I-Poems: A Window Into the Personal Experiences of Family Caregivers of People Living With Advanced Cancer.

BACKGROUND: To date, there is little understanding of how caring during advanced cancer can be a transformational experience for personal becoming for family caregivers (FCGs). FCGs experience personal becoming as they create their own meaning of health and illness and choose patterns relating to the self-identity of the past while reaching forward into the unknowns. Gaining greater insight into a potentially positive aspect of cancer caregiving can contribute to family caregiver well-being and quality of life. OBJECTIVE: This paper identifies I-Poems within cancer caregiver narratives and explores them for themes of personal becoming. The narrative environment created space for FCGs to construct and share their voices; at the same time, the analytic method of poetic inquiry provided the voice of the FCGs to be seen, heard, and contextually explored. METHODS: As a secondary analysis, we used five cancer caregiver narrative texts obtained from the primary study to create individual I-Poems. Each of the I-statements within the cancer caregiver narrative texts was lifted and repositioned into a poem format while retaining the chronological order and voice of the participant. We then explored the I-Poems for converging themes of personal becoming as emerged from the primary narrative-thematic analysis. RESULTS: I-Poems were created from each of the five participants caregivers' narratives and then explored for themes of personal becoming. Each of the participant stories is briefly introduced, followed by their I-Poem. We found that the I-Poems converged with emergent themes and provided a first-person representation of their caring journey and transformation of being. DISCUSSION: I-Poems are a postmodern form of poetic inquiry that can be used alongside thematic analysis to explore personal meaning of caring for someone with advanced cancer and how FCGs experience personal transformation of self. While we found I-Poems to be a meaningful and useful form of analysis for some narrative data, we propose an evolved genre of poetic inquiry-We-Poems-to be used in dyadic nursing research and with FCGs who are in partnered relationships.

Themes of Liminality: Stories From Cancer Family Caregiver Narratives.

Cancer family caregivers dwell in an evolving landscape of ambiguity and in-betweenness, as "betwixt and between," in a space of unknowing. This space of unknowing exists within a transformational threshold of liminality, between what was known prior to the cancer and what will be known and embodied in the future. Theoretically grounded in Unitary Caring Science, this study used narrative inquiry alongside photo elicitation to cocreate cancer caregiver narratives and identify themes of liminality. Four thematic threads of liminality were identified as woven within and across the cancer caregiver narratives; stories of paradox, time warp, life disruption, and waiting in silence.

Aesthetic Knowing: Cut-Ups and Haiku Poems.

Enhancing course design and pedagogy to encourage engagement and creativity is fundamental in doctoral education. Using poetry is an innovative way to enrich nursing education through aesthetic knowing. The authors in this paper aim to describe an educational exercise utilizing the Cut-Up Method to create haiku poems. PhD nursing students used the Cut-Up Method to produce haiku poems describing the meaning of nursing science. Themes from the haiku poems include relationship building, caring and caring relationships, and the evolution of nursing. Learning activities promote aesthetic knowing to facilitate engagement, creativity, and collaboration. The Cut-Up Method and haikus are creative ways of developing aesthetic knowing.

The Colorado Collaborative for Nursing Research: Providing Trended Nurse-Sensitive Patient Outcome Data Across Entities.

Nurse leaders lack timely access to trended electronic health record (EHR) data to drive decision making. Robust nurse-sensitive patient outcome data are difficult to locate in EHRs and largely absent across entities. The Colorado Collaborative for Nursing Research is currently testing a federated data system to get nurse leaders the information they need, when they need it.

Capturing the Central Line Bundle Infection Prevention Interventions: Comparison of Reflective and Composite Modeling Methods.

BACKGROUND: The central line (CL) bundle interventions are important for preventing central line-associated bloodstream infections (CLABSIs), but a modeling method for testing the CL bundle interventions within a health systems framework is lacking. OBJECTIVES: Guided by the Quality Health Outcomes Model (QHOM), this study tested the CL bundle interventions in reflective and composite, latent, variable measurement models to assess the impact of the modeling approaches on an investigation of the relationships between adherence to the CL bundle interventions, organizational context, and CLABSIs. METHODS: A secondary data analysis study was conducted using data from 614 U.S. hospitals that participated in the Prevention of Nosocomial Infection and Cost-Effectiveness Refined study. The sample was randomly split into exploration and validation subsets. RESULTS: The two CL bundle modeling approaches resulted in adequate fitting structural models (RMSEA = .04; CFI = .94) and supported similar relationships within the QHOM. Adherence to the CL bundle had a direct effect on organizational context (reflective = .23; composite = .20; p = .01) and CLABSIs (reflective = -.28; composite = -.25; p = .01). The relationship between context and CLABSIs was not significant. Both modeling methods resulted in partial support of the QHOM. DISCUSSION: There were little statistical, but large, conceptual differences between the reflective and composite modeling approaches. The empirical impact of the modeling approaches was inconclusive, for both models resulted in a good fit to the data. Lessons learned are presented. The comparison of modeling approaches is recommended when initially modeling variables that have never been modeled or with directional ambiguity to increase transparency and bring confidence to study findings.

