Developing and testing instruments to measure client outcomes at the Comox Valley Nursing Center.

A Nursing Centre in Canada was initiated to demonstrate nursing practice in a primary health care context, unencumbered by conventional health care agency parameters. As one part of a multimethod evaluation, a 5 instrument client questionnaire was designed. The main instrument was developed by the researchers to measure the impact of the Centre and nurses' work from the perspective of clients. No established instrument could be found that was appropriate for the Centre's diverse client population and nature and variation in outcomes. To guide the development of the new instrument, minimally structured client interviews were conducted with 15 clients. To assess the validity and reliability of other selected instruments for the population, clients were asked to comment on the appropriateness of items. Based on findings, the Nurses' Work and Client Outcomes Questionnaire (NWCOQ) was developed, the Client Satisfaction Questionnaire and demographic questions modified, and a Cantril Self-Anchoring ladder to assess health status was supported for use. An open section was added to invite further description of clients' experiences, in particular, the unexpected, contrary or outstanding. Further pilot work was done and the refined five instrument questionnaire then was used to survey all clients who used the Centre during a seven month period. Findings from the NWCOQ revealed the nature of the nurses' work and the degree change occurred for clients on multiple health dimensions: physical, emotional, managing their situation, and group and community involvement. Clients were highly satisfied with the Centre and experienced many positive outcomes. The quantitative instruments and results were examined in relation to results from other data collection approaches and data sources. The NWCOQ has evidence of content validity and internal consistency reliability. The use of qualitative methods to develop and refine quantitative instruments for assessment of health outcomes for diverse client populations is highly recommended. This strategy is feasible even when outcome measurement timeframes are short.

Urban outpost nursing: the nature of the nurses' work in the AIDS prevention street nurse program.

The AIDS Prevention Street Nurse Program in Vancouver, Canada focuses on HIV and sexually transmitted diseases (STD) prevention within a context of harm reduction and health promotion targeted at marginalized, hard to reach, high-risk populations. As part of a large evaluation project that included interviews with street nurses, clients, and other service providers together with document analysis, the nature of the street nurses' work and its fit within the provision of health care were described. The street nurses' work reflected the following themes: reaching the marginalized high-risk populations for HIV/STDs; building and maintaining trust, respect, and acceptance; doing HIV/AIDS and STD prevention, early detection, and treatment work; helping clients connect with and negotiate the health care system; and influencing the system and colleagues to be responsive. The findings and their implications for community health nursing practice are examined.

Harm reduction theories and strategies for control of human immunodeficiency virus: a review of the literature.

AIM: To provide a comprehensive review of the literature on harm reduction theories and strategies related primarily to licit and illicit drug use. BACKGROUND: Although human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) disease transmission is well understood, it continues to spread, particularly among injection drug users (IDUs). Despite early indications that HIV would be contained within the IDU community, it is spreading to non-IDU sexual partners and to children of IDUs, threatening a more widespread epidemic. METHODS: An examination of research studies and theoretical writings including reviews and policy papers published in English between 1990 and 2000. RESULTS: Harm reduction does not seek to eliminate drug use; it focuses on minimizing the personal and social harms and costs associated with drug use and spread of HIV. It seeks to ameliorate conditions surrounding drug use responsible for the spread of HIV in the IDU community: unequal access to health services; sharing of infected needles; racial and social discrimination; poverty; exposure to street violence; inadequate housing; lack of employment; poor general or mental health and other demographic and social determinants. Some controversial harm reduction strategies are described: methadone maintenance programmes, illegal drugs dispensing under controlled conditions, needle exchanges, HIV testing, vein maintenance, safe-sex and would-care programmes. CONCLUSION: The main challenge is to get IDUs to protect themselves against HIV when suffering physical and social privations and addiction needs. Diverse perspectives on harm reduction are problematic with consequences for success of drug use initiatives. Practical, ethical and theoretical complexities exist but further research is needed to build support for a harm-reduction orientation in practice and policy formulation.

