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Although pain management is integral to the caregiving role, there is a paucity of evidence synthesizing specific challenges family caregivers (FCs) face when managing pain for their care partners. This review comprehensively identified and summarized such challenges in the setting of advanced illnesses. Electronic databases (PubMed, CINAHL, PsycINFO, Scopus, and Health and Psychosocial Instruments) were searched using index and keyword methods for all articles published before April 2021. Fifty-five studies were included in this review. Most articles were published within the last 10 years (54%) in community settings, with home hospice care comprising the majority (50%). Most studies included patients with an advanced cancer diagnosis (84%), and 16% of the studies included patients with a noncancer diagnosis. Four major categories of challenges were identified: (1) caregiver-related issues (e.g., fears, beliefs, function), (2) caregivers' limited knowledge and skills in pain management (e.g., verbal and nonverbal pain assessment skills, pharmacological knowledge, documentation, safe management of medication), (3) communication challenges with health care providers, and (4) patient-related issues (e.g., inability to report pain). Many of these challenges have not been fully addressed in prior literature. Thus, this review provides a framework for needed future research to develop interventions that target FCs' specific challenges in providing pain management. The results also highlight a significant lack of research surrounding challenges faced by caregivers of care partners having a noncancer, dementia, or multimorbidity diagnosis.

Little research has compared item functioning of the Patient-Reported Outcomes Measurement Information System (PROMIS®) anxiety short form 6a and the generalized anxiety disorder 7-item scale using item response theory models. This was a secondary analysis of self-reported assessments from 67 at-risk U.S. military veterans. The two measures performed comparably well with data fitting adequately to models, acceptable item discriminations, and item and test information curves being unimodal and symmetric. The PROMIS® anxiety short form 6a performed better in that item difficulty estimates had a wider range and distributed more evenly and all response categories had less floor effect, while the third category in most items of the generalized anxiety disorder 7-item scale were rarely used. While both measures may be appropriate, findings provided preliminary information supporting use of the PROMIS® anxiety short form 6a as potentially preferable, especially for veterans with low-to-moderate anxiety. Further testing is needed in larger, more diverse samples.

Families who raise children with genetic conditions manage health care within the context of cultural communities. For Amish families, although genetic conditions are prevalent and have been well reported, few studies document family management of these conditions. This article describes Amish family management strategies in light of the Family Management Framework’s contextual factors. Ethnographic data captured variations in perspectives from Amish families with children with diverse genetic conditions, Amish community members, and health care providers. Findings describe families at the center of decision making and health care management for children with genetic conditions, utilizing health care professionals and their surrounding Amish community members as resources. Amish families’ management strategies lie across a spectrum from home-oriented to medical-oriented, and this spectrum is elaborated in the findings and discussion of this article.

Objective To explore and describe older African Americans’ patterns and perceptions of managing chronic osteoarthritis pain. Methods A convergent parallel mixed-methods design incorporating cross-sectional surveys and individual, semistructured interviews. Setting One hundred ten African Americans (≥50 years of age) with clinical osteoarthritis (OA) or provider-diagnosed OA from communities in northern Louisiana were enrolled. Results Although frequency varied depending on the severity of pain, older African Americans actively used an average of seven to eight self-management strategies over the course of a month to control pain. The average number of self-management strategies between high and low education and literacy groups was not statistically different, but higher-educated adults used approximately one additional strategy than those with high school or less. To achieve pain relief, African Americans relied on 10 self-management strategies that were inexpensive, easy to use and access, and generally perceived as helpful: over-the-counter (OTC) topicals, thermal modalities, land-based exercise, spiritual activities, OTC and prescribed analgesics, orthotic and assistive devices, joint injections, rest, and massage and vitamins. Conclusions This is one of the first studies to quantitatively and qualitatively investigate the self-management of chronic OA pain in an older African American population that happened to be a predominantly higher-educated and health-literate sample. Findings indicate that Southern-dwelling African Americans are highly engaged in a range of different self-management strategies, many of which are self-initiated. Although still an important component of chronic pain self-management, spirituality was used by less than half of African Americans, but use of oral nonsteroidal anti-inflammatory drugs and opioids was relatively high.

Background and Objectives Cognitively impaired individuals are at increased risk for functional and behavioral difficulties at mealtimes, leading to compromised eating performance, low food and fluid intake, and negative functional and nutritional outcomes. Nursing assistants are the most critical front-line care staff and best positioned to manage the personal and environmental factors that influence resident eating performance. Identifying nursing assistants’ perceptions of barriers and facilitators to engaging residents in eating will provide important experientially based foundation for developing and testing evidence-driven interventions to promote mealtime care. Methods A qualitative descriptive study was conducted in three sites: two nursing homes and one hospital gero-psychiatric inpatient unit. Six focus groups were conducted with a purposive sample of 23 nursing assistants who regularly provided mealtime care to residents with cognitive impairment. Interview questions addressed barriers and facilitators at resident, caregiver, environmental (facility), and policy levels in optimizing mealtime care. Audio recordings of focus groups were transcribed and analyzed using qualitative descriptive content analysis. Both barriers and facilitators were organized into a hierarchical taxonomy based on similarities and differences framed by the Social Ecological Model. Results The majority of barriers and facilitators were at the caregiver level. Caregiver-level barriers included lack of preparation and training, competing work demands, time pressure, and frustration. Caregiver-level facilitators included caregiver preparation and motivational, technical, informational, and instrumental assistance. Environmental-level barriers and facilitators related to the physical, social, and cultural environment and facility practices. Only barriers to optimizing mealtime care were identified at resident and policy levels. Conclusions Nursing assistants identified multilevel barriers as well as a wide range of caregiver and environmental facilitators to optimizing dementia mealtime care. Findings can inform the development and implementation of multifaceted innovative mealtime assistance and staff training programs to promote resident eating performance while fostering person-centered individualized mealtime care practice.

