experience “widowhood” with-
lyzing data. Few details were provided about out being legally or socially identified as
methods such as content analysis (Rushton, widowed; this topic warrants further study.
2007) and thematic analysis (Bent & Magilvy, Further research is needed on transitions in
2006). Finally, in describing or interpreting care and home-care satisfaction, particularly
social support, a critical factor in bereave- as technological innovations permit aging in
ment and in widowhood, nurse researchers place. A meta-synthesis of qualitative find-
should consider moving beyond the dichot- ings about bereavement of older widows is
omy of positive–negative support to the dia- warranted. Finally, nurse researchers should
lectical view proposed by other disciplines. actively engage in interdisciplinary dialogue
We also identified implications for about theoretical and empirical relation-
design, inclusion criteria, and sampling that ships between the concepts of bereavement
are pertinent to both qualitative and quanti- and widowhood. each person could pro-
tative studies. Because widowhood is rarely a vide different data about the same loss over
short-term experience, longitudinal designs time; persons who have been widowed for
would yield more useful information than the same period of time provide unique
the usual cross-sectional designs. Duration data about being bereaved. To individual-
of widowhood is a particularly critical inclu- ize interventions, nurses must understand
sion criterion, but Scannell-Desch (2005a, the bereavement experience, how it changes
2005b) was one of the few scholars who over time, and how it interfaces with the
carefully defined such a criterion. Bent and experience of being a widowed person to
Magilvy (2006) called for attention to diver- influence health.
sity in sampling and greater restrictions on
inclusion criteria in studies with widowed Eileen J. Porter
persons, but there is an inherent conflict in Kathy A. Johnson
550 n WOMen’S heALTh
osteoporosis, breast and ovarian cancer, uri-
Women’s health nary incontinence, the autoimmune diseases,
W–Z violence, and poverty.
health had been construed such that
“Women’s health” is a phrase that has male behavior was regarded as normative,
changed dramatically in meaning over the and research conducted exclusively on males
past few decades. Although it used to denote was typically generalized to all human
a focus on health care issues that affected beings. When women did not fare as well
only women—historically involving matters with the same treatment, they were regarded
such as gynecologic, reproductive, obstet- as atypical. It was simply not considered that
ric, and breast health or disease—it now the female body responded to health prob-
denotes a focus on the experience of women lems and to treatment modalities differently
with health. This encompasses an expanded from the male. From Freud to Kohlberg, the-
biopsychosocial perspective that takes into oretical models had been constructed so that
account the overall well-being of the woman, women were regarded as less developed
which is shaped by the fit between the when they did not act in a fashion similar
woman and her environment. In this new to men. even when studied, the sociocul-
era, women’s health is concerned not only tural factors shaping health problems in girls
with women’s diseases, but their diseases, and women were ignored, for example, the
too, and coincides with nursing’s longstand- relationship between learned helplessness
ing emphasis on the interface between and and some kinds of depression, and between
among genetic, physiologic, psychosocial, anorexia and the popular (yet unhealthy)
economic, cultural, generational, develop- admonition that you can never be too rich
mental, and lifestyle factors in determining nor too thin.
health. Women’s health now includes wom- Social health systems also had been prej-
en’s experiences with all health and illness udicial in important respects. Insurance pol-
states, and, importantly, woman’s responses icies did not necessarily cover health matters
to these various states. unique to women, for example, breast pros-
Women’s health research began as a cri- theses post mastectomy. Women were not in
tique of existing practices and their effects research and policy-making positions pro-
on women’s well-being. In 1985, the Public portionate to their numbers, responsibilities,
health Service Task Force on Women’s and educational preparation. The burden of
health Issues examined the role of the family caregiving that women largely bear
Department of health and human Services remained invisible, notably in estimates of
in addressing women’s health and found that the gross national product.
women were often not included as subjects in The Office of Research on Women’s
health research. Women, especially women health (ORWh) was established in 1990
of childbearing potential, had historically within the Office of the Director of the
been excluded from the first two stages of national Institutes of health (nIh) to address
drug testing due to concerns about affect- these lacunae. A decade later, not coinciden-
ing current or future pregnancy outcomes tally, the majority of human subjects enrolled
and effects from normal hormonal changes in all extramural nIh research were women,
in women subjects during trials. even female and they were represented in Phase III clin-
animals had typically not been used in con- ical trials.
structing animal models because of “their Often led by nurses, women’s health
hormonal fluctuations.” The health problems research became relatively mainstream in
that women suffer from disproportionately the ensuing years. S. K. Donaldson (2000)
were also not often studied, for example, analyzed the achievements of nursing
WOMen’S heALTh n 551
research between 1960 and 1999 and identi- of women’s reality. The research that has
fied substantial strengths in the area of wom- resulted has been informed by how women
en’s health. The Center for Women’s health describe their lived experience. A feminist W–Z
Research at the university of Washington, ethic has emerged that is neither focused on
supported by the national Institute of “doing good” nor “doing unto others what
nursing Research, has increased the under- one would wish for oneself” but rather with
standing of menstrual cycle change, includ- providing care that builds on the patient’s
ing the menopausal transition (Mitchell, own perceptions of what is good for her.
Woods, & Mariella, 2002). The center has The ORWh, which celebrated its
also played a role in translational research, 20th year in 2010, developed an Agenda
for example, offering a video presentation to for Research on Women’s health for the
help women in deciding if hormone therapy twenty-first century (Pinn, 2001). In 2009,
is appropriate for them (Woods, 2002). the ORWh held public hearings and mul-
One area of common concern to the first tidisciplinary scientific workshop meetings
five Centers of Geriatric nursing excellence in multiple locations to update the agenda.
funded by the hartford Foundation is the The purpose of this very public method
experience of family caregivers, who are for discussion was to ensure that women’s
largely women (Archbold & Stewart, 1996). health will remain in the forefront of scien-
nurses have also brought new understand- tific work and that it will be addressed in a
ings to other developmental transitions, for comprehensive manner. The very methods
example, the experience of women as moth- used for identifying and defining the pri-
ers/grandmothers (McBride & Shore, 2001), orities in research for women are aligned
and how puberty may differentially affect with nursing’s approach to research and
girls in comparison to their male counterparts care—seeking input from the public, mul-
(Austin, Dunn, & huster, 2000). The ORWh tiple health disciplines, and scientists.
has collaborated with various nIh institutes Many of the ORWh’s identified priorities
to fund Specialized Centers of Research of continue to dovetail with the focus of nurs-
Sex and Gender Factors Affecting Women’s ing research; for example, interdisciplinary
health. The one based at the university of approaches to chronic multisystem diseases
Michigan is conducting research on the pel- with multifactorial etiology, caregiving,
vic floor, and nurses have pioneered thera- diversity and health disparities, gender dif-
peutic use of pelvic floor muscle training in ferences in health and illness, and health-
women (Miller, 2002). related quality-of-life issues. Indeed, most
Because one of its fundamental beliefs is of the research centers supported by the
the need to proceed from an understanding of national Institute of nursing research
the person–environment fit, nursing has long focus on healthy living and the prevention
been concerned about the importance of con- of chronic disorders, health disparities and
text in understanding health behavior. nurse vulnerable populations, or quality of life in
midwives, for example, tend not to talk about chronic illness. Developing effective ways
“delivering the baby,” preferring instead to to manage chronicity, as opposed to serial
focus on the mother and how she would pre- management of a number of diseases, is of
fer her labor and delivery to go. nurses were particular concern to nurse researchers.
among the first to question a preference for Women’s health research has made
the so-called objective view of the researcher, major strides in the inclusion of females as
historically male, over the subjective view research subjects and is moving toward
of the patient (McBride & McBride, 1981). understanding variances in experiences of
They took the lead in use of the diary/health women in diverse groups. Women vary sig-
journal as a way to analyze the complexity nificantly according to their circumstances.
552 n WOMen’S heALTh
Thus, nursing research does not just include change than ever before. With this shift,
girls and women, rather nurses are looking many women, especially women of color, are
W–Z at experiences of women in heretofore under- interested in identifying lifestyle changes for
studied populations, for example, the diverse managing symptoms, reserving medication
cultures, the women of color, the elderly, the for severe symptoms and only if nonpharma-
rural and inner-city women, the poor, the cological methods for symptom management
lesbians, and the women with disabilities. are unsuccessful.
The resulting findings are fueling a move- nursing research is recognizing the
ment toward greater emphasis on the design importance of quality of life in the men-
of tailored interventions. opause transition and taking a fresh look
nurses are also at the forefront of rede- at what symptoms are experienced and
fining natural life events as normal and ask- which experienced symptoms are both-
ing women to identifying ways to manage ersome (Alexander et al., 2003, 2004). This
such events that work in the context of their work goes beyond national studies evaluat-
daily lives. Women of varied ethnic and ing menopause symptoms such as the Study
socioeconomic backgrounds are increas- of Women’s health Across the nation (Avis
ingly interested in actively self-managing et al., 2001; Gold et al., 2000). Several previ-
their own health issues (Alexander, 2010; ously unrecognized yet bothersome symp-
MacLauren & Woods, 2001) and using nat- toms were identified because the women
ural therapies such as complementary and themselves were asked to provide firsthand
alternative medicine instead of seeking accounts of their experiences instead of
traditional medical care (Brett & Keenan, responding to defined symptoms on a ques-
2007; Daley et al., 2006; Keenan et al., tionnaire (Alexander et al., 2003, 2004).
2003; newton, Buist, Keenan, Anderson, nurses are also asking women what
& LaCroix, 2002). Women have indicated strategies they are using to manage bother-
a high satisfaction in working with nurse some symptoms associated with the meno-
practitioners (Alexander, 2004) because of pause transition and what strategies they are
the nursing philosophy nurse practitioners willing and interested in trying for symp-
use of supporting a patient and working tom management. Women have identified
in a partnership with her to achieve mutu- creative self-management strategies such as
ally identified goals as opposed to directing diet changes and exercise, stress manage-
her care. ment practices, and biofeedback (Alexander
The menopause transition provides et al., 2003, 2004; MacLauren & Woods,
excellent examples of the work nurses are 2001). Complementary and alternative med-
doing to dismantle the medicalization of icine therapies such as acupuncture have
a natural life event. Menopause symptom been studied to identify efficacy in reducing
management had become highly medical- symptoms associated with the menopause
ized because symptoms associated with the transition (Cohen, Rousseau, & Carey, 2003).
menopause transition were seen as a “prob- Woman have been asked about their use of
lem” that required “fixing” by medicine. As botanicals, vitamin and mineral supple-
the medicalization of menopause is being ments, nonhormone prescription medica-
dismantled, women are reclaiming meno- tions, and homeopathy and how effective
pause as a normal life transition (Alexander, these therapies were (Kupferer, Dormire, &
Motter, Ruff, Rousseau, & White, 2005; Becker, 2009).