The desi ways: traditional health practices of South Asian women in Canada.

Although many South Asian immigrants have made their homes in Canada, little research has examined health behaviors in this population and fewer studies have examined the use of traditional health practices. As part of a larger study on health-seeking patterns of South Asian women living in Western Canada, an analysis was done on the use of traditional health practices. Using critical ethnographic methods, data were collected through face-to-face individual interviews (n = 50), focus group discussions (n = 12), and community meetings with a cross section of women in the South Asian community. Interviews were conducted in the language of each participant's choice. Thematic analysis was done on the transcribed interviews. Women's descriptions of traditional health practices varied and consisted of home remedies, dietary regimens, prayers, rituals, and consultation with hakims, veds, babajis, pundits, homeopaths, and jyotshis. Choosing to use traditional health practices was influenced by family members, the nature and severity of problems, beliefs and prior experiences, and the feasibility of using these practices. Traditional health practices were used on a daily or episodic basis. Women rarely used traditional health practices exclusively. Traditional health practices were used for small problems or when conventional medicines did not work. For women to meet their health needs, health care providers must be culturally sensitive and respect women's choices to use traditional health practices.

Postoperative pain management in frail older adults.

PURPOSE: To evaluate the Frail Elder Pain Management Program (FEPMP) implemented for patients who had hip fracture repairs at a community hospital in 1995. Based on standards of geriatric and pain management practice, the FEPMP included education sessions, preprinted analgesic orders, pain flow sheets, written resources, and clinical support. A Logic Model reflected the program's conceptualization. DESIGN: Preexperimental pretest and posttest design. SAMPLE: A random sample of 50 charts of patients aged 75 and older who had hip fracture repairs were audited from each of two periods: the preimplementation period (1994-95) and the postimplementation period (1997-98). METHODS: A chart audit tool was developed, tested, and used. Data were analyzed using descriptive, parametric and nonparametric statistics. FINDINGS: Surgeons' prescriptions and nurses' pain management practices improved significantly (p = .0001). Pain assessment modestly improved. Patient outcomes also improved. IMPLICATIONS FOR PRACTICE AND EDUCATION: A programmatic approach to pain management is effective for improving practice and outcomes for frail elders.

Men's perspectives on individual and family coping with their wives' breast cancer and chemotherapy.

Little research has examined the impact of cancer and chemotherapy treatment for breast cancer from men's perspectives as partners, fathers, and caregivers. This research, part of a larger study describing women's, partners', and children's perspectives, aims to describe men's perspectives on their experiences and how their wives' breast cancer and chemotherapy impacted them and their families, to describe what facilitated and hindered their coping, and to suggest interventions to assist men and their families to manage the experience with less stress. This participatory action study used qualitative naturalistic inquiry methods. Semistructured interviews were conducted with 11 male partners. Two major themes were identified: focusing on a wife's illness and care, and focusing on the family to keep life going. Nine sub-themes cut across the major themes: being there, relying on health care professionals, being informed and contributing to decision making, trying to keep patterns normal and family life going, helping out and relying on others, being positive, putting self on hold, adapting work life, and managing finances.

Evaluation of the AIDS Prevention Street Nurse Program: one step at a time.

The AIDS Prevention Street Nurse Program uses specially prepared community health nurses to focus on HIV and STD prevention with marginalized, hard-to-reach and high-risk clients within a broader context of harm reduction and health promotion. Street nurses (n = 17), service providers (n = 30), representatives of other HIV/STD programs in the province of British Columbia, Canada (N = 5), and clients (n = 32) were interviewed during an evaluation for the purpose of describing the nurses' work, the challenges the nurses' face, the fit of the program with other services, and the impact of the nurses' work. This article describes the impact of the nurses' work on clients. Impact/outcome changes reflected a progression from knowledge to behavioural levels and to major indicators of health/illness. Impact on clients included: knowing more about HIV/AIDS, their own situation, and options; receiving essential supplies to reduce harm and promote health; changing behaviour to reduce disease transmission, improve resistance, and promote health; connecting with help; feeling better about themselves and others; feeling supported; influencing others; receiving earlier attention for problems; being healthier with or without HIV; making major changes in drug use; and likely decreasing morbidity and mortality. The Program was found to be clearly effective in making a positive impact on clients.