Background Prevalence and complexity of persons with multiple chronic conditions (MCC), also known as multimorbidity, are shifting clinical practice from a single disease focus to one considering MCC and symptoms. Although symptoms are intricately bound to concepts inherent in MCC science, symptoms are largely ignored in multimorbidity research and literature. Purpose Introduce an Integrated Model of Multimorbidity and Symptom Science. Methods Critical integrative review and synthesis process. Findings The model comprises three primary domains: 1. Contributing/ Risk Factors; 2. Symptom/Disease/Treatment Interactions; and 3. Patient Outcomes. Discussion The model highlights the multilevel nature of contributing factors and the recursive interactions among multiple etiologies, conditions, symptoms, therapies, and outcomes.

Background Osteoarthritis is a long-term condition, and four core treatments are recommended to minimize the interference of pain and symptoms on their daily function. However, older Black Americans have traditionally been at a disadvantage in regard to knowledge of and engagement in chronic disease self-management and self-care. Surprisingly, minimal research has addressed understanding motivational factors key to self-management behaviors. Thus, it is important to understand if older Black Americans’ self-management is supported by current recommendations for the management of symptomatic osteoarthritis and what factors limit or motivate engagement in recommended treatments. Objective Our objectives are to: (1) identify stage of engagement in four core recommended treatments for osteoarthritis, (2) describe the barriers and motivators to these recommended treatments, and (3) construct an understanding of the process of pain self-management motivation. Design A mixed-methods concurrent parallel design. Setting Participants were recruited from communities in northern Louisiana, USA. Participants Black Americans (≥50 years of age) with clinical osteoarthritis and/or provider-diagnosed osteoarthritis were enrolled. One hundred ten participants completed the study, and 18 of these individuals were also interviewed individually. Methods Data were collected using in-person surveys and interviews. Over a period of 11 months, close- and open-ended surveys and in-depth interviews were conducted with participants. Descriptive statistics describe utilization/engagement level as well as barriers and motivators of recommended treatments for non-surgical osteoarthritis. Content and thematic analyses of interviews summarized perspectives on the process and role of motivation in pain self-management. Results Overall, engagement levels in treatments ranged from very low to high. Over 55% of older Black Americans were actively engaged in two of the recommended treatments: land-based exercise and strength training. Major motivators included reduction in pain and stiffness and maintenance of mobility and good health. The majority of participants were not using water-based exercise and self-management education. Primary barriers were lack of access, time, and knowledge of resources. Conclusions In order to maximize the benefits of osteoarthritis pain self-management, older Black Americans must be equipped with the motivation, resources, information and skills, and time to engage in recommended treatment options. Their repertoire of behavioral self-management did not include two key treatments and is inconsistent with what is recommended, predominantly due to barriers that are difficult to overcome. In these cases, motivation alone is not optimal in promoting self-management. Providers, researchers, and community advocates should work collaboratively to expand access to self-management resources, particularly when personal and community motivation are high.

The Patient Reported Outcomes Measurement System (PROMIS) offers standardized assessment measures of clinically relevant patient reported outcomes. This study evaluated the reliability and validity of select PROMIS measures with United States Military Veterans following orthopedic surgery. Data for the current study were collected as part of a pilot randomized control trial assessing the efficacy of a one day Acceptance and Commitment Therapy workshop on persistent post-surgical pain in at-risk Veterans undergoing orthopedic surgery. Sixty-seven participants completed surveys three months after surgery. Participants completed the following PROMIS instruments: PROMIS Anxiety Short Form 8a, PROMIS Depression Short Form 8b, and PROMIS pain interference short form 8a. PROMIS measures were compared to the Generalized Anxiety Disorder 7-item scale (GAD-7), the Patient Health Questionnaire 9-item scale (PHQ-9), and the Brief Pain Inventory (BPI) pain interference subscale (respectively). All three PROMIS measures demonstrated excellent internal consistency (Cronbach’s alphas ranged from .93 - .96) and each loaded onto a single factor. The PROMIS measures were moderately correlated with their respective comparison measures (r = .69 - .76). The PROMIS anxiety and PROMIS depression measures were highly correlated to one another (r = .91). Findings highlight the potential utility of these PROMIS measures in Veterans following orthopedic surgery and the overlap between the PROMIS depression and anxiety measures in this sample.

