A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Integrative medicine (IM) is a unique clinical paradigm that may be applied across numerous healthcare professions and diverse settings. With its focus on whole person health and lifestyle medicine, it advocates utilizing complementary and alternative medicine in addition to traditional treatments in order to achieve an individual’s optimal wellness. Literature supports how significantly this distinctive, promising field of practice can help reduce overall healthcare costs, alleviate the heavy burden of chronic disease, bolster efforts focused on preventive measures, and improve both patient outcomes along with practitioner wellbeing. In order to meet a growing demand for easily accessible, ongoing professional education in IM, the Arizona Center for Integrative Medicine launched an innovative curriculum called the Integrative Medicine in Residency (IMR). This online, two hundred hour, integrative course premiered with eight Family Medicine Residencies across the United States. The purpose behind this study was to aid in developing an appropriate compilation of instruments for a long-term follow‐up questionnaire for IMR graduates, distribute the survey to a trial cohort, and present a summary of the pilot survey results. The instrument was developed in order to: provide feedback on the course, aid in future program modification, determine how graduates implement what they learned through IMR, identify barriers to care, and help distinguish areas where physicians may need additional support to better incorporate IM into practice. The final forty‐four‐question survey, with quantitative and qualitative measures, was distributed in 2015 over three months to residents that graduated between 2011‐2014 via their program directors. All candidates were sent an email with an embedded link to Survey Monkey. Through this series of online, self‐reported responses, the questionnaire was filled out in real time and results were auto‐populated into a secure excel file for further statistical analysis. Our trial cohort attained valuable responses from thirty‐one graduates. Results demonstrated that students were largely satisfied with their education and pleased with the personal and professional impacts following their IMR training; however, barriers to care most notably reported were time, cost, and patient receptivity. This study emphasizes the importance of providing easy access to ongoing IM education for physicians, while also highlighting the equal importance of future research into how to better support healthcare providers seeking to provide the comprehensive IM therapy all patients deserve.

Moral injury is a relatively new psychological syndrome characterized by profound emotional, cognitive, and social pain following perceived moral violations. Though often overlapping, moral violations can involve either the perpetration of a moral transgression (via action or inaction) or the experience of a moral betrayal by a trusted other. In each case, symptoms of moral injury may include guilt, shame, anger, loss of trust and meaning, and social withdrawal. To date, the study of moral injury has remained nearly exclusive to the military arena. In turn, the aim of this thesis is to highlight the relevance of moral injury to other populations vulnerable to its effects. These include: 1) justice-involved individuals found Not Criminally Responsible on Account of Mental Disorder who may experience moral injury after regaining insight into their offending behaviour; and 2) Public Safety Personnel who are often exposed to morally ambiguous situations while under high levels of social responsibility. To appreciate the impact of moral injury for these populations, adequate tools must first be developed to measure and assess it. The three studies included in this dissertation outline the key steps to instrument development using a mixed-method approach: first, a qualitative investigation with justice-involved individuals explores the unique emotional consequences following a criminal offence that will inform subsequent phases of instrument development; second, quantitative inquiries are taken to construct, evaluate, and employ a new moral injury assessment for Public Safety Personnel to uncover important causes and consequences of moral injury in this group. This dissertation serves as a strong indicator that moral injury is a unique and costly health outcome relevant across societal groups. / Dissertation / Doctor of Philosophy (PhD) / Moral injury is a new psychological syndrome developed to understand an individual’s response to a moral trauma. As with other traumatic stress disorders, some people may develop a moral injury after experiencing a situation or event that violates deeply held moral standards. These morally injurious events may be moral violations perpetrated by the individual and result in deep feelings of shame and guilt, or may be moral betrayals by a trusted other and result in feelings of anger and loss of trust. To better understand the causes, symptoms, and consequences of moral injury, we must first develop tools to measure and assess it. This thesis outlines the key steps involved in developing new moral injury assessments in two groups who have an elevated risk of experiencing morally injurious events and so may be more likely to develop a moral injury: justice-involved individuals found Not Criminally Responsible and Public Safety Personnel.

