First year death rates remain unacceptable high for the end-stage renal disease (ESRD) population. New effective methods are vital to improve first year morbidity and mortality outcomes for the population transitioning from Stage 4 chronic kidney disease (CKD) to ESRD)/Stage 5 CKD. Based on current methods, evidence-based recommendations made by nephrology providers are frequently not heeded by patients in Stage 4 CKD. Low levels of patient knowledge, self-efficacy, and a poor ability to self-manage CKD negatively influence a patient’s ability to follow provider recommendations. The group visit (GV) intervention has demonstrated improvements in disease-related outcomes through increased levels of patient knowledge, self-efficacy, and disease self-management for other chronic diseasses such as diabetes and congestive heart failure (CHF). No data are available for the use of GVs in CKD The purpose of the study was to develop and test a nurse practitioner-facilitated chronic CKD GV model versus usual nephrology care for Stage 4 CKD patients (knowledge, selfefficacy/self-management, physiological data, and satisfaction). As classified by the National Kidney Foundation’s (NKF) staging system, Stage 4 CKD is considered severe kidney disease, with a decrease in the functional capacity of the kidney as determined by a glomerular filtration rate (GFR) of 15-30 ml/min. It is common for patients with Stage 4 CKD to progress to Stage 5 CKD/end-stage renal disease (ESRD), requiring dialysis or transplantation to survive. Preliminary instrumentation and feasibility studies were conducted prior to a pilot study of a CKD GV model. The development and validation of the Stage 4 CKD Knowledge Instrument was completed with 59 Stage 4 patients. Findings supported reliability (KuderRichardson-20 [KR] = .89) and content validity (I-CVI = .97, S-CVI= 1.0) Feasibility of the CKD GV model was assessed with a single group, pretest-posttest design using a convenience iv sample of eight Stage 4 patients. Results demonstrated an improvement in knowledge of CKD from a median of 69% to 86% (p =.012). No improvements were noted in self-efficacy scores (p = .230). GV satisfaction ranged from very good to excellent. Feasibility was supported by a high retention rate (100%). No barriers to participant recruitment or GV implementation were encountered. The pilot study used a two-group, repeated measures experimental design, with a sample of 30 Stage 4 CKD patients from two office locations of an outpatient nephrology practice. Patients were randomized to the GV intervention or to usual nephrology care. CKD-knowledge, self-efficacy, and self-management scores were collected at baseline, six months, and nine months. Physiological data were measured at baseline, six months, and nine months. GV satisfaction was obtained after the completion of GVs (six months). Nephrology practice satisfaction was obtained from by both groups at nine months. MANOVA for repeated measures was calculated for data collected at the three time points. Twenty-six of 30 patients completed the study, with four patients ineligible to complete the study due to progression to ESRD and dialysis initiation. GV attendance was 92%. CKD knowledge was statistically improved for both groups (F(1.498, 34.446) = 6.363, P = .008). While not statistically significant, a favorable upward trend in the mean scores for the subscales of self-management (communication, partnership in care, and self-care) was demonstrated in the GV patients, with a lack of improvement found in the usual care group for these subscales. Selfefficacy scores revealed a non-significant improvement in mean scores for the GV patients during the GVs, not seen with usual care patients. GV satisfaction was again high with the vast majority of patients requesting use of GVs in their future nephrology care. v Current methods of intervention in the Stage 4 CKD population have made little impact on reducing first-year ESRD mortality and morbidity rates. Opportunities to intervene in the poor outcomes begin in the predialysis care of Stage 4 patients. Based on the documented success of multidisciplinary approaches in predialysis care, of GVs in other chronic diseases, and of chronic illness care based on the CCM, a high probability for success exists with the application of GVs in CKD. Although limited by a small sample size, promising improvements in the subscales of disease self-management, self-efficacy, CKD knowledge, and high satisfaction with the GV model for GV participants were revealed in this study. Further research is warranted for the CKD GV model on a larger randomized sample in other locations. Much needed data would be provided on which to base decisions for use of the CKD GV intervention in the predialysis care of Stage 4 patients.

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This thesis examines the processes by which the self-concept is shaped by chronic illness in later life. This study contributes to our understanding of the development of the self in later life by examining patterns of continuity and change. Twenty-four women diagnosed with osteoarthritis (0A) were interviewed. The participants were community dwelling females, aged between 67 to 85 years. They were selected to reflect a range of OA, from mild to severe forms of the disease. A qualitative approach, more specifically, the grounded theory method was adopted for this study. The findings illustrate that OA in later life presents a source of change for the self concept. However, the influence of these processes of change vary considerably. In particular, the significance of change for the self-concept is shaped by the individual's perception of the impact of chronic illness for the self. These are shaped by several factors. The impact of OA on the self is influenced by the ways in which the person's multiple identities are affected. And, the person's perception of continuity and change for her "overall" or global sense of self must be considered. Finally, the type of process mechanisms that are drawn upon shape the person's perception of continuity and change. Such processes include: shifting and non-shifting prominence hierarchies, the ability to adjust and accommodate to one's limitations and the extent to which interactions and valued identities are modified, social comparison, reflected appraisal, and the dialogue between the past, the present, and the future self. The data show that older people do reflect some of the same issues that have previously been revealed by studies of chronic illness which do not focus on later life. However, experiences of chronic illness in later life also present unique variations. / Thesis / Master of Arts (MA)

In writing this autoethnography, I invite you to enter into my world. It is not a world that is easy, or altogether happy. In the end, though, it is a story of survival and of perseverance. Trauma touches almost every person in some way. War, sexual abuse, physical and emotional abuse, death, and difficult life events color how we make sense of the world. Trauma may happen in one blinding moment or slowly eat away at us for years. Writing is often a way to cope with that trauma. This dissertation represents a small portion of my traumatic lived experiences that led me up to the doctoral process, and those that occurred in the ten years it took me to complete my dissertation. / Doctor of Philosophy / In writing this autoethnography, I invite you to enter into my world. It is not a world that is easy, or altogether happy. In the end, though, it is a story of survival and of perseverance. Trauma touches almost every person in some way. War, sexual abuse, physical and emotional abuse, death, and difficult life events color how we make sense of the world. Trauma may happen in one blinding moment or slowly eat away at us for years. Writing is often a way to cope with that trauma. This dissertation represents a small portion of my traumatic lived experiences that led me up to the doctoral process, and those that occurred in the ten years it took me to complete my dissertation.

The relationships between marital communication of later-life couples coping with chronic, physical illness, caregiver depression and marital satisfaction were examined in this study of 25 patients and their spouse caregivers. Guided by Bowen Theory, lag sequential analyses and sequence repetition analyses were conducted on observational data to determine the effects of open communication, closed communication, and pursuer-distancer communication on caregiver depression and marital satisfaction. The findings indicate that reciprocal closed communication between caregivers and spouses was positively related to caregiver depression, reciprocal open communication between caregivers and spouses was negatively related to marital satisfaction, and reciprocal pursuer-distancer communication was negatively related to marital satisfaction. Further, sustained pursuer-distancer communication was related to higher caregiver depression. Communication patterns were found to be related to family of origin relationships. Possible explanations for these findings and implications for family therapy and future research are discussed. / Ph. D.

Background: Asthma is a chronic inflammatory lung disease that most often emerges in childhood and affects millions of children around the world. Asthma can affect parents and their children more or less depending on how severe asthma is. When children are cared for, parents are an important and necessary resource for the child's well-being. That´s why it´s important to support not only the child but also parents in the care process. Aim: The purpose of this literature study is to describe experiences of parents who care for a child with asthma. Method: This study was based on systematic literature search which was based on ten qualitative articles that responded to the purpose of the study. Results: The results showed that parents caring for a child with asthma often experienced concern, frustration, hope and need for knowledge about asthma. Parents experienced great deal of concern before child was diagnosed, during deterioration periods and concern about negative side effects medication could cause in the future for the children. Frustration emerged when dealing with health care professionals and school/preschool staff. Despite everyday concern, frustration, lack of knowledge parents still felt hope for the future. Conclusion: Nurses have continuous contact with parents that care for children with asthma. Parents caring for child with asthma need a great deal of support from health care system to be able to manage child's illness best way they can. Increased understanding and knowledge about parents experience makes it possible for nurses to have an open dialog with parents and include them better in their child's care.

This Master's Thesis reports on the experiences of Type 2 Diabetes of Lesbian, Queer, and Women-Loving Women. The thesis examines the impact of sexual orientation on experiences with diabetes, and how this chronic disease affects the way a woman views herself, her health, and her body image. Each participant presented her narrative and world views in regards to her diabetes health care and management, stress and trauma, and management of relationships. Through narrative analysis, I have revealed differing mechanisms of coping and explanatory models; the many women of this study selectively chose to be more open about her sexual orientation than her diabetes status.