NURSING SCIENCE <p> COPING AND HEALTH-RELATED QUALITY OF LIFE IN RENAL TRANSPLANT PATIENTS <p> HONGXIA LIU <p> Dissertation under the direction of Professor Kathleen Dwyer <p> Purpose. The purpose of this study was to investigate the relationships among transplant-related clinical factors, cognitive appraisal of health, perceived self-efficacy, perceived social support, coping, and health-related quality of life (HRQOL) in renal transplant patients using a theoretically derived model. <p> Method. Using a descriptive cross-sectional design, a convenience sample of 160 participants following renal transplantation was recruited from an outpatient transplant clinic [N=55 < 1 yr post transplant; N=105 1 - 3 yrs post transplant]. Standardized instruments were used to measure the key constructs. <p> Results. Path analysis demonstrated that perceived self-efficacy had a significant direct effect on negative primary appraisal of health and physical HRQOL, and had both direct and indirect effects through primary appraisal on disengagement coping. Perceived social support had significant direct effects on negative primary appraisal of health and engagement coping, and an indirect effect on disengagement coping through negative primary appraisal. History of transplant related hospitalizations and medication side effects had significant direct effects on primary cognitive appraisal of health. Medication side effects had a direct effect on mental HRQOL. Results also indicated that negative primary appraisal of health had a significant direct effect on disengagement coping, physical and mental HRQOL. The findings suggested that engagement coping had a significant direct effect on physical HRQOL, while disengagement coping had a significant direct effect on mental HRQOL <p> Using multivariate analysis of variance to examine the effects of clinical factors on psychosocial variables, participants reporting more symptoms (>17) appraised their health more negatively, used more disengagement coping, had lower degrees of perceived self-efficacy, physical and mental HRQOL than those with fewer symptoms (¡Ü17). Participants less than one year post-transplant used more engagement coping, reported higher degrees of perceived self-efficacy and perceived social support than participants in the later period post-transplant. <p> Conclusion. HRQOL of renal transplant patients is the outcome of a complex interplay between clinical factors, personal and social resources, cognitive appraisal of health, and coping strategies. Holistic interventions including physical and psychosocial components are needed to help renal transplant patients cope with transplantation and improve their HRQOL.

NURSING SCIENCE THE DEVELOPMENT OF THE NORMALIZATION ASSESSMENT MEASURE CYNTHIA ANN SCHNETTER ONEAL Dissertation under the direction of Professor Dr. Kenneth Wallston Normalization is an adaptation mode commonly used among individuals and families experiencing chronic illness. Normalization occurs when individuals use cognitive and behavioral coping strategies in order to maintain typical life patterns despite the effects of the chronic illness. Due to the lack of a quantitative measure for normalization, the current state of the science is based primarily upon qualitative research. In order to further refine the normalization concept and to clarify previous contradictory findings, an instrument to measure normalization was needed. The purpose of this dissertation was to: (1) develop a normalization measure; and (2) ascertain the psychometric properties of the developed instrument. A 20 item normalization measure was developed (alpha = .86) utilizing a cross-sectional design with a sample of 152 individuals diagnosed with at least one of four conditions: rheumatoid arthritis, osteoarthritis, lupus, and fibromyalgia. Content validity was established using previous research findings, an expert panel and focus groups. Convergent validity was demonstrated by positive relationships between the normalization measure and (1) problem focused coping and (2) sick role nonacceptance. Additionally, convergent validity was established by a negative relationship between the normalization measure and emotion focused coping. Discriminant validity was determined by a nonsignificant relationship between the normalization measure and a measure of social desirability bias. Construct validity was evident by correlations between the normalization measure and measures for the following constructs based on the conceptual framework for normalization: perceived control, illness intrusiveness, quality of life, and social ties. Higher normalization scores correlated with higher perceived control scores, greater quality of life scores, increased social ties scores and lower illness intrusiveness scores. Thus, this new internally consistent and valid measure of normalization will facilitate the use of quantitative research for further exploring the conditions under which normalization leads to optimum outcomes.

