Development of a Child Abuse Level Management (CALM) Guide for Research with Young Children.

Reporting child abuse or neglect is an ethical expectation and a legislated mandate of behavioral and health care professionals in the United States. In particular, researchers who investigate parent-child dyads are responsible for submitting procedures and informed consent documents to institutional review boards that provide for the protection of children. The challenge for researchers is to recognize failing quality of parent-child interaction, prior to any event of maltreatment and to intercede in a deteriorating dynamic. The obligation to report any suspicions of child maltreatment supersedes the responsibility to provide for confidentiality of research data. The purpose of this paper is to describe the rationale for the development of a research protocol guide, Child Abuse Level Management (CALM), and address protection of children in research. The CALM is a brief, flexible guide designed for use by researchers to help identify and respond to negative trends in the parent-child interaction during data collection. Suggested intervention scripts are provided that can be modified for specific culture-focused samples. The CALM guide can be used for training of data collectors using simulations prior to initiating any study involving higher-risk dyads.

Extended family support for parents faced with life-support decisions for extremely premature infants.

PURPOSE: To outline parents' descriptions of extended family involvement and support surrounding decision making for their extremely preterm infant. DESIGN: Collective case study design in a prospective, descriptive, longitudinal research. Seventy-five digitally recorded interviews were done with parents before and after the birth. SAMPLE: Fifty-four parents (40 mothers, 14 fathers). MAIN OUTCOME VARIABLE: Categories of family involvement and support in the parents' decision making. RESULTS: Most parents did not seek advice from family members for life-support decisions made prenatally. Instead, parents made the decision as a couple with their physician without seeking family input. Family members provided certain types of support: emotional support, advice and information, prayer, and instrumental help such as child care. Most parents described at least one way their family supported them. For postnatal and end-of-life decisions, parents were more likely to seek advice from extended family in addition to the other forms of support.

Development of a spiritual self-care practice scale.

BACKGROUND AND PURPOSE: Development of a valid, reliable instrument to measure spiritual self-care practices of patients with heart failure. METHODS: African American patients (N = 142) with heart failure participated in the study. Spiritual advisors from several religious groups reviewed the Spiritual Self-Care Practices Scale (SSCPS) for content validity. Construct validity was determined using a principal components factor analysis. Reliability was established using Cronbach's alpha coefficients. RESULTS: Religious advisors provided suggestions to improve content validity. Four factors consistent with spiritual practices (personal spiritual practices, spiritual practices, physical spiritual practices, and interpersonal spiritual practices) emerged from the factor analysis. The alpha coefficient was moderate at 0.64. CONCLUSIONS: Results indicated the SSCPS was reliable and valid for measuring spiritual self-care practices among African Americans with heart failure. Additional testing is needed to confirm results in other patient groups with chronic illnesses.

Testing a multi-group model of culturally competent behaviors among underrepresented nurse practitioners.

Diversifying the health professional workforce and enhancing cultural competence are recommended for decreasing health disparities. We tested a structural equation model of the predictors of culturally competent behaviors in a mailed survey of three groups of underrepresented nurse practitioners (n = 474). Our model had good fit and accounted for 29% of the variance in culturally competent behaviors. Life experiences with diversity had direct effects on awareness/sensitivity and behaviors, and diversity training had a direct effect on behaviors. Cultural awareness/sensitivity mediated the relationship between life experiences with diversity and culturally competent behaviors; all paths remained after controlling for covariates. For unique experiences that contribute to workplace diversity, life experiences with diversity, and diversity training are important for culturally competent behaviors.

A three-dimensional model of cultural congruence: framework for intervention.

Culture provides the context for all health care and social service throughout the human life span. Improving end-of-life and palliative care and enhancing patient and family outcomes requires a nuanced understanding of cultural contexts for those who provide care and those who receive it. The authors of this article propose an emerging model of culturally congruent care that can guide intervention for social workers, mental health professionals, nurses, and other health care workers caring for a diverse population of patients, families, and communities.

Development of a Web-based educational intervention to improve cross-cultural communication among hospice providers.

In this article, the authors describe the theoretical foundation, development, and content of a Web-based educational intervention to improve cross-cultural communication about end-of-life concerns and report on the preliminary evaluation of this intervention using a qualitative study design. The data were collected with non-structured questions in a convenience sample of 21 hospice providers. Participants reported that they found the training appropriate and useful. Participants also reported finding the online delivery convenient and the interactive format valuable. Improving the quality of cross-cultural patient-provider communication can contribute to reducing disparities at end-of-life.