South Asian womens' views on the causes of breast cancer: images and explanations.

Using ethnoscience methods, interviews with 50 South Asian women living in Western Canada were conducted and analyzed to explore explanations and images of breast cancer. Embedded in the women's stories of breast cancer were distinctive, often vivid and fear-provoking images of abnormal growth. Explanations about the causes of breast cancer involved five domains of belief. The first domain was of a physical nature and centred on damage to the breast. A second domain of explanations, 'can catch it,' focused on the way this disease could be spread to others. Other women attributed breast cancer to the ways women could 'bring it upon yourself,' often linking a negative lifestyle with the development of cancer. Many women attributed cancer to being 'in the hands of others,' explaining the cancer was caused by careless words, curses or divine power. Finally, breast cancer was seen as something that could be passed down in the family. The taxonomy developed in this study provides a useful framework for understanding the explanations that might underlie women's health-seeking behaviours and for developing culturally suitable counseling strategies.

Breast health practices and South Asian women.

Breast cancer is an important women's health issue in all communities. To detect breast cancer early, all women should practise monthly breast self-examination, have regular clinical breast examinations and attend mammography screening at suggested intervals. Participation in these breast health practices is influenced by a wide variety of factors, including how women define health and health practices, priorities in women's lives and their explanations of the causes of diseases such as cancer.

Beliefs related to breast health practices: the perceptions of South Asian women living in Canada.

Breast cancer is becoming a major concern for many South Asian women. Clinical observations of women from a South Asian community living in Canada revealed an under use of early detection strategies. The purpose of this qualitative ethnoscience study was to examine breast health practices from the perspective of South Asian women to provide a foundation for the development of culturally suitable breast health services for this group. Open-ended interviews were conducted with a convenience sample of 50 South Asian women over the age of 30 who had not been diagnosed with breast cancer. Adequate representation of the main religious groups (i.e. Sikh, Hindu, Muslim and Christian) was ensured through sampling techniques. Analysis of translated interviews involved identification of themes and the development of a taxonomy to represent relationships among emerging cultural themes and domains. Four central domains of beliefs related to breast health practices were identified: beliefs about a woman's calling, beliefs about cancer, beliefs about taking care of your breasts and beliefs about accessing services. These beliefs hold important implications for how health promotion strategies should be structured and offered, In particular, attention must be paid to the language that is used to talk about breast cancer, the importance of the role of the family in women's health decisions and traditions related to using narratives to share information and advice.

Getting back to normal: the family experience during early stage breast cancer.

PURPOSE: To describe the process of normalization as it emerged from a study of families coping with early stage breast cancer. DESIGN: Qualitative, grounded theory. SAMPLE: Fifty-five women newly diagnosed with early stage breast cancer and their families. Fifty-eight percent had lumpectomy, and the remainder had mastectomy. Some had no further treatment, but others received radiation, chemotherapy, or tamoxifen. Nineteen women had positive nodes. METHODS: Five semistructured family and couple interviews for each family from diagnosis to one year later. MAIN RESEARCH VARIABLES: Process of normalization, issues and challenges faced, and problems coping. FINDINGS: Getting back to normal, defined as a safe, desirable, and stable state, was important for these families. Strategies used to get back to normal included seeing their families as normal, maintaining or returning to usual patterns quickly, minimizing disruptiveness, deemphasizing sick role demands, reframing negatives, and putting the cancer behind them. Factors influencing the process were family perspective of cancer, visibility or disruptiveness of symptoms of and treatments for cancer, family flexibility, experience with illness, life stage, and congruency of views. CONCLUSIONS: Families who adjust more easily view changes from normal as temporary, are flexible, see themselves as normal given the demands of their situation, share similar views, experience less major disruption or intrusiveness from treatments and their side effects, and appropriately use strategies to get back to normal. IMPLICATIONS FOR PRACTICE: Study findings emphasize the importance of maintaining normal routines as much as possible and getting back to normal quickly. Nurses must accurately assess family coping to identify those having difficulty and those at risk for difficulty. Nurses can support families' efforts to be normal and get back to normal by providing information about what is generally expected and what resources are available that might be helpful. Nurses need to be accessible to provide counseling and/or refer as needed.