Family therapists face a dramatic increase in the cultural diversity of their clients. Multicultural competence will help family therapists meet the needs of their increasingly diverse clientele (Kocarek, Talbot, Batka, & Anderson, 2001). The measurement of multicultural competence is necessary in order to evaluate the outcomes of multicultural competence programs and the services that minority persons receive. This study reports the development of an instrument to assess clients' perceptions of their therapists' multicultural competence that can be used in individual and family therapy. This instrument was developed through three phases: item generation and theme development, client feedback and evaluation of interrater reliability, and pilot and validity testing. Winsteps (Linacre, 2001) software was used to scale the measurement data to the Rasch Rating Scale Model, and evaluate the dimensionality, rating scale use, item fit, person fit, reliability and precision, as well as to create norms for interpreting the measures. Preliminary support for the MTCI-CV suggests a fairly reliable and valid measure at this stage. Additionally, logistic ordinal regressions were conducted to determine whether MTCI-CV measures are associated with client satisfaction level and goal attainment level. We found that positive client perceptions of therapist cultural competence (on the MTCI-CV) significantly contribute to the probability of clients expressing satisfaction and goal attainment in therapy. / Ph. D.

Womens roles in the work force have increased, however, womens positions in the household have not changed greatly (Lennon & Rosenfield, 1994). While paid work research has focused significantly on the qualities of roles, household work research has not (Janzen & Hellsten, 2007). As the few existing instruments that do measure the quality of household work roles lack psychometric evidence (Janzen & Hellsten, 2007), a new instrument assessing all aspects of the quality of household work roles and possessing evidence of validity and reliability is required. The first step in the instrument development process is the identification and definition of relevant constructs. Thus, the main purpose of the study was to identify household work themes. Four focus groups of triple role women were performed with a total of 20 participants. A snowball sampling technique was used to recruit participants. Thematic analysis of the transcripts identified eight themes: No End Result, Scheduling, Time Constraints, Psychological Strain, Equality in Work, Value, Money, and Reward. The results found women to enjoy certain aspects of household work, but that they lead busy and hectic lifestyles. The themes created in the study were placed into a table of specifications this is to guide future instrument development research in which items can be included for each of these eight themes.

Womens roles in the work force have increased, however, womens positions in the household have not changed greatly (Lennon & Rosenfield, 1994). While paid work research has focused significantly on the qualities of roles, household work research has not (Janzen & Hellsten, 2007). As the few existing instruments that do measure the quality of household work roles lack psychometric evidence (Janzen & Hellsten, 2007), a new instrument assessing all aspects of the quality of household work roles and possessing evidence of validity and reliability is required. The first step in the instrument development process is the identification and definition of relevant constructs. Thus, the main purpose of the study was to identify household work themes. Four focus groups of triple role women were performed with a total of 20 participants. A snowball sampling technique was used to recruit participants. Thematic analysis of the transcripts identified eight themes: No End Result, Scheduling, Time Constraints, Psychological Strain, Equality in Work, Value, Money, and Reward. The results found women to enjoy certain aspects of household work, but that they lead busy and hectic lifestyles. The themes created in the study were placed into a table of specifications this is to guide future instrument development research in which items can be included for each of these eight themes.

A multiple-pass cell is developed and applied to enhance the Raman signal from methane-air flames for temperature measurements. Stable operation of the cell was demonstrated and studied in two alignment modes. In the ring mode, the beams are focused into a ring of ~ 3 mm diameter at the center of the cell, and spectra were recorded at low dispersion (0.26 nm/pixel). Temperature is calculated from the ratio of the intensity of Stokes to anti-Stokes signal from nitrogen. Temperature is also inferred from the shapes of the Stokes and anti-Stokes peaks in the spectrum. The uncertainty in the value of flame temperature in these measurements was ±50 K. The signal gain from 100 passes is a factor of 83. Signal to noise ratio (SNR) improved by a factor of 9.3 in room temperature air with an even higher factor in flames. The improvement in SNR depends on the acquisition time and is best for short acquisition times. In the two point mode, multi passing is achieved simultaneously with high spatial resolution as the laser is focused at two small regions separated by ~ 2 mm at the center of the cell. The probe regions are 300 [mu]m × 200 [mu]m. The vast improvement in the spatial resolution is achieved at the cost of a reduced number of passes and signal gain. The two point mode is operated with 25 passes at each point with a signal gain factor of ~20; the SNR gain depends on the data acquisition time. Spectra were recorded at high dispersion (~0.03 nm/pixel). Temperature is inferred from curve fitting to the high resolution Stokes spectrum of nitrogen in methane-air flames. The curve fit is based on very detailed simulation of Raman spectrum of nitrogen. The final model includes the angular dependence of Raman scattering, electrical and mechanical anharmonicity in the polarizability matrix elements, and the presence of a rare isotope of nitrogen in air. The uncertainty in the value of temperature in the least noisy data is ±9 K. The sources of uncertainty in temperature and their contribution to the total uncertainty are also identified. / text