Alexander et al., 2003, 2004; Kaufert, Boggs, nursing focuses on providing care to
ettinger, Woods, & utian, 1998; MacPherson, women in an individualized manner. After
1981; Woods & Mitchell, 1999). More women the surprising results of the Women’s health
report that menopause is a normal life Initiative were revealed, which identified the
WORKPLACe VIOLenCe n 553
possibility that the risks of estrogen–proges- additional insights into sex versus gender
tin hormone therapy outweighed benefits differences.
among postmenopausal women (Rossouw W–Z
et al., 2002), the national Association of Ivy M. Alexander
nurse Practitioners in Women’s health was Angela Barron McBride
one of the first organizations to decipher the
results and call for individualizing care for
each woman (Wysocki, Alexander, Schnare,
Moore, & Freeman, 2003). Instead of identify- WorkplaCe ViolenCe
ing hormone therapy as too great a risk to be
used for any woman, nurse Practitioners in
Women’s health leaders called for thought- Workplace violence is defined as “vio-
ful interpretation of results and careful lent acts (including physical assaults and
evaluation of each woman’s risk factors, threats of assaults) directed toward persons
personal and family history, and clinical at work or on duty” (Centers for Disease
symptoms in addition to her individual pref- Control and Prevention/national Institute
erences for symptom management (Wysocki of Occupational Safety and health, 2002).
et al., 2003). Most workplace violence falls into one of four
nursing research and scholarly work categories:
related to the menopause transition has pro-
vided unique and important knowledge Type I (Criminal intent): results while a crimi-
that adds to the field of women’s health. It nal activity (e.g., robbery) is being commit-
also provides a framework for developing ted and the perpetrator has no legitimate
research that questions what is known and relationship to the workplace.
assures that the woman’s voice is clearly Type II (Customer/client): the perpetrator is
heard with regard to identifying what symp- a customer or client at the workplace (e.g.,
toms are occurring, what symptoms are health care patient) and becomes violent
bothersome, and how to best manage bother- while being served by the worker.
some symptoms. Type III (Worker-on-worker): employees or
The next challenges faced by nursing in past employees of the workplace are the
the many areas of women’s health research perpetrators in this case.
are to further expand the current under- Type IV (Personal relationship): the perpetra-
standings of health and illness in women tor in this case usually has a personal rela-
of varied ethnic, racial, and cultural back- tionship with an employee (e.g., domestic
grounds. It will be important to continue violence in the workplace).
to explore women’s responses to health, ill-
ness, and their environments and women’s nonfatal assaults are much more com-
preferences for varied approaches to maxi- mon than fatal assaults, especially in health
mizing health and managing disease. nurse care. however, current surveillance systems
researchers must be careful to not wholly capture fatal assaults better than nonfatal
reject “biology as destiny,” so that women’s assaults because of widespread underreport-
health research will not inadvertently min- ing and difficulties obtaining data on less
imize the physiologic pathways involved in visible forms of workplace violence (Barling,
responses to stressful psychosocial condi- Dupré, & Kelloway, 2009). According to the
tions. Future research must, therefore, be Bureau of Labor Statistics (BLS), assaults and
concerned with women’s experiences that violent acts were the second leading cause of
exist within the interface between the behav- occupational injury or death among all work-
ioral and the biomedical sciences to provide ers, and is the leading cause among women
554 n WORKPLACe VIOLenCe
in 2009. Between 2004 and 2008, an average of 68 per 1,000 workers compared with an over-
564 workers per year died as a result of work- all rate of 12 per 1,000 workers. nurses had
W–Z place violence (BLS, 2010). By comparison, an incidence rate of 22 per 1,000 workers, the
the Department of Justice’s national Crime highest rate in the “medical” category. Rates
Victimization Survey (nCVS), estimates that for other nurse specialties or units were not
1.9 million incidents of nonfatal workplace available, but it is well recognized that emer-
violence occurred in the workplace each year gency department personnel face a signifi-
from 1992 to 1996 (Warchol, 1998). Twelve cant risk of injury from assaults by patients
percent of all victims reported physical inju- or their families; with weapon-carrying pre-
ries, 6% of the workplace crimes resulted in senting the opportunity for severe or fatal
injury that required medical treatment, and injuries. A recent survey of 69 u.S. emer-
only 44% of all incidents were reported to the gency departments found that 20% reported
police. A more recent report from a nationally that guns or knives were brought to their
representative study found that 41.4% of all emergency departments on a daily or weekly
workers reported incidents of psychological basis (Kansagra et al., 2008).
aggression, whereas 6% reported incidents of Violence in mental health has an exten-
physical aggression at work (Schat, Frone, & sive history, with the first documented case
Kelloway, 2006). of a patient fatally assaulting a psychiatrist in
Workplace violence (Type II) is a docu- 1849 (Bernstein, 1981). until the 1990s, most
mented occupational hazard in the health studies that examined the risk of violence to
care and service sectors (Centers for Disease psychiatrists and other therapists focused on
Control and Prevention/national Institute the victim’s role, the assaultive patient’s char-
of Occupational Safety and health, 2009; acteristics, and contextual factors surround-
Lipscomb & Love, 1992; Warchol, 1998). In ing the assault. Since that time, research has
the united States, the health care sector included the inquiry of organizational and
leads all other industry sectors in the inci- environmental risk factors; with nurses and
dence of nonfatal workplace assaults. From aides a focus of study.
1994 to 2005, nursing, psychiatric, and home Bensley et al. (1997) compared the num-
health aides were victims of nearly 30% of ber of workers’ compensation claims from
workplace assaults resulting in lost work- a Washington State psychiatric hospital,
days, which was the highest proportion of formal incident reports, and the number of
assault injury by broad occupational group- incidents of assault reported on a survey
ing in the united States (BLS, 2006). In 2005, measuring attitudes and experiences related
the BLS rate of nonfatal assaults among to assaults. She found that 73% of staff sur-
health care workers was 8.8 cases per 10,000, veyed reported at least a minor injury related
which was nearly four times higher than in to a patient assault in the past year. Only
the overall private sector workforce. Among 43% of those reporting moderate, severe, or
these assault victims, 30% were government disabling injuries related to assault filed a
employees, even though they make up only worker’s compensation claim. The survey
18% of the workforce. found an assault incidence rate of 437 per
The more sensitive nCVS, a population- 100 employees per year, a rate that underesti-
based household survey, provides rates of mated incident reports of assaults by a factor
violent crimes by occupation. In 12% of the of more than five (Bensley et al., 1997).
1.7 million episodes of workplace-related environmental and organizational fac-
violence annually in the united States, the tors associated with patient assaults include:
victim was a health care or mental health understaffing, workplace security, shift,
care worker. According to the nCVS, mental unres tricted access to movement, and
health professionals had an incidence rate of transporting patients (Centers for Disease
WORKPLACe VIOLenCe n 555
Control and Prevention/national Institute participation in training and aggressive
of Occupational Safety and health, 2002). behavior by inpatients on 27 inpatient wards
A 2005 national Survey of the Work and in a California State hospital and found that W–Z
health of nurses, a comprehensive survey wards with higher staff attendance at the
of a large sample of employed regulated training experienced lower rates of injury.
Canadian nurses (n = 18,676) found that Lehmann, Padilla, Clark, and Loucks (1983)
abuse by patients was related to being male, found significantly higher knowledge and
having less experience, working non-day confidence in trained staff.
shifts, and perceiving staffing or resources Runyan, Zakocs, and Zwerling (2000)
as inadequate, nurse–physician relations reviewed 137 articles mentioning violence
as poor, and coworker and supervisor sup- prevention intervention and found that
port as low (Shields & Wilkins, 2009). Lee, only 10 of the articles reflected a databased
Gerberich, Waller, Anderson, and McGovern intervention. All interventions took place in
(1999) found that among 105 nurses who health care: five studies evaluated violence
had filed a worker’s compensation claim for prevention training interventions (includ-
work-related assault injuries, the presence ing Lehmann et al., 1983; Carmel & hunter,
of security personnel reduced the rate of 1990), three examined postincident psycho-
assault, whereas the perception that admin- logical debriefing programs, and two eval-
istrators considered assault to be part of the uated administrative controls to prevent
job, having received assault prevention train- violence. All were quasi-experimental, with-
ing, a high patient/personnel ratio, working out a formal control group and with equivo-
primarily with mental health patients, and cal findings.
working with patients who had a long hospi- The health care workplace must be made
tal stay increased the risk of assault. safe for all health care workers through the
The one patient characteristic that has use of currently available engineering and
been singled out as a strong risk factor for administrative controls, such as security
violence is a history of violent behavior. A alarm systems, adequate staffing, and train-
number of studies have documented that ing. The Occupational Safety and health
a small number of patients are responsi- Administration (1996, 2004) published the
ble for the majority of assaults (hillbrand, Guidelines for Preventing Workplace Violence for
Foster, & Spitz, 1996). Drummond, Sparr, Healthcare and Social Service Workers, which
and Gordon (1989) examined an interven- described the key elements of any proac-
tion designed to identify patients with a tive health and safety program including:
history of violence and found that flagging management commitment and employee
charts of patients with histories of assaul- involvement, a written violence prevention
tive or disruptive behavior reduced assaults program, a worksite analysis, hazard preven-
against staff by 91%. tion and control, medical management and
Many psychiatric settings now require postincident response, training, and educa-
that all patient care providers receive annual tion, and record-keeping and evaluation of
training in the management of aggressive the program. Implementation of the guide-
patients. however, few studies have exam- lines has been found to be feasible within
ined the effectiveness of such training (Beech the mental health and social service work
& Leather, 2006). hurlebaus and Link (1997) settings (Adamson, Vincent, & Cundiff, 2009;
found a significant improvement in nurses’ Lipscomb et al., 2006). Findings from the inpa-
knowledge but no difference in confidence tient mental health workplace indicate that a
and safety after taking an aggressive behavior comprehensive violence prevention program
management program. Carmel and hunter is associated with a reduction in risk factors
(1990) examined the relationship between for violence (Lipscomb et al., 2006).
556 n WORKPLACe VIOLenCe
The focus of this entry has been Type II Researchers have found that violence expe-
(patient/client) violence; however, no health rienced by health care staff is associated
W–Z care setting is immune from other types with lower patient ratings of the quality of
of workplace violence. With an increase in care (Roche, Diers, Duffield, & Catling-Paull,
health care services delivered outside the 2009). When staff members are injured, the
acute care setting, community-based workers remaining staff members may have to work
are at risk of serious or even fatal injury from excessive overtime or under conditions of
Type I (criminal intent) violence. Type III vio- short staffing. Replacement staff may not be
lence (worker-on-worker), often referred to as familiar with the patients and lack crucial
“lateral violence” is gaining increased recog- information regarding patients’ highly indi-
nition as a major problem in the health care vidual needs, triggers, and behaviors. In all
setting. scenarios, the quality of care suffers.
