Covered lives and seamless systems: nursing workforce development and integration in Arizona's managed-care environment.

Responding to demands that nursing leaders conduct business in creative proactive ways, the authors of this department share the work of The Robert Wood Johnson Foundation's national program, Colleagues in Caring: Regional Collaboratives for Nursing Work Force Development. The purpose of this initiative is to enhance regional and state collaborative planning and implement actions and policies to address the rapid changes occurring in the United States nursing labor market. This department, edited by Mary Fry Rapson, PhD, RN, CS, National Program Director and Rebecca B. Rice, EdD, RN, National Deputy Director, presents the ongoing work of the program, highlighting the work of the 20 individual collaboratives. Regional approaches to the expected program outcomes and specific challenges and opportunities that are unique to each region's environment are included.

Quality health outcomes model. American Academy of Nursing Expert Panel on Quality Health Care.

PURPOSE: Donabedian's 1966 framework of structure, process, and outcome has guided three decades of study in the United States of the elements needed to evaluate and compare medical care quality. Donabedian's perspective was essentially linear, assuming that structures affect processes, which in turn affect outcomes. Patient characteristics are sometimes considered as mediating outcomes and clinical interventions are considered to be processes. A model is presented in the following article that relates multiple factors affecting quality of care to desired outcomes. It extends previous models by positing dynamic relationships with indicators that not only act upon, but reciprocally affect the various components. SCOPE AND SOURCES: The proposed model was derived from a synthesis of the authors' experience in quality of care practice and research, as well as selected previous theories. CONCLUSIONS: The quality health outcomes model is sufficiently broad (a) to guide development of databases for quality improvement and outcomes management, (b) to suggest key variables in clinical intervention research, and (c) to provide a framework for outcomes research and outcomes management that compares not only treatment options, but organizational or system level interventions. The model also has several policy implications.

Experienced and inexperienced mothers' maternal competence during infancy.

In an exploratory study 136 experienced (multiparous) mothers and 166 inexperienced (primiparous) mothers were studied to determine differences in their self-reported maternal role competence, and variables predicting their competence at postpartal hospitalization, 1, 4, and 8 months following birth. The two groups did not differ in their maternal role competence over the 8 months. Inexperienced mothers' competence was higher at 4 and 8 months than at early postpartum and 1 month, indicating a developmental process in maternal role achievement, but no change was observed in experienced mothers' maternal competence. From 45% to 56% of the variance in experienced mothers' maternal competence was explained over the four test periods, and from 43% to 50% among inexperienced mothers. Self-esteem was a consistent, major predictor of maternal competence for both groups. Maternal fetal attachment, readiness for pregnancy, and pregnancy risk variables were explanatory of experienced mothers' maternal competence only. Sense of control was explanatory only of inexperienced mothers' competence at 1, 4, and 8 months.

Predictors of role competence for experienced and inexperienced fathers.

Paternal competence was compared for 79 experienced fathers (one or more children) and 93 inexperienced (first-time) fathers at early postpartum, 1, 4, and 8 months following birth. No differences in paternal competence by previous experience in the father role were found at any test period, nor did the trajectories of change differ between the two groups. Paternal competence means at 4 and 8 months did not differ, but were significantly higher than 1-month means. During the 8-month period, 30% to 61% of the variance in experienced men's paternal competence was explained; the range for inexperienced men was 31% to 49%. Depression was a major predictor for experienced fathers at 1, 4, and 8 months; partner relationships were predictive at 1 and 4 months. Sense of mastery and family functioning were consistent predictors for inexperienced fathers, who also reported greater anxiety and depression than experienced fathers at 4 and 8 months after birth.

Community empowerment in rural health care.

The Healthy Communities 2000 mandate calls for public health leaders to involve community members in setting health priorities and implementing programs in response to the national health objectives for the year 2000 (American Public Health Association, 1991). This paper describes community involvement through a community empowerment nursing intervention and evaluates its application in a rural community. A community health nursing project (AHCPR, Grant No. HS06801) with three interventions, one of which was community empowerment, was designed to address the health needs of small, rural, underserved, primarily Mexican American communities in Arizona. Community empowerment in this project was based on the community-development approach to community organization, and involved community health nurses and lay health workers, called promotoras, who are key persons in community development. The implementation of two health fairs, one the result of the community-empowerment intervention, is described and evaluated in relation to community health. The community-empowerment intervention was based on community participation and responsibility, hallmarks of the second health fair, reflecting lay expertise and cooperation among various levels of the community. Successes and limitations of the health fairs provide feedback for developing a community-empowerment intervention.

Paternal-infant attachment of experienced and inexperienced fathers during infancy.