The purpose of this study was to develop an instrument to measure the sense of competence of traditional age college students across the dimensions that define the construct. The Sense of Competence Scale-Revised (SCS-R) was developed to provide a measure of Chickering’s (1969) first vector, an important psychosocial construct. Administrators can use data from the instrument to modify an institution’s academic and social environment to enhance the development of the intellectual, physical, and interpersonal competencies of college students. During the development and validation, various aspects of the SCS-R were examined in accordance with the validity framework outlined by Messick (1995). According to Messick (1995), the validity of measures can be examined in terms of six forms of evidence; content, substantive, structural, generalizability, external and consequential. The six forms of evidence function as general standards for all educational measurement (Messick, 1995). During the study the content aspect of validity was addressed through the creation of concept maps and test blueprints. In addition, the content aspect of validity was addressed by creating and selecting items by reviewing the literature and hosting brainstorming sessions, items were then reviewed by student development theory experts, pilot tested, field tested and then items with high technical quality were selected for the final instrument. The substantive aspect of validity was addressed through an analysis of item rating scale functioning, person fit to the measurement scales, and item difficulty. The structural aspect of validity was addressed by evidence of the instrument’s dimensionality. The generalizability aspect of validity was addressed through an analysis of item/person reliability. The evidence generated from the study suggested that the chosen items for the SCS-R provide reliable and valid estimates of a student’ s personal assessment of their intellectual, physical and interpersonal abilities. / Ph. D.

Nurses experience stress, fear and anger while they are trying to reconcile their ideals/ goals about health care with its inadequacies and abuses (Jameton, 1984:5), while at the same time trying to stay true to their convictions (Lindh et al., 2010:552). Moral distress is experienced when nurses cannot adhere to these goals (Corley, 2002:637). Conflicting moral principles, stress-provoking and contradicting demands weaken the nurse’s sense of control, power and autonomy (Lützen et al., 2010:213). The current descriptions of moral distress inadequately define the concept, and this might lead to the inconsistent use of the term moral distress. Therefore, conceptual clarity is needed. Current available instruments measure antecedents and situations causing moral distress. Therefore, an instrument measuring the attributes of moral distress is urgently needed. Such an instrument might be used in a variety of clinical departments because it is not based on department-specific situations but on the attributes of moral distress. Moral distress has a great impact on the nurse, patient care and the organization. This research used Benson and Clark’s (1982) method of instrument development as a theoretical framework. It is the aim of this study to develop and validate an instrument to measure moral distress in the clinical health care context of the professional nurse. In order to attain this aim the following objectives were set: To conduct an integrative literature review to identify antecedents, consequences, attributes and empirical indicators of moral distress; to conduct interviews to explore professional nurses’ experience of moral distress; to develop an instrument to measure moral distress in professional nurses; to validate the instrument. A qualitative and quantitative research design with explorative, descriptive and contextual strategies was used. The research process was divided into phases. During Phase One, an integrative literature review was conducted and the population included all available national and international data on moral distress in nurses/ nursing and sampling included all-inclusive sampling. Data analysis was performed through descriptive synthesis.Phase Onealso included semi-structured interviews and the population included professional nurses working in hospitals and clinics in the North-West Province. The sampling method applied was purposive sampling. Tesch’s method was used as data analysis method. During Phase Two, a content validation was conducted and the population included experts in the field of moral distress and instrument validation, and purposive sampling was applied. Data collection was done through the instrument that was developedand data analysis was the content validity index. Phase Twoalso included a qualitative evaluation which was conducted and the population consisted of professional nurses working in hospitals and clinics in the North-West Province and purposive sampling was applied. Data was collected through the developed instrument and a focus group session. Data analysis was conducted through aconsensus discussion. During Phase Three, a pilot study was conducted and the population was professional nurses working ina hospital with different departments and clinics in the Free State Province. All-inclusive sampling was applied and the instrument that was developed was used as data collection. Data analysis included: Descriptive statistics, factor analysis (exploratory, confirmatory and Bartlett’s test of spherity), Cronbach’s alpha coefficient, correlations and ANOVA. According to the results from the face-, content-, exploratory and confirmatory, discriminant- as well as divergent validity, the instrument has been shown to be valid. The Cronbach’s alpha for the Moral Distress Instrument was deemed reliable. Finally, the research was evaluated and limitations were identified. Recommendations for nursing education, -practice, research and policy were formulated. / PhD (Nursing), North-West University, Potchefstroom Campus, 2014