Workplace violence prevention efforts Research evaluating intervention
must be examined within the larger context directly at the primary, secondary, and ter-
in which health care is delivered. The wide tiary prevention of violence across health
availability of handguns, limits on public care settings is critically needed to reduce
funding for social services, and the need workplace violence and ultimately improve
to balance health care worker and patient patient care. A secure and healthful work
rights, are all contextual factors that impact environment is essential to a positive envi-
the risk of violence within individual health ronment of care.
care organizations. evidence exists to dem-
onstrate the inextricable link between staff Jane Lipscomb
safety and the quality/safety of client care. Cassandra Okechukwu
References
Aarnoudse-Moens, C., Weisglas-Kuperus, N., van 93–3411, pp. 7–87). Bethesda, MD: National Institutes
Goudoever, J., & Oosterlaan, J. (2009). Meta-analysis of Health.
of neurobehavioral outcomes in very preterm and/ Abramowitz, S., Cote, A. A., & Berry, E. (1987). Analyzing
or very low birth weight children. Pediatrics, 124(2), patient satisfaction: A multi-analytic approach. Quality
717–728. Retrieved from CINAHL Plus with Full Text Review Bulletin, 13, 122–130.
database. Abramson, L. Y., & Alloy, L. B. (2006). Cognitive vulnera-
Aaronson, L. S., Teel, C., Cassmeyer, V., Neuberger, G. bility to depression: Current status and developmental
B., Pallikkathayil, L., Pierce, J., et al. (1999). Defining origins. In T. E. Joiner, J. S. Brown, & J. Kistner (Eds.),
and measuring fatigue. IMAGE: Journal of Nursing The interpersonal, cognitive and social nature of depres-
Scholarship, 31, 45–50. sion (pp. 83–100). Mahwah, NJ: Lawrence Erlbaum
Aaronson, N. K. (1988). Quality of life: What is it? How Associates Publishers.
should it be measured? Oncology, 2, 69. AbuAlRub, R. (2004). Job stress, job performance, and
Abbey, J. C., Andrews, C., Avigliano, K., Blossom, R., social support among hospital nurses. Journal of
Bunke, B., Engberg, N., et al. (1973). A pilot study: The Nursing Scholarship, 36, 73–78.
control of shivering during hypothermia by a clinical AbuAlRub, R., Omari, F., & Abu Al Rub, A. (2009). The
nursing measure. Journal of Neurosurgical Nursing, 5(2), moderating effect of social support on the stress–satis-
78–88. faction relationship among Jordanian hospital nurses.
Abbey, J. C., & Close, L. (1979, May 2–5). A study of con- Journal of Nursing Management, 17, 870–878.
trol of shivering during hypothermia. Paper presented at AbuAlRub, R., Omari, F., & Al-Zaru, I. (2009). Support,
the 12th Annual Communicating Nursing Research satisfaction and retention among Jordanian nurses
Conference, WICHEN/WSRN, Denver, CO. in private and public hospitals. International Nursing
Abdellah, F., & Levine, E. (1957). Developing a measure Review, 56, 326–332.
of patient and personal satisfaction with nursing care. Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick,
Nursing Research, 5, 100–108. H. S., Steve, K., Muzzy, W., et al. (2010). Prevalence and
Abdellah, F. G. (1959). How we look at ourselves. Nursing correlates of emotional, physical, sexual, and financial
Outlook, 7(3), 273. abuse and potential neglect in the United States: The
Abdellah, F. G. (1969). The nature of nursing science. national elder mistreatment study. American Journal of
Nursing Research, 18, 390–393. Public Health, 100(2), 292–297.
Abegunde, D. O., & Stanciole, A. E. (2008). The eco- Ackerman, M. H., Ciechoski, M. J., & Marx, L. M. (1992).
nomic impact of chronic diseases: How do house- Current trends in enteral feeding. Gastroenterology
holds respond to shocks? Evidence from Russia. Social Nursing, 14(5), 233–236.
Science Medicine, 66, 2296–2307. Ackley, B., Ladwig, G. B., Swan, B. A., & Tucker, S.
Abela, J. R. Z., Zinck, S., Kryger, S., Zilber, I., & Hankin, J. (2008). Evidence-based nursing care guidelines:
B. L. (2009) Contagious depression: Negative attach- Medical-surgical interventions. St. Louis, MO: Mosby
ment cognitions as moderator of the temporal associa- Elsevier.
tion between parental depression and child depression. Action Design. (1996). Organizational learning in action:
Journal of Clinical Child and Adolescent Psychology, 38, New perspectives and strategies. Weston, MA: Author.
16–26. Adams, J. S., Steele, S., Kettles, A. M., Walker, H., Brown,
Abraham, I. L., Chalifoux, Z., & Evers, G. C. M. (1992). I., Collins, M., et al. (2009). Experience of collaborative
Conditions, interventions, and outcomes: A quanti- research practice in forensic mental health. British
tative analysis of nursing research (1981–1990). In P. Journal of Forensic Practice, 11(4), 5–14.
Moritz (Ed.), Patient outcomes research: Examining the Adams, P. F., Dey, A. N., & Vickerie, J. (2007). Summary
effectiveness of nursing practice (NIH Publication No. health statistics for the U.S. population: National
558 n REFERENCES
Health Interview Survey, 2005. Vital and Health of the U.S. Preventive Services Task Force. Rockville,
Statistics, 10, 1–104. MD: Author.
Adams, W. (1996). Alcohol use in retirement commu- Agency for Healthcare Research and Quality. (2008). U.S.
nities. Journal of the American Geriatrics Society, 44, Preventive Services Task Force. Retrieved July 14, 2008,
1082–1085. from http://www.ahrq.gov/clinic/USpstfix.htm
Adamson, A., Vincent, A., & Cundiff, J. (2009). Common Agency for Healthcare Research and Quality. (2009).
ground, not a battle ground: violence prevention at a 2009 National Healthcare Quality & Disparities Report.
detoxification facility. Journal of Psychosocial Nursing Rockville, MD: Author. www.ahrq.gov/qual/qrdr09.
and Mental Health Services, 47(8), 28–35. htm
Aday, L. (2001). At risk in America: The health and health Agency for Healthcare Research and Quality. (2010a).
care needs of vulnerable populations in the United States Web Healthcare 411: News Series from AHRQ. Retrieved
(2nd ed.). San Francisco, CA: Jossey-Bass, Inc. from http://healthcare411.ahrq.gov
Aday, L., & Andersen, R. (1974). A framework for the Agency for Healthcare Research and Quality. (2010b).
study of access to medical care. Health Services Research, Patient safety indicators overview. Rockville, MD: Health
9, 208–220. and Human Services. Retrieved December 5, 2010,
Addington, J., & Adington, D. (2008). Symptom remis- from http://www.qualityindicators.ahrq.gov/
sion in first episode patients. Schizophrenia Research, Agency for Healthcare Research and Quality. (2010c).
106, 281–285. Surveys on patient safety culture. Rockville, MD:
Adler, N. E., & Newman, K. (2002). Socioeconomic Author. Retrieved from http://www.ahrq.gov/qual/
disparities in health: Pathways and policies. Health patientsafetyculture/
Affairs, 21(2), 60–76. Agency for Healthcare Research and Quality. What is
Adler, N. E., & Rehkopf, D. H. (2008). U.S. disparities in comparative effectiveness research. Retrieved from http://
health: Descriptions, causes, and mechanisms. Annual effectivehealthcare.ahrq.gov/index.cfm/what-is-
Review of Public Health, 29(1), 235–252. comparative-effectiveness-research1
Adler, R. (Ed.). (2006). Doorway thoughts: Cross cultural Agras, W. S. (2001). The consequences and costs of the
care for older adults: Volume 2. Ethnogeriatrics Committee eating disorders. Psychiatric Clinics of North America,
of the American Geriatrics Society. Sudbury, MA: Jones 24(2), 371–379. Retrieved from http://www.psych.the-
and Bartlett. clinics.com/article/S0193–953X(05)70232-X/abstract
Adler, R., & Kamel, H. (Eds.). (2004). Doorway thoughts: Agrawal, A., Jacobson, K. C., Prescott, C. A., & Kendler,
Cross cultural care for older adults: Volume 1. Ethnogeriatric K. S. (2002). A twin study of sex differences in social
Committee of the American Geriatrics Society. Sudbury, support. Psychological Medicine, 32, 1155–1164.
MA: Jones and Bartlett. Agrawal, A., Scherrer, J. F., Grant, J. D., Sartor, C. E.,
Administration on Aging. (2009). Aging in the 21st cen- Pergadia, M. L., Duncan, A. E., et al. (2010). The effects
tury, demography. Retrieved August, 20, 2010, from of maternal smoking during pregnancy on offspring
http://www.aoa.gov/AoARoot/Aging_Statistics/ outcomes. Preventive Medicine, 50(1–2), 13–18.
future_growth/aging21/demography.aspx Ahijevych, K. (2009). Biological models for studying and
Adolfsson, J. (1995). Deferred treatment for clinically assessing tobacco use. Annual Review of Nursing, 27,
localized prostate cancer. European Journal of Surgical 145–168.
Oncology, 21, 333–336. Ahlström, B. H., Skärsäter, I., & Danielson, E. (2009).
Affonso, D. D., De, A., Horowitz, J. A., & Mayberry L. Living with major depression: Experiences from
J. (2000). An international study exploring levels of families’ perspectives. Scandinavian Journal of Caring
postpartum depressive symptomatology. Journal of Sciences, 23, 309–316.
Psychosomatic Research, 49, 207–216. Ahlström, B. H., Skärsäter, I., & Danielson, E. (2010). The
Agarwal, R., Gupta, D., Ray, P., Aggarwal, A. N., & Jindal, meaning of depression in family life: The viewpoint of
S. K. (2006). Epidemiology, risk factors and outcome of the ill parent. Journal of Clinical Nursing, 19, 284–293.
nosocomial infections in a respiratory intensive care Ahluwalia, I. B., Morrow, B., Hsia, J., & Grummer-Strawn,
unit in North India. Journal of Infection, 53(2), 98–105. L. M. (2003). Who is breast-feeding? Recent trends
Agency for Healthcare Policy and Research. (1998). from the Pregnancy Risk Assessment and Monitoring
Consumer health informatics and patient decision making System. Journal of Pediatrics, 141, 486–491.