Seventy-nine experienced fathers (with one or more previous children) and 93 inexperienced (first-time) fathers were studied for differences in paternal-infant attachment at postpartal hospitalization and at 1, 4, and 8 months following birth. No significant differences were observed between the groups for reported attachment to their infants; scores varied little. Over the 8-month period, from 27% to 47% and from 9% to 22% of the variance in attachment was explained for experienced fathers and inexperienced fathers, respectively. Fetal attachment was a major predictor for attachment for experienced fathers at the first three test periods, explaining 19% of the variance at early postpartal hospitalization, 16% at 1 month, and 9% at 4 months. It was a major predictor for inexperienced fathers the first month only, explaining 13% of the variance at early postpartal hospitalization and 15% at 1 month. Depression was the second most important predictor. For experienced fathers, it explained 8% of attachment at early postpartum and 22% at 8 months; for inexperienced fathers, it explained 7% at 1 month and 9% at 4 months. Environmental factors such as social support and stress had no effects on fathers' attachment to their infants.

Maternal-infant attachment of experienced and inexperienced mothers during infancy.

Differences between maternal-infant attachment and variables affecting attachment were studied for 136 experienced mothers (one or more previous children) and 166 inexperienced (first-time) mothers during the postpartal hospitalization and at 1, 4, and 8 months. Experienced mothers did not differ from inexperienced mothers in maternal-infant attachment at any test period. Fetal attachment explained decreasing amounts of the variance in inexperienced mothers' attachment to their infants over the first 4 months, explaining 11% during postpartal hospitalization, 7% at 1 month, and 4% at 4 months. Fetal attachment entered the experienced mothers' regressions during the early postpartal period only, explaining 3% of the variance. Findings showed that explained variance in maternal-infant attachment for the four test periods ranged from 23% to 43% for experienced mothers and from 13% to 38% for inexperienced mothers.

An overview of data transformation.

There is an increasing awareness of the need to examine data distribution or assumptions prior to performing statistical analyses. If the data display evidence of violating assumption(s), the researcher can perform data transformation. This article focuses on explaining data transformations, discussing common transformations, providing rationale for performing them, and discussing interpretation of the transformation when results are presented.

Predictors of paternal role competence by risk status.

One hundred seventeen men whose partners had experienced a low-risk pregnancy (LRM) and 61 men whose partners had been hospitalized during pregnancy for an obstetrical risk (HRM) were studied to determine whether they differed in paternal role competence from the time of their partners' early postpartal hospitalization to 1, 4, and 8 months after birth. No differences were found between LRM and HRM in paternal role competence, and their trajectory of paternal competence did not differ. During the 1-month and 8-month postpartal period, paternal competence increased from 76.07 to 77.14 for HRM and from 77.21 to 78.29 for LRM. From 15% to 34% of the variance in paternal competence was explained among HRM, and from 41% to 44% was explained among LRM. Anxiety was the major predictor of paternal role competence for HRM, and sense of mastery and depression were major predictors for LRM.

The effects of child temperament, maternal characteristics, and family circumstances on the maladjustment of school-age children.

Eighty-nine mothers with children between the ages of 8 and 11 years reported perceptions of their child's adjustment and temperament, and described concurrent family circumstances such as socioeconomic status, level of parental distress, major life events experienced, maternal hassles, and their own psychiatric symptoms. A conceptual model hypothesizing the direct and indirect effects of family circumstances, maternal characteristics, and child temperament on the maladjustment of school-age children was tested using causal modeling with residual analysis. Fifty-six percent of child externalizing behavior was directly explained by the negative reactivity and nonpersistence of the child's temperament, and maternal hassles. A total of 33% of the variance of internalizing behavior was explained by the direct effects of negative reactivity of the child's temperament and maternal hassles. For both externalizing and internalizing behavior, a total of 54% of the variance in maternal hassles was explained by three variables: maternal psychiatric symptoms contributed 34%, major life events added 15%, and the intensity of the mother's temperament added an additional 5%. These three variables have a direct effect on maternal hassles and together had an indirect effect of .24 on child externalizing behavior through maternal hassles. Likewise, they have a direct effect on maternal hassles and together had an indirect effect of .31 on child internalizing behavior through maternal hassles.

Predictors of maternal role competence by risk status.

One hundred twenty-one high-risk women (HRW) and 182 low-risk women (LRW) were studied at postpartal hospitalization and at 1, 4, and 8 months after giving birth to determine whether they would differ in the achievement of perceived maternal competence and whether predictors of maternal competence would differ for the two groups over time. No significant differences were found in the maternal role competence of HRW and LRW or in the trajectory of change over time. Maternal role competence increased at 4 and 8 months over earlier levels. Selected variables explained from 33% to 52% of HRW's maternal competence and from 29% to 51% of LRW's maternal competence over the four test periods. Self-esteem and mastery were consistent predictors of maternal competence for both groups. Fetal attachment was a predictor of competence among HRW only.

Predicting the outcomes of living with asthma.