Testing the Quality Health Outcomes Model Applied to Infection Prevention in Hospitals.

OBJECTIVE: To test the Quality Health Outcomes Model to investigate the relationship between health care-associated infection (HAI) prevention interventions, organizational context, and HAI outcomes using structural equation modeling. METHODS: Variables for adherence to the central line bundle, organizational context, and central line-associated bloodstream infections (CLABSIs) were selected for this secondary data analysis from 614 US hospitals that participated in the Prevention of Nosocomial Infection and Cost-effectiveness-Refined study. One half of the dataset was used for exploration of the concepts, the second half for confirmation of the measurement models and testing of the structural model. RESULTS: The final model resulted in a good fit to the data (χ (1215) = 1906.86, P < .00; comparative fit index = 0.94; root mean square of error of approximation = 0.04). A significant relationship was noted between adherence to the central line bundle interventions and organizational context (ß = 0.23, P < .01), whereas the relationship between context and CLABSIs was not significant (ß = -0.20, P = .78). CONCLUSIONS: This study supports a relationship between greater adherence to HAI interventions and higher levels of organizational context and highlights the complexity of measuring organizational context. Given the importance of preventing HAIs, ongoing research is needed to reveal the exact aspects of context that influence interventions and outcomes.

Confirmation of the Validity of the Relational Coordination Survey as a Measure of the Work Environment in a National Sample of Infection Preventionists.

BACKGROUND: Health care-associated infections (HAIs) are leading causes of morbidity and mortality. Prevention of HAIs requires multifaceted approaches that consider the work environment in which interventions are implemented. PURPOSE: This study assessed the construct validity of the Relational Coordination Survey (RCS) as a measure of the work environment in infection prevention departments. METHODS: Data were obtained from 614 infection preventionists (IPs). Factor analysis and structural equation modeling tested the hypothesized model. RESULTS: Cronbach's alpha for the 28-item RCS was .91. Factor analyses confirmed a four-factor solution that explained 58.17% of the variance. The fit indices for the model indicated an adequate fit, χ²(346) = 699.38, p < .00; comparative fit index = .94; root mean square error of approximation = .06. CONCLUSIONS: The RCS may be a useful tool for measuring aspects of the work environment for IPs.

The Colorado Collaborative for Nursing Research: nurses shaping nursing's future.

Nurses in the present health care environment have been reduced too often to being providers of safe, competent care rather than quality care. In response, the Institute of Medicine has recommended that nurses become more involved in making changes to the health care system and use data more effectively. If nursing intends to follow these recommendations, the profession needs (a) fresh perspectives to assist in making health care system changes, (b) partnerships between nurse scientists and nurse clinicians to generate and implement data, and (c) capture of the proper value of nursing as distinct from other elements of health care delivery. The Colorado Collaborative for Nursing Research is an effort to meet the recommendations of the Institute of Medicine. The Colorado Collaborative for Nursing Research has a three-arm structure: a research forum where nurse academicians and nurse clinicians can launch collaborative projects; a research support services arm from which nurse collaborators can obtain help with modeling, statistics, writing, and funding; and a data extraction/data sharing mechanism to inform the decision making of nurse leaders.

Examining construct and predictive validity of the Health-IT Usability Evaluation Scale: confirmatory factor analysis and structural equation modeling results.