(AHCPR Pub. No. 98-N001). Rockville, MD: Author Ahmed, A. H., & Sands, L. P. (2010). Effect of pre- and
Agency for Healthcare Research and Quality. (2001). postdischarge interventions on breastfeeding outcomes
Translating Research into Practice (TRIP)-II: Fact sheet and weight gain among premature infants. Journal of
(AHRQ Publication No. 01-P017). Rockville, MD: Obstetric, Gynecologic, and Neonatal Nursing, 39(1), 53–63.
Author. Retrieved September 7, 2010, from http:// Ai, A. L., & Bolling, S. F. (2002). The use of complemen-
www.ahrq.gov/research/trip2fac.htm tary and alternative therapies among middle-aged
Agency for Healthcare Research and Quality. (2006). The and older cardiac patients. American Journal of Medical
guide to clinical preventive services. Recommendations Quality, 17(1), 21–27.
REFERENCES n 559
Aiken, L., Clarke, S., & Sloane, D. (2002). Hospital staffing, health care.” Journal of the American Academy of Nurse
organisation and quality of care: Cross-national find- Practitioners, 22(11), 602–611.
ings. Nursing Outlook, 50, 187–194. Alexander, I. M., Motter, S., Ruff, C., Rousseau, M. E.,
Aiken, L., Clarke, S., Sloane, D., Lake, E., & Cheney, T. & White, D. P. (2005). Reasons for use, discontinua-
(2008). Effects of hospital care environment on patient tion, or avoidance of hormone therapy among Black
mortality and nurse outcomes. Journal of Nursing women (abstract). Menopause, 11(6), 661.
Administration, 38(5), 223–229. Alexander, I. M., Ruff, C., Rousseau, M. E., White, K.,
Aiken, L., & Lake, E. (1994). Lower Medicare mortality Motter, S., McKie, C., et al. (2003). Menopause symp-
among a set of hospitals known for good practice. toms and management strategies identified by black
Medical Care Research, 32(8), 771–787. women (abstract). Menopause, 10(6), 601.
Aiken, L. H. (2002). Superior outcomes for magnet hos- Alexander, I. M., Ruff, C., Rousseau, M. E., White, K.,
pitals: The evidence base. In M. L. McClure & A. S. Motter, S., McKie, C., et al. (2004, April 1–3). Experiences
Hinshaw (Eds.), Magnet hospitals revisited: Attraction and and perceptions of menopause and midlife health among
retention of professional nurses (pp. 61–81). Washington, black women. Paper presented at the Eastern Nursing
DC: American Nurses Publishing. Research Society (ENRS) 16th Annual Scientific
Aiken, L. H., Clarke, S. P., Cheung, R. B., Sloane, D. M., & Sessions, Partnerships: Advancing the Research
Silber, J. H. (2003). Education levels of hospital nurses Agenda for Quality Care, Quincy, MA.
and surgical patient mortality. Journal of the American Alexopoulos, G. S. (2005). Depression in the elderly.
Medical Association, 290, 1617–1623. Lancet, 365, 1961–1970.
Aiken, L. H., Clarke, S. P., Silber, J. H., & Sloane, D. (2003). Algase, D. L. (1999a). Wandering: A dementia-compro-
Hospital nurse staffing, education, and patient mor- mised behavior. Journal of Gerontological Nursing, 25(9),
tality. LDI Issue Brief, 9(2), 1–4. 10–16.
Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., Algase, D. L. (1999b). Wandering in dementia: State of
& Silber, J. H. (2002). Hospital nurse staffing and the science. In J. J. Fitzpatrick (Ed.), Annual review
patient mortality, nurse burnout, and job dissatisfac- of nursing research (Vol. 17, pp. 165–218). New York:
tion. Journal of the American Medical Association, 288, Springer.
1987–1993. Algase, D. L., Beck, C., Kolanowski, A., Whall, A., Berent,
Aiken, L. H., Smith, H. L., & Lake, E. T. (1994). Lower A., Richards, K., et al. (1996). Need-driven dementia-
Medicare mortality among a set of hospitals known compromised behaviour: An alternative view of dis-
for good nursing care. Medical Care, 32(8), 771–787. ruptive behaviour. American Journal of Alzheimer’s
Ajzen, I., & Fishbein, M. (1980). Understanding attitudes Disease, 11(6), 10–19.
and predicting social behavior. Englewood Cliffs, NJ: Algase, D. L., Moore, D. H., Venderweed, C., & Gavin-
Prentice Hall. Dreschnack, D. (2007). Mapping the maze of terms
Akyol, A. (2007). Hand hygiene among nurses in Turkey: and definitions in dementia related wandering. Aging
Opinions and practices. Journal of Clinical Nursing, and Mental Health, 11, 686–698.
16(3), 431–437. Allam, S., Blyth, S., Fraser, A., Hodgson, S., Howes, J.,
Alba-Juez, L. (2009). Perspectives on discourse analysis: Repper, J., et al. (2004). Our experience of collaborative
Theory and practice. Newcastle upon Tyne: Cambridge research: Service users, carers and researchers work
Scholars Publishing. together to evaluate an assertive outreach service.
Albert, N. M. (2008). Promoting self-care in heart fail- Journal of Psychiatric and Mental Health Nursing, 11(3),
ure: State of clinical practice based on the perspec- 365–373.
tives of healthcare systems and providers. Journal of Allegranzi, B., & Pittet, D. (2007). Healthcare-associated
Cardiovascular Nursing, 23(3), 277–284. infection in developing countries: Simple solutions to
Alberts, M. J., Hademenos, G., Latchaw, R. E., Jagoda, A., meet complex challenges. Infection Control and Hospital
Marler, J. R., Mayberg, M. R., et al. (2000). Consensus Epidemiology, 28(12), 1323–1327.
statement: Recommendations for the establishment of Allen, J., & Close, J. (2010). The NICHE geriatric resource
primary stroke centers. JAMA, 283, 3102–3109. nurse model: Improving the care of older adults with
Alegria, M., Canino, G., Shrout, P. E., Woo, M., Duan, N., Alzheimer’s disease and other dementias. Geriatric
Vila, D., et al. (2008). Prevalence of mental illness in Nursing, 31(2), 128–132.
immigrant and non-immigrant U.S. Latino groups. Allen, J. K., & Dennison, C. R. (2010). Randomized tri-
American Journal of Psychiatry, 165, 359–369. als of nursing interventions for secondary prevention
Alexander, I. M. (2004). Characteristics of and problems in patients with coronary artery disease and heart
with primary care interactions experienced by an eth- failure: A systematic review. Journal of Cardiovascular
nically diverse group of women. Journal of the American Nursing, 25(3), 207–209.
Academy of Nurse Practitioners, 16(7), 300–310. Allen, M. L., Elliott, M. N., Fugligni, A. J., Morales, L.
Alexander, I. M. (2010). Emancipatory actions displayed S., Hambarsoomian, K., & Schuster, M. A. (2008). The
by multi-ethnic women: “Regaining control of my relationship between Spanish language and substance
560 n REFERENCES
use behavior among Latino youth: A social network org/online/en/home/practicemgt/codingresources/
approach. Journal of Adolescent Health, 43, 372–379. groupvisitcoding.html
Allen, T., Eby, L, Poteet, M., Lentz, E., & Lima, L. (2004). American Academy of Pediatrics Committee on
Career benefits associated with mentoring for prote- Environmental Health. (2005). Lead exposure in
ges: A meta-analysis. Journal of Applied Psychology, 89, children: Prevention, detection, and management.
127–136. Pediatrics, 116(4), 1036–1046.
Allen, V. M, Joseph, K., Murphy, K., Magee, L., & Ohlsson, American Academy of Pediatrics Committee on
A. (2004). The effect of hypertensive disorders in preg- Nutrition. (2005). Pediatric nutrition handbook (5th ed.).
nancy on small for gestational age and stillbirth: A Elk Grove Village, IL: Author.
population based study. BMC Pregnancy Childbirth, American Association of Colleges of Nursing. (1998).
4(1), 17. Policy and guidelines for prevention and management
Alligood, M. R., & Tomey, A. M. (2002). Nursing theory: of substance abuse in the nursing education commu-
Utilization & application. St. Louis: Mosby. nity. AACN Position Statement. Washington, DC:
Alqaissi, N. M., & Dickerson, S. S. (2010). Exploring com- Author.
mon meanings of social support as experienced by American Association of Colleges of Nursing. (2006). The
Jordanian women with breast cancer. Cancer Nursing, essentials of doctoral education for advanced nursing prac-
33(5), 353–361. tice. Washington, DC: Author. Retrieved from aacn.
Als, H. (1986). A synactive model of neonatal behavioral nche.edu/DNP/pdf/essentials.pdf
organization: Framework for assessment of neurode- American Association of Colleges of Nursing. (2009).
velopment in the premature infant and for support Nursing shortage fact sheet. Retrieved July 30, 2009,
of infants and parents in the neonatal intensive care from http://www.aacn.nche.edu/media/pdf/Nrsg
environment. Part 1: Theoretical framework. Physical ShortageFS.pdf
and Occupational Therapy in Pediatrics, 3/4(6), 1–53. American Association of Critical Care Nurses. (2004).
Als, H., Duffy, F. H., & McAnulty, G. B. (1996). AACN Practice alert on pulmonary artery/central venous
Effectiveness of individualized neurodevelopmental pressure measurement (pp. 1–4). Aliso Viejo: Author.
care in the newborn intensive care unit (NICU). Acta (Revised December 2009 by E. Bridges.)
Paediatrica. Supplement, 416, 21–30. American Association of Critical Care Nurses. (2010).
Als, H., Gilkerson, L., Duffy, F. H., McAnulty, G. B., Retrieved August 16, 2010, from http://www.aacn.
Buehler, D. M., Vandenberg, K., et al. (2003). A three- org/wd/practice/content/research/research-mis-
center, randomized, controlled trial of individualized sion-and-vision.pcms?pid=1&&menu=practice#
developmental care for very low birth weight preterm Mission
infants: Medical, neurodevelopmental, parenting, and American Association of Critical Care Nurses. (2010).
caregiving effects. Journal of Developmental & Behavioral Retrieved August 16, 2010, from http://www.aacn.org/
Pediatrics, 24(6), 399–408. wd/practice/content/grant.pcms?menu=practice&
Alvarez, J., Pavao, J., Mack, K. P., Chow, J. M., Baumrind, lastmenu
N., & Kimerling, R. (2009). Lifetime interpersonal vio- American Association of Homes and Services for the
lence and self-reported Chla mydia trachomatis diag- Aged. (2006). Overview of assisted living. Alexandria,
nosis among California women. Journal of Women’s VA: Author.
Health, 18(1), 57–63. American College of Obstetricians and Gyneco logists.
Alzheimer’s Association. (2010). Alzheimer’s dis- (2009, July). Intrapartum fetal health rate monitoring:
ease facts and figures. Retrieved from http://www. Nomenclature, interpretation, and general manage-
alz.org/documents_custom/report_alzfacts ment principles (Practice Bulletin No. 106). Obstetrics &
figures2010.pdf Gynecology, 114, 192–202.