Genomic nurse scientists are at the intersection of human genomics research and the science of health. As the potential health benefits of precision medicine are considered, it is timely to reflect on nursing science's contributions to advancing the understanding of genomic aspects of health. During the decade of the 1990s, genetics was recognized as an essential component of nursing science (Lashley, 1997; Pesut, 1999), but was not yet a prominent focus of nursing research. Over the past two decades, the National Institute of Nursing Research (NINR) has identified the importance of the basic, behavioral, and social science aspects that influence health across populations, communities, and healthcare settings (NINR, 2011; Sigmon, Grady, & Amende, 1997). Also, during this period, the NINR has maintained an emphasis on the integration of behavior and biology (Grady, 2006). The current NINR Strategic Plan (NINR, 2011) continues this emphasis with its focus on investigation of multiple determinants of health, including genomics.During this same time period, a trajectory of genomics research was mapped (Green, Guyer, & National Human Genome Research Institute, 2011) in which the progression of genomic science moved from understanding the structure of the genome, through understanding the biology of genomes and disease, to advancing the science of medicine and improving the effectiveness of healthcare. Phases of clinical translation of genomic discovery to improve health include genome-based discovery, evidence-based recommendations, incorporation into the healthcare system, and evaluation of impact on health of populations (Khoury, Gwinn, Bowen, & Dotson, 2012). This trajectory of genomic science research also includes discovery of biology of diseases and symptoms, as well as examination of nursing interventions tailored for clients based on genomic variations (Munro, 2015). The dissemination and implementation phase addresses how to enable application of best evidence to improve healthcare outcomes (Eccles & Mittman, 2006). An awareness of genomic aspects of emerging areas of science was identified by the Council for the Advancement of Nursing Science (CANS) Idea Festival Committee (Henly et al., 2015) as a priority in its report on implications for PhD education. New healthcare policies will be needed to enable translation of genomic discoveries into health care (Institute of Medicine, 2014, 2015). Elements of the Precision Medicine Initiative (www.whitehouse.gov/precisionmedicine) are consistent with a nursing science agenda, as described in the NINR Strategic Plan (NINR, 2011), that includes a focus on innovation, as well as health promotion, disease prevention, and advancing quality of life. Further, the future of symptom science is envisioned as including knowledge development regarding genomic and context factors influencing symptom development and expression (Corwin et al., 2014).An invitational workshop at the National Institutes of Health (NIH) produced the Genomic Nursing Science Blueprint (hereafter referred to as the Blueprint), which identified crucial genomics problems relevant to health (https://www.ninr.nih.gov/sites/www.ninr.nih.gov/files/ jnu_12007_Rev_EV.pdf; Calzone et al., 2013). The systematic evidence review, key stakeholder testimony, and main meeting generated the listing of research topics that were then mapped into the NINR Strategic Plan, which contains themes of symptom science, wellness, self-management, and end-of-life and palliative care. The Blueprint contains four components: health promotion and disease prevention, advancing quality of life, innovation, and training, plus a fifth category of cross-cutting themes (e.g., health disparity and policy). In August 2013, a genomic nursing science workshop was convened by the NINR and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, to consider research topics that address behavioral and social sciences, as well as the biological aspects of genomic nursing science (Tully & Grady, 2015). …

Studies document that osteoarthritis-related joint pain is more severe in African American older adults, but research on the personal experience of osteoarthritis pain self-management in this population is limited. Using a qualitative descriptive design, our objective was to extend our understanding of the experience of life with osteoarthritis pain. Eighteen African Americans (50 years and older) were recruited from Louisiana to participate in a single semi-structured, in-depth interview. A conventional content analysis revealed that “Bearing the pain” characterized how older African Americans dealt with osteoarthritis. Bearing the pain comprised three actions: adjusting to pain, sharing pain with others, and trusting God as healer. We discovered that a metapersonal experience subsumes the complex biopsychosocial-cultural patterns and the intricate interaction of self, others, and God in living with and managing osteoarthritis pain. Study findings have implications for application of more inclusive self-management frameworks and interventions.

Objective To evaluate an interactive tool designed to help patients communicate their social resources supportive of home recovery to health care providers. Methods Seventy medical and surgical inpatients completed the D-CEGRM social resource interview, demographic queries, and discharge readiness surveys (RHDS) at discharge. Two weeks later, patients completed post-discharge coping difficulty surveys (PDCDS). Nurses unassociated with patients’ clinical care reviewed structured clinical notes created from the D-CEGRM and categorized patients as likely to have “inadequate” or “adequate” supportive resources for home self-management. Nurse decision making was tracked using an adjudication process, and post-hoc comparisons in patient characteristics, RHDS, and PDCDS were conducted. Results Nurses categorized 36 patients (51%) as having inadequate resources. Number and accessibility of supports, presence of negative relationships, and previous struggles meeting health-related needs were important decision-making factors. Post-hoc comparisons revealed significant differences in demographic risk factors and discharge readiness ratings for those with inadequate vs. adequate resources. Conclusion The D-CEGRM may be an efficient tool for patients to communicate access to social resources, and an effective facilitator of transitional care planning. Practice Implications: The D-CEGRM may provide a useful assessment of patients’ home context and guide for transitional care planning.

High levels of pain, significant anxiety, or depressive symptoms before surgery put patients at elevated risk for chronic pain and prolonged opioid use following surgery. The purpose of this preliminary study was to assess the efficacy of a 1-day Acceptance and Commitment Therapy (ACT) workshop in “at-risk” veterans for the prevention of chronic pain and opioid use following orthopedic surgery. In a randomized controlled trial, 88 at-risk veterans undergoing orthopedic surgery were assigned to treatment as usual (TAU; n = 44) or TAU plus a 1-day ACT workshop (n = 44). Pain levels and opioid use were assessed up to 3 months following surgery. Pain acceptance and values-based behavior were assessed at baseline and 3-month follow-up. Participants who completed the ACT workshop reached pain and opioid cessation sooner than those in TAU. Postoperative complications exhibited a moderating effect on these outcomes, such that the effects of ACT were greater in patients without complications. Increases in pain acceptance and values-based behavior, processes targeted in ACT, were related to better outcomes. These promising results merit further investigation in a larger clinical trial. Providing an intervention before surgery for at-risk veterans has the potential to change clinical practice from a focus on management of postoperative pain to prevention of chronic pain in at-risk individuals. Perspective This pilot study compared the effects of a 1-day preventive behavioral intervention (ACT) to TAU in at-risk veterans undergoing orthopedic surgery. Three months following the intervention, veterans receiving ACT exhibited quicker cessation of pain and opioid use. Focusing on preoperative pain management may help prevent chronic postsurgical pain.