BACKGROUND: In a previous study, we developed the Health Information Technology Usability Evaluation Scale (Health-ITUES), which is designed to support customization at the item level. Such customization matches the specific tasks/expectations of a health IT system while retaining comparability at the construct level, and provides evidence of its factorial validity and internal consistency reliability through exploratory factor analysis. OBJECTIVE: In this study, we advanced the development of Health-ITUES to examine its construct validity and predictive validity. METHODS: The health IT system studied was a web-based communication system that supported nurse staffing and scheduling. Using Health-ITUES, we conducted a cross-sectional study to evaluate users' perception toward the web-based communication system after system implementation. We examined Health-ITUES's construct validity through first and second order confirmatory factor analysis (CFA), and its predictive validity via structural equation modeling (SEM). RESULTS: The sample comprised 541 staff nurses in two healthcare organizations. The CFA (n=165) showed that a general usability factor accounted for 78.1%, 93.4%, 51.0%, and 39.9% of the explained variance in 'Quality of Work Life', 'Perceived Usefulness', 'Perceived Ease of Use', and 'User Control', respectively. The SEM (n=541) supported the predictive validity of Health-ITUES, explaining 64% of the variance in intention for system use. CONCLUSIONS: The results of CFA and SEM provide additional evidence for the construct and predictive validity of Health-ITUES. The customizability of Health-ITUES has the potential to support comparisons at the construct level, while allowing variation at the item level. We also illustrate application of Health-ITUES across stages of system development.

A Longitudinal Approach to Understanding the Relationship Between Symptom Status and QOL.

This study demonstrates how a variant of growth curve modeling known as longitudinal parallel-process modeling can yield an understanding of the effect of symptoms on quality of life (QOL). A two-level hierarchical linear model with random intercepts and slopes was implemented within a structural equation modeling approach. The data (N = 367) comes from a large database of persons with HIV-associated illness. Twenty-three symptoms based on the Sign and Symptom Checklist for Persons with HIV disease and items measuring QOL from the general health status scales were used. Each respondent completed from 1 to 11 questionnaires. The number of reported symptoms had a significant association with patient QOL over time. These findings suggest that appropriate symptom management has the potential to improve patient QOL. This study demonstrates how a state-of-the-art longitudinal modeling technique evaluates the relationship between concurrent rates of change in measurements of two relevant variables.

Shape shifters: biobehavioral determinants and phenomena in symptom research.

Symptom assessment and management are critical to patient-centered care. Traditionally, the determinants of a symptom are viewed as separate from the phenomena associated with that symptom. By separating determinants and phenomena, however, the complexity and dynamism of the patient experience are ignored. Likewise, categorizing symptom determinants and phenomena as solely biological or behavioral minimizes their dimensionality and may hinder interdisciplinary dialogue. Here we propose that determinants and phenomena are not fixed but shift between each other depending on perspective. To illustrate this way of thinking the metaphor of the "shape shifter" from folklore is used. A shape shifter moves between states and may be seen differently by the same person at different times or by multiple individuals at one time. To guide discussion, we present 5 exemplars of increasing complexity, wherein a determinant becomes a phenomenon or vice versa, depending upon context. Suggestions for statistical testing of the model are included with each. We conclude by exploring how shifting between determinants and phenomena may affect symptom cluster assessment and management.

Establishing measurement invariance: English and Spanish Paediatric Asthma Quality of Life Questionnaire.

BACKGROUND: Registered nurses and nurse researchers often use questionnaires to measure patient outcomes. When questionnaires or other multiple-item instruments have been developed using a relatively homogeneous sample, the suitability of even a psychometrically well-developed instrument for the new population comes into question. Bias or lack of equivalence can be introduced into instruments through differences in perceptions of the meaning of the measured items, constructs, or both in the two groups. OBJECTIVE: To explain measurement invariance and illustrate how it can be tested using the English and Spanish versions of the Paediatric Asthma Quality of Life Questionnaire (PAQLQ). METHODS: A sample of 607 children from the Phoenix Children's Hospital Breathmobile was selected for this analysis. The children were of ages 6-18 years; 61.2% completed the PAQLQ in Spanish. Testing measurement invariance using multiple-group confirmatory factor analysis, a series of hierarchical nested models, is demonstrated. In assessing the adequacy of the fit of each model at each stage, both χ2 tests and goodness-of-fit indexes were used. RESULTS: The test of measurement invariance for the one-factor model showed that the English and Spanish versions of the scale met the criteria for measurement invariance. The level of strict invariance (equal factor loadings, intercepts, and residual variances between groups) was achieved. DISCUSSION: Confirmatory factor analysis is used to evaluate the structural integrity of a measurement instrument; multiple confirmatory factor analyses are used to assess measurement invariance across different groups and to stamp the data as valid or invalid. The PAQLQ, a widely used instrument having evidence to support reliability and validity was used separately in English- and Spanish-speaking groups. Traditional methods for evaluating measurement instruments have been less than thorough, and this article demonstrates a well-developed approach, allowing for confident comparisons between populations.