The purpose of this project was to assess the relationship of maternal psychosocial factors on maternal competence for infant feeding in a sample of first-time, adolescent mothers. A cross-sectional, correlational design was used for this study. Mothers (n=67) were recruited from a pediatric primary care clinic and a local WIC clinic. All mothers completed semi-structured interviews that included standardized measures with the PI per approved Institutional Review Board protocols. Maternal age ranged between 15 to 22 years. Reports of maternal self-esteem and social support were high, along with a moderate percentage of mothers reporting high depressive symptoms. Most mothers attempted to breastfeed (53%) but few breastfed their infant beyond six months. Inappropriate food choices (e.g., french fries) and practices such as cereal in their babies bottles and starting solid foods prior to six-months of age were reported. Additional inappropriate feeding practices identified included giving greater than 6 ounces of juice a day and 8 ounces of water a day, and incorrectly preparing the formula. Only 12% of mothers reported a healthcare professional as influential in telling them how to feed their baby. Maternal attitudes related to infant feeding were found to be related to psychosocial factors. Higher depressive symptoms and lower self-esteem and functional social support were associated with maternal concern that the infant was undereating and at risk for becoming underweight, concern that the infant was hungry and not satisfied, and concern that the infant was overeating and at risk for becoming overweight. Maternal knowledge of infant feeding practices was negatively related to maternal depressive symptoms. In addition, maternal skills related to infant feeding were negatively associated to depressive symptoms and positively associated with reports of high social support. <p> This study adds to the growing body of knowledge and helps frame future research related to the numerous contextual factors in adolescent mothers lives (e.g., their primary support person) and the impact on their parenting practices. In addition, it raises the notion of the importance of evaluating the psychosocial health of young mothers and the influence it can play on their parenting practices.

This mixed method study explored continuing bonds in children who lived with advanced cancer, as well as in bereaved families who lost a child to cancer. The study also examined associations among continuing bonds, coping strategies, and grief symptoms. Participants included 107 bereaved parents and siblings (ages 8-18) of 41 children who died from cancer. Survivors separately answered 2 open-ended questions and completed 3 questionnaires. Qualitative content analysis identified major themes related to continuing bonds, and quantitative correlations identified associations among continuing bonds, coping strategies, and grief symptoms. In sum, continuing bonds may be a response to stress for bereaved families and ill children, including both coping strategies and automatic responses, resulting in both positive and negative grief symptoms. This study contributes to the state of the science on continuing bonds within pediatric palliative care.

For most women pregnancy is a positive transition in their life. The diagnosis of a fetal abnormality creates an uncertain outcome for the transitional process of becoming a parent. A prenatal diagnosis of fetal abnormality is characterized as an emotionally devastating and profoundly stressful event for women because it involves making difficult reproductive choices such as continuation of pregnancy with no intervention, elective termination, or, in selected cases, experimental fetal therapy. This descriptive correlational study examined the relationships among womens decisional conflict, anxiety, and coping strategies following a diagnosis of fetal abnormality. Fifty-five women who had a confirmed diagnosis of fetal abnormality prior to 24 weeks gestation were interviewed. Standardized instruments were used to obtain data on womens decisional conflict, anxiety and coping strategies. Overall, women had low levels of total decisional conflict, but high levels of uncertainty in choice, moderately high levels of anxiety and used proportionately more emotion-focused than problem-focused coping strategies. Women who received a diagnosis of a lethal fetal abnormality had higher anxiety and uncertainty in choice than women who received a non-lethal diagnosis. Womens level of anxiety and use of escape-avoidance coping also were found to be significant predictors of decisional conflict. The findings of this study provide a deeper understanding of the decision dilemma and the pattern of coping as important factors affecting womens resolution of the decisional conflict following diagnosis of fetal abnormality.

