Janice Penrod

A Discussion of Chain Referral As a Method of Sampling Hard-to-Reach Populations

Nursing research often requires inquiry into sensitive topics that involve hidden or hard-to reach populations. However, identifying and sampling these populations for research purposes is often fraught with difficulties. Barriers include society’s lack of tolerance of diverse groups, social stigma, concern for issues of confidentiality, and fear of exposure because of possible threats to security. Chain referral sampling techniques are proposed to minimize bias while maintaining privacy and confidentiality. Techniques of chain referral sampling are detailed for use in researching sensitive topics and hidden populations. When carefully planned and executed, this sampling design offers transcultural nurse researchers a reasonable method for accessing and studying special populations that are particularly hard-to-reach.

Concept analysis: examining the state of the science.

As methods for analyzing concepts have proliferated in nursing, a critical methodological issue has arisen. Analytic techniques for examining conceptual meaning have incorporated varied strategies for advancing the concept under the rubric of concept analysis, concept development, and theory building. The authors argue that this evolution has created methodological confusion. Following a discussion of a conceptualization of concepts and concept-theory-truth linkages, methods of concept analysis are critiqued in terms of the purpose and the nature of the findings produced by analyses using both traditional and emergent methods. The authors argue that concept analysis is a process of strategic examination of the scientific literature that results in an integrated perspective of the state of the science, or what is known about the concept. In contrast, concept advancement refers to techniques that emphasize the synthesis of new or deeper knowledge that is relevant to the discipline. The authors conclude that disentangling concept analysis from techniques for concept advancement is critical to enhancing the utility of concept-based research in nursing.

Reframing person-centered nursing care for persons with dementia.

Alzheimer’s dementia manifests in a complex clinical presentation that has been addressed from both biomedical and phenomenological perspectives. Although each of these paradigmatic perspectives has contributed to advancement of the science, neither is adequate for theoretically framing a person-centered approach to nursing care. The need-driven dementia-compromised behavior (NDB) model is discussed as an exemplar of midrange nursing theory that promotes the integration of these paradigmatic views to promote a new level of excellence in person-centered dementia care. Clinical application of the NDB promotes a new level of praxis, or thoughtful action, in the care of persons with dementia.

Heart Failure and Palliative Care: Implications in Practice

The number of people with heart failure is continually rising. Despite continued medical advances that may prolong life, there is no cure. While typical heart failure trajectories include the risk of sudden death, heart failure is typically characterized by periods of stability interrupted by acute exacerbations. The unpredictable nature of this disease and the inability to predict its terminal phase has resulted in few services beyond medical management being offered. Yet, this population has documented unmet needs that extend beyond routine medical care. Palliative care has been proposed as a strategy to meet these needs, however, these services are rarely offered. Although palliative care should be implemented early in the disease process, in practice it is tied to end-of-life care. The purpose of this study was to uncover whether the conceptualization of palliative care for heart failure as end-of-life care may inhibit the provision of these services. The meaning of palliative care in heart failure was explored from three perspectives: scientific literature, health care providers, and spousal caregivers of patients with heart failure. There is confusion in the literature and by the health care community about the meaning of the term palliative care and what the provision of these services entails. Palliative care was equated to end-of-life care, and as a result, health care providers may be reluctant to discuss palliative care with heart failure patients early in the disease trajectory. Most family caregivers have not heard of the term and all would be receptive to an offer of palliative care at some point during the disease trajectory.

Supporting Older Adults Living With Multiple Chronic Conditions

This qualitative study was conducted using focus groups to explore the strategies commonly employed by older adults (N = 37) to manage multiple chronic conditions. Key strategies identified were relating with health care providers, medicating, exercising, changing dietary patterns, seeking information, relying on spirituality and∕or religion, and engaging in life. Although social support was not mentioned as a discrete strategy, the participants’ social networks were embedded in all of the categories. This study supports building a partnership of care in which nurses and other health care professionals function in supportive and educative roles to enhance the older person’s lifelong self-care management and ability to stay in control of multiple chronic health conditions.