Distinguishing between-person and within-person relationships in longitudinal health research: arthritis and quality of life.

BACKGROUND: Many health measures (e.g., blood pressure, quality of life) have meaningful fluctuation over time around a relatively stable mean level for each person. PURPOSE: This didactic paper describes two closely related statistical models for examining between-person and within-person relationships between two or more sets of measures collected over time: the latent intercept model with correlated residuals (LI) in structural equation modeling framework and the multivariate multilevel model (MVML) in multilevel modeling framework. RESULTS: We illustrated that the basic LI model and the MVML model are equivalent. We presented an illustrative example using a national arthritis data resource to examine between-person and within-person relationships of symptom status, functional health, and quality of life in arthritis patients. DISCUSSION: Additional design and modeling issues for the treatment of missing data are considered. We discuss contexts in which one of the two models may be preferred. Mplus and SAS syntax are available.

Breast cancer and symptom clusters during radiotherapy.

BACKGROUND: Symptom clusters assessment shifts the clinical focus from a specific symptom to the patient's experience as a whole. Few studies have examined breast cancer symptom clusters during treatment, and fewer studies have addressed symptom clusters during radiation therapy (RT). The theoretical underpinning of this study is the Symptoms Experience Model. Research is needed to identify antecedents and consequences of cancer-related symptom clusters. OBJECTIVE: The present study was intended to determine the clustering of symptoms during RT in women with breast cancer and significant correlations among the symptoms, individual characteristics, and mood. METHODS: A secondary data analysis from a descriptive correlational study of 93 women at weeks 3 to 7 of RT from centers in the mid-Atlantic region of the United States, Symptom Distress Scale, the subscales of the Positive and Negative Affect Scale, Life Orientation Test, and Self-transcendence Scale were completed. RESULTS: Confirmatory factor analysis revealed symptoms grouped into 3 distinct clusters: pain-insomnia-fatigue, cognitive disturbance-outlook, and gastrointestinal. The pain-insomnia-fatigue and cognitive disturbance-outlook clusters were associated with individual characteristics, optimism, self-transcendence, and positive and negative mood. The gastrointestinal cluster correlated significantly only with positive mood. CONCLUSIONS: This study provides insight into symptoms that group together and the relationship of symptom clusters to antecedents and mood. IMPLICATIONS FOR PRACTICE: These findings underscore the need to define and standardize the measurement of symptom clusters and understand variability in concurrent symptoms. Attention to symptom clusters shifts the clinical focus from a specific symptom to the patient's experience as a whole and helps identify the most effective interventions.

The importance of assessing symptoms and symptom clusters in critical care units.

In the highly technological environment of critical care, a comprehensive symptom assessment from the patient's perspective is routine. There is a paucity of research related to symptom management in the critical care environment. The lack of understanding of the symptom experience for critical care patients could represent missed opportunities to manage symptoms and minimize suffering. This article discusses the importance of assessing symptoms and symptom clusters in critical care patients and challenges surrounding the assessment of symptom clusters. By understanding symptom clusters, critical care nurses can develop more comprehensive assessments, as well as more tailored intervention strategies.

Patterns of change in symptom clusters with HIV disease progression.

CONTEXT: With better antiretroviral treatments (ARTs), persons living with HIV (PLWH) are living longer, healthier lives. Therefore, they also experience more medical comorbidities that come with normal aging, as well as side effects of multiple treatments and long-term sequelae of HIV. It can be hard to know whether symptoms reported by PLWH are related to comorbidities or are signs of HIV disease progression and possible treatment failure. OBJECTIVES: The current study was designed to disentangle these issues by examining within-person symptom changes in data collected from a cohort of PLWH before the advent of highly efficacious ART. METHODS: This study was a secondary analysis of symptom reports in longitudinal data collected from 246 PLWH in 1992-1994. Multilevel modeling was used to test for changes over time in HIV-related symptom clusters. Analyses also tested the effects of person-level demographic covariates and co-occurring mental health symptoms on HIV symptoms and examined the magnitude of within-person versus between-person variations in reported symptom severity. RESULTS: Two of six HIV-related symptom clusters, malaise/fatigue and nausea/vomiting, increased over time in the context of HIV disease progression, but the other four did not. Changes were independent of baseline disease severity or psychological covariates. There was substantial within-person variability in absolute symptom severity. CONCLUSION: Relatively small but consistent changes in symptoms related to nausea or fatigue may suggest HIV disease progression, but changes in other HIV symptom clusters may instead be related to comorbidities or normal aging. Further research is recommended on symptom progression in PLWH.