Approximately 14% of US preschoolers are overweight. Examining parental perceptions of child body weight is crucial because successful prevention and treatment of childhood obesity is linked to parental awareness of child body weight. Although studies have demonstrated that parents of toddlers and preschoolers have incorrect perceptions of their childs body weight, little is known about factors that may be associated with these perceptions. The purpose of this study was to examine relationships between parental perceptions of toddler and preschool child body weight and psychosocial factors such as parental efficacy, health literacy, and level of concern for child weight. Research questions included: 1) what is the parents perception of the toddler or preschool childs body weight? and 2) what factors are associated with the accuracy of parental perceptions of the toddler or preschool childs body weight? Participants for this descriptive-correlational study were solicited at a pediatrician's office and a WIC clinic. Parental participants completed four surveys and answered two open-ended questions. Quantitative analyses included descriptive statistics, correlations, and regression analyses. Answers to open-ended questions were analyzed using content analysis. Over one-third of the children in the sample were at risk for overweight or already overweight. However, less than six percent of parents felt their child had an elevated body weight. Furthermore, less than one-third of parents in the study were concerned that their child would become overweight or need to diet later in life. Results from logistic regression analyses demonstrated that the parents health literacy level was a statistically significant predictor of the accuracy of their perceptions regarding their childs body weight (p<.05). However, the parents concern regarding child weight and perceived level of efficacy did not significantly predict the accuracy of their perceptions. Content analyses revealed that parents are often uncertain how to define healthy or unhealthy body weights in children. Parents in the study often relied on subjective observations to determine the appropriateness of child body weight, but many were open to counseling and education from medical professionals, Internet resources, and other objective sources.

NURSING SCIENCE DEVELOPMENT AND VALIDATION OF THE STUDENT ACTIVATION MEASURE RACHEL A. KINDER Dissertation under the direction of Professor Kenneth A. Wallston Student activation is defined as a level of engagement in learning that a student has in reaching his or her academic goals. Students are activated when they have the necessary knowledge, skills, and confidence; take responsibility for their own learning; think critically; and implement strategies to be successful in their academic programs. With the current nursing shortage and a limited number of nursing student positions, it is critical that nursing programs have high retention and graduation rates, as well as high first-time NCLEX-RN pass rates. In order to identify nursing students who are at-risk for failure, an instrument to measure student activation was needed. The purpose of this dissertation was to validate an instrument that measures student activation and examine whether such an instrument can be used to identify stages of activation of nursing students. A 20-item Student Activation Measure was developed (alpha = .94) utilizing a multi-group, two-phase data collection design. A convenience sample (N=442) of bachelor of science and associate of science in nursing students was selected for this study. Principal components analysis supported that the SAM is a unidimensional measure with two highly correlated underlying factors that indicate level of activation: Taking Action and Having Knowledge and Confidence. Convergent validity was demonstrated by positive and significant relationships between student activation and measures of activation-related constructs, and a negative and significant relationship with psychological vulnerability. Discriminant validity was determined by nonsignificant relationships with measures of social desirability bias, strength of religious faith, and political stance. Significant differences in mean scores were found between Semester II (Medical-Surgical I) and Semester IV (High Acuity) for Taking Action. After controlling for age, marital status, number of hours worked and cumulative GPA, students in a baccalaureate nursing program continued to have significantly higher mean scores on Knowledge and Confidence than students in an associate nursing program. Thus, this new internally consistent and valid measure of student activation will facilitate identification of students who are less involved in their own learning and thereby at-risk for failure in their nursing program and on the NCLEX-RN.