In this study, researchers compare and contrast issues regarding diabetes self-management between persons in good versus poor glycemic control. The sample comprises low-income racially diverse adults with diabetes from four mid-western community health centers; 44 patients participated in eight focus groups divided by control status (HbA1c of > 9 [uncontrolled] or < 7 [controlled]). Themes common to both groups included the impact of dietary restrictions on social interactions, food cravings, the impact of mental health on self-management, and the importance of formal and informal (friends and family) support. Those in the uncontrolled groups described fear about being able to control their diabetes, confusion about self-management, and difficulty managing their diabetes while caring for family members. Although those in the controlled groups acknowledged difficulties, they discussed resisting cravings, making improvements with small changes, positive feelings about their ability to control their diabetes, and enjoying new foods and exercise. Interventions should include mental health support, incorporate formal and informal patient support structures, and address literacy issues. Health care providers and intervention personnel should be very concrete about how to do self-management tasks and guide patients on how to alter their diabetes regimens for social and other important life events.

Collaborative goal setting (CGS) is a cornerstone of diabetes self-management support, but little is known about its feasibility and effectiveness during routine care. The aim of this study was to evaluate the implementation of an existing CGS intervention when integrated by primary care staff. Using a mixed-methods approach guided by the RE-AIM framework, intervention adoption, implementation, reach, and effectiveness were evaluated over 12 months. Three of four sites adopted the CGS intervention, in which 521 patients with type 2 diabetes (9–29 % of those targeted) received CGS. For those with suboptimal glycemic control (A1C ≥ 7.5 %), %A1C decreased by 1.1 for those receiving CGS (n = 204, p

This bibliometric review profiles the focus, dissemination, and impact of genomic nursing science articles from 2010 to 2014.Data-based genomic nursing articles by nursing authors and articles by non-nurse principal investigators funded by the National Institute of Nursing Research were categorized into the Genomic Nursing Science Blueprint nursing areas.Bibliometric content analysis was used.A total of 197 articles met the inclusion criteria. Of these, 60.3% were on biologic plausibility, 12.1% on client self-management, 11.1% on decision making or decision support, 8.1% on family, and 4.0% on communication, with the remaining 4.0% of articles focused on other topics. Few (11.6%) addressed healthcare disparities in the study purpose. Thirty-four references (17.2%) were cited 10 or more times.Research-based genomic nursing science articles are in the discovery phase of inquiry. All topics were investigated in more than one country. Healthcare disparities were addressed in few studies. Research findings from interdisciplinary teams were disseminated beyond nursing audiences, with findings addressing biologic discovery, decision making or support, and family being cited most frequently. Gaps in the reviewed articles included cross-cutting themes, ethics, and clinical utility. Interdisciplinary research is needed to document clinical and system outcomes of genomic nursing science implementation in health care.Although the review identifies areas that are encountered in clinical practice, relevance to practice will depend on evaluation of findings and subsequent development of clinical guidelines.

Health concerns and management strategies among families of young and middle-age adults with Huntington’s disease (HD) are unknown. This study developed and tested psychometric properties of the Huntington Disease Family Concerns and Strategies Survey (HDFCSS). Focus group data from 91 adult family members were used to develop content. Content analysis yielded four domains that were transferred into Personal, Person With HD, Community Health Care Services, and Strategies scales. Focus group data, expert validation, and cognitive interviews demonstrated survey content validity. Cronbach’s alpha internal consistency coefficients for the scales were 0.83 or above. The measure can be used to generate reliable and valid data to identify adult family members’ health-related concerns and management strategies for themselves and persons with HD.

This paper is a report of a study conducted to examine the emotional experience of caregiving by family carers of people with Huntington disease and to describe strategies they used to deal with that experience.Huntington disease, commonly diagnosed in young to middle adulthood, is an inherited single gene disorder involving loss of cognitive, motor and neuropsychiatric function. Many family members become caregivers as well as continuing as parents and wage earners. The emotional aspects of caregiving contribute to mental health risks for family members.Focus groups were conducted with 42 adult carers of people with Huntington disease in four United States and two Canadian Huntington disease centers between 2001 and 2005. Data were analyzed through descriptive coding and thematic analysis.All participants reported multiple aspects of emotional distress. Being a carer was described as experiencing disintegration of one's life. Carers attempted to cope by seeking comfort from selected family members, anticipating the time when the care recipient had died and/or using prescription medications. Spousal carers were distressed by the loss of their relationship with their spouse and dealt with this by no longer regarding the person as an intimate partner. Carers were concerned about the disease risk for children in their families and hoped for a cure.Emotional distress can compromise the well-being of family carers, who attempt to maintain multiple roles. Nurses should monitor carer mental health, identify sources of emotional distress and support effective strategies used by carers to mediate distress.

