Research
on Clinical Problems in Nursing Gives Rise to
Improvements
in
Practice and Patient Care
The goal of nursing research is to build a body of knowledge that will enable practicing nurses to prom0te and protect the health of individuals, families, and communities, and to assist individuals and families to cope effectively with illness. Today nurses in hospitals and nursing homes or caring for patients at
To further illustrate the scope of current nursing research on this campus, Dr. Priscilla
Ulin is studying heatth needs, health beliefs, and health behavior in a Colombian community. Research contributes to the development of new knowledge: to be meaningful in a practice discipline, it must also be used to improve practice. A thre*year project to encourage the utilization of research in nursing practice is
home and nurses working in community health face complex, interrelated problems-pain, fatigue, and nausea, for example, often come together, causing immense human suffering; the problems of inadequate nutrition, immobility, and disturbed rest and sleep prevent recovery of the ill; the interrelated problems of poverty and unhealthy lifestyle often stand
led by Dr. Sandra Funk, Dr. Mary Champagne, Dr. Laurel Archer Copp, and Elizabeth Tornquist. Last spring, the group held a national conference on Key Aspects of Comfort; their second conference, in spring 1989, will focus on Key Aspects of Recovery. The aim of the project is t0 encourage the use of research
in the way of maintaining health. The studies presently being conducted by nurses in the UNC-Chapel
findings by making them widely available in a form that is understandable to clinicians, with suggestions and support for implementation. Volumes of research from the conferences are being published by Springer. The group is also providing an inlormation center to
Hill School of Nursing encompass
many of these problems. For example, effective care of the aging population will be a major challenge to the health care delivery system in the next cen-
in the hospitalized elderly complicates care, upsets patients and families, and may lead to numerous complications. Dr. Virginia Neelon and Dr. Mary Champagne, with co-investigators Dr. Carol Hogue and
Dean Laurel Archer Copp
tury. Confusion
facilitate ongoing communication between cardiovascular disease,
in an effort to
prevent
such disease.
A high+isk population in our
society, the
of confusion development and interventions to
youngest population, is premature infants. Dr. Diane Davis and colleagues are studying sleepwake states in these infants in an effort to
prevent 0r reduce acute confusion in the elderly
identify factors affecting development. Dr.
and improve functional recovery. Dr. Hogue is also looking at ways t0 predict falls in medically unstable older adults residing in the
Margaret Miles, Dr. Davis, and Annette Frauman are studying the impact of longterm stay of medically fiagile children on parents.
Eleanor McConnell, are investigating patterns
community, since this is one way t0 prevent hospitalization and possible institutionalization.
Another area of major concern in society today is cardiovascular diseases. Researchers in the School of Nursing are currently studying cardiovascular disease in both adults and children. Dr. Joanne Hanell is investigating the effects of routine nursing procedures on the cardiac output of patients with acute myo cardial infarction; and Dr. Harrell and Annette Frauman are identifyint children at risk for
Nurses are concerned about families as
well as patients and therefore, several current faculty studies focus on families. The transition to parenthood by infertile couples is the focus of the research of Dr. Margarete Sandelowski, Dr. Diane Davis, and Dr. Betty Harris. Parents' responses to a child's terminal illness or suicide are the concern of Dr. Margaret Miles. Dr. Barbara Germino and Dr. Sandra Funk are examining family concerns after a family member's cancer diagnosis.
researchers and clinicians. Thus School oi
Nursing faculty make the full circle-drawing on clinical problems as the bases of their research, conducting studies to solve these problems, and ensuring that the solutions move into practice, s0 as t0 improve nursing care and enrich both practice and inquiry. And as observed recently by UNC-CH Chancellor Paul Hardin, "lt seems to me nursing research is also characterized by compassionl'
*Dean Laurel Archer
Copp
Dr. Laurel Archer Copp has been Dean of the UNC-CH Scltool of Nursing since 1975. She has published N)merlas books and articles on the subjects of pain and pain management, and is presently editor of the Journal of Professional Nursing.
Promoting Health Among th6 EHerly disease treatment.
care practitioners
At the same time, health
in these
13 sites hope that
routine screening for various physical conditions, coupled with counseling from nurses
on healthy lifestyles, will reduce risk behavior and improve the quality of life for elderly
in the program. The routine medical checkup can help in the early detection of disease; the counseling covers such topics as nutrition and weight control, exercise, participants
medication awareness, and tobacco and alcohol use, among others. According t0 Dr. KincadeNorburn, "This study along with several other similar ones that will soon be conducted elsewhere could significantly affect future
national health care policyi' Kincade-Norburn of the evaluation that will
serves as director
come out ol the interviews, which are scheduled to be finished by spring 1990. The principal
investigator for this project is Dr. Joseph P. Morrissey, deputy director HSRC and associate professor of social medicine at UNC-CH.
Aided by Hazel Kiser, rcceptionist (left), Drs. loseph MorrissE and Jean KincadeNorburn review patient files at Village Fanily Medicine in Chapel Hill, one of the 13 primary care practice sites involved in the Medicarc project.
Health promotion among the elderly, especially efforts to encourage and enable older adults to take care of themselves, has been a major research interest of Dr. Jean KincadeNorburn for at least six years. "Health promotion for
the elderly is very different from that for young adultsl' explains KincadeNorburn,
in UNC's School associate in the
research assistant professor
of Nursing and research
Health Services Research Center (HSRC). In
the young, it means prevention of disease; but as adults over 65 may already be afflicted with disease, health promotion for these people means helping them to cope with and perhaps to mitigate the impact of illness, whether it be chronic or acute.