Amar, A. F., & Gennaro, S. (2005). Dating violence in col- American College of Physicians. (2005). Inno vations: Group
lage women: Associated physical Injury, healthcare medical visits. Retrieved from http://www.acpon-
usage, and mental health symptoms. Nursing Research, line.org/running_practice/patient_care/group_
54(4), 235–242. visits/
Amarneh, B., AbuAlRub, R., & Abu Al-Rub, N. (2009). American Diabetes Association. (2008). Economic costs
Co-workers’ support and job performance among of diabetes in the U.S. in 2007. Diabetes Care, 31(3),
nurses in Jordanian hospitals. Journal of Research in 596–615.
Nursing, 14(6), 10.1177/1744987109347134. American Diabetes Association. (2010). Standards of
Amella, E., Grant, A., & Mulloy, C. (2008). Eating behav- medical care in diabetes—2010. Diabetes Care, 33(Suppl.
ior in persons with moderate to late-stage dementia: 1), S11–S61.
Assessment and interventions. Journal of the American American Dietetic Association. (2009). Position of the
Psychiatric Nurses Association, 13, 360–367. American Dietetic Association: Weight manage-
American Academy of Family Physicians. (2010). Coding ment. Journal of the American Dietetic Association, 109,
for group visits. Retrieved from http://www.aafp. 330–346.
REFERENCES n 561
American Heart Association. (2004). Stroke: Patient educa- American Nurses Association. (2010). Nursing
tion tool kit. Dallas, TX: Author. Infor mation & Data Set Evaluation Center.
American Heart Association. (2006). Dietary recommen- Retrieved September 21, 2010, from http://
dations for children and adolescents: A guide for prac- nu r s i n g wo rld.o r g/M a i n M e nu C at e g o r i e s/
titioners. Pediatrics, 117(2), 544–559. ThePracticeofProfessionalNursing/Nursing
American Heart Association. (2009). Scientific state- Standards/DocumentationInformatics/NIDSEC.
ments: Dietary recommendations for children and aspx
adolescents. American Journal of Lifestyle Medicine, 3(2), American Nurses Association. (2010a). Ethics and human
106–109. rights [Position statements]. Retrieved from http://
American Heart Association. (2009a). Angioplasty and nursingworld.org
cardiac revascularization statistics. American Heart American Nurses Association. (2010b). Nursing: Scope
Association’s Heart Disease and Stroke Statistics—2009 and standards of practice (2nd ed.). Silver Spring, MD:
update. Retrieved August 25, 2010, from http://www. Nursesbooks.org.
americanheart.org/presenter.jhtml?identifier=4439 American Nurses Association. (2010c). Nursing’s social
American Heart Association. (2010). Heart disease and stroke policy statement: The essence of the profession (3rd ed.).
statistics—2010 update. Dallas, TX: Author. Silver Spring, MD: Nursesbooks.org.
American Medical Association. (1992). Diagnostic and American Nurses Credentialing Center. (2008). The
treatment guidelines on elder abuse and neglect. Chicago: magnet model components and sources of evidence. Silver
Author. Spring: Author.
American Medical Association. (2007). Current procedural American Psychiatric Association. (1994). Diagnostic
terminology 2008: Professional edition. Chicago: Author. and statistical manual of mental disorders (4th ed.).
American Medical Association. (2010). Retrieved August Washington, DC: Author.
8, 2010, from www.ama American Psychiatric Association. (2000). Diag nostic and
American Nurses Association (Ed.). (1998). Multi state reg- statistical manual of mental disorders (4th ed., text revi-
ulation of nurses. Wadhinton, DC: Author. sion). Arlington, VA: Author.
American Nurses Association. (1975). Human rights American Psychological Association. (2005). The behav-
guidelines for nurses in clinical and other research. Kansas ioral health care needs of rural women. Rural women’s
City, MO: Author. work group of the rural task force of the American
American Nurses Association. (1984). Addictions and Psychological Association’s committee on health.
psychological dysfunctions in nursing. Kansas City, MO: Retrieved December 8, 2010, from http://www.aps.org/
Author. rural/ruralwomen.pdf
American Nurses Association. (1985). Human rights Amir, L. H., & Donath, S. (2007). A systematic review of
guidelines for nurses in clinical and other research. Kansas maternal obesity and breastfeeding intention, initia-
City, MO: Author. tion and duration. BMC Pregnancy and Childbirth, 7, 9.
American Nurses Association. (1999). Core prin- ANA Position Statement. (2007, July 13). Registered
ciples on telehealth. Report of the Interdisciplinary nurse utilization of nursing assistive personnel in all
Telehealth Standards Working Group, March 25, 1998. settings. Retrieved August 4, 2010, from http://
Washington, DC: Author. nursingworld.org/MainMenuCategories/Health
American Nurses Association. (2001a). Code of ethics for careandPolicyIssues/ANAPosition Statements/uap.
nurses with interpretive statements. Washington, DC: spx
American Nurses Publishing. Anders, M., Turner, L., &Wallace, L. S. (2006). Use of deci-
American Nurses Association. (2001b). Health sion rules for osteoporosis prevention and treatment:
and safety survey. Retrieved May 16, 2008, from Implications for nurse practitioners. Journal of the
www.nursingworld.org/MainMenuCategories/ American Academy of Nurse Practitioners, 19, 299–305.
OccupationalandEnvironmental/occupational- Andershed, B. (2006). Relatives in end-of-life care: Part 1.
health/HealthSafetySurvey.aspx A systematic review of the literature the five last
American Nurses Association. (2003). Social policy state- years, January 1999–February 2004. Journal of Clinical
ment. Washington, DC: Author. Nursing, 15(9), 1158–1169.
American Nurses Association. (2004). Nursing: Scope and Anderson, G. C. (1977). The mother and her newborn:
standards of practice. Silver Spring, MD: Nursesbooks. Mutual caregivers. Journal of Obstetric, Gynecologic, and
org. Neonatal Nursing, 6(5), 50–57.
American Nurses Association. (2007). Public health nurs- Anderson, G. C. (1989). Risk in mother–infant separa-
ing: Scope and standards of practice. Washington, DC: tion postbirth. Image: Journal of Nursing Scholarship, 21,
Author. 196–199.
American Nurses Association. (2008). Nursing informat- Anderson, G. C. (1995). Touch and the kangaroo method.
ics: Scope and standards of practice. Silver Springs, MD: In T. Field (Ed.), Touch and infancy (pp. 35–51). Hillsdale,
Author. NJ: Erlbaum.
562 n REFERENCES
Anderson, G. C. (1999). Kangaroo care of the premature Angres, D. H., & Bettinadi-Angres, K. (2008, October).
infant. In E. Goldson (Ed.), Nurturing the premature The disease of addiction: Origins, treatment and
infant: Developmental interventions in the neonatal inten- recovery. Disease-a-Month, 54(10), 696–721. Retrieved
sive care nursery. New York: Oxford University Press. October 25, 2009, from http://www.diseaseamonth.
Anderson, G. C., Chiu, S. H., Dombrowski, M. A., Swinth, com/article/S0011–5029(08)00092–8/abstract
J. Y., Albert, J. M., & Wada, N. (2003). Mother–newborn Anhalt, K., Telzrow, F., & Brown, L. (2007). Maternal
contact in a randomized trial of kangaroo (skin-to- stress and emotional status during the perinatal
skin) care. Journal of Obstetric, Gynecologic, & Neonatal period and childhood adjustment. School of Psychology
Nursing, 32(5), 604–611. Quarterly, 22(1), 74–90.
Anderson, G. C., Dombrowski, M. A. S., & Swinth, J. Y. Annas, G. J. (1993). Standard of care: The law of American
(2001). Kangaroo care: Not just for stable premies any- bioethics. New York: Oxford University Press.
more. Reflections on Nursing Leadership, 27, 32–34. Annas, G. J. (1995). How we die. Hastings Center Report,
Anderson, J. A., & Willson, P. (2008). Clinical decision 25, 512–514.
support systems in nursing. Computers, Informatics, Annie E. Casey Foundation. (2008). A road map for juve-
Nursing, 26(3), 151–158. nile justice reform. 2008 KIDS COUNT Data Book.
Anderson, K. L., & Burckhardt, C. (1999). Baltimore, MD: Author. Retrieved August 1, 2010,
Conceptualization and measurement of quality of life from http://www.aecf.org/~/media/Pub licationFiles/
as an outcome variable for health care intervention AEC180essay_booklet_MECH.pdf
and research. Journal of Advanced Nursing, 29, 298–306. Anotayanonth, S., Subhedar, N. V., Neilson, J. P., &
Anderson, L. S., Riesch, S. K., Pridham, K. A., Lutz, K. Harigopal, S. (2010) Betamimetics for inhibiting pre-
F., & Becker, P. T. (2010). Furthering the understand- term labour. Cochrane Database of Systematic Reviews,
ing of parent–child relationships: A nursing scholar- (2), 00075320–100000000-03261.
ship review series. Part 4: Parent–child relationships Anthony, J. S., & Barry, D. G. (2009). Perceptions of health
at risk. Journal of Specialists in Pediatric Nursing, 15(2), status among women and men in an urban homeless
111–134. population. Journal of National Black Nurses’ Association,
Anderson, S., & Whitaker, R. (2010). Household routines 20(1), 36–41.
and obesity in US preschool-aged children. Pediatrics, Anthony, M. (2004). Shared governance models: The the-
125(3), 420–428. ory, practice, and evidence. Online Journal of Issues in
Anderson, S., Michelman, J., Johnson, R. M., & Quick, K. Nursing, 9(1), 4.
(2008). Rate setting and disclosure in continuing care Anthony, N., & Greenley, D. (1993). Recovery from men-
retirement communities (CCRCs). Journal of Health Care tal illness: The guiding vision of the mental health ser-
Finance, 34, 55–65. vices system in the 1990’s. Psychological Rehabilitation
Anderson, S. L. (1990). Patient advocacy and whistle- Journal, 16, 11–24.
blowing in nursing: Help for the helpers. Nursing Anthony, S., & Jack, S. (2009). Qualitative case study
Forum, 25(3), 5–13. methodology in nursing research: An integrative
Anderson, T., Linden, L., Allen, M., & Gibbs, E. (2009). review. Journal of Advanced Nursing, 65(6), 1171–1181.
New graduate RN work satisfaction after complet- AORN. (2008). Perioperative Nursing Data Set (3rd ed.).
ing an interactive nurse residency. Journal of Nursing Denver, CO: Author.