The objective of the study was to examine veterans' perceptions of problems and benefits of outsourcing inpatient care from Veterans Affairs (VA) hospitals to private sector hospitals. Primary data were collected from a cross-section of 42 veterans who were VA users and nonusers using focus groups. Focus group discussion examined reasons patients use VA care, differences between VA and civilian care, positive and negative impacts of outsourcing, and special needs of veterans. Analyses revealed five domains related both to use of VA services and perceptions of outsourcing: costs, access, quality of care, contract (i.e., a covenant between veterans and the U.S. government), veteran milieu, and special needs. Participants identified a variety of potential positive and negative impacts. In general, veterans perceived more advantages than disadvantages to outsourcing VA care but still expressed significant concerns related to outsourcing. These issues should be considered in the development of future policy toward outsourcing VA care to the private sector.

Background: The positive association between individual social support and diabetes health outcomes is well established. However, most tools for assessing social support are highly structured and are rarely used in clinical settings and/or clinical outcomes research. A novel tool that has been shown to engage patients in the identification and use of their social networks is the Colored Eco-Genetic Relationship Map (CEGRM). Objective: The purpose of this pilot study was to explore the feasibility of using the CEGRM adapted for eliciting information about how individuals with diabetes use their social networks to support their self-management efforts. Methods: A sample of 18 adult patients with diabetes completed the newly created diabetes-CEGRM (D-CEGRM) alongside structured questions regarding social support for diabetes self-management. Results: Whereas structured questions elicited information about participants’ use of social networks, the D-CEGRM expanded on answers from structured questions by identifying both positive and negative aspects of social support, additional individual and community-based resources, and nuanced interpersonal information about the individuals involved. Discussion: The D-CEGRM appears to be feasible and useful in assessing the social networks of adults with diabetes and how they are used to support tasks related to self-management. The information elicited by completing the D-CEGRM expanded on information collected through structured questions about social support in a way that might better address research questions and inform clinical decision making.

The aim of the study was to identify psychometric properties of an inventory of voice-hearing experiences. One hundred fifteen psychiatric nurses rated the language content represented on two forms of the Inventory of Voice Experiences (IVE Forms A and B) and another psychiatric rating scale (Brief Psychiatric Rating Scale, or BPRS) while viewing a videotaped assessment of an experienced voice hearer. Findings revealed modest to moderate support for internal consistency and concordance of the language represented on the measures as well as moderate support for convergent validity of IVE Forms A and B and modest support for their convergence with the BPRS. Nurse ratings of the inventory of voice experiences explained 14–15% of the variation in the same nurses' ratings of the hallucinated symptom item on the BPRS measure. The findings augment the position that not all hallucinated voices are indicative of clinical pathology. More focused assessments of psychiatric symptoms are needed to clarify their characteristics, underlying neural mechanisms, and the strategies needed to treat them. Two parallel forms of an inventory of voice experiences, thus, were developed to measure a broad array of positively and negatively toned voice-hearing phenomenology. The purpose of this exploratory study was to identify psychometric properties for the two measures. A sample of 115 psychiatric nurses used IVE Forms A and B and the BPRS to rate language content for the hallucinated voices and psychiatric symptoms of an experienced voice hearer while viewing a videotaped assessment of the client. Findings from the study revealed modest to moderate support for internal consistency and concordance of the language content represented on the IVE. Other findings revealed moderate support for convergent validity of the IVE Forms A and B as well as modest support for their convergence with the BPRS. Nurse ratings of the hallucinated voice-hearing phenomenology measured with the IVE explained 14–15% of the variation in the same nurses' ratings of the hallucinated symptom item on the BPRS measure. The findings point to the argument that not all hallucinated voices are indicative of clinically significant pathology and some might even assist voice hearers with activities of everyday living. Psychometric properties identified in the study provide initial support for the reliability and validity of the IVE Forms A and B and are a basis for further refinement and testing of the two measures.

There are many potential benefits associated with the use of computerized clinical reminders for both health care providers and patients. Clinical reminders are designed to reduce the likelihood that an aspect of care will “fall though the cracks” during a busy exam, ensure that care is well-documented so that the range of health care providers interacting with each patient will have full access to the patient history, and increase standardization across patient exams. While most agree that the concept of clinical reminders is good, recent research indicates that some providers do not use clinical reminders when available (Demakis et al, 2000). This paper describes the qualitative portion of a survey study aimed at exploring the perceived facilitators and barriers to clinical reminder use within Veterans Administration health care facilities.

The rapid uptake of qualitative approaches in translational research can be best understood in the context of recent innovations in health services research, as well as an overarching concern with improving the quality of health care. Qualitative approaches highlight the human dimension in health care by foregrounding the perceptions, experiences, and behaviors of both consumers and providers of care. As such, these methods are particularly useful for addressing the complex issues related to improving health care quality and implementing system change. This overview traces a brief history of the factors contributing to the recent and rapid growth of qualitative methods in health research in general and translational research in particular; describes the varieties of qualitative approaches employed in this research; and illustrates the utility of these approaches for variable identification, instrument development, description/explanation of patient/provider perceptions and behaviors, individual/organizational change, and theory refinement.