As an "add-on" study to the Medicare project, Kincade-Norburn is assisting Dr. Mark Williams of UNC's Department of Medicine in his measurement of function in 1,240 of the 2,400 participants. Williams has devised a
viding reimbursement for preventive services by granting waivers to existing regulations so
Timed Manual Performance Test which has already proven to be a good predictor of functional decline in the severely disabled; now he wishes to try this test in a community setting to see whether it is a predictor of declining health. The idea is to measure an older adult's ability to perform everyday activities related to self-care by means of a timed test in which he or she is asked to complete task which simulate those everyday activities. The subject is asked, for example, t0 open and close several doors built into a single panel and equipped with a variety of latches, or to pick up a number of paper clips one at a time. These and other tasks
to determine whether of selected preventive health services might in the long run reduce the cost of
require one to demonstrate a level of dexterity necessary for functional independence, which is quite different, Kincade-Norburn points out,
KincadeNorburn is currently involved in a variety of research projects related to this central interest. One of the most significant of these began in October 1985 and involves 2,400 elderly participants as well as 13 primary care practice sites (both rural and urban)
in central North Carolinas Research Tliangte area. Whereas Medicare does not normally cover preventive services for the elderly apart from the pneumococcal vaccination, the Health Care Financing Administration (HCFA) is pro-
researchers can attempt coverage
E.il
D.E.A.Y.O.R
S
fessionals, says Kincade-Norburn, "will have a better handle on the problems and practices actually out there" and will be able to help by providing important resources and services.
Tho additional projects of interest to
ffi
#* *
Kincade-Norburn are planned but awaiting the necessary funds. A study 0f horticultural therapy will combine the efforts of Kincade Norburn and Elizabeth K. Moore of UNC's Botanical Gardens Foundation. Kincade-Norburn
will
be evaluating the fieldwork directed by Moore in four different public housing units
in Durham, North Carolina, two of which will implement a gardening program and two of which will be "control" units. Moore will assist interested residents over 65 in acquiring the tools, seeds, and advice necessary for
planting and tending their own gardens.
Be-
cause horticultural therapy has found much success among other populations, such as the incarcerated and the mentally handicapped,
Kincade-Norburn and Moore want t0 measure the degree to which it can improve the health and quality of life of low-income elderly who normally do not have the resources for such "self-help" therapy. Ultimately the co-investigators will write a manual for distribution among city housing authorities nationwide explaining how to implement the program in their own areas. Similarly, a project manual is expected to result from a study Kincade-Norburn wants t0 conduct involving 0ne-0n-0ne health promotion and small group discussions between a nurse and residents of several Continuing Care Retirement Communities (CCRC$. "l chose this type of setting for this studyl' says Kincade-Norburn, "because it appears to be
Dr. Jean Kincade-Norburn and research assistant Alison Woomert work on survey instrument to be used in the national self-care study.
from simply asking someone whether he can dress himself or whether he is capable of doing house or yard work. Funded by the Robert Wood Johnson Foundation, Williams' study is scheduled to conclude in March 1990. Kincade-Norburn serves as co-investigator with Dr. Gordon DeFriese, director of HSRC, on a research project recently funded by the National lnstitute on Aging. In-home surveys will be conducted among 3,600 people over 65 years of age nationwide in an attempt t0 find out just what older Americans living at home actually do to take care of themselves. Exactly how do they cope, for instance, with chronic illness (such as arthritis) 0r acute illness (such as an upper respiratory infection)
not serious enough to require hospitalization care? What do they use in the way of ambulatory devices or other special equipment t0 compensate for various physical disabilities? What sort of exercise do they get, and how do they regulate their diets? As the completed surveys come in,
or nursing home
Kincade-Norburn, DeFriese, and colleagues
will
analyze them to see how widely, if at all, self-care practices among various subpopulations of the survey sample differ-from region to region, for instance. When more is
the living arrangement of the future for many older Americansl' She explains that the typical CCRC is an ideal place for the practice of health promotion since professionals-such as the nurses involved in this project-can bring health care and counseling right to the entire community, where such physical resources as meeting rooms and recreational equipment are centrally and conveniently located. As a group, points out Kincade-Norburn, these projects emphasize healthy lifestyle and
functional independence in the community. Through such an approach health care professionals can contribute to the general well being of older adults and at the same time them-and the taxpayer-a great deal of money that would otherwise be spent on treatment of illness. save
known about what helps older Americans to remain functionally independent and living at home (after all, only 5 percent of all elderly live in nursing homes), then health care pro-
-Allison
Bulsterbaum
Determining Norms for Prematuile Infants For almost 15 years, premature infants have intrigued Diane Holditch Davis. Ever since she was a nurse in neonatal intensive care units in San Diego and Honolulu, she has wanted to learn how to provide better nursing care for premature infants. "l became interested in trying to provide a better and more comprehensive service to these childrenl' says the UNC-CH researcher who received her Ph.D. in developmental psychobiology three years ago. Now an assistant professor in the UNC School of Nursing, Davis is in the middle of a study analyzing behavioral development patterns in premature infants. "What I'm trying to do is to find answers to questions that will provide a basis for making clinical decisionsl' Between
7 and 10 percent of babies born
States are premature. 0f that number, half may need some minor hospital care and have a slightly increased risk of later health problems, but generally grow into normal children. The other half need inten-
in the United
sive care treatment, Davis says. About 80 percent ol the premature infants who need intensive care survive; 30 percent of them will experience major developmental problems, such as cerebral palsy, mental retardation, blindness, and deafness. Another 10 percent of those premature