Administration, 39, 165–169. Apantaku, L. M. (2000). Breast cancer diagnosis and
Ando, M. (2003). The effect of short and long-term screening. American Family Physician, 62(3), 596–602,
life review interview on the psychological well- 605.
being of young adults. Psychological Reports, 93, Aparasu, R. R., & Hegge, M. (2001). Autonomous ambu-
595–602. latory care by nurse practitioners and physician assis-
Ando, M., Morita T., Akechi, T., & Okamoto, T. (2010). tants in office-based settings. Journal of Allied Health,
Efficacy of short-term life review interviews on the 30(3), 153–9.
spiritual well-being of terminally ill cancer patients. Apovian, C. M. (2010). The causes, prevalence, and
Journal of Pain and Symptom Management, 39(6), treatment of obesity revisited in 2009: What have we
993–1002. learned so far? American Journal of Clinical Nutrition,
Andolesk, K. M., & Kelton, G. M. (2000). Risk assessment. 91, 277S–279S.
Primary Care: Clinics in office practice, 27(1), 71–103. Appel, N., Campbell, S. H., Lynch, N., Novotny, J. (2007).
Androwich, I. M., Bickford, C. S., Button, P. J., Hunter, Creating effective advisory boards for schools of nurs-
K. M., Murphy, J., & Sensmeier, J. (2003). Clinical infor- ing. Journal of Professional Nursing, 23, 343–350.
mation systems: A framework for reaching the vision. A report from the Coalition for Health Services Research:
Washington, DC: American Nurses Publishing. Health reform: What it means for health services
Angold, A., Costello, E. J., & Erkanli, A. (1999). research. (2010). Health Services Research, 45(3), ix–xxi.
Comorbidity. Journal of Child Psychology and Psychiatry, Archbold, P. G., & Stewart, B. J. (1996). The nature of
40(1), 57–87. the caregiving role and nursing interventions for
REFERENCES n 563
caregiving families. In E. Swanson & T. Tripp-Reimer Arthur, D., Pang, S., & Wong, T. (2001). The effect of
(Eds.), Series on issues in gerontological nursing (Vol. 1, technology on the caring attributes of an interna-
pp. 133–156). New York: Springer Publishing. tional sample of nurses. International Journal of Nursing
Ardell, D. B. (2010). Wellness models of the past and the new Studies, 38, 37–43.
REAL wellness model of the future. Retrieved from www. Arthur, H. M., Daniels, C., McKelvie, R., Hirsh, J., &
seekwellness.com Rush, B. (2000). Effect of preoperative intervention on
Ardell, D. B. (n.d.). Worksite wellness that includes every- preoperative and postoperative outcomes in low-risk
body and changes everything, not just health risks and patients awaiting elective coronary artery bypass graft
medical costs. Retrieved August 20, 2010, from www. surgery. Annals of Internal Medicine, 133, 253–262.
workandwellness.com Artieta-Pinedo, I., Paz-Pascual, C., Grandes, G., Remiro-
Arditi-Babchuk, H., Feldman, R., & Eidelman, A. I. Fernandezdegamboa, G., Odriozola-Hermosilla, I.,
(2009). Rapid eye movement (REM) in premature neo- Bacigalupe, A., et al. (2010). The benefits of antenatal
nates and developmental outcome at 6 months. Infant education for the childbirth process in Spain. Nursing
Behav Dev, 32(1), 27–32. Research, 59, 194–202.
Argyris, C. (1980). Inner contradictions of rigorous research. Arulkumaran, S., Penne, L. K., & Rao, K. B. (2005). The
San Diego: Academic Press. management of labour (2nd ed.). Hyderabad, India:
Argyris, C. (1982). Reasoning, learning, and action: Individual Orient Longman Private Ltd.
and organizational. San Francisco, CA: Jossey-Bass. Aschengrau, A., & Seage, G. R. (2008). Essentials of epide-
Argyris, C. (1993). Knowledge for action. San Francisco, miology in public health (2nd ed.). Sudbury MA: Jones &
CA: Jossey-Bass. Bartlett Publishers.
Argyris, C. (2002). Double-loop learning. Teaching and Aselage, M. B., & Amella, E. J. (2010). An evolutionary
research. Learning and Education, 1, 206–219. analysis of mealtime difficulties in older adults with
Argyris, C., Putnam, R., & Smith, D. M. (1985). Action sci- dementia. Journal of Clinical Nursing, 19(1–2), 33–41.
ence: Concepts, methods, and skills for research and interven- Ashcraft, A., Owen, D., & Feng, D. (2006). A comparison
tion. San Francisco, CA: Jossey-Bass. of cognitive and functional care differences in four
Argyris, C., & Schön, D. A. (1974). Theory in practice. San long term care settings. Journal of the American Medical
Francisco, CA: Jossey-Bass. Directors Association, 7(2), 96–101.
Argyris, C., & Schön, D. A. (1989). Participatory action Ashford, K. B., Hahn, E., Hall, L., Rayens, M. K., Noland,
research and action science compared. American M., & Collins, R. (2010). Measuring prenatal sec-
Behavioral Scientist, 32, 612–623. ondhand smoke exposure in mother-baby couplets.
Argyris, C., & Schön, D. A. (1996). Organizational learning Nicotine Tobacco Research, 12(2), 127–135.
II: Theory, method, and practice. Reading, MA: Addision- Ashton, D. M., Lawrence, H. C., III, Adams, N. L., III, &
Wesley. Fleischman, A. R. (2009). Surgeon general’s confer-
Armola, R. R., Bourgault, A. M., Halm, M. A., Board, R. ence on the prevention of preterm birth. Obstetrics &
M., Bucher, L., Harrington, L., et al. (2009). 2008–2009 Gynecology, 113(4), 925–30.
Evidence-Based Practice Resource Work Group of Asplund, K., Gustafson, Y., Jacobsson, C., Bucht, G.,
the American Association of Critical-Care Nurses. Wahlin, A., Peterson, J., et al. (2000). Geriatric-based
American Journal of Critical Care, 18(5), 405–409. versus general wards for older acute medical patients:
Aroian, K. J. (2001). Immigrant women’s health. In N. A randomized comparison of outcomes and use of
Woods, D. Taylor, & J. Fitzpatrick (Eds.), Annual review resources. Journal of the American Geriatrics Society,
of nursing research (Vol. 19, pp. 179–226). New York: 48(11), 1381–1388.
Springer Publishing. Assad, L. G., & de Oliveira Viana, L. (2005). Ways of
Aroian, K. J., Hough E. S., Templin, T. N., Kulwicki, A., learning in the practice of the attending nurse. Revista
Ramaswamy, V., & Katz, A. (2009). A model of mother– Brasileira de Enfermagem, 58, 586–591. (In Portuguese;
child adjustment in Arab Muslim Immigrants to the English abstract).
US. Social Science and Medicine, 69, 1377–1386. Assailly, J. P. (2004). The prevention of young driv-
Aroian, K. J., Norris, A. E., & Chang, L. (2003). Gender dif- er’s DWI (driving while intoxicated and RWDI
ferences in psychological distress among immigrants (riding with a driver under influence) in Europe: A
from the former Soviet Union. Sex Roles, 48(1/2), 39–51. social-sequential model. Traffic Injury Prevention, 5,
Aroian, K. J., Norris, A. E., González de Chávez 237–240.
Fernández, M. A., & Averasturi, L. M. G. (2008). Association for Applied Psychophysiology and
Gender differences in psychological distress among Biofeedback. (2008). What is biofeedback. Retrieved
Latin American immigrants to the Canary Islands. August 25, 2010, from http://www.aapb.org/home.
Sex Roles, 59, 107–118. html
Arras, J. (1994). The technologic tether: An introduction Association of Perioperative Registered Nurses. (2008).
to ethical and social issues in high-tech home care. Perioperative nursing data set (3rd ed.). Denver, CO:
Hastings Center Report, 24(5), 51–52. Author.
564 n REFERENCES
Astrup, J., Siesjo, B. K., & Symon, L. (1981). Thresholds Ayres, C. G., & Griffith, H. M. (2007b). Promoting con-
in cerebral ischemia—The ischemic penumbra. Stroke, sistent clinical preventive services guidelines among
12(6), 723–725. competing health plans. Journal for Healthcare Quality,
Attree, M. (2001). Patients’ and relatives’ experiences and 29(3), 37–43.
perspectives of ‘good’ and ‘not so good’ quality care. Babrow, A. S. (2001). Uncertainty, value, communication,
Journal of Advanced Nursing, 33(4), 456–466. and problematic integration. Journal of Communication,
Audi, R. (2006). Philosophy. In D. M. Borchert (Ed. in 51(3), 553–573.
chief). In Encyclopedia of philosophy (2nd ed., Vol. 7, pp. Bachman, K. (2007). Obesity, weight management, and
325–337). New York: Thomson Gale. health care costs: A primer. Disease Management, 10(3),
Augustyn, M., & Simons-Morton, B. G. (1995). Adolescent 129–137.
drinking and driving: Etiology and interpretation. Badger, T. A. (1996a). Family members’ experiences liv-
Journal of Drug Education, 25, 41–59. ing with members with depression. Western Journal of
Austin, J. L. (1975). Lectures. In J. O. Urmson & M. Sbisà Nursing Research, 18, 149–171.
(Eds.), How to do things with words (2nd ed.). Cambridge, Badger, T. A. (1996b). Living with depression: Family
MA: Cambridge University Press. members’ experiences and treatment needs. Journal
Austin, J. K., & Dunn, D. W. (2000). Children with epi- of Psychosocial Nursing and Mental Health Services, 34,
lepsy: Quality of life and psychosocial needs. Annual 21–29.
Review of Nursing Research, 18, 26–47. Baernholdt, M., Jennings, B. M., Merwin, E., & Thornlow,
Austin, J. K., Dunn, D. W., & Huster, G. A. (2000). D. (2010). What does quality care mean to nurses in
Childhood epilepsy and asthma: Changes in behavior rural hospitals? Journal of Advanced Nursing, 66(6),
problems related to gender and change in condition 1346–1355.
severity. Epilepsia, 41, 615–623. Baernholdt, M., & Mark, B. A. (2009). The nurse work
Austin, J. K., Harezlak, J., Dunn, D. W., Huster, G. A., environment, job satisfaction and turnover rates in
Rose, D. F., & Ambrosius, W. T. (2001). Behavior prob- rural and urban nursing units. Journal of Nursing
lems in children before first recognized seizures. Management, 17(8), 994–1001.