Symptom attributions were contrasted between male and female myocardial infarction victims (N = 157) who were comparable on age, cardiac risk status, medical history, symptom presentation, and other variables. Women were less likely than men to attribute their prehospital symptoms to cardiac causes. In the context of hearing symptom attributions or advice from support persons, women were less likely than men to report receiving a cardiac attribution or advice to seek medical attention. Results have implications for how victim gender influences the lay interpretation of cardiac symptoms.

Before psychometric instruments can be used for populations other than those for whom they were originally developed, validation of cultural appropriateness is essential. This article describes the assessment of the cultural appropriateness of the Finding Meaning Through Caregiving Scale (FMTCS) with Korean female family caregivers. The FMTCS measures finding meaning among caregivers from an existential perspective and has three subscales: Loss/Powerlessness, Provisional Meaning, and Ultimate Meaning. The instrument’s cultural appropriateness was examined through semistructured interviews with ten Korean-born female family caregivers, five caregivers living in Korea, and five living in the United States. The interview data are reported according to the three dimensions described by Flaherty and colleagues (1988): content, semantic, and conceptual equivalence. Although the majority of items of the FMTCS appeared applicable to Korean caregivers, items on the Loss/Powerlessness and Provisional Meaning subscales asking caregivers about feelings related to missing their past relationships or communications appeared inappropriate for many Korean daughters-in-law. Of equal importance, a unique source of meaning among Korean caregivers that is not assessed in the FMTCS is an interpersonal context, including the importance caregivers place on teaching children and feeling proud of one’s caregiving accomplishments in the eyes of other relatives. The addition of new items that address the interpersonal context is warranted to improve the instrument’s cultural appropriateness for Korean caregivers.

The purpose of this descriptive study was to generate information about imminent concerns of adult children that could serve as initial context for development of a meaningful framework for coping with an ongoing parent care situation. Ninety-two adult children pre-selected for self-reports of crisis were interviewed about their concerns and goals for caregiving and asked to discuss experiences of crisis in the previous six months of caregiving. Key issues pertaining to their experiences were extracted from notes of the interviews and classified according to their common properties. Cohen's kappa for interrater reliability of the classifications was .79 while percentage agreement was 98 percent. The results of the study point to the presence of multiple issues pertaining to significant life and death events, relational burdens, early experiences with the family of origin, and focal patterns of distress and coping. Synthesis of the findings reveals overriding concerns for making improvements in one's family of origin, created family of adulthood, and middle-aged self. Findings have implications for experiential adult education in the area of filial maturity and caregiving.

Conducting intervention research in nursing home (NH) settings is particularly challenging because of the advanced age and frailty of the participants and the characteristics of the setting itself. The purpose of this project was to better understand the barriers and facilitators to the research process in NHs. Three primary data sources were used: investigator field notes, guided interviews with the research team and NH staff members, and research assistant (RA) e-mail communications. Data were analyzed using qualitative content and matrix analytic techniques. Barriers to the research process were largely congruent with previously identified NH staff characteristics, such as lack of communication between NH staff and the research team, ineffective nursing leadership, decreased staff-to-resident ratios, and high turnover of NH staff. Research facilitators emerged in two overlapping areas, intraresearch team issues such as the flexibility and compatibility of the RAs, effective NH staff-to-research team communication, and the presence of an effective nurse leader in the NH.

Interpreter Facilitation for ndividuals with Limited English Proficiency

To identify consistent provision of clinical preventive services, we sought to benchmark all acute care Veterans Affairs Medical Centers (VAMCs) against each other nationally on the basis of multiple evidence-based, performance measures to identify facilities performing consistently higher and lower than expected.The 1998 Veterans Health Survey assessed the self-reported delivery of evidence-based clinical preventive services in a stratified national sample of 450 ambulatory care patients seen at each VAMC. Proportions appropriately receiving each service within the recommended time interval were calculated for 138 VAMCs. Percentile ranks for each outcome were assigned. Two approaches were used for benchmarking performance. First, a scaled score for each facility was calculated across the set of 12 measures. Second, facilities were ranked based on the sum of the percentile ranks over a range of specific high cutoffs (eg, 70-80%) and above a range of lower cutoffs (eg, 40-50%). Ranking was validated by comparing with deciles of ranks on chart audit (External Peer Review Program, EPRP) data using Kendall's tau-b and chi2 quality-of-fit test. Differences between consistently high adherence (CHA) and low adherence (CLA) facilities were compared using the Wilcoxon rank sum test on 14 VHS and 11 EPRP outcomes.Data from 39,939 patients (67% response rate) were examined. In combination, cutoffs of greater than 50th percentile and greater than 75th percentile rank yielded 12 of 14 VHS and 6 of 11 EPRP measures different between CHA and CLA facilities. The scaled-score approach resulted in 20 CHA and 14 CLA facilities. The sum of outcomes ranked above 50th percentile and over 75th percentile for CHA facilities (n = 17) was 15 or more. The sum of outcomes ranked above the same cutoffs for CLA facilities (n = 16) was 3 or less. EPRP and 1998 VHS data demonstrated that the survey measures and benchmarking approaches were both reliable and valid. Both approaches resulted in multiple differences between CHA and CLA facilities; differences were greater using the percentile rank approach.The VA has successfully encouraged adoption of evidence-based clinical preventive services throughout its health care system. However, facilities show wide variation in their levels of delivery and can be distinguished on the basis of their consistently high or low levels of adherence. Examining service delivery across multiple performance indicators allows identification of opportunities to improve clinical practice guideline implementation and the delivery of preventive services. This approach identifies model institutions where focused investigation of factors associated with consistent performance may be particularly fruitful.