Nurses experience stress, fear and anger while they are trying to reconcile their ideals/ goals about health care with its inadequacies and abuses (Jameton, 1984:5), while at the same time trying to stay true to their convictions (Lindh et al., 2010:552). Moral distress is experienced when nurses cannot adhere to these goals (Corley, 2002:637). Conflicting moral principles, stress-provoking and contradicting demands weaken the nurse’s sense of control, power and autonomy (Lützen et al., 2010:213). The current descriptions of moral distress inadequately define the concept, and this might lead to the inconsistent use of the term moral distress. Therefore, conceptual clarity is needed. Current available instruments measure antecedents and situations causing moral distress. Therefore, an instrument measuring the attributes of moral distress is urgently needed. Such an instrument might be used in a variety of clinical departments because it is not based on department-specific situations but on the attributes of moral distress. Moral distress has a great impact on the nurse, patient care and the organization. This research used Benson and Clark’s (1982) method of instrument development as a theoretical framework. It is the aim of this study to develop and validate an instrument to measure moral distress in the clinical health care context of the professional nurse. In order to attain this aim the following objectives were set: To conduct an integrative literature review to identify antecedents, consequences, attributes and empirical indicators of moral distress; to conduct interviews to explore professional nurses’ experience of moral distress; to develop an instrument to measure moral distress in professional nurses; to validate the instrument. A qualitative and quantitative research design with explorative, descriptive and contextual strategies was used. The research process was divided into phases. During Phase One, an integrative literature review was conducted and the population included all available national and international data on moral distress in nurses/ nursing and sampling included all-inclusive sampling. Data analysis was performed through descriptive synthesis.Phase Onealso included semi-structured interviews and the population included professional nurses working in hospitals and clinics in the North-West Province. The sampling method applied was purposive sampling. Tesch’s method was used as data analysis method. During Phase Two, a content validation was conducted and the population included experts in the field of moral distress and instrument validation, and purposive sampling was applied. Data collection was done through the instrument that was developedand data analysis was the content validity index. Phase Twoalso included a qualitative evaluation which was conducted and the population consisted of professional nurses working in hospitals and clinics in the North-West Province and purposive sampling was applied. Data was collected through the developed instrument and a focus group session. Data analysis was conducted through aconsensus discussion. During Phase Three, a pilot study was conducted and the population was professional nurses working ina hospital with different departments and clinics in the Free State Province. All-inclusive sampling was applied and the instrument that was developed was used as data collection. Data analysis included: Descriptive statistics, factor analysis (exploratory, confirmatory and Bartlett’s test of spherity), Cronbach’s alpha coefficient, correlations and ANOVA. According to the results from the face-, content-, exploratory and confirmatory, discriminant- as well as divergent validity, the instrument has been shown to be valid. The Cronbach’s alpha for the Moral Distress Instrument was deemed reliable. Finally, the research was evaluated and limitations were identified. Recommendations for nursing education, -practice, research and policy were formulated. / PhD (Nursing), North-West University, Potchefstroom Campus, 2014

Previous systematic reviews indicate a lack of reporting of reliability and validity evidence in subsets of the medical education literature. Psychology and general education reviews of factor analysis also indicate gaps between current and best practices; yet, a comprehensive review of exploratory factor analysis in instrument development across the continuum of medical education had not been previously identified. Therefore, the purpose for this study was critical review of instrument development articles employing exploratory factor or principal component analysis published in medical education (2006-2010) to describe and assess the reporting of methods and validity evidence based on the Standards for Educational and Psychological Testing and factor analysis best practices. Data extraction of 64 articles measuring a variety of constructs that have been published throughout the peer-reviewed medical education literature indicate significant errors in the translation of exploratory factor analysis best practices to current practice. Further, techniques for establishing validity evidence tend to derive from a limited scope of methods including reliability statistics to support internal structure and support for test content. Instruments reviewed for this study lacked supporting evidence based on relationships with other variables and response process, and evidence based on consequences of testing was not evident. Findings suggest a need for further professional development within the medical education researcher community related to 1) appropriate factor analysis methodology and reporting and 2) the importance of pursuing multiple sources of reliability and validity evidence to construct a well-supported argument for the inferences made from the instrument. Medical education researchers and educators should be cautious in adopting instruments from the literature and carefully review available evidence. Finally, editors and reviewers are encouraged to recognize this gap in best practices and subsequently to promote instrument development research that is more consistent through the peer-review process.