Pediatrics, 107(1), 115–122. Baggs, J. G. (2007). Nurse–physician collaboration in
Austin, W., Bergum, V., & Goldberg, L. (2003). Unable to intensive care units. Critical Care Medicine, 35(2),
answer the call of our patients: Mental health nurses’ 641–642.
experience of moral distress. Nursing Inquiry, 10(3), Baggs, J. G., Ryan, S. A., Phelps, C. E., Richeson, J. F., &
177–183. Johnson, J. E. (1992). The association between inter-
Austin, W., Kagan, L., Rankel, M., & Bergum, V. (2008). disciplinary collaboration and patient outcomes in a
The balancing act: Psychiatrists’ experience of moral medical intensive care unit. Heart Lung, 21(1), 18–24.
distress. Medicine, Health Care, and Philosophy, 11(1), Bagley, B. (2000). Building for tomorrow: The ideal-
89–97. ized design of clinical office practices. Family Practice
Avant, K. C. (1990). The art and science of nursing diag- Management. Retrieved from http://www.aafp.org/
nosis development. Nursing Diagnosis, 1(2), 51–56. fpm/20000500/13buil.html
Avery, M. D., Cohen, B. A., & Walker, J. D. (2008). Bailey, D., Wallace, M., Latini, D. M., Hegarty, J., Carroll,
Evaluation of an online graduate nursing curriculum: P. R., Klein, E. A., et al. (2009). Measuring illness uncer-
Examining standards of quality. International Journal tainty in older men undergoing active surveillance
of Nursing Education Scholarship, 5(1), 1–17. (AS) for prostate cancer. Applied Nursing Research, from
Avis, N. E., Stellato, R., Crawford, S., Bromberger, J., http://www.appliednursingresearch.org/article/
Ganz, P., Cain, V., et al. (2001). Is there a menopausal S0897-1897(09)00077-9
syndrome? Menopausal status and symptoms across Bailey, S., & Heitkemper, M. (2001). Circadian rhythmic-
racial/ethnic groups. Social Science and Medicine, ity of cortisol and body temperature: Morningness–
52(2001), 345–356. eveningness effects. Chronobiology International, 18(2),
Ayalon, L., Arean, P., Bornfeld, H., & Beard, R. (2009). 249–261
Long term care staff beliefs about evidence based Bailey, S., Letiecq, B. L., & Porterfield, F. (2009). Family
practices for the management of dementia and agi- coping and adaptation among grandparents rearing
tation. International Journal of Geriatric Psychiatry, 24, grandchildren. Journal of Intergenerational Relationships,
118–124. 7(2), 144–158.
Ayres, C., & Griffith, H. (2008). Consensus guidelines: Baird, C., & Fornili, K. (2008). Effective health care deliv-
Improving the delivery of clinical preventive services. ery and integrated behavioral health screening. Journal
Health Care Management Review, 33(4). of Addictions Nursing, 19(3), 174–177.
Ayres, C. G., & Griffith, H. M. (2007a). Perceived barri- Bakas, T., Austin, J. K., Okonkwo, K. F., Lewis, R. R., &
ers to and facilitators of the implementation of prior- Chadwick, L. (2002). Needs, concerns, strategies, and
ity clinical preventive services guidelines. American advice of stroke caregivers the first 6 months after dis-
Journal of Managed Care, 13(3), 150–155. charge. Journal of Neuroscience Nursing, 34(5), 242–251.
REFERENCES n 565
Bakas, T., Champion, V., Perkins, S. M., Farran, C. J., & Bambini, D., Washburn, J., & Perkins, R. (2009). Outcomes
Williams, L. S. (2006). Psychometric testing of the of clinical simulation for novice nursing students:
revised 15-item Bakas Caregiving Outcomes Scale. Communication, confidence, clinical judgment.
Nursing Research, 55(5), 346–355. Nursing Education Perspectives, 30(2), 79–82.
Bakas, T., Farran, C. J., Austin, J. K., Given, B. A., Bandura, A. (1977). Self-efficacy: Toward a unifying
Johnson, E. A., & Williams, L. S. (2009). Content valid- theory of behavioral change. Psychological Review, 84,
ity and satisfaction with a stroke caregiver inter- 191–215.
vention program. Journal of Nursing Scholarship, 41, Bandura, A. (1986). Social foundations of thought and action.
368–375. New Jersey: Prentice Hall.
Bakas, T., Pressler, S. J., Johnson, E. A., Nauser, J. A., & Bandura, A. (1994). Social cognitive theory and exercise
Shaneyfelt, T. (2006). Family caregiving in heart fail- of control over HIV infection. In R. J. DiClemente and
ure. Nursing Research, 55(3), 180–188. J. L. Peterson (Eds.), Preventing AIDS: Theories and
Bakitas, M., Lyons, K. D., Hegel, M. T., Balan, S., Brokaw, methods of behavioral interventions (pp. 25–59). New
F. C., & Ahles, T. (2009). Effects of a palliative care York: Plenum Press.
intervention on clinical outcomes in patients with Bandura, A. (1995). Self-efficacy in changing societies. New
advanced cancer. JAMA, 302, 741–749. York: Cambridge University Press.
Bakken, S., Cimino, J. J., & Hripcsak, G. (2004). Promoting Bandura, A. (1997). Self-efficacy: The exercise of control.
patient safety and enabling evidence-based prac- New York: W.H. Freeman and Company.
tice through informatics. Medical Care, 42(Suppl. 2), Bandura, A., Adams, N., & Beyer. (1977). Cognitive
II49–II56. processes mediating behavioral change. Journal of
Bakken, S., Coenen, A., & Saba, V. (2004). ISO reference Personality and Social Psychology, 35(3), 125–149.
technology model: Nursing diagnosis and action mod- Banks, M. R., & Banks, W. A. (2002). The effects of animal-
els look to testing for practical application. Healthcare assisted therapy on loneliness in an elderly population
Informatics, 21(9), 52. in long-term care facilities. Journal of Gerontology, 57(7),
Bakken, S., Holzemer, W. L., Portillo, C. J., Grimes, R., 428–432.
Welch, J., & Wantland, D. (2005). Utility of a standardized Banning, M. (2008). A review of clinical decision mak-
nursing terminology to evaluate dosage and tailoring of ing: Models and current research. Journal of Clinical
an HIV/AIDS adherence intervention. Journal of Nursing Nursing, 17(2), 187–195.
Scholarship, 37(3), 251–257. Banting, F. G., Best, C. H., Collip, J. B., Campbell, W. R., &
Bakken, S., Stone, P. W., & Larson, E. L. (2008). A nursing Fletcher, A. A. (1922). Pancreatic extracts in the treat-
informatics research agenda for 2008–18: Contextual ment of diabetes mellitus. Canadian Medical Association
influences and key components. Nursing Outlook, Journal, 12(3), 141–146.
56(5), 206–214. Bard, M. (1984). Summary of the informal discussion of
Bakken, S., Warren, J. J., Lundberg, C., Casey, A., Correia, functional states: Quality of life. Cancer, 53, 2317.
C., Konicek, D., et al. (2002). An evaluation of the use- Barling, J., Dupré, K., & Kelloway, E. (2009). Predicting
fulness of two terminology models for integrating workplace aggression and violence. Annual Review of
nursing diagnosis concepts into SNOMED Clinical Psychology, 60, 671–692.
Terms. International Journal of Medical Informatics, 68(1– Barnard, K. E., & Eyres, S. J. (1979). Child health assess-
3), 71–77. ment: Part 2. The first year of life. Hyattsville, MD: U.S.
Balanced Budget Act of 1997, Pub. L. No. 105–33. Department of Health, Education, and Welfare, Public
Washington, DC: U.S. Congress. Health Service, HRA, Bureau of Health Manpower.
Balcazar, H. G., de Heer, H., Rosenthal, L., Aguirre, M., Barnard, K. E., Hammond, M. A., Booth, C. L., Bee, H. L.,
Flores, L., Puente, F. A., et al. (2010). A promotores de Mitchell, S. K., & Spieker, S. (1989). Measurement and
salud intervention to reduce cardiovascular disease meaning of parent child interaction. In F. Morrison, C.
risk in a high-risk Hispanic border population, 2005– Lord, & D. Keating (Eds.), Applied developmental psy-
2008. Preventing Chronic Disease, 7(2). Retrieved from chology (Vol. 3). New York: Academic.
www.cdc.gov/pcd/issues/2010/mar/09_0106.htm Barnason, S., Zimmerman, L., Nieveen, J., Schulz, P.,
Baldwin, D. C. (1996). Some historical notes on interdis- Miller, C., Hertzog, M., et al. (2008). Relationships
ciplinary and interprofessional education and practice between fatigue and early postoperative recovery out-
in health care in the USA. Journal of Interprofessional comes over time in elderly patients undergoing cor-
Care, 10, 173–187. onary artery bypass graft surgery. Heart & Lung, 37,
Ballantyne, G. H. (2002). Robotic surgery, telerobotic 245–256.
surgery, telepresence, and telementoring. Surgical Barnason, S., Zimmerman, L., Nieveen, J., Schulz, P.,
Endoscopy, 16(10), 1389–1402. Miller, C., Hertzog, M., et al. (2009). Influence of a
Balsdon, L. (2009). Tackling overweight and obesity symptom management telehealth intervention on
using public health promotion. Primary Health Care, older adults’ early recovery outcomes after coronary
19(10), 32–36. artery bypass surgery. Heart & Lung, 38(5), 364–376.
566 n REFERENCES
Barnes, L. L., Mendes de Leon, C. F., Wilson, R. S., Barsevick, A., Beck, S. L., Dudley, W. N., Wong, B.,
Bienias, J. L., & Evans, D. A. (2004). Social resources Berger, A. M., Whitmer, K., et al. (2010). Efficacy of
and cognitive decline in a population of older African an intervention for fatigue and sleep disturbance
Americans and Whites. Neurology, 63(12), 2322–2326. during cancer chemotherapy. Journal of Pain and
Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Symptom Management, 40(2), 200–216.
Complementary and alternative medicine use among Barthes, R. (1975). The pleasure of the text. New York: Hill
adults and children: United States, 2007 (National Health & Wang.
Statistics Report No. 12). Hyattsville, MD: National Bartick, M., & Reinhold, A. (2010). The burden of subop-
Center for Health Statistics. Retrieved from http:// timal breastfeeding in the United States: A pediatric
www.cdc.gov/nchs/data/nhsr/nhsr012.pdf cost analysis. Pediatrics, 125(5), e1048–e1056.
Barnsteiner, J. H. (1993, Spring). The online journal of Bartick, M., Stuebe, A., Shealy, K. R., Walker, M., &
knowledge synthesis for nursing. Reflections, 19(1), 8. Grummer-Strawn, L. (2009). Closing the quality gap:
Barnsteiner, J. H., Reeder, V. C., Palma, W. H., Preston, Promoting evidence-based breastfeeding care in the
A. M., & Walton, M. K. (2010). Promoting evidence- hospital. Pediatrics, 124(4), e793–e802.
based practice and translational research. Nursing Bartlett, E. E. (1986). Historical glimpses of patient educa-
Administration Quarterly, 34(3), 217–225. tion in the United States. Patient Education Counseling,
Barone, S. H., Roy, C. L., Keville C., & Frederickson, K. 8(2), 135–149.