From Theory to Practice: The Development of Assessment Guides from Qualitatively Derived Theory

In this article, a method of using qualitative research findings to develop a patient assessment guide is described. Qualitatively derived theory is deconstructed to form the theoretical components of the guide. Nursing assessment questions and behavioral signs are then elicited from the theory. Intervention strategies are extrapolated both from theory and from clinical nursing knowledge. Finally, the assessment guide is implemented and evaluated using techniques of qualitative outcome analysis to modify the guide and expand the repertoire of intervention strategies. This process is illustrated using two projects: hope (from concept analysis) and living with bipolar disorders (from grounded theory). Assessment guides provide a method for directly applying qualitative research to practice and constitute a valid and useful means of patient assessment and intervention.

Review Article: A Model of Palliative Care for Heart Failure

The heart failure illness trajectory is both complex and unpredictable, which makes providing palliative care services to patients with heart failure a challenge. As a result, although services are needed, few tend to be offered beyond basic medical management. The traditional model of palliative care is typically based on palliative care being considered a system of care delivery most appropriate for patients with a predictable illness/death trajectory, such as terminal cancer. This type of model, which is based on the ability to predict the course of a terminal disease, does not fit the heart failure trajectory. In this article, we propose a new model of palliative care that conceptualizes palliative care as a philosophy of care that encompasses the unpredictable nature of heart failure.

A Model of Caregiving Through the End of Life: Seeking Normal

Informal family caregivers provide significant contributions to end-of-life (EOL) care. A theoretical model of the phases and transitions of EOL caregiving was explicated using grounded theory methods to explore the experiences of 46 family caregivers of adults suffering a variety of life-limiting conditions. The derived model describes four phases of caregiving spanning prediagnosis through bereavement. Phases are demarcated by key transitions experienced when the illness progression manifestly challenges the established “steady state” achieved by the caregiver. The basic social process was defined as “seeking normal” as caregivers sought reliable patterns of everyday life while meeting the demands of caregiving. Understanding the progression of EOL caregiving enables clinicians to better support family caregivers as both coproviders and corecipients of care.

End-of-Life Caregiving Trajectories

The purpose of this study is to illustrate variations in caregiving trajectories as described by informal family caregivers providing end-of-life care. Instrumental case study methodology is used to contrast the nature, course, and duration of the phases of caregiving across three distinct end-of-life trajectories: expected death trajectory , mixed death trajectory, and unexpected death trajectory. The sample includes informal family caregivers (n = 46) providing unpaid end-of-life care to others suffering varied conditions (e.g., cancer, organ failure, amyotrophic lateral sclerosis). The unifying theme of end-of-life caregiving is “seeking normal” as family caregivers worked toward achieving a steady state, or sense of normal during their caregiving experiences. Distinct variations in the caregiving experience correspond to the death trajectory. Understanding caregiving trajectories that are manifest in typical cases encountered in clinical practice will guide nurses to better support informal caregivers as they traverse complex trajectories of end-of-life care.

Concept advancement: Extending science through concept-driven research.

As methods for concept analysis have evolved, scholars have confounded the initial exploration of a concept with techniques for developing the conceptual unit, extending nursing theory, and establishing nursing knowledge. We argue that nursing is at a critical juncture in the methodological development of concept-driven research. In order to maximize the potential contribution of this type of research, approaches to concept analysis must be held separate and distinct from approaches to concept advancement. We advocate the use of principle-based concept analysis to determine appropriate techniques for advancing a concept. Concept advancement refers to strategic concept-driven inquiries that incrementally build the specification of conceptual meaning to a more precisely defined unit of meaning that has greater utility for research application. Examples of a project that employed strategic techniques for concept advancement are used to illustrate the flow of serial small projects.