Language differences between health providers and consumers create a central barrier to the delivery of health education. This article presents the results of an analysis of more than 75 bi/multilingual health sites available on the Internet. The review criteria and a summary of the key features of the best sites are presented. Limitations common to most sites are identified. Recommendations and caveats in the use of bilingual health information sites are introduced.

Osteoarthritis represents one of the leading causes of chronic joint pain in older adults. Over 60% of older African Americans (AAs) attribute chronic pain to arthritis, and joint pain is more frequently reported than stiffness or swelling. A higher proportion of AAs (38.7%), experience severe osteoarthritis pain as compared to 36.4% of Hispanic Americans, 28.7% American Indians, 23.1% Caucasian Americans, and 18.5% Asian Americans. Managing osteoarthritis requires both self-management and provider management. Land- and water-based exercise, thermotherapy, pharmacological interventions, use of assistive and/or orthotic devices, and participation in self-management programs are key self-management strategies to manage osteoarthritis symptoms. Because older AAs have less control over pain, some suggest they may need more assistance with self-management; however, identification of barriers and motivators to engagement key strategies has been overlooked. A convergent, parallel mixed-methods study, using surveys and qualitative interviews, was conducted with 70 community-dwelling African American seniors (67.2 ± 13.2). The majority of AAs did not engage in water-based exercise, use assistive/orthotic devices, or ever participated in a self-management program, while most used thermotherapy and pharmacological interventions. Content analysis indicate major barriers to engagement as issues/work commitments, no motivation or interest to exercise and fear of falling, lack of knowledge on appropriate exercises, no access to pool and inability to swim, unaware of any osteoarthritis self-management programs, need to protect organs from side effects of pharmacological interventions, and the pain itself. Motivators were a need to maintain health, mobility and function, exercising with a group, and to obtain pain relief.

The UIHC Department of Nursing is nationally known for its work on use of research to improve patient care. This reputation is attributable to staff members who continue to question "how can we improve practice?" or "what does the latest evidence tell us about this patient problem?" and to administrators who support, value, and reward EBP. The revisions made in the original Iowa Model are based on suggestions from staff at UIHC and other practitioners across the country who have implemented the model. We value their feedback and have set forth this revised model for evaluation and adoption by others.

With the mapping of the human genome has come the opportunity for nursing research to explore topics of concern to the maintenance, restoration, and attainment of genetic-related health. Initially, nursing research on genetic topics originated primarily from physical anthropology and froma clinical, diseasefocused perspective. Nursing research subsequently focused on psychosocial aspects of genetic conditions for individuals and their family members. As findings emerge from current human genome discovery, new programs of genetic nursing research are originating froma biobehavioral interface, ranging fromthe investigations of the influence of specific molecular changes on gene function to social/ethical issues of human health and disease. These initiatives reflect nursing’s response to discoveries of gene mutations related to phenotypic expression in both clinical and community-based populations. Genetic research programs are needed that integrate or adapt theoretical and methodological advances in epidemiology, family systems, anthropology, and ethics with those from nursing. Research programs must address not only populations with a specific disease but also communitybased genetic health care issues. As genetic health care practice evolves, so will opportunities for research by nurses who can apply genetic concepts and interventions to improve the health of the public. This article presents an analysis of the evolution of genetic nursing research and challenges for the future.

Relocation to more supportive housing is a potentially stressful life event for older adults. Under the best of circumstances, the older adult will be relatively healthy and able and willing to participate in relocation decisions. However, this is not always possible. Nurses have a critical role to play in helping families identify the most appropriate housing alternative, helping plan the relocation, and helping older adults adjust to their new homes. Relocation is particularly stressful for ethnic elders who may not understand the housing options available, or may fear prejudicial treatment and exclusion in the various settings. Nurses need to take time for careful assessment of the older adults' preferences, and to provide information needed to help them make relocation decisions within the context of their existing support networks.

Most nurses function as generalists; however, some function in "expert" roles based on informal training as Resource Nurses. Training usually focuses on assessment and management of a specific problem, with the goal of creating a readily available "expert" for every unit. The primary activity of the Resource Nurse is to provide expert care, education, and consultation for patients, families, and staff. The Iowa-Veterans Affairs Nursing Research Consortium (IVANRC) addressed the need to manage acutely confused/delirious clients by training staff nurse volunteers (N = 129) from all units of the four Iowa Veterans Affairs facilities to act as unit-based acute confusion Resource Nurses (ACRNs). A day-long workshop included didactic content addressing etiology and presentation of acute confusion (AC), use of the IVANRC protocol to assess for AC, and basic information on treatment and management of AC. The nurses also participated in an efficacy-based experiential learning program on AC assessment that involved demonstrating assessment of AC and role enactment practice exercises in which ACRNs practiced the assessment. A test of knowledge of AC and perceived level of confidence in assessing acutely confused patients was administered before and after completion of the program. Paired t tests comparing pre- and posttest scores showed that knowledge and confidence significantly increased for the nurses as a result of their participation in the educational program. Eighteen months later, a second program was conducted to update current ACRNs and train additional RNs to enact this role. Pre- and posttest scores were obtained, with paired t tests showing a significant increase in knowledge for the participants. Twenty-four (49%) of the second program attendees had attended the first program. These participants had significantly higher scores on the second program pretest than those participants who had not attended the previous program, indicating a retention of knowledge from the first program.

