Childrens development of illness knowledge is a research area that can inform interventions and practice designed for pediatric populations. Preschoolers development of illness knowledge, in particular, is important because this age group represents the earliest stage of illness knowledge development that also affords researchers children who have adequate verbal skills to communicate their knowledge. The lack of psychometrically tested instruments to evaluate preschoolers illness knowledge is a major gap in this research area. The purpose of this descriptive study was to examine the psychometric properties of a newly developed instrument called the Illness Knowledge Questionnaire (IKQ). The study had three sequential, complementary phases and uses mixed methods to analyze data. Phase I was designed to establish the content validity of the IKQ with a sample of content and instrument design experts. The specific aim of Phase II was to pilot the revised IKQ post Phase I with a sample of children within three age groups (4- 5 year olds, 8-9 year olds, and 11-12 year olds). Finally, Phase III had three specific aims to establish scale structure, reliability and construct validity of the revised IKQ post Phase II with a sample of 4-5, 8-9 and 11-12 year old children.

Because surgery, radiation, and/or chemotherapy disrupt lymphatic structures, damage soft tissue leading to scar tissue formation and fibrosis, and further affect lymphatic function, head and neck cancer patients may be at high risk for developing secondary lymphedema. Head and neck cancer patients may develop secondary lymphedema externally (e.g., face) and internally (e.g., larynx). It not only influences patients most visible body areas (e.g., face and neck), but it also impacts critical physical functions (e.g., breathing and swallowing). These issues are understudied. The possible factors contributing to secondary lymphedema after head and neck cancer are unknown. The study was conducted to examine the associations among the severity of lymphedema, symptoms, functional status, and quality of life in head and neck cancer patients. The study also examined the possible factors contributing to the presence of secondary lymphedema in head and neck cancer patients. A convenience sample of 103 head and neck cancer patients were recruited at the Vanderbilt-Ingram Cancer Center. Several significant findings were generated from this study. First, the study findings suggest that lymphedema in head and neck cancer patients is a very common late-effect. The study identified that head and neck cancer patients may not only develop external lymphedema (such as facial and neck area), but also have internal lymphedema (such as pharynx and larynx) after their cancer treatment. The findings from this study demonstrated that the severity of lymphedema was statistically significantly associated with swallowing difficulty, mucous/dry mouth-related symptoms, and impaired body image. The study found that the severity of combined (internal and external) lymphedema was statistically significantly associated with head and neck cancer patients quality of life status. In addition, the study found that types and dosages of cancer treatment were statistically significantly associated with whether or not head and neck cancer patients presented with lymphedema. Thus, the study provides an insight regarding the importance of addressing lymphedema in head and neck cancer patients.

Purpose. The purpose of this dissertation research study was to investigate the associations among learned helplessness, depressive symptoms, and targeted demographic, clinical, and psychosocial factors in individuals who experienced a recent acute myocardial infarction (AMI). Method. Using a descriptive cross-sectional design, a convenience sample (N=75) was recruited from cardiology clinics in the middle Tennessee region. Standardized instruments and measures were used to evaluate all study variables. Results. A statistically significant, direct relationship was found between learned helplessness and depressive symptoms, suggesting that individuals who had higher self-reported levels of learned helplessness also reported more depressive symptoms. No statistically significant associations were observed among the number of AMI events, the number of co-morbidities, learned helplessness, and depressive symptoms. Statistically significant, inverse associations were identified among social support, self-efficacy, learned helplessness, and depressive symptoms. These findings suggest that individuals who reported higher levels of social support and self-efficacy experienced less learned helplessness and less depressive symptoms. Univariate associations also suggested younger individuals and those with a lower estimated yearly household income reported more depressive symptoms following an AMI. Additionally, individuals who identified themselves as either unemployed or disabled exhibited more depressive symptoms. Hierarchical regression analysis was performed to evaluate the multivariate associations among all study variables. After controlling for the influence of other study variable, learned helplessness continued to significantly contribute to the occurrence of depressive symptoms in individuals following AMI. Conclusion. These results indicate learned helplessness is uniquely associated with depressive symptoms in individuals following an AMI. Additional research in needed to determine the potential longitudinal impact of learned helplessness on depressive symptoms, morbidity, and mortality in this population.

