An exploration and advancement of the concept of trust.

BACKGROUND: Trust is a concept used both in everyday language and in the scientific realm. An exploration of the conceptualizations of trust within the disciplines of nursing, medicine, psychology and sociology, revealed that trust is an ambiguous scientific concept. AIMS: In order to increase the pragmatic utility of the concept of trust for scientific application, further clarification and development of the concept was undertaken. METHODS: First, a concept analysis was conducted with the aim of clarifying the state of the science of discipline-specific conceptualizations of trust. The criterion-based method of concept analysis as described by Morse and colleagues was used (Morse et al. 1996a, 1996b, Morse 2000). This analytic process enabled the assessment of the scientific maturity of the concept of trust. The interdisciplinary concept of trust was found to be immature. Based on this level of maturity it was determined that in order to advance the concept of trust toward greater maturity, techniques of concept development using the literature as data were applied. In this process, questions were "asked of the data" (in this case, the selected disciplinary literatures) to identify the conceptual components of trust. RESULTS: The inquiry into the concept of trust led to the development of an expanded interdisciplinary conceptual definition by merging the most coherent commonalties from each discipline. CONCLUSIONS: The newly developed interdisciplinary conceptualization advances the concept toward maturity, that is, a more refined, pragmatic and higher-order concept. The refined concept of trust transcends the contextual boundaries of each discipline in a truly interdisciplinary scientific fashion.

Childhood farm injuries in Old-Order Amish families.

Unintentional injuries are the leading cause of death and disabilities in the United States among children, with the incidence even greater among children who live on a farm. Information exists about farming accidents on mainstream U.S. farms; however, little is known about the Amish farms. The purpose of this study was to investigate injuries among Old-Order Amish in Pennsylvania. Teachers in Amish schools were surveyed about their experiences with accidents/injuries among children on the farm. Seventy percent of the teachers reported a childhood farm injury in their family, with the majority attributing this to farm animals. Injuries may be preventable if age-appropriate tasks are assigned to children and they are properly supervised.

The meaning of social support for the critically ill patient.

Social support has been shown to be important for the critically ill patient. However, what constitutes adequate support for these patients has not been investigated. Thus, the purpose of this qualitative study was to investigate patients' perceptions of their need for and adequacy of the social support received while they were critically ill. Thirty adult patients who were critical during some point of their stay in the intensive care unit (ICU) stay were interviewed, once stable. Interviews were tape-recorded and began with an open-ended question regarding the ICU experience. This was followed by open-ended focused questions regarding social support, such as 'Who were your greatest sources of social support while you were critically ill?' 'What did they do that was supportive or unsupportive?' Data were analyzed according to Miles and Huberman (1994). The categories that emerged were need for social support based on patient perceptions (not number of visitors), quality of support (based on perceptions of positive and negative behaviors of supporters) and lack of support. This study found that quality of support was more important than the actual number of visitors. Patients with few visitors may have felt supported, while those with numerous visitors felt unsupported. Patients who felt unsupported also were more critical of the staff and the care they received. Nurses need to individually assess patients regarding their need for support, and assist family/friends to meet these needs.

Qualitative outcome analysis: evaluating nursing interventions for complex clinical phenomena.

PURPOSE: To describe a method that allows evaluating nursing interventions derived from a qualitative research project, and that shows appropriate interventions. ORGANIZING FRAMEWORK: Qualitative research has expanded over the last decade and has contributed significantly to understanding patients' experiences of health, illness, and injury. Yet the value of qualitative research in determining clinical interventions and subsequently evaluating the effects of these interventions on patients' outcomes has been limited. This method is used to confirm the efficacy of nursing interventions when experience changes over time, to extend the repertoire of intervention strategies, and to further clinicians' understanding of possible outcomes. DESIGN: From a completed study, Qualitative Outcome Analysis (QOA) enhances the identification of meaningful intervention strategies and plans for utilization. The researcher identifies the type of qualitative data that will enable the interpretation and evaluation of interventions, devises a means of data recording and analysis, and finally, disseminates the findings. CONCLUSIONS: QOA is a systematic means to confirm the applicability of clinical strategies developed from a single qualitative project, to extend the repertoire of clinical interventions, and to evaluate clinical outcomes.

The need to know: experiences of critically ill patients.

BACKGROUND: Critically ill patients vary in their memories of their experience in the intensive care unit. Some have little recall and need to learn about their critical illness. Others have more vivid memories of their experiences, some of which were extremely unpleasant. Patients' not knowing what was happening may have exacerbated the unpleasant experiences. OBJECTIVES: To elicit the experience of knowing for critically ill patients and to explore the differences in perceptions between patients who were intubated and those who were not intubated during the illness. METHODS: Grounded theory was used to explore the meaning of knowing and not knowing and the process by which knowing occurs. Unstructured interviews were done with 14 patients. RESULTS: Knowing had 2 phases: the need to know (1) during and (2) after the critical illness. The first phase had 3 facets: needing information, needing to be oriented, and having confusing perceptions. The second phase had 2 facets: needing information about what had happened and piecing together events. Many experiences with knowing during and after a critical illness were similar for both intubated and nonintubated patients. The main difference was the intensity of the experience in some categories. CONCLUSIONS: Critically ill patients have a strong need to know throughout and after their time in the intensive care unit. Nurses must address this need for constant reorientation to the past and present in these patients. In addition, adequate nursing staff must be available for these patients.

Going it alone: the experiences of spouses of critically ill patients.

Spouses of critically ill patients are faced with major changes in responsibilities while their spouse is in the intensive care unit. Using grounded theory methods, this qualitative study investigated the changes in responsibilities and the impact these additional responsibilities (such as financial decision making and child care) had on patients' spouses. Patients' spouses need help to meet their needs and alleviate some stress so they can "be there" for their critically ill partner.

Establishing and maintaining trust during acute care hospitalizations.

The concept of trust is significant in nursing; however, it remains inadequately defined and operationalized. The purpose of this study was to advance the development of the concept of trust by exploring patients' perspectives of processes of establishing and maintaining trust in health care providers during acute care hospitalizations. Grounded theory methods, including theoretical sampling and the constant comparative processes, were used. The sample included 50 adult inpatients with a wide variety of medical-surgical diagnoses who discussed their experiences while hospitalized. The core variable linking the process of developing and maintaining trust was meeting expectations. Through a series of interactions with health care providers and other hospital personnel, patients used monitoring behaviors to evaluate congruency between their expectations of care and the actual behaviors of providers. From this evaluation, three trajectories were identified based on whether expectations were met, exceeded, or unmet. Trust was shown to be dynamic and thus permits opportunities for interventions to redirect the trajectory.

Feeling safe: the psychosocial needs of ICU patients.

PURPOSE: To describe the psychosocial needs of critically ill patients, including descriptions of patients' experiences when these needs are not met, and behaviors of families, friends, and ICU staff that help or impede meeting these needs. DESIGN: A qualitative research design was used. Participants were 45 adult critically ill patients in the medical or surgical ICU for a minimum of 3 days in a large, rural American tertiary care center. METHODS: Data collection and analysis were conducted using methods of grounded theory, including theoretical sampling and the constant comparative process. Unstructured tape-recorded interviews were conducted with patients once they were stable in the ICU or immediately following their transfer to a general unit. Data were collected and analyzed simultaneously. This process continued until saturation was reached and a model of the psychosocial needs of ICU patients was developed. FINDINGS: The overwhelming need of ICU patients was to feel safe. The perception of feeling safe was influenced by family and friends, ICU staff, religious beliefs, and feelings of knowing, regaining control, hoping, and trusting. CONCLUSIONS: ICU patients in this study said that feeling safe was their overarching need. Patients described feelings of distress when they did not feel safe and stated how family, staff, and religion could both positively and negatively affect this feeling. Nurses can intervene in numerous areas to foster the feeling of safety in critically ill patients.

Increasing smoking cessation counseling by advanced practice nurses.

The magnitude of individual and societal problems caused by tobacco use mandates that all primary care providers identify and advise smokers to quit. However, this topic has received little attention in the nurse practitioner literature. The purpose of this project is to identify effective methods by which advanced practice nurses can increase the identification and counseling of smokers by reviewing research on this topic. The articles for review were obtained through a computerized literature search and a review of related reference lists. The articles were analyzed and categorized into three groups: office-wide interventions to increase provider identification and counseling of smokers, smoking cessation training programs for providers, and studies using the stages of change theory. Provider smoking cessation programs and office-wide reminders increased the identification and counseling of patients who smoke. The stages of change theory helped explain the steps smokers must progress through to cease smoking. Interventions appropriate for various stages in the cessation process are suggested.

The perception of farm safety and prevention issues among the Old Order Amish in Lancaster County, Pennsylvania.

The purpose of this study was to explore farm safety and prevention issues within an Old Order Amish community. A qualitative ethnographic approach was used to explore perceptions of Amish adults as to the issues related to farm safety and prevention for their children. Access to this community was facilitated through two contact people who were well known in the community. Data were collected using semistructured interviews and recorded as field notes. Data analysis was done by looking for themes based on the questions asked about safety and prevention. From this analysis, four themes were found related to safety and prevention. They included education of the parents, education of the children, home and farm preventive measures, and enforcement of established rules. In addition, childhood readiness was found to be another important issue related to farm safety. Childhood readiness was found to have three themes, developmental appropriateness, parental control and supervision, and birth order of the child. Data from this study suggested that farm safety is a concern of the Old Order Amish in Lancaster County. Their perceptions of safety and prevention issues centered on the incidents that have occurred and are considered dangerous. It is important to look at the identified safety and prevention and childhood readiness themes to identify the most beneficial approaches for the Amish to promote safety on their farms.

Looking out for the patient and ourselves--the process of family integration into the ICU.

As more intensive care units (ICU) are adopting the policy of unrestricted family visiting, families are playing an increasing role in the unit. This role may be restricted to being involved in discussions and decisions related to the patient or may entail a caregiving role. This study examined how families and nurses interact to increase or decrease the family's involvement in the ICU, how nurses maintain control, how families remain on guard, endure and find their niche in the ICU. The techniques of grounded theory were used to develop a model of the process of family integration into the ICU. This model was developed around the core variable of 'looking out for the patient-looking out for ourselves'. The perspectives of ICU nurses, families and ICU patients in the process of looking out for the patient while they look out for themselves are discussed, as well as nurses maintaining the position of power and families remaining on guard and enduring the ICU experience.

Culturalizing health care for a culturally diverse population: the Amish.

Advanced practice nurses (APNs) are often the major source of primary care for culturally diverse groups. Working with patients who have values that differ from the mainstream culture can make delivery of health care complex and challenging. The purpose of this qualitative study was to use grounded theory methods to explore the process by which APNs develop and maintain therapeutic relationships with a culturally unique group, the Amish. Nine APNs who practiced primarily with Amish patients were interviewed about their strategies to promote therapeutic relationships. The process of culturalizing health care emerged as the strategy used by the APNs. Specific themes were learning the culture, developing a relationship, individualizing care, being comfortable with abilities, and working two systems. Rather than expecting patients to conform to the mainstream cultural beliefs and practices, APN informants used a variety of methods that allowed Amish patients to blend self-care practices with conventional (i.e., English care).

Clarifying the social support theory-research linkage.

Social support is a multi-faceted concept that has been difficult to conceptualize, define and measure. Although this concept has been extensively studied, there is little agreement among theoreticians and researchers as to its theoretical and operational definition. As a result, the concept remains fuzzy and almost anything that infers a social interaction may be considered social support. Social support researchers have consistently ignored the complexity of the concept and have measured the variable in a simplistic manner. The purpose of this article is to analyse the linkage between theory and research related to social support by categorizing definitions of social support, exploring the theoretical aspects and conceptualizations of the concept, proposing models of social support, and examining how social support is measured in current social support research (1993-1996). The inadequacy of current research and directions for future study are discussed.

Establishing the nurse-family relationship in the intensive care unit.

The nurse-family relationship in the intensive care unit (ICU) may replace the traditional nurse-patient relationship due to the patient's compromised state. As a result, the nurse-family relationship becomes extremely important. Nurses and families may develop a relationship in which they work together to benefit the patient, or an inadequate relationship may develop. In this study, strategies used by nurses and families to either develop or inhibit the development of the nurse-family relationship were identified. Using unstructured interviews with ICU nurses and family members of ICU patients, categories of strategies were identified and behaviors described. Nurses and families perceived that they each displayed only positive behaviors yet identified inhibiting behaviors of the other. Once the behaviors were shown to nurses as secondary informants, they were able to identify with their negative behaviors. An understanding of these strategies will help nurses to reevaluate their practice and enhance their understanding of the behaviors of family members.

Criteria for concept evaluation.

One of the roles of qualitative enquiry is the utilization of qualitative methods for the development, refinement or modification of concepts. Yet, to date, there are no criteria for evaluating the adequacy of a concept. In this paper, the anatomy of a concept is presented, methods of concept analysis critiqued, and criteria for evaluation of the level of maturity of a concept suggested. Evaluation of criteria include assessment of: the definition of the concept, the characteristics of the concept, the conceptual preconditions and outcomes, and the conceptual boundaries. The authors argue that evaluation of a concept must necessarily precede concept development research (using a Wilsonian-derived method, a critical analysis of the literature, or qualitative enquiry) and precede more formal research procedures (such as operationalization or identification of the variables).

Wilsonian methods of concept analysis: a critique.

Wilsonian methods of concept analysis--that is, the method proposed by Wilson and Wilson-derived methods in nursing (as described by Walker and Avant; Chinn and Kramer [Jacobs]; Schwartz-Barcott and Kim; and Rodgers)--are discussed and compared in this article. The evolution and modifications of Wilson's method in nursing are described and research that has used these methods, assessed. The transformation of Wilson's method is traced as each author has adopted his techniques and attempted to modify the method to correct for limitations. We suggest that these adaptations and modifications ultimately erode Wilson's method. Further, the Wilson-derived methods have been overly simplified and used by nurse researchers in a prescriptive manner, and the results often do not serve the purpose of expanding nursing knowledge. We conclude that, considering the significance of concept development for the nursing profession, the development of new methods and a means for evaluating conceptual inquiry must be given priority.

Concept analysis in nursing research: a critical appraisal.

The four major methodological approaches to concept analysis (Wilson-derived methods, qualitative methods, critical analysis of the literature, and quantitative methods) are compared. The authors suggest that qualitative methods and methods that critically analyze the literature may be selected according to the level of the maturity of the concept and the purpose of the analysis. These methods have the ability to facilitate inquiry for concept development, delineation, comparison, clarification, correction, and identification. Quantitative methods may be used for exploring concepts (e.g., delineating conceptual boundaries), and quantitative instrumentation may be used for concept validation, operationalization, and measurement, thus complementing concept analysis methods by moving inquiry into another level of investigation. The authors conclude by presenting criteria for the selection of an appropriate research approach for concept analysis and criteria for evaluating concept analysis research.

Graduate education for nurse practitioners: are advanced degrees needed for practice?

Although the number of master's prepared nurse practitioners has expanded in the last 30 years, few master's level behaviors seem to be incorporated into the role. This study compared both actual and ideal role behaviors of master's and non-master's prepared nurse practitioners. These behaviors included the technical behaviors that all nurse practitioners should perform and master's level nursing behaviors. Two hundred state-certified nurse practitioners were mailed questionnaires asking them to identify their actual and ideal role behaviors. The results showed no difference in the actual role behaviors performed by both groups. In terms of ideal role behaviors, non-master's prepared nurse practitioners rated the majority of the technical and master's level behaviors higher than master's prepared nurse practitioners. In light of the upcoming changes in our health care system and the potential demand for more nurse practitioners, this study questions the need for all nurse practitioners to be educated at the master's level.