Mediation and moderation: Testing relationships between symptom status, functional health, and quality of life in HIV patients.

We extended Wilson and Cleary's (1995) health-related quality of life model to examine the relationships among symptoms status (Symptoms), functional health (Disability), and quality of life (QOL). Using a community sample (N = 956) of male HIV positive patients, we tested a mediation model in which the relationship between Symptoms and QOL is partially mediated by Disability. Common and unique ideas from three approaches to examining moderation of effects in mediational models (Edwards & Lambert, 2007; Preacher, Rucker, & Hayes, 2007; MacKinnon, 2008) were used to test whether (a) the direct relationship of Symptoms to QOL and (b) the relationship of Disability to QOL are moderated by age. In the mediation model, both the direct and the indirect (mediated) effects were significant. The direct relationship of Symptoms to QOL was significantly moderated by age, but the relationship of Disability to QOL was not. High Symptoms were associated with lower QOL at all ages, but that this relationship became stronger at older ages. We compare the three approaches and consider their advantages over traditional approaches to combining mediation and moderation.

Confirmation of the validity of the HAQ-DI in two populations living with chronic illnesses.

The assessment of functional health in chronic illnesses such as HIV/AIDS and rheumatoid arthritis is central to the measurement of health-related quality of life. The purpose of this article is to report the testing and comparison of the measurement structure of the Health Assessment Questionnaire-Disability Index (HAQ-DI), a measure of functional health, in 917 persons living with HIV/AIDS and 901 individuals with rheumatoid arthritis. The samples come from data collected as part of the Arthritis, Rheumatism, and Aging Medical Information System (ARAMIS) and AIDS Time-Oriented Health Outcome Study (ATHOS) projects. Using confirmatory factor analysis (CFA), the hypothesized structure represented by a general factor (functional health) and eight measured items was tested separately. Based on the fit indexes, the model fit the ATHOS data (chi2 = 36.933, p < .0117; CFI = 1.000; SRMR = 0.025). After correlating the error terms for two of the measured items, the model also fit the ARAMIS data (chi2 = 302.34, p = .0000; CFI = 0.937; SRMR = 0.041). This analysis provides further support of the construct validity of the HAQ-DI for persons living with HIV/AIDS or rheumatoid arthritis.

Development of a model to measure symptom status in persons living with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is a chronic illness with a constellation of symptoms. The management of which is important for quality of life. Our review of the literature indicated that there is currently no standardized approach to measuring the symptom status of persons living with RA. OBJECTIVE: The purpose of this study is to report the development and initial validation of a structure to measure symptom status in persons living with RA. METHODS: For this secondary analysis, there were 901 female patients with complete symptom checklists available from the Arthritis, Rheumatism, and Aging Medical Information System. A tentative structure using exploratory factor analysis was developed, the structure was replicated in a separate sample using confirmatory factor analysis, and then hypothesized relationships with an external criterion (functional health) was tested using structural equation modeling. The symptom checklist contains 31 symptoms. The stem question is, "Have you had any of the following symptoms during the past 6 months; if yes mark all that apply." RESULTS: A two-factor structure for measuring symptom status was identified, RA Pain Symptoms and General Symptoms. Using the external criterion, we also demonstrated that the two factors were different and that the RA Pain Symptoms Factor had a stronger impact on functional health. This provides evidence of the discriminant as well as predictive validity of the RA Pain Symptoms Factor. DISCUSSION: Effective symptom management is an important outcome for nursing practice. Because the assessment of symptoms is the first step in symptom management, the identification of a measurement structure is an essential step.

Reconsidering the assessment of symptom status in HIV/AIDS care.

Symptom management is one of the predominant components of HIV/AIDS care. Frameworks that adequately posses sufficient construct validity and that reflect the symptom experience related to HIV disease, treatment, and medications have been limited. Without validated measures, nurses and other care providers are limited in their ability to accurately assess symptomology and to make appropriate changes to care regimens. The purpose of this article is to demonstrate a method for evaluating symptom status based on the Sign and Symptom Check-List for Persons with HIV disease (SSC-HIV) as well as to provide further support as to the validity of the SSC-HIV. The method to evaluate symptom status that is shown uses a measurement model approach that allows for the assessment of symptom clusters and may be more appropriate than traditional approaches. The sample for this analysis comes from the AIDS Time-Oriented Health Outcome Study. Results further support the SSC-HIV as a valid measure of HIV-related symptoms.