Using clinical models to frame outcomes evaluation: the Arizona Nurses' Association Nursing Report Card Project.

The American Nurses Association (ANA) inaugurated Nursing's Safety and Quality Initiative in 1994. This multiphased initiative provides a framework for the application of the Nursing Care Report Card for Acute Care that aims to evaluate the nature and strength of the linkages between nursing care and nursing-sensitive quality indicators in the acute care setting. Arizona is one of six states participating in this investigation. This article describes the development of the Arizona Nurses' Association (AzNA) Nursing Report Card Project and associated model.

Dehydration: biological considerations, age-related changes, and risk factors in older adults.

Maintenance of water balance is essential to normal physiologic function and vigorous aging. Older adults, however, frequently experience alterations in fluid homeostasis, which result in dehydration. This article describes the physiology of water balance, age-related changes that influence fluid regulation, and associated risk factors for dehydration in older adults. Fluid hygiene is an important health promotion activity for this age group, but when efforts to prevent imbalance are unsuccessful, early identification and intervention to correct problems should be done to minimize adverse consequences. Although much is known about fluid homeostasis, dehydration, and contributory factors in the aging process, water disorders remain prevalent in this group. A great deal of work is still needed to determine "best practices" and creative clinical interventions to support adequate fluid intake behaviors. Both quality management programs and research studies provide avenues for systematic evaluation.

Elder-caregiver care negotiations as dances of dependency.

Well-developed metaphors function as heuristic devices for the communication of scientific ideas. When applied to common, typical situations, metaphorical conceptualization enables a richer and deeper understanding. In this article, the routinized and taken-for-granted situation of elder-caregiver care negotiations is examined through the use of a dance metaphor, the dance of dependency. Metaphorical models of theory are intended to be elaborated and developed in ways that good poetic metaphors are not. Therefore, we systematically describe the general aspects of the dance (rules, facilitators, performances, aesthetics) and relate the specific elements of a dance to the dance of dependency. The picture that emerges is one of elder-caregiver care negotiations as performances, with elders as agents who actively and creatively engage caregivers in their dances of dependency. Participants in these dances sustain a complex organization of behavior to meet the situational demands and maintain themselves as fully integrated participants, based on standards set forth by the jointly negotiated working consensus of the dyad. The resulting description extends what is currently understood about everyday care negotiations, allowing an appreciation of the processes and dynamics by which care negotiations and elder-caregiver relational cultures in multiple contexts unfold, change, and are challenged.

Development and testing the Elder Concerns about Memory Scale.

This article describes the development and testing of an instrument to measure elders' concerns about their memory. The content validity was assessed using a panel of experts. Internal consistency reliability and criterion-related and predictive validity were evaluated using three samples of community-based elders. This brief paper-and-pencil instrument should be helpful to nurse clinicians in numerous settings for assessing the magnitude of elder clients' concern and in planning appropriate interventions to address their distress.

Toward a cross-cultural perspective of family caregiving.

This article is part of a symposium that explores the issues involved in developing cross-culturally equivalent conceptualizations and measures for studying family caregiving. The examples used are from the instrument development phase of an ongoing program of research designed to generate and test a theory that explains the quality of family caregiving for frail elders at home. This article provides the background for the symposium by introducing the symposium's unifying theme: cross-cultural equivalence. The process described is based on the experiences of the cross-cultural research team and Berry's model for developing cross-culturally equivalent research.

Toward a cross-cultural understanding of family caregiving burden.

This article is part of a symposium describing the development of cross-culturally relevant instruments to measure familism, caregiver burden, and quality of elder caregiving among Anglo- and Mexican American caregivers. This article explores issues involved in measuring caregiving burden. Caregiving burden is thought to adversely affect family caregiving, but the influence of culture on perceptions of burden has not been explored. Because no research focuses on caregiving burden among Mexican American caregivers, the first step involved reviewing the literature for cultural factors influencing caregiving and using the expertise of the cross-cultural team to identify and compare the meaning of caregiving burden in both groups. Next, two instrumentation studies were done to analyze the items on Poulshock and Deimling's Burden Instrument for comparable meaning and internal consistency within and between groups. The third step involved assessing the validity of Poulshock and Deimling's conceptualization of burden cross-culturally.

The relevance of familism in cross-cultural studies of family caregiving.

Although familism has been studied in both Mexican American and Anglo families, there is controversy about whether familism in both groups is the same. Research has shown great within-group variability, and in addition, the kinship structure in the two groups is fundamentally different. This article explores the cross-cultural issues in conceptualizing familism and its relevance to caregiving among Anglo and Mexican American caregivers. Based on data obtained in an ongoing research program, the process of arriving at similarities and differences in the expression of familism is discussed using Berry's criteria for achieving cultural equivalence.

Uncovering the cultural context for quality of family caregiving for elders.

This article is part of a symposium exploring issues in developing cross-culturally equivalent conceptualizations and measures for a study of elder family caregiving. This article describes the development of an instrument to measure quality of elder family caregiving among Anglo and Mexican American caregivers. Following a review of typical approaches for evaluating quality of caregiving, a cross-cultural standard for excellence in elder caregiving is described. An instrument consistent with the United Nations Universal Declaration of Human Rights, the QUALCARE Scale, is identified as an appropriate cross-cultural instrument for assessing the quality of elder family caregiving. Refinement of the QUALCARE Scale using Berry's model for cross-cultural research, which necessitated identification of appropriate cross-cultural indicators of quality, is described. Examples of this process of indicator clarification are given for several basic human rights, based on the cross-cultural research team members' experiences with Anglo and Mexican American caregivers.

Effects of the situational context and interactional process on the quality of family caregiving.

A staged theoretical model designed to explain the quality of elder caring by family members was tested. The model posits how the situational context, interactional process, and caregiving burden perceived by the caregiver affect the quality of elder caring. The purpose was to determine the amount of variance explained by the interactional process beyond that explained by the situational context and caregiving burden. Data were collected from 209 elder-caregiver dyads using interviews, observations, and caregiver self-reports. The strongest predictors of caregiving burden were the caregiver's stressful negative life events (situational context) and discrepancy between past and present image of elder (interactional process). The strongest predictors of quality of elder caring were the caregiver's perception of subjective burden and a monitoring role definition on the part of the caregiver (interactional process).

Forgetfulness in elders: strategies for protective caregiving.

Nurses working with elders know from experience that an elder being viewed as forgetful negatively affects both the quality and the quantity of elders' social relationships. Avoiding stigmatization, in the presence of increased forgetting, presents a challenge for elders and their caregivers. Gerontologic nurses can assist forgetful elders with their personal impression management. They can protect these elders from being labeled by their social group. However, in order to assist elders in maintaining acceptable social impressions, nurses need to understand the impression management process and effective strategies for assisting forgetful elders in social situations.