Children's experiences with mothers' early breast cancer.

This article describes children's experiences with mothers' early stage breast cancer, a neglected area of study. Of 55 families from a larger study, 12 families had children between the ages of 2 and 21 years living at home. Family interviews, including the children when possible, at diagnosis and four additional times over the first year, were transcribed and content-analyzed. Two major themes emerged: awareness (entailing the child's cognitive awareness and emotional/behavioral response) and dependence. The child's developmental level influenced his or her understanding and the nature of the demands on the child and family. Because of the dependency needs of preschoolers, a chief concern for their parents was child care. Parents thought preschoolers were too young to understand so they gave simple explanations. Minor behavior problems were noted. More information was shared with school-aged children who believed their mother's situation was serious. Although children's concerns decreased, they remained evident months later. Effects of stress were noted. Home and caregiving demands usually increased and often interrupted adolescent's moves to independence and created role confusion and increased tension. Implications for parents and health professionals about interacting with children are suggested.

Family decision making about living related kidney donation.

Little information is available on how families make decisions about living related kidney donation. The purpose of this study, therefore, was to explore the family decision making process in identifying and selecting a living related kidney donor, to identify factors that assist or inhibit the decision making, and to explore issues and concerns raised by families about the experience. The qualitative method of grounded theory was used. Ten recipients, their living related donors, and their family members were interviewed individually and as a group prior to and after the transplant. Four decisions were required of most families. Three decision-making patterns--straightforward, moderately straightforward, and complex were identified as well as the factors that influenced the process.

Family communication patterns in coping with early breast cancer.

Diagnosis of a life-threatening disease is a major family stressor. How family members communicate with each other about the situation and their fears has received little study. The communication patterns of 41 couples where the woman was newly diagnosed with Stage 1 or 2 breast cancer were investigated. Family interviews were done at five points, from the time of diagnosis to 1 year later. Qualitative grounded theory methods were triangulated with responses to the Couple Communication Scale and State Trait Anxiety Inventory. Three major types of couple discussion patterns about fears, doubts, and emotional issues were seen, based on whether they shared similar or different views about the importance of talking. Some couples talked openly or reasonably openly. Others did not talk to each other, although a few of these talked to other people. Another group, who held divergent views, demonstrated more problems in their communication. Selective open disclosure was generally perceived as the most satisfactory of the patterns. Quantitative findings generally supported the talking themes that emerged.

The Uncertainty Stress Scale: its development and psychometric properties.

This paper describes the development and testing of a new scale--The Uncertainty Stress Scale--which measures uncertainty in illness-related situations, and the stress, threat, and positive feelings generated from the uncertain state. The theoretical and empirical basis of the scale is presented. Evidence which supports the scale's reliability and its content, concurrent, and construct validity is presented from several studies of people experiencing acute and chronic medical conditions. Descriptions and rationales for revisions are described.

Issues, problems, and challenges for families coping with breast cancer.

There is a scarcity of research that examines the adaptation of the family to breast cancer from the family's perspective. This study analyzed 12 families from the time of diagnosis to 12 months later. Issues, problems, and challenges that partnered families faced during the initial year were identified through five interview points. Frequency of the problems identified and the challenges encountered shifted over time.