There is much evidence indicating that cancer and its treatment has an impact on the lives of cancer patients families, as well as on the patients themselves. At present, however, there is no questionnaire to assess the quality of family life among families with a member with cancer. The purpose of this study was to develop a Family Quality of Life Questionnaire (FQOL) for use with families with an adult cancer patient. The questionnaire assessed four domains of family life: Family interactions, family roles, family communication, and family emotional support. There were three phases to questionnaire development. In Phase 1, items were generated from a literature review and a semi-structured interview with 12 families with a member with cancer. In Phase 2, the items were reviewed for content validity by ten cancer experts. In Phase 3, the FQOL questionnaire was piloted with 151 cancer patients and 151 family members. The dimensionality of the measure was examined using confirmatory factor analysis, and reliability and construct validity were examined. Results indicated that the FQOL questionnaire was multi-dimensional. Results from Phase 1 and 2, and Cronbach's alpha coefficients supported the four a priori domains, but results of confirmatory factor analysis did not support these four domains and need to be further examined. The internal consistency and test-retest reliability of subscales and total scores were adequate. Convergent validity was supported for the total FQOL scores, Family Interaction, and Family Communication subscales for all participants, but the Family Role and the Family Emotional Support subscales had inconsistent findings and thus received mixed support for convergent validity. Discriminant validity was partially supported in this study. <p> The FQOL questionnaire will require some additional development but this study represents an important first step. The FQOL questionnaire will be useful as a research instrument to measure FQOL of cancer families to assess how different treatments affect the family, and for health care providers to assess patients FQOL so interventions can be developed to improve the FQOL of their patients.

NURSING SCIENCE USING THE THEORY OF PLANNED BEHAVIOR TO ASSESS PROSTATE CANCER SCREENING INTENT AMONG AFRICAN AMERICAN MEN DONNA KENERSON Dissertation under the direction of Professor Rolanda Johnson Prostate cancer incidence and mortality represents a disparity among African American men when compared to other populations. This study involved the examination of sociocultural variables and prostate cancer screening intent of African American men using the Theory of Planned Behavior (TPB). The constructs of the theory assessed in this study included attitudes, social norms, situational barriers, and prostate cancer knowledge, and other contributory factors associated with prostate cancer screening intent. Convenience sampling was used to recruit African American men (N=69) from multiple faith-based sites in Nashville, Tennessee. Multiple linear regression was used to determine the overall contribution of all the independent variables to the self-report of intent to screen, as well as the unique contributory information of each variable. Possible associations of each of the demographic, screening and family history variables, as well as perceived risk of prostate cancer with screening intent was conducted using bivariate tests. Overall, the constructs of attitude, subjective norms, situational barriers, and prostate cancer knowledge did not demonstrate a statistically significant (Multiple R = .475, R2 = .226, Adjusted R2 = .108, p = .067) association with prostate cancer screening intentions. However, social influence was the strongest unique contributor to prostate cancer screening intent. Perceived benefits of screening had a statistically significant correlation (r = .285, p = .018) with prostate cancer screening. Social influence was found to be statistically significantly associated with intent to screen (r = .337, p = .005). The cost of prostate cancer screening had a statistically significant correlation (r = -.278, p = .021) with prostate cancer screening intent. The results of this study suggest that social and cultural factors may influence prostate cancer screening behaviors among African American men.

In this dissertation study, cognitive vulnerability, characterized by negative patterns of thinking, was shown to be positively correlated with the prevalence and number of negative life events and increased depressive symptoms in young adolescents. The three cognitive vulnerabilities found to be correlated with increased depressive symptoms were 1) dysfunctional attitudes (negative biases about self or events), 2) negative inferential style (inferences about cause, consequence, and one's ability to influence the outcome of an event), and 3) ruminative response style (attention is fixated on one's emotional state). The relationships between cognitive vulnerability, negative life events, and number of depressive symptoms were not significantly different by age, gender, or ethnicity. However, adolescents from lower socioeconomic backgrounds reported significantly more dysfunctional attitudes and more negative life events within the family. This study provides important information about the unique contribution of cognitive vulnerabilities to prevalence and number of depressive symptoms in young adolescents. This knowledge is needed to increase awareness that screening and preventative efforts need to be initiated early before adolescents develop persistent negative patterns of thinking and multiple depressive symptoms.