In BriefIn working with diverse populations, health practitioners often view patients’ culture as a barrier to care. Inverting this problem by viewing the barriers as arising from the culture of biomedicine provides greater direction for practice. Integral to the delivery of culturally appropriate diabetes care are practitioner competencies in specific areas of cultural knowledge, as well as specific skills in intercultural communication, tripartite cultural assessment, selecting among levels of intensity of cultural interventions (neutral, sensitive, innovative, or transformative), adapting patient education, and developing community partnerships.

1 With placement of a family member with Alzheimer's disease on a SCU, the family does not relinquish the caregiving role, rather they take on different roles in relation to the residents. 2 Family visitation of the residents on the SCU is an integral part of family involvement in care of individuals with Alzheimer's disease, as well as SCU functioning. 3 Within the context of changing relationships with the residents, family members visited the residents as a sense of duty to "be faithful," to monitor care by "being their eyes and ears," and to foster a sense of family through ongoing relationships and family rituals. 4 Nurses have critical roles in promoting physical, emotional, and interactive environments which foster family visitation on SCUs.

Continuity Theory is a psychosocial theory of aging which posits that as middle-aged and elderly adults adapt to changes associated with the normal aging process, their past experiences, decisions, and behaviors will form the foundation for their present and future decisions and behaviors. Regardless of the clinical setting, nurses working with elderly individuals may find Continuity Theory helpful in viewing the experience or elders in a holistic way that incorporates a life course perspective. By applying Continuity Theory to clinical practice, nurses may be better able to provide individualized, clinically appropriate care to elders.

Given the broad acceptance for the need to develop middle-range theory to support nursing practice, nursing scientists must consider how to proceed with dispatch to develop these theories. This article suggests using the concepts in the newly developing taxonomies of nursing knowledge as the building blocks for these theories. Taxonomies of nursing diagnoses (NANDA), nursing interventions (NIC), and nursing outcomes (NOC) can speed the construction of the theories needed for nursing practice.

This article has set forth a strategy to increase family/staff cooperation in the care of persons institutionalized with AD. The FIC program was developed as an outgrowth of research that demonstrated family member dissatisfaction with their roles. It is specifically designed to provide a partnership role with staff for families whose relatives with AD are institutionalized. Hypothesized outcomes include the reduction of stress in caregiving, increased satisfaction in role and improved patient cognitive and functional outcomes. Testing of the FIC is currently underway.

To explore Korean American women's symbolic meanings related to their breasts and cervix, to examine attitudes and beliefs about breast and cervical cancer, and to find relationships between the participants' beliefs and their cancer screening behaviors.Descriptive, qualitative analysis.Southwestern United States.33 Korean-born women at least 40 years of age.In-depth, face-to-face, individual interviews were conducted in Korean. A semistructured interview guide was used to ensure comparable core content across all interviews. Transcribed and translated interviews were analyzed using descriptive content analysis.Breast cancer, cervical cancer, cancer screening, beliefs, and Korean American women.Korean American women's symbolic meaning of their breasts and cervix are closely related to their past experiences of bearing and rearing children. Negative life experiences among older Korean American women contributed to negative perceptions about cervical cancer. Having information about cancer, either correct or incorrect, and having faith in God or destiny may be barriers to obtaining screening tests.Korean American women's symbolic meanings regarding their breasts and cervix, as well as their beliefs about breast cancer and cervical cancer and cancer screening, are associated with their cultural and interpersonal contexts. Their beliefs or limited knowledge appear to relate to their screening behaviors.Interventions that carefully address Korean American women's beliefs about breast cancer and cervical cancer as well as associated symbolic meanings may increase their cancer screening behaviors. Clinicians should consider Korean American women's culture-specific beliefs and representations as well as their life experiences in providing care for the population.

The Hmong are an ethnic minority from Southeast Asia who constitute a growing U.S. population. Gerontological nurses need to understand the cultural meaning and rituals associated with dying, death, and the bereavement process of Hmong Americans. Critical to this is the structure and role of clan and family as a source of support and their involvement in the decision-making process. In this article, we provide an overview of the traditional spiritual beliefs related to life and death with implications for end-of-life and postmortem care. Information was acquired through invited field experiences. Published literature and consultation with Hmong elders were used to clarify, enhance, and validate this understanding.

Purpose: The Family Care Conference (FCC) is an elder-focused, family-centered, community-based intervention for the prevention and mitigation of elder abuse. It is based on a family conference intervention developed by the Maori people of New Zealand, who determined that Western European ways of working with child welfare issues were undermining such family values as the definition and meaning of family, the importance of spirituality, the use of ritual, and the value of noninterference. The FCC provides the opportunity for family members to come together to discuss and develop a plan for the well-being of their elders. Design and Methods: Using a community-based participatory research approach, investigators piloted and implemented the FCC in one northwestern Native American community. The delivery of the FCC intervention has grown from having been introduced and facilitated by the researchers, to training community members to facilitate the family meetings, to becoming incorporated into a Tribal agency, which will oversee the implementation of the FCC. Results: To date, families have accepted and appreciated the FCC intervention. The constructive approach of the FCC process helps to bring focus to families' concerns and aligns their efforts toward positive action.Implications:The strength-based FCC provides a culturally anchored and individualized means of identifying frail Native American elders' needs and finding solutions from family and available community resources.