The purpose of this study was to explore the impact of person and disease predictors on psychosocial and morbidity outcomes in adults with chronic asthma. Ninety-five asthmatic adults were followed for 60 days with standardized questionnaires and three interviews. Amount of distress during an asthma episode, perceived danger from asthma, and appraisal of social support were predictors of emergency room visits. Self-care, perceived life stress, nocturnal symptoms, and amount of distress during an asthma episode were predictors of depression. Financial status and the absence of nocturnal symptoms of asthma predicted life satisfaction.

The dilemma of seeking urgent care: asthma episodes and emergency service use.

Asthma is an invisible and unpredictable chronic illness characterized by recurrent episodes of airflow obstruction and airway inflammation. Until recently, psychological factors were thought to play a major role in this condition. The notion of an emotionally-based illness serves to discredit asthma as a 'real' illness among health professionals and patients alike, contributes to the sense of stigma that persons who have asthma experience, and impedes effective management. Findings from research with a sample of 95 adults with physician diagnosed and documented asthma indicate that persons who have asthma walk a tightrope between delaying formal medical intervention and seeking treatment too soon. Uncertainty about the quality and speed of care available in an emergency department shapes, in part, the nature of the lived experience of asthma and affects feelings of control over the illness. These concerns create a push-pull dynamic, as individuals struggle to make decisions about emergency department use that will provide relief, ensure autonomy, deter the experience of stigma, and diminish the threat of death.

Focus on psychometrics. Development and administration of a survey instrument for cross-cultural research.

The purpose of this article is to provide a brief review of guidelines for development of culturally appropriate measures of phenomena. The principles are illustrated by citing an example of their use in developing a survey instrument to be used with a rural Mexican American and Euro American population. Discussion focuses on practical issues of implementing the approaches suggested in the literature and adds to the literature about issues in formatting and administration of survey instruments used in cross-cultural research.

Factor analysis of the Maternal Fetal Attachment Scale.

The purpose of this study was to assess the validity of the Maternal Fetal Attachment Scale (MFAS) subscales using factor analysis. The 23-item MFAS is composed of five subscales that have been used to represent the theorized dimensions of prenatal attachment. Two samples of MFAS scores were submitted to principal axis factoring with varimax rotation. The resulting solutions failed to correspond to the subscales of the MFAS and were also different from one another. These results indicate that the use of the MFAS subscales, as currently constructed, is problematic.

Predictors of partner relationships during pregnancy and infancy.

The partner relationship of 153 women hospitalized for a high-risk pregnancy, 75 of their partners, 218 women who experienced a low-risk pregnancy and 147 of their partners was studied to determine risk-status or gender differences at pregnancy, the postpartal hospitalization, 1, 4, and 8 months following birth. A theoretical causal model predicting partner relationships was tested, followed by model respecification to derive the best explanatory model for each group. No differences were observed between low- and high-risk mothers' partner relationship; however, high-risk fathers scored lower than low-risk fathers. Partner relationships for all groups were significantly higher during pregnancy and at birth than at 4 and 8 months after birth. Respecified models explained from 26% to 63% of the variance in partner relationship during pregnancy, and from 31% to 52% at 8 months after birth.

Focus on psychometrics. Aggregating family data.

Instruments to collect data about families are often administered to all or some individuals within the family. Researchers may wish to use these individual scores to describe the family. The purpose of this article is to describe the special issues with aggregation of data when only a small number of family members are used as respondents. A refinement of the definition of aggregation for family researchers is proposed to assist researchers to focus on specific issues when data are to reflect subgroups within the family. A few examples of changes in findings are reported to illustrate the effects of different aggregation schemes when two members of the family are used as respondents.

Clinical markers of asthma severity and risk: importance of subjective as well as objective factors.

The purpose of this study was to explore patient perceptions of asthma severity and danger from asthma, correlate them with objective measures, and assess the impact of psychologic variables on the perception of severity. Recognition of patients at greatest risk for fatal attacks requires identifying those with severe asthma. In our study of 95 adults with asthma, we found that the subjective factors of perceived severity and perceived danger and the objective factors of medications, hospitalizations, history of intubation, and pulmonary function were important markers of asthma severity and risk. Our findings indicate that asthmatic adults make independent self-assessments that generally correlate with objective markers of increased risk of mortality and increased severity of the asthma. The perception of high severity was significantly correlated with depression, panic-fear, frequency of emergency department visits, and with an objective index of risk of death. The latter includes variables obtainable from history alone (number of medications to control symptoms, need for prednisone, prior intubation, and prior recent hospitalization) and is correlated with spirometric indexes of airflow obstruction, occurrence of nocturnal symptoms, and number of emergency department visits.

Focus on psychometrics. Scaling stimuli with magnitude estimation.

Magnitude estimation has been shown to be a useful model for scaling physical and social stimuli. This scaling method holds promise for researchers who are interested in scaling the individual's perceptions of physiological states such as breathlessness as well as social phenomena such as intrusiveness or difficulty in performing a task. The purpose of this article is to provide information about magnitude estimation as a scaling method in general and about the use of magnitude estimation to scale the individual's subjective responses to stimuli.