(2008). Instruments used in Roy Adaptation Model– Bartley, K. B., & Haney, R. (2010). Shared medical appoint-
based research review, critique, and future directions. ments: Improving access, outcomes, and satisfaction
Nursing Science Quarterly, 21(4), 353–362. for patients with chronic cardiac diseases. Journal of
Barr, D. A. (2008). Health disparities in the United States: Cardiovascular Nursing, 25(1), 13–19.
Social class, race, ethnicity, and health. Baltimore: Johns Barton, D. S., Gowdy, M., & Hawthorne, B. W. (2005).
Hopkins University Press. Mentorship programs for novice nurses. Nurse Leader,
Barr, T. L., Latour, L. L., Lee, K. Y., Schaewe, T. J., Luby, 3, 41–44.
M., Chang, G. S., et al. (2010). Blood–brain barrier Bartram, T., Joiner, T., & Stanton, P. (2004) Factors affect-
disruption in humans is independently associated ing the job stress and job satisfaction of Australian
with increased matrix metalloproteinase-9. Stroke, nurses: Implications for recruitment and retention.
41(3), e123–e128. Contemporary, 17(3), 293–304.
Barratt, E. (1989). Community psychiatric nurses: Their Bassett, K. (1996). Anthropology, clinical pathology and
self-perceived roles. Journal of Advanced Nursing, 14, then electronic fetal monitor: Lessons from the heart.
42–48. Social Science and Medicine, 42, 281–292.
Barrere, C., & Ellis, P. (2002). Changing attitudes among Bastian, P. J. Carter, B. H., Bjartell, A., Seitz, M.,
nurses and physicians: A step toward collaboration. Stanislaus, P., Montorsi, F., et al. (2009). Insignificant
Journal for Healthcare Quality, 24(3), 9–15. prostate cancer and active surveillance: From defi-
Barrett, F., & Jones, D. (1999). Development and testing of nition to clinical implications. European Urology, 55,
functional health pattern assessment screening tool. 1321–1332.
In M. Rantz & P. LeMone (Eds.), Proceedings of the 13th Batchelor, J. (2008). Failure to thrive revisited. Child Abuse
North American Diagnoses Association. Glendale, CA: Review, 17, 147–159.
CINAHL Information Systems. Bathum, M. E., & Bauman, L. C. (2007). A sense of
Barrington, C., & Messias, D. K. H. (2010, February 19). community among immigrant Latinas. Family and
Exploring racial/ethnic dynamics in the new south: A case Community Health, 30(3), 167–177.
study of West Columbia, South Carolina. Latinas and Beach, M. C., & Inui, T. (2006). Relationship-centered
Latinos in the U.S. South: Immigration, Integration, and care. A constructive reframing. Journal of General
Identity. Tuscaloosa, AL: University of Alabama. Internal Medicine, 21(Suppl. 1), S3–S8.
Barron, C. R. (2000). Stress, uncertainty, and health. In Beach, S. R., Schulz, R., Yee, J. L., & Jackson, S. (2000).
V. H. Rice (Ed.), Handbook of stress, coping and health Negative and positive health effects of caring for a
implications for nursing research, theory, and practice (pp. disabled spouse: Longitudinal findings from the care-
517–539). Thousand Oaks, CA: Sage Publications. giver health effects study. Psychology and Aging, 15(2),
Barry, R. A., Kochanska, G., & Philibert, R. A. (2008). 259–271.
G X E interaction in the organization of attachment: Beauchamp, T. L., & Childress, J. F. (2009). Principles of
Mothers’ responsiveness as a moderator of children’s biomedical ethics (6th ed.). New York: Oxford.
genotypes. Journal of Child Psychology and Psychiatry, Beck, A., & Hatcher, A. (2003).Future directions in
49(12), 1313–1320. human–animal bond research. American Behavioral
Barry, T., Brannon, D., & Mor, V. (2005). Nurse Aide Scientist, 47(1), 79–93.
empowerment strategies and staff stabiolity: Effects Beck, C. T. (1993). Teetering on the edge: A substantive
on nursing home resident outcomes. Gerontologist, theory of postpartum depression. Nursing Research,
45(3), 309–317. 42, 42–48.
REFERENCES n 567
Beck, C. T., & Gable, R. K. (2001). Postpartum Depression Belle, D., & Doucet, J. (2003). Poverty, inequality, and
Screening Scale. Los Angeles: Western Psychological discrimination as sources of depression among US
Services. women. Psychology of Women Quarterly, 27, 101–113.
Beck, C. T., & Watson, S. (2010). Subsequent childbirth Bellinger, D. C. (2004). Lead. Pediatrics, 113(Suppl. 4),
after a previous traumatic birth. Nursing Research, 59, 1016–1022.
241–249. Ben Natan, M., Shahar, I., & Garfunkel, D. (2009).
Beck, K. L., & Larrabee, J. H. (1996). Measuring patients’ Disclosing bad news to patients with life-threatening
perceptions of nursing care. Nursing Management, 27, illnesses. International Journal of Palliative Nursing,
32B, 32D. 15(6), 276–281.
Becker, R. O., & Selden, G. (1985). The body electric: Bendixen, R. M., Levy, C. E., Olive, E. S., Kobb, R. F., &
Electromagnetism and the foundation of life. New York: Mann, W. C. (2009). Cost effectiveness of a telereha-
William Morrow. bilitation program to support chronically ill and dis-
Beckstrand, J., Ellett, M. L. C., & McDaniel, A. (2007). abled elders in their homes. Telemedicine and e-Health,
Predicting the internal distance to the stomach 15(1), 31–38.
for positioning nasogastric and orogastric feeding Bengston, V. L., Kim, K-D, Meyers, G., & Eun, K-S. (Eds.).
tubes in children. Journal of Advanced Nursing, 59(3), (2000). Aging in east and west families, states, and elderly.
274–289. New York: Springer Publishing, Inc.
Beebe, L. H. (2001). Community nursing support for Benner, P. (1984). From novice to expert: Excellence and
clients with schizophrenia. Archives of Psychiatric power in clinical nursing practice. Menlo Park: Addison-
Nursing, 15, 214–222. Wesley.
Beebe, L. H., Smith, K., Burk, R., Dessieux, O., Velligan, Benner, P., & Tanner, C. (1987). Clinical judgment:
D., Tavakoli, A., et al. (2010). Effect of a motivational How expert nurses use intuition. American Journal of
group intervention on exercise self-efficacy and out- Nursing, 87(1), 23–31.
come expectations for exercise in schizophrenia spec- Benner, P., Tanner, C., & Chesla, C. (1996). Expertise in
trum disorders. Journal of the American Psychiatric nursing practice: Caring, clinical judgment, and ethics.
Nurses Association, 16(2), 105–113. New York: Springer.
Beebe, L. H., Smith, K., Crye, C., Addonizio, C., Strunk, Benner, P., Tanner, C., & Chesla, C. (1996). Implications for
D. J., Martin, W., et al. (2008). Telenursing intervention basic nursing education in clinical judgement and ethics.
increases psychiatric medication adherence in schizo- Philadelphia, PA: Springer Publishing.
phrenia outpatients. Journal of the American Psychiatric Benner, P. A., Tanner, C. A., & Chesla, C. A. (1996).
Nurses Association, 14(3), 217–224. Expertise in nursing practice: Caring, clinical judgment,
Beeber, L. S., Holditch-Davis, D., Perreira, K., Schwartz, and ethics. New York: Springer.
T. A., Lewis, V., Blanchard, H., et al. (2010). Short-term Bennett, S. J., Welch, J. L., Eckert, G. J., Oldridge, N. B., &
in-home intervention reduces depressive symptoms Murray, M. D. (2006). Nutrition in chronic heart fail-
in early head start Latina mothers of infants and tod- ure with coexisting chronic kidney disease. Journal of
dlers. Research in Nursing & Health, 33(1), 60–76. Cardiovascular Nursing, 21(1), 56–62.
Beeber, L. S., & Miles, M. S. (2003). Maternal mental Bensink, M., Hailey, D., & Wootton, R. (2006). A system-
health and parenting in poverty. In J. J. Fitzpatrick, atic review of successes and failures in home tele-
M. S. Miles, & D. Holditch-Davis (Eds.), Annual Review health: Preliminary results. Journal of Telemedicine and
of Nursing Research (Vol. 21, pp. 303–331). New York: Telecare, 12(Suppl. 3), 8–16.
Springer. Bensley, L., Nelson, N., Kaufman, J., Silverstein, B., Kalat,
Beech, B., & Leather, P. (2006). Workplace violence in the J., & Walter Shields, J. (1997). Injuries due to assaults on
health care sector: A review of staff training and inte- psychiatric hospital employees in Washington state.
gration of training evaluation models. Aggression and American Journal of Industrial Medicine, 31, 92–99.
Violent Behavior, 11(1) 1359–1789. Bent, K. N., & Magilvy, J. K. (2006). When a partner dies:
Begley, A. M. (2008). Guilty but good: Defending vol- Lesbian widows. Issues in Mental Health Nursing, 27(5),
untary active euthanasia from a virtue perspective. 447–459.
Nursing Ethics, 15, 434–445. Bentley, J. P., & Thacker, P. G. (2004). The influence of risk
Beitz, J., & Bliss, D. (2005). Preparing a successful grant and monetary payment on the research participation
proposal: Part 1. Developing research aims and the sig- decision making process. Journal of Medical Ethics, 30,
nificance of the project. Journal of Wound, Ostomy, and 293–298.
Continence Nursing, 32, 16–18. Berdes, C., & Eckert, J. M. (2001). Race relations and care-
Bell, R. P., & McGrath, J. (1996). Implementing a research giving relationships: A qualitative examination of
based kangaroo care program in the NICU. In L. perspectives from residents and nurse’s aides in three
Brown (Ed.), Nursing clinics of North America: Vol. 31(2). nursing homes. Research on Aging, 23(1), 109–126.
Maternal/fetal nursing (pp. 387–303). Philadelphia, PA: Berenson, R., & Zuckerman, S. (2010, July). How will hos-
Saunders. pitals be affected by health care reform? Timely analysis of
The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.
Discover the best professional documents and content resources in AnyFlip Document Base.
Search
Encyclopedia of Nursing Research
- 1 - 50
- 51 - 100
- 101 - 150
- 151 - 200
- 201 - 250
- 251 - 300
- 301 - 350
- 351 - 400
- 401 - 450
- 451 - 500
- 501 - 550
- 551 - 600
- 601 - 650
- 651 - 700
- 701 - 732
Pages: