The purpose of the dissertation research is to describe the Qatif sociocultural response to children with sickle cell disease (SCD) and pain and how the Qatif sociocultural environment shapes the responses of children with SCD and pain. Significant outcomes of the project include descriptions of Arab Muslim child, parent, and community perspectives on chronic or ongoing pain, and the effect of cultural orientation on the development of pain response patterns. The study method was focused ethnography. Participants included children with SCD and family caregivers during illness episodes. Individuals associated with the Qatif community representing specific community perspectives were also interviewed. Community informants included nurses, physicians, schoolteachers, social workers, and adults with SCD. Data management and analysis were facilitated using ATLAS.ti qualitative research software (Muhr, 1997). The experiences and views of participant groups were described. Categories and themes extracted from data linked the views of the Qatif community, family caregivers, and children with SCD. Mothers provide the majority of care for children in pain, and resort to using biomedical institutions when symptoms become unmanageable. Most children with SCD live their lives fully with transitory pauses for pain episodes. Qatif family and community social structures are supportive of children and adults with SCD and pain with the goal that all community members participate fully in family and community life. Three overarching themes are identified: "Having pain affirms weakness", "Control is in our hands", and "A place for everyone here." Study results demonstrate that religious precepts drawn from basic Islamic teachings support both tolerance of pain and suffering, and seeking cures. Benefits of suffering pain with patience include enhancement of the sufferer's relationship with God, family, and community. Using caring and molding responses, family and community members guide children to endure pain for intrinsic spiritual and social benefits. Implications for practice and further research are described in detail in the dissertation.

The therapeutic nurse-patient relationship is the core of nursing practice. This grounded theory study used symbolic interactionism, identity theory and ethics as a theoretical perspective to examine nurse-patient relationships. The opinions and experiences of twelve professional nurses were explored to discover the process and events involved when a nurse engaged in a nontherapeutic relationship with a patient. A core process, Breaching the Nurse-Patient Relationship, was identified from the interviews. The core process identified three stages in the process with conditions in each stage that showed progression from each condition in each stage to the next stage. The first stage in the process revealed five conditions that make the nurse vulnerable for engaging in nontherapeutic activities with a patient. Stage one, with the five conditions, was the preliminary process that lead to stage two. In stage two, the nurse engaged in nontherapeutic activities/relationships with the patient. The nurse was either under-involved or over-involved in the nurse-patient relationship but clearly the nurse deviated from the therapeutic realm of the relationship. There were eight conditions in stage two that identified the process of the nurse leaving the therapeutic role to engage in a nontherapeutic role with the patient. The last stage was characterized by the consequences that the nurse, patient and profession of nursing had to face as a result of the nontherapeutic nurse-patient relationship.

Problem and background. Caregiving for elderly family members can be viewed as a part of and extension of supportive behaviors between individuals. Consequently, there are cultural undertones to caregiving and what is supportive in one culture may not be in another. Mexican American caregiving has not been well studied; however, Mexican Americans are reported to be more likely to use family as resource for solving problems than non-Hispanic whites. Purpose. Guided by caregiving framework developed by Bowers (1987), Wilson (1989) and Nolan et al. (1995, 1996, & 1997) this study employed grounded theory to formulate a conceptual model of intergenerational caregiving among Mexican American families focusing on characteristics of the temporal axis which defines caregiving in terms of (1) family structure or generational attitudes (historical time); (2) what and how shared understandings with elders and among family members influence who assumes the caregiver role and when (kin time); (3) how entry into the caregiving role affects the entire family (intergenerational development time); and (4) how entry into the caregiving role affects the caregivers' peer relationships (peer time). This study also builds theory about how acculturation influences family care giving. Design, methods. This exploratory study was guided by grounded theory methodology where interviews were taped and analyzed using grounded theory's constant comparative method of analysis. Sample. The sample consisted of Mexican American caregivers (n = 10) of various generations over the age of 21 who provided at lest one intermittent service (without pay at least once a month) to an elder, related through consanguinal or acquired kinship ties. Results. Grounded theory of Role Acceptance comprised of four phases: (1) Introduction: Early Caregiving Experiences; (2) Role Reconciliation; (3) Role Imprint; and (4) Providing/Projecting Care. Significance. This study provides a Mexican American intergenerational caregiving model that can be utilized to study varied generations of Mexican American caregivers. It also provides a framework for comparison with other groups of caregivers. Results of this study also inform health professionals about ways in which Mexican American caregivers view caregiving. This information has potential to increase cultural competence in delivery of health care to elders and their families.

Perceptions are an important component of the decision-making process and interactions between adult children and the older parent. The purposes of this correlational, cross-sectional study were (a) to test the psychometric properties of the Categories of Decision Making Scale; and (b) to describe the perceptions of the mother/daughter dyad and the match of perceptions with a specified theoretical perspective. The major variables in the model included general and specific expectations, dyadic intimacy, partner's decision strategies, and categories of decision-making. The convenience sample consisted of 12 dyads, older mothers and caregiving daughters, in the community who received questionnaires by mail. A model of Perceptual Congruence of the Mother/Daughter of the Dyad was developed to examine the factors "WE" (agreement of the dyad members) and "I" (disagreement of the dyad members). Two methods of analysis were used to analyze the data, Multitrait-Multimethod (MTMM) and Factor Analytic Structural Equation Modeling (FASEM). Key findings indicated that the Categories of Decision Making scale demonstrated sufficient validity and reliability for describing the decision making of daughters and mothers for this small sample. The MTMM analysis demonstrated congruence, indicating agreement on the "WE" factor with dyadic intimacy, mothers' involvement in decision making, and confidence in mothers' decision making abilities. The FASEM models demonstrated "WE" agreement on the variables of dyadic intimacy and positive decision strategies. Comparison of both methods of analysis, MTMM and FASEM indicated mothers and daughters agreed only on dyadic intimacy. In this study, daughters perceived the mothers used more negative decision making strategies than the mothers perceived the daughters to use while making decisions. The daughters believed negative decision making strategies were caused by higher specific parental expectations and resulted in diminished intimacy between mother and daughter. In summary, there was agreement within the dyad on dyadic intimacy, but congruence was not found on expectations, decision strategies, or categories of decision-making. The findings suggest that daughter/mother dyadic decision-making is very complex with both partners perceiving the interaction differently. These differences may cause difficulties with the decision making process and poor outcomes for the dyadic members.

The purpose of this study was to further develop treatment theory for SHIP psychoeducational interventions in order: (1) to discover those interventions which proved to contribute toward significant change rate in the self-reported perceptions of breast cancer patients concerning their feelings of personal 'well-being', (2) to assess the stability of the SHIP's treatment effect during the follow-up data collection period, (3) to profile which individuals were most likely to benefit from specific components of SHIP interventions, and (4) to test the processes by which the SHIP interventions affected the outcome. Outcomes studied were change in: self-help, enabling skills (belief-in-self, cognitive reframing, & problem solving), uncertainty level, psychological adjustment, and 'well-being'. Profiling factors were personal characteristics, medical characteristics, baseline support level, and baseline mastery level. Data were derived from the Self-Help Interventions Project (SHIP), an experimental, longitudinal study which had provided psychoeducational interventions to women with breast cancer in order to help them cope with their situation. The SHIP interventions consisted of education and psychological components. A nonprobability sample of 307 women was randomized into one of five possible treatment groups and a natural learning condition/control group. Study results revealed that, in general, change patterns in outcomes were as expected, though magnitude of change rates was modest to moderate. Significant impact was strongest for those who participated in: the Self-Help Independent Study plus Uncertainty Management combined intervention, and the Self-Help Independent Study intervention. Recommendations include: (1) re-examine intervenors' characteristics through further secondary data analysis of the SHIP study; (2) replicate part of this study using only the stronger components such as the combined Self-Help Independent Study/Uncertainy Management groups, and the individual Self-Help control group in a more homogeneous and larger sample size; (3) use alternative methods of measurement to capture the changes in outcomes. For example, measure functional status through the categories of 'performing self-care', and 'returning to school/work/hobby'; and (4) measure more frequently in order to determine the possibility of using "booster" lessons.

The impact health care delivery changes have on nursing and subsequently on the health of individuals, families, and the community are unknown to the nursing profession as well as the public. Delineation of patient outcomes sensitive to nursing care and their benchmarks would enable the nursing profession to evaluate system changes being implemented. Establishing targets for patient outcomes will provide facilities with benchmarks to measure themselves against. The purposes of this study were first, to identify if the nurse sensitive patient outcomes identified by the AAN expert panel are appropriate and second, to establish benchmarks for these outcomes that are applicable across the continuum of care. The appropriateness and benchmarks were determined through a Delphi study with nurse experts identified from the health care continuum of primary health care providers, hospitals, home care, hospice, and long term care. The five patient outcomes are Appropriate Self Care Behaviors, Symptom Management, Health Promoting Behaviors, Perceptions of Being Well Cared For, and Health Related Quality of Life (HRQOL). All patient outcomes were deemed appropriate for all healthcare settings. Two indicators of Health Related Quality of Life were excluded by the panel from Acute Care. Consensus was reached for the majority of patient outcomes. There were only seven benchmarks out of 18 for each continuum of care (a total of 90) that did not achieve consensus. The acute care participants did not reach consensus on one indicator within Health Promoting Behaviors. The remaining six were from Hospice participants: one indicator of Appropriate Self Care, all indicators of Health Promoting Behaviors and two within Health Related Quality of Life. The majority of benchmarks were in the mid to high range. Long Term Care tended to have lower scores than the other settings. Patient self care behaviors were very low for hospice patients. The indicators that did not meet consensus criteria were stable indicating that scores were not changing between rounds. Sample size of participants prevent citation of results for Home Care, Hospice and Long Term Care. Benchmarks can be set and used to evaluate the effectiveness of nursing care and the impact of system changes.

Chronic stress exerts a damaging influence on the physiology of the body and on a person's well-being. There is growing interest in nonpharmacologic interventions to address stress-related health problems, such as tension headaches, the focus of this research. Four research questions were examined: (1) Are there differences in the six study variables (perceived stress, time pressure, spiritual practices, sIgA, and tension headache intensity and duration) between the intervention and comparison groups? (2) What combination of variables best explains sIgA and tension headache intensity and duration? (3) Do spiritual practices function as a mediator of relationships between the psychological variables, sIgA, and headache intensity and duration? (4) How do group, gender, payment, and religious background affect changes in headache intensity and duration over time? A mixed pre-/post-experimental design with pre-/post-longitudinal measurements was used to examine the questions. The sample consisted of 50 women and 14 men with tension headaches, aged 18-70; 34 were randomly assigned to an intervention group and 30 to a comparison group. Intervention participants received an 8-week mindfulness meditation class, 2 hours a week. Comparison participants received an 8-week educational class in headaches, 1½; hours a week. Pre- and post-testing measurements were obtained on study variables and headache intensity and duration, as noted in diaries. Analysis results, using ANCOVA, multiple regression, and growth curve analysis, indicated that (1) the intervention group had a significantly higher post-treatment sIgA level than the comparison group; (2) in the combined groups, 14% of the total variance in sIgA, and 25% of the total in headache intensity post-test was explained by their pre-test scores; 62% of the explained variance in headache duration post-test was explained by its pre-test, sIgA pre-test, and stress post-test; (3) spiritual practices did not function as a mediator within the proposed model; (4) group, gender, payment, or religious background did not relate to a significant decrease in headache symptoms in either group. The intervention of mindfulness meditation affected an increase in sIgA level, had a near significant effect on spiritual practices over time, and did not cause significant changes in perceived stress or time pressure.

Multidisciplinary adolescent sexuality research deals mostly with risk- and demographic factors and intervention programs. The social-developmental process through which female adolescents manage relationships to become sexual women has not been defined. This research sought to bring to light the ways in which female adolescents discover, develop, and use management skills to navigate the socio-sexual environment of adolescence. A synthesis of symbolic interactionist and life span developmental frameworks informed the research. Semi-structured interviews yielded data which were analyzed using the constant comparative method. A grounded theory pertaining to female adolescent sexuality management emerged with Relationship Management as its core category. The causal conditions to Relationship Management were named Coming of Age and included Entering Puberty, Noticing Boys and Feeling Ready for a Relationship. The action/interaction strategies were named Dealing With Boys and included Public Presentation of Self, Profiling, Trying to Communicate, and Controlling the Relationship. The consequences of action/interaction strategies were named What Might Happen and consisted of Relationship Outcomes, Physical Outcomes, Effects on Reputation and Effects on the Life Course. The context for the action/interaction activities was named The Kind of Girl I Am and consisted of What I Know About Myself and What I Believe About Others. Intervening conditions were called My World and included Peer Group Influence, Family influence and School Influence. The findings suggest the need to view female adolescents as active managers of their emerging sexuality.

A retrospective validation study was implemented to identify the defining characteristics of the nursing diagnosis Alteration in Comfort-Pain, specifically chest pain. The interventions instituted by coronary care nurses to relieve the chest pain were also explored. Fifty-two records were reviewed. A Demographic Instrument (DI) and Alteration in Comfort-Pain (Chest Pain) Intervention Instrument (ACPII) were developed for the study and the Alteration in Comfort-Pain Assessment Tool for Chest Pain (ACPAT-CP) was revised from the Alteration in Comfort-Pain Assessment Tool (ACPAT) for the study. The three instruments were assessed for content validity and reliability. The critical defining characteristic was determined to be a verbal complaint of chest pain with or without a specific descriptor and nurses made the appropriate nursing diagnosis for chest pain in the majority of the records reviewed. Nursing interventions documented for the relief of chest pain were interdependent interventions, specifically monitoring and an electrocardiogram. The results indicated that there is a need for improved documentation in nurses' notes.

An exploratory study was designed to discover what are the self-care activities in persons with rheumatoid arthritis and the relationships among self-care activities, antecedent factors, and the consequent factor, quality of life. Content analysis was used to determine rheumatoid arthritis persons' descriptions of self-care activities and Orem's six categories of health-deviation self-care requisites that contribute to self-care activities. Antecedent factors which were associated with self-care activities included interpersonal, intrapersonal, and disease characteristics. Interpersonal factors included five domains; intrapersonal factors included three domains; and disease characteristics had four domains. The findings suggested that some antecedent factors, such as marital status, income, educational level, significant others, psychological support, physical support, number of years ill, and other diseases were associated with subjects' self-care activities. The findings also suggested that subjects' self-care activities were related to their quality of life. Recommendations for nursing practice and further research were discussed.