NURSING SCIENCE UNDERSTANDING THE RELATIONSHIP BETWEEN GENDER, PREVIOUS CARDIAC EVENT AND PREHOSPITAL DELAY BEHAVIOR IN ACUTE MYOCARDIAL INFARCTION Cynthia G. Waller Dissertation under the direction of Professor Kenneth A. Wallston Using Leventhals Self-Regulation model as a conceptual framework, the purpose of this dissertation was to examine the relationship between gender, a previous cardiac event, and their interaction on prehospital delay time and then, using the Modified Response to Symptom Questionnaire, to examine the relationships between gender, previous cardiac event, and their interaction with the patients behavioral, cognitive, and emotional coping responses to acute myocardial infarction (AMI) symptoms on prehospital delay time. A secondary data analysis of 780 patients with a confirmed diagnosis of an AMI from coronary care units and cardiac step-down units in academic medical centers and community hospitals in four different countries was conducted. Using a 2 x 2 factorial design, results demonstrated that gender, previous cardiac event, and their interaction did not directly have an impact on the log to the base 10 of prehospital delay time once age, years of education, and geographic location of the patient was statistically controlled for. Gender, a previous cardiac event, and their interaction did, however, affect symptom attribution to the heart, perceived severity of AMI symptoms, level of anxiety, perceived ability to control symptoms, and whether or not patients ignored and/or self-treated symptoms which, in turn, affected the amount of time it took for the patient to get to the hospital. Level of anxiety and perceived severity of symptoms were significantly correlated to one another and both coping responses significantly shortened prehospital delay time. Symptom attribution, symptom severity, ignored symptoms, accessed a healthcare provider, and level of anxiety accounted for 23% of the variance in prehospital delay time with ignoring AMI symptoms causing significantly longer and symptom attribution to the heart causing significantly shorter prehospital delay times. Symptom attribution to the heart serves as a differentiator of individuals who request medical assistance in a timely manner. Perceived severity of symptoms and the emotional response to signs and symptoms serve as important predictors of delay and can serve as cues for action. Nurses need to continually remind patients/families about the signs and symptoms of an AMI, the importance of not ignoring symptoms, and the value in accessing EMS in a timely manner.

NURSING SCIENCE THE INFLUENCE OF ORGANIZATIONAL AND PERSONAL FACTORS ON U.S. ARMY NURSE CORPS OFFICERS INTENT TO LEAVE THE ARMY LINDA W. FISHER Dissertation under the direction of Professor Ann F. Minnick The studys purpose was to compare organizational, personal, and economic factors in military and civilian nurses to: a) determine if differences exists between the two groups intent to leave (ITL), b) determine how structural empowerment, psychological empowerment, and job satisfaction factors predict ITL, and c) explore the influence of personal and economic factors on ITL. This is important because poor nurse retention in the Army Nurse Corps (ANC) at the mid-career level (losses of up to 20%) can have devastating consequences on the future of ANC leadership. This study used a targeted comparative group design including all US Army nurses [2nd Lieutenant to Major (n=3163)] and a single hospital sample of civilian registered nurses (n=861). Too few of the civilian respondents (12.7%, n=26) reported ITL and meaningful comparative statistical analysis was not possible. The final analysis focused on the Army respondents (response rate=19.7%). The Army respondents were highly representative of the total ANC population. Frameworks of organizational structure and empowerment (including Kanter and Laschinger) guided survey content. The instruments used were Conditions of Work Effectiveness Questionnaire-II, Psychological Empowerment Instrument, job satisfaction scale, economic and demographic questions, and ITL items. This studys findings validate those of previous investigators who reported high associations between Job Satisfaction (p=<.001) (Larrabee, 2003), control over life, difficulty starting a family and ITL (Gahol, 2005). The inverse relationship with Income Contribution Percent and ITL appears to be a new finding in the ANC population. The cluster analysis revealed three clusters that defined individuals with ITL. They differed in income contribution percent, age, years with employer, rank, advanced degrees, marital status, dependents, and home ownership. A single solution may produce little increase in retention. A three group targeted strategy may yield a greater increase in retention. The fact that only 12.7% of the civilian nurses planned to leave their Magnet hospital versus 18.5% of Army nurses, may indicate that the Army could benefit from exploring the possibility of Magnet recognition for Army hospitals.