Exploring parents' environmental needs at the time of a child's death in the pediatric intensive care unit.

OBJECTIVE: Many childhood deaths in the United States occur in intensive care settings. The environmental needs of parents experiencing their child's death in a pediatric intensive care unit must be understood to design facilities that comfort at the time of death and promote healing after loss. The purpose of this study is to explore parents' environmental needs during their child's hospitalization and death in the pediatric intensive care unit. DESIGN: Descriptive qualitative study. SETTING: A university-affiliated children's hospital. PARTICIPANTS: Thirty-three parents of 26 children who died in a pediatric intensive care unit. INTERVENTIONS: Semistructured, in-depth, videotaped interviews were conducted with parents 2 yrs after their child's death. Interviews were analyzed by an interdisciplinary research team using established qualitative methods. MEASUREMENTS AND MAIN RESULTS: Environmental themes identified through parent interviews included 1) places remembered, 2) spatial characteristics, 3) services for daily living, 4) parent caregiving, 5) access, and 6) presence of people. Places remembered by parents in most detail included the pediatric intensive care unit patient rooms and waiting room. Spatial characteristics pertaining to these places included the need for privacy, proximity, adequate space, control of sensory stimuli, cleanliness, and safety. Parents needed facilities that enabled self-care such as a place to eat, shower, and sleep. Parents also needed access to their child and opportunities to participate in their child's care. Parents described the physical presence of people, such as those who provide professional and personal support, as another important environmental need. CONCLUSIONS: The pediatric intensive care unit environment affects parents at the time of their child's death and produces memories that are vivid and long lasting. Positive environmental memories can contribute to comfort during bereavement whereas negative memories can compound an already devastating experience. Parents' perspectives of the pediatric intensive care unit environment can provide insight for adapting existing spaces and designing new facilities.

Crossing disciplinary boundaries in end-of-life education.

There is a tremendous need to educate professional nurses and other health care providers in the care of the dying person. Both nurses and physicians have begun to recognize the need to cross traditional disciplinary boundaries to provide the complex care required during the last human transition. This article describes the evolution of a unique interdisciplinary graduate course on end-of-life issues at Wayne State University. Using a new model centered on narrative and culture, the course focuses on the synthesis of concepts from many of the stories told by and about dying people, their families and communities, and their various caregivers. The effects of 5 years of experience with the course on students, faculty, and the university community are described, and future directions are suggested.

Differences in veterans' and nonveterans' end-of-life preferences: a pilot study.

BACKGROUND: Investigators conducting focus groups on end-of-life preferences noted that veterans voiced opinions that strongly differed from those of nonveterans. OBJECTIVE: The objective of this study was to further explore differences between veterans' and nonveterans' end-of-life preferences. METHODS: Ten focus groups and a pilot survey were conducted. SETTING AND SAMPLE: The focus groups consisted of Arab Muslims, Arab Christians, Hispanics, blacks, and whites stratified by gender (n = 73). Fifteen male veterans were included across all five racial groups. MEASURES: A moderator discussion guide was used to lead the focus groups and a pilot survey asked about demographic information and end-of-life preferences. RESULTS: Veterans were more likely to be married (p < 0.05) and less connected to their cultural group (p < 0.05) than nonveterans. The focus group results indicated that veterans in this study were more likely to oppose the use of heroic measures compared to nonveterans. More so than nonveterans, veterans felt that their doctors should be frank and open (p < 0.05) were strongly in favor of do-not-resuscitate (DNR) orders (p < 0.10), yet were less likely to have a proxy (p < 0.10) or durable power of attorney p < 0.01). Comparing end-of-life preferences, veterans felt less strongly than nonveterans about remembering personal accomplishments (p < 0.05), being listened to (p < 0.05), being with friends (p < 0.01), or being comfortable with their nurse (p < 0.05), but did want to be around their pets at the end of life p < 0.10). IMPLICATIONS: The Department of Veterans Affairs is in a unique position to improve endof- life care for veterans. Providing end-of-life care that is congruent with the veteran's wishes can improve satisfaction and increase cost effectiveness by eliminating unacceptable services.

Enhancing cultural competence among hospice staff.

A critical component in making hospice and palliative care services accessible and acceptable to diverse communities is preparation of all providers to enhance cultural competence. This article reports a study designed to test an educational intervention aimed at expanding cultural awareness, sensitivity, and competence with a multi-disciplinary and multilevel team of hospice workers. The purpose of this quasi-experimental, longitudinal, crossover design was to test the effects of an educational intervention for multidisciplinary hospice providers. Findings demonstrated that even with a modest face-to-face intervention, cultural competence scores were significantly greater after the educational intervention for participants in both groups. Although the intervention proved successful at enhancing cultural competence scores among diverse types of hospice workers, limitations and logistic insights gained from this pilot suggest the need for examination of alternative methods of program delivery.

Environments of care: a curriculum model for preparing a new generation of nurses.

This article provides a perspective on the community-based curriculum model that has guided undergraduate education for the past decade, discusses some of the problems that have emerged with the community-based approach, and proposes an alternative approach for consideration and discussion. The community-based model is discussed in relation to three major areas of concern: faculty and preceptor implementation of the curriculum, entry into practice and hiring pattern disjunctions, and trends and unexpected consequences of changes in the health care system. The Environments of Care Model, proposed as an alternative curriculum approach, conveys a broad perspective on health and illness, based on a multiple determinants of health paradigm and a systems framework.

Wound care at end of life.

Nurses are in a unique and privileged position with regard to both end-of-life care and wound care. Expert wound care can greatly contribute to the relief of physiologic stress on the human organism and psychosocial and physical distress at the end of life. Using what is known from both domains,nurses apply critical thinking to assist patients, families, and other caregivers in maintaining the maximum possible integrity of the physical body of the dying person. The manner in which nurses approach wound care with dying patients and the ability to preserve patient dignity and family respect while doing necessary palliative interventions also can serve the healing of emotional wounds in the dying process.

Cultural competence in hospice.

Research shows that ethnic minorities access hospice care significantly less often than Caucasians. In part, this has been attributed to the lack of cultural competence among hospice staff. To assess cultural competence among hospice workers, this article evaluates the results of a descriptive, exploratory survey that was submitted to 125 interdisciplinary hospice employees and completed by 113 of those employees. Cultural-competence behavior scores varied widely based on two factors: increased education and previous cultural-diversity training. The results of this study provide information regarding cultural competence in hospice. In their efforts to provide culturally appropriate end-of-life care, hospices can use the information in this study to implement intervention plans aimed at increasing cultural competence among hospice staff.

Worksite "lunch and learn": a collaborative teaching project.

Overall, the collaborative teaching project in community health nursing was successful in meeting the needs of students, faculty, the HMO, the employer, and the community. Health education program outcomes and the lessons learned from the processes indicated the collaboration should continue and be expanded. In subsequent academic years, faculty and HMO staff worked to identify additional employer groups and to make this type of learning experience available to a larger number of nursing students. As career paths diverged, this specific collaboration dissolved. However, the opportunities and challenges observed in this collaborative teaching project have been carried forward into new collaborations.

Development of a Cultural Competence Assessment instrument.

This article describes initial testing of an instrument designed to provide evidence of cultural competence among health care providers and staff. The Cultural Competence Assessment (CCA) instrument was based on a model describing cultural competence components (fact, knowledge, attitude, and behavior). Content and face validity were confirmed through expert panel review, subject feedback, and field-testing. The CCA was administered to an interdisciplinary health care team in a community hospice setting. Preliminary findings suggest that the CCA performed well. Internal consistency reliability for the scale was 0.92. Construct validity by factor analysis demonstrated that 25 items had loadings above 0.42. Construct validity was supported with a significant correlation to the widely used Inventory for Assessing the Process of Cultural Competence among Health care Professionals (IAPCC). Validity also was supported by significant differences between individuals with different educational levels and prior diversity training. The CCA is a promising tool to measure cultural competence in populations with a wide range of educational levels and backgrounds.

Health risk assessment in an urban Hispanic community.

PURPOSE: This study describes the health risks of urban Hispanic adults and compares the health risks of persons who identified themselves as "not overweight'' with those who identified themselves as "overweight.'' DESIGN: A descriptive correlational design was used to examine current health risks. SETTING: The study, a part of a larger community action study, was conducted in the predominantly Hispanic/Latino community of Southwest Detroit. A Roman Catholic parish, a central component of this community, served as the study setting. SAMPLE: One hundred ninety-three Hispanic adults participated. METHODS: Following administration of an information sheet, participants were asked to complete the 22-item Personal Health Risk Assessment, available in both English and Spanish versions, which measured health status and demographic characteristics. FINDINGS: Significant differences in blood pressure, diabetes, and the total number of health risks between the "not overweight'' and "overweight'' groups were identified, with the "overweight'' participants scoring higher on these subscales. CONCLUSIONS: Findings from this study highlight the prevalence of cardiovascular risk factors and the greater clustering of cardiovascular risk factors among persons identifying themselves as overweight. IMPLICATIONS FOR PRACTICE: This study supports the need for active participation of clinical nurse specialists in health-promotion activities and intervention research in this growing population.

Challenges to Recruitment of Urban African American Patients with Cancer Pain.

There are many assumptions about recruitment of African Americans to cancer studies. The population is often characterized as older, low income, with limited education, scarce resources, and distrust of the health care system. Support systems for African Americans are reported to be centered on family and church communities. Observations made during recruitment and enrollments for a longitudinal intervention study with urban African Americans with cancer pain are presented. Majority of the subjects being recruited in this study are well educated, knowledgeable about research and very open to healthcare providers and researchers. Our population is younger than anticipated and struggling with an absence of family, faith, or community supports. They are more connected in terms of phone ownership, but often difficult to contact due to interruptions in phone service, housing insecurity and time demands related to medical care for their cancer. We conclude that familiarity with cultural patterns of a population of interest is necessary, but local and individual assessment is critical to successful recruitment to research.

Conceptual and design issues in instrument development for research with bereaved parents.

Many childhood deaths in the United States occur in pediatric intensive care units (PICUs) and parents have special needs in this death context. As an interdisciplinary research team, we discuss conceptual and design issues encountered in creating a new instrument, the Bereaved Parent Needs Assessment-PICU, for assessing parents' needs in this setting. Using a qualitative approach, our team previously explored how the culture and related ways of providing care in one urban Midwestern children's hospital PICU affected parents' bereavement needs and experiences. We describe using this qualitative foundation in the development of a new quantitative instrument to more widely validate and measure bereaved parents' needs around the time of a child's death across multiple PICUs. We highlight a series of issues that warrant consideration in designing a research instrument for this vulnerable population including setting and context, format and content, temporality, recruitment, and content expertise.

Spirituality and spiritual self-care: expanding self-care deficit nursing theory.

The authors propose an integration of the concepts of spirituality and spiritual self-care within Orem's self-care deficit nursing theory as a critical step in theory development. Theoretical clarity is needed to understand the contributions of spirituality to health and well-being. Spirituality is the beliefs persons hold related to their subjective sense of existential connectedness including beliefs that reflect relationships with others, acknowledge a higher power, recognize an individual's place in the world, and lead to spiritual practices. Spiritual self-care is the set of spiritually-based practices in which people engage to promote continued personal development and well-being in health and illness.

Parental bereavement needs in the pediatric intensive care unit: review of available measures.

BACKGROUND: Pediatric intensive care units (PICUs) are highly technological settings in which advanced care is used to restore health to critically ill children; however, they are also places where children die. Understanding the needs of parents bereaved in this setting is essential for better family care. OBJECTIVE: To systematically review the extant literature to identify instruments potentially useful for assessing the needs of parents bereaved in the PICU. METHODS: We searched PubMed™, CINAHL™, and Health and Psychosocial Instruments™ for tools to assess family needs during a relative's hospitalization. From 357 abstracts, 96 articles were reviewed that described 31 instruments. Fifteen instruments were selected based on their (1) use with parents and/or the bereaved, (2) use in PICU, neonatal intensive care, or pediatric wards, (3) measurement of family needs or related constructs, and (4) published psychometrics. Need-related constructs included satisfaction with family care and environmental stress since these have been related to met and unmet needs, respectively. RESULTS: No instruments specifically designed to assess the needs of parents bereaved in the PICU were identified. Most tools reviewed showed validity and reliability in the populations and settings for which the tools were intended; however, validity and reliability were not established for parents bereaved in the PICU. No tools addressed the full range of needs for parents bereaved in the PICU. CONCLUSIONS: A new instrument is needed to adequately assess the needs of parents bereaved in the PICU. Patient conditions, illness trajectories, and life course perspectives must be considered in designing a new tool.