Teaching qualitative research through participatory coursework and mentorship.

Many doctoral programs in nursing now offer at least one course in qualitative research. Yet it remains a challenge to adequately prepare new qualitative researchers due to lack of faculty expertise and mentorship, student unfamiliarity with qualitative research when entering the doctoral program, and uncertainty as to appropriate teaching methods. The authors describe how they addressed these issues historically and in their current two-course qualitative research sequence. Accompanying reports of four studies conducted by students who completed the two-course sequence during academic year 1996 to 1997 provide evidence of the viability of the authors' approach and serve as the basis for recommendations to others who use a similar strategy for teaching qualitative research.

A rural vision of a healthy community.

Nurses can take a leadership role in the process of helping rural Americans to recognize and implement their vision of a healthy community. This necessitates an understanding of rural communities' perceptions of health and health care and allows nurses to more appropriately provide primary health care. As defined by the World Health Organization, primary health care is comprised of concepts of essentiality, community participation, intersectorial collaboration, access, and empowerment (Barnes et al., 1995). A focused ethnography involving 150 residents was conducted in a midwestern rural community and included 56 personal and 8 focus group interviews. A qualitative analysis of responses to the question, "What is your vision of a healthy community?" was conducted using Leininger's (1985) categories of economics, social-kinship, cultural, political-legal, religion, technology, and education. An eighth category of environmental concern emerged from the data. Responses were further assimilated into descriptive statements reflecting the community's vision of a healthy community, including issues of accessible and technologically adequate healthcare, job availability, strong community support by schools and churches, a caring community membership, and an attractive, pollution-free environment. This analysis demonstrates the need for application of primary health care at the level of community in designing services to achieve healthy rural communities.

The experiences of families with a relative in the intensive care unit.

OBJECTIVE: To describe the experiences of families with a relative in the intensive care unit (ICU). DESIGN: Retrospective, descriptive, and qualitative. SETTING: The surgical-trauma ICU in a midwestern university-affiliated tertiary medical center. PARTICIPANTS: Eighteen women and 2 men with relatives in a surgical trauma ICU. OUTCOME MEASURES: Focus group and individual unstructured interviews. RESULTS: A group interpretive process was used to code, categorize, and identify themes found in the transcribed interviews. Four categories of experiences were identified: hovering, information seeking, tracking, and the garnering of resources. Hovering is an initial sense of confusion, stress, and uncertainty. Information seeking is a tactic used both to move out of the hovering state and to identify the patient's progress. Tracking is the process of observing, analyzing, and evaluating patient care and status and the family's own satisfaction with the environment and with care givers. The garnering of resources is the act of acquiring what family members perceive as needed for themselves or their relative. CONCLUSIONS: Families experience a sense of uncertainty that is eventually resolved by seeking information and resources. Health care professionals can minimize the stress associated with hospitalization of relatives in the ICU by anticipating and addressing the family's needs for information and resources.

The role of the lay midwife in childbirth in rural Portugal.

The following article was written shortly after the fieldwork was completed in 1979. The research was conducted just after Portugal's 1974 revolution, prior to which a repressive political regime allowed virtually no social research. Since that time, some significant works have been published, but no other ethnographies focus on the role of the lay midwife. The kind of information obtained in this study required then, and would now require, heavy reliance on ethnographic fieldwork. This publication may serve as a baseline for comparative research. An epilogue provides some updating of statistical information about infant mortality rates; however, little can be determined about rural-urban differences. The limited information available suggests that very little may have changed in the last 15 years for the lay midwives in the rural villages studied.

A place to be yourself: empowerment from the client's perspective.

This article describes a focused ethnography of a group of chronically mentally ill clients who were involved in a client-run drop-in center. Spradley's (1979) Developmental Research Sequence guided the research. Data were obtained from interviews, participant-observation and documents review. The qualitative analysis identified the major theme of empowerment, which had four process domains: participating, choosing, supporting and negotiating. These domains represented four levels of empowerment for this group. From the client's perspective, empowerment meant they participated more in the community, their choices were increased, they provided support for each other and they negotiated on a more equal basis with staff. A fifth domain, personal significance, described the effects of empowerment for each individual.

Health beliefs related to diarrhea in Haitian children: building transcultural nursing knowledge.

Regardless of where they live or under what circumstances, mothers throughout the world seem to have a compelling desire to provide the best possible health care for their children (Huston, 1979). Haitian mothers living in the Dominican Republic were no exception. The health beliefs and practices of these mothers related primarily to diarrhea among their children which demonstrated a concern and resourcefulness that is commendable. The results of this study clearly indicate the importance of transcultural nurses conducting culturally relevant research as a basis to develop sound health programs in developing countries. Diarrhea was identified as the single most important threat to a child's health in these communities. That mothers did not know about the correct ingredients and/or proportions for oral rehydration solutions (Western views) was of interest. Although the Dominican government makes some commercial packets of ORS, most of the women interviewed did not have ready access to this product. This finding reflected the need for transcultural nurses to offer to teach mothers how to make ORS using the sugar, salt, and water they had available. Since the mothers' perception that diarrhea was a dangerous threat to their children's health, was verified by childhood mortality statistics in the bateys, it would seem that ORS could make a significant impact on the health status of the children. Breastfeeding also was a major health belief factor associated with the treatment of diarrhea. Even though the majority of mothers believed breast feeding should be continued if a child had diarrhea, a number believed it should be discontinued. Nurses working with CHWs will need to emphasize the importance of breastfeeding and help them to develop creative ways of communicating this information to the mothers. The second most dangerous threat to the child identified by the mothers was respiratory ailments. This suggests a new area of concentration for future research and training of CHWs. A host of new questions related to respiratory problems such as health beliefs, causative factors, course of disease, traditional treatments, mortality rate, etc. need to be investigated. When transcultural nurses plan health care programs for women and children in other cultures, it is important to recognize the concerns mothers have for their children, and their intense desire to nature and care for them. In this study, mothers willingly participated and demonstrated active interest in learning to use methods to improve the health and well being of their children. It is well documented (Lieban, 1977) that established health beliefs are not automatically discarded when new knowledge is made available, but that exploration and incorporation of new information when presented in a culturally relevant framework does occur. An understanding of local beliefs surrounding health is fundamental to the development of appropriate transcultural nursing interventions.

PIP: Interviews conducted by community health workers with 83 Haitian women working in sugar cane fields in the Dominican Republic underscored the importance of understanding local health beliefs so that culturally appropriate interventions are implemented. The respondents all had at least 1 child under 5 years of age; their average age was 29 years and they had a mean parity of 4.9. The mothers identified gastrointestinal problems, chiefly diarrhea, as the greatest threat to their child's health. 82% of the mothers had at one time had a diarrheal episode among her children and 31% reported that a child currently had diarrhea; 16% said at least 1 child had died of diarrhea. Water, food, and microbes were identified as the major cause of diarrhea. Although not routinely cited as a cause of diarrhea, the evil eye (transmitted by male of female witches) was viewed by all but 1 mother as a powerful factor in child mortality. The foods mothers claimed they would give a child with diarrhea included lemonade, soups, bananas, and other fruit juices. Both cooking oil and milk were considered harmful. Of concern was the finding that 38% of mothers would discontinue breastfeeding during a diarrhea episode. None of the mothers had heard of oral rehydration; however, most were treating diarrhea with a solution prepared by pouring boiling water over herbs and leaves. This practice suggests that these mothers can be instructed to prepare oral rehydration solutions in which all ingredients are precisely measured. Since diarrhea is a major cause of child mortality in these Haitian communities in the Dominican Republic, promotion of oral rehydration could make a significant contribution to child survival. It is essential, however, that all such interventions incorporate existing beliefs and present new information in a culturally relevant framework.

Patients' perspectives of the role of care providers in amyotrophic lateral sclerosis.

Interviews with 41 patients with amyotrophic lateral sclerosis regarding their perspectives of the roles of doctor, nurse, and allied health personnel showed that emotional support, information, and access to assistive devices were the primary expectations that they held for each of these professional roles. In addition, physicians were expected to evaluate the progress of the disease, help with immediate problems, and continue research to find a cure. Patients wanted to see a physician at each clinic visit. In being given the diagnosis of amyotrophic lateral sclerosis, patients expected the physician to be straightforward, honest but not premature, sensitive to patients' readiness for information, and to convey some degree of hope. Patients were accurate in their knowledge of the disease, but came to the clinic expecting help in managing the illness.

Ten criteria for evaluating qualitative research proposals.

With the proliferation of interest in qualitative research in nursing comes the attendant problem of how to evaluate it appropriately. Qualitative research has its own unique history, philosophical foundations, and methodologies that separate it from the quantitative approach. Although the literature is crowded with guidelines for evaluating the latter, little is offered for the qualitative reviewer. The Research Proposal Evaluation Form: Qualitative Methodology is a partial solution to this dilemma. It provides a framework for critiquing the proposal phase of a qualitative study and can be an important guide both for the educator and for the novice researcher.

Illness experience in a chronic disease--ALS.

The representative case study method was used in a 1-year longitudinal study of two individuals with a chronic, degenerative, terminal neurological disease, ALS (amyotrophic lateral sclerosis, also known as Lou Gehrig's Disease). Participants were interviewed in their homes every 2 months to examine the effects of the illness on relationships with family, friends and the health care system. Changing ideas regarding causation, the use and evaluation of various therapies, use of illness role models, spiritual changes and symptom experience were also explored. Kleinman's concept of explanatory models guides the analysis of the data, although we argue for a greater emphasis on evaluation of therapies within this model.

Notes on health care and traditional birth attendants in the region of Yogyakarta, Indonesia.

PIP: A major in health care services in Indonesia since the 1950s is the development of a national health system with emphasis on service to rural communities. To achieve this a network of 5000 public health centers, or PUSKEMAS, was built throughout the country. Staffing depends upon a nationally legislated requirement that medical school graduates complete 3-5 years of mandatory service in a rural area before they can apply for training in a clinical specialty or go into private practice. The health care system is organized into a hierrachy of resort, with the local health centers screening high-risk cases of all types, which then are referred to regional hospitals and, if necessary, to the university hospital which maintain a full array of health care specialists. Philosophically, there is a strong emphasis on service and coummunity health and a deemphasis on premature adoption of sophisticated technologies. The values of community orientation, service, and sensitivity to cultural differences are trangibly expressed in an interdisciplinary rural community health project now being carried out at Gadjah Mada University (GMU), with funding from the government of the Netherlands. Students make weekly visits to a rural village where they have a simple program foccusing on the weighing of babies. During this process, health screening, health education in proper nutrition, child development, and continuation of breadt feeding are done. Another grassroots coumunity health project is a research project in which members of women's clubs in the rural villages volunteer to do rudimentary screening for high risk pregnancy. The women were trained to check on a monthly basis blood pressure, height, and weight, and to report any significant changes to health professionals at the nearest PUSKEMAS. A shift from simply providing health services to a strong emphasis on health education is advocated. Near Yogyakarta, the midwife holds a respected position within her coummunity and provides supportive assistance in the home during the delivery and for 35 days thereafter, during which time daily massage is given to both mother and baby. The women do not recognize the need for prenatal care and usually seek help only at the time of delivery. The traditional birth attendant, because of her integration and high status within her community, traditional birth attendant, because of her integration and high status within her community, can be an effective allay in the effort to reduce infant and maternal morbidity and mortality.^ieng