Healthcare literature stresses the need for increased patient safety and quality; the current healthcare environment necessitates fiscal responsibility. Approximately 4.3 million births occur in the United States every year at a cost of approximately $16 billion dollars. Perinatal nurses manage the care for hospitalized childbearing women and their newborns and share responsibility for quality outcomes. The perinatal nurses role in safety and quality cannot be minimized. The need to make perinatal nursing processes visible and the ability to assess which processes yield the best outcomes support the need for retrievable, measureable perinatal data and for tools to quantify outcomes related to perinatal safety and quality. An example of such a tool for the childbearing population is perinatal failure to rescue. This study explored whether elements of a perinatal failure to rescue tool could be specifically defined and whether those defined elements exist in any of four selected standard nursing terminologies. This was an exploratory study with mixed methods. The two-phased approach included a modified Delphi study followed by cross-mapping of terms to four standard nursing terminologies, with cross-mapping validation by an expert panel. The Delphi study had 29 participants and was completed in three rounds. Consensus of at least 75% was achieved for 76 individual perinatal failure to rescue elements. The elements were mapped to each of four standard nursing terminologies, CCC, ICNP, LOINC and SNOMED-CT. While each standard language contained some failure to rescue elements, more than 80% were identified to be present in SNOMED-CT. A five-member expert panel validated 100% of the mapping findings. Study results provide a foundation for further research focused on eventual incorporation of perinatal failure to rescue elements into electronic documentation systems.

<p>NURSING SCIENCE <p>SATISFACTION WITH PATIENT-CENTERED CARE AND SELF-CARE EDUCATION IN LEFT VENTRICULAR ASSIST DEVICE PATIENTS <p>STEVE BRIAN WIDMAR <p>Dissertation under the direction of Professor Ann F. Minnick <p>The studys purposes were to: a) describe care structure and ventricular assist device (VAD) patient self-care education processes used in hospitals, and b) describe VAD patient reports of patient-centered care and satisfaction with care. <p>The study used a prospective cross-sectional design. AIM 1: A mailed 26-item survey, based on the Minnick and Roberts framework, was sent to all VAD centers in the United States (N = 111) in 2011. Two subsequent mailings with computer or paper completion options resulted in a return rate of 63% (n = 71). AIM 2: A 59-item survey, adapted from the Health Consumer Assessment of Healthcare Providers and Services (HCAHPS) survey and from Young & Minnick (1996), was completed via telephone with five patients receiving VAD therapy from one high-volume VAD hospital. <p>Programs varied in their use of Advanced Practice Nurses and VAD coordinator advanced practice inpatient nursing (p < .05). There was no standard method of providing postoperative VAD patient self-care education or evaluating self-care across hospitals. Most VAD programs (75%) used more than two resources in providing self-care education in addition to education materials provided by the VAD device manufacturer. Almost half of VAD programs (46%) used more than two methods of self-care evaluation for each skill set. <p>Patients were satisfied with patient-centered care and self-care education, and were grateful for regained independence and reduced heart failure symptoms. Patients reported uncertainty regarding their performance in emergencies. Preparation of local non-VAD hospitals to care for VAD patient health emergencies was identified as a need. <p>Further research is needed to explore relationships between VAD care processes and other outcomes such as survival and readmissions. Understanding the processes of self-care education and patient reports of patient-centered care after VAD implantation is necessary to improve VAD education and outcomes.

This dissertation study examined hospital structures and processes associated with outcomes among hospitalized injured older adults (HIOA). The Minnick and Roberts Outcomes Production Model guided the design of a study that examined: 1) presence of geriatric-specific quality indicators in acute care hospitals that provide care to HIOAs; 2) associations among mutable organizational factors and adoption of quality indicators; and 3) the extent to which mutable organization factors, including geriatric-specific quality indicators explained variations in one adverse event (deep vein thrombosis [DVT] or pulmonary embolus [PE]) in HIOAs. Findings indicate that adoption of geriatric-specific quality indicators remains low. Factors associated with adoption of quality indicators included computerized support for clinical decision-making and comprehensive geriatric assessment. In a final regression model that represented four levels of hypothesized influence, after controlling for the influence of all other variables, the strongest adjusted associations with rates of DVT or PE were for comorbidities, and hospitals with simulated home and community rehabilitation environments. Despite ten years of efforts promoting adoption of geriatric-specific quality indicators, much progress remains to be made. The occurrence of DVT/PE in HIOAs remains a problem. Postoperative thromboembolism must be carefully considered as a quality indicator.

RAPE TRAUMA: A STUDY OF PREFERRED RAPE DISCLOSURE METHODS AND FACTORS INFLUENCING PSYCHOLOGICAL OUTCOMES IN RAPE VICTIMS CARRIE M. CARRETTA Dissertation under the direction of Professor Sheila H. Ridner, PhD, RN, FAAN This project is concerned with contextual factors influencing psychological outcomes in rape victims, including factors that may be protective of psychological sequelae (depression, anxiety, posttraumatic stress disorder) known as rape trauma, and further explores the possible impact of disclosure history and preferences. In this dissertation I explore these factors through a conceptual framework, derived from theories of hope, coping, and rape trauma in female adult survivors of rape via an anonymous online survey. Few studies to date have attempted to examine the effect of the perpetrator/victim relationship on rape trauma (RT), and those that have did not clearly delineate appropriate possible categories. This is the first known study that has attempted to provide a group differences analysis based on RT (depression, anxiety, PTSD), delineating specific perpetrator categories. Findings from this study found no statistically significant differences among the groups highlighting that rape is a traumatic experience irrespective of the perpetrator. Findings relative to the type of rape shed light on the significance between the type of rape experience and rape trauma related to depression, anxiety and PTSD. Post-hoc analysis of the overall difference in depression revealed that the multiple rape group (p = .010) and the forcible sex group (p = .016) had higher levels of depression than did the group experiencing sex stress. There was also a statistically significant difference among the type of rape trauma groups in the rates of PTSD (Likelihood Chi-Square p = .044). Thus, consideration of type of rape may play a potential integral role in informing future interventions. Additionally, this study explored possible protective factors of rape relative to psychological outcomes. Both hope and present perceived control were inversely statistically significantly associated at 0.33 or above (10% of the shared variance) with all three RT outcome measures (depression, anxiety, PTSD). Findings from this study have illuminated the significance of hope to both present and future perceived control and coping, as well as demonstrated that hope is the most integral of the possible protective factors related to RT outcomes. Further, canonical analysis revealed that lower levels of hope, present perceived control, and decreased use of acceptance coping, along with an increased tendency toward substance use for coping, higher propensity for self-blame, higher levels of behavioral disengagement, and a tendency to use denial and self-distraction for coping was associated with higher levels of depression and trait anxiety. Finally, disclosure history and preferences were found to play a key role relative to victim treatment seeking and self-blame, and validated that participants overwhelmingly preferred follow-up contact online rather than face-to-face or by telephone. The study found that 24% of participants admitted this was their first disclosure, with 79% of those citing first-time disclosure, and 70% who had previously disclosed preferring the online venue. Thus, victims may be more readily reached, and thus be more open to disclosure and pursuit of treatment via an online vehicle. These factors therefore, warrant further in depth exploration. Approved ______________________________________Date________

NURSING SCIENCE ENERGY EXPENDITURE AND SUBSTRATE UTILIZATION IN OBESE INDIVIDUALS WITH HEART FAILURE JOSHUA PHILLIP SQUIERS Dissertation under the direction of Professor Michael Vollman Heart failure (HF) is a severely limiting terminal illness that affects over 5.7 million Americans per year. Changes in body composition during the course of HF appear to significantly affect morbidity and mortality. Little is known, however, regarding the systemic level energetics that lead to body composition changes and subsequent changes in morbidity and mortality. The purpose of this cross-sectional, exploratory study was to determine the feasibility of using 24 hour whole room indirect calorimetry in the HF population, and to provide an initial description of resting energy expenditure and substrate utilization differences between healthy obese individuals and obese patients with ischemic HF (N = 10). Five obese HF subjects were recruited and five healthy obese control subjects were selected from the Vanderbilt Universitys Energy Balance Laboratories calorimetry database. The five HF subjects were admitted for a 24 hour whole room calorimetry, including measurement of resting energy expenditure and substrate utilization, body composition, anthropometric measures, and were compared against the five control subjects. Results from this study suggest that obese HF patients have a 16.6% increase in REE (0.0267 vs. 0.0223 kcal/min/kg LM, p = 0.08) and a lower RQ (0.738 vs. 0.898, p = 0.043) compared with healthy obese individuals. These results from this limited research sample suggest that there is an increasing metabolic demand associated with HF, along with a preference toward fat metabolism at rest. Feasibility was confirmed with each subject providing more than 90% of analyzable calorimetry data during a 24 hour measurement period. Whole room indirect calorimetry provides a novel, highly accurate technique for future examination of substrate and systemic energetic questions related to the HF disease process. Further research is needed to clarify the effects of changes in REE and RQ in patients with HF. Ultimately, providing an accurate description of the energetic cost of HF, and the mechanisms behind these costs may lead to potential clinical interventions to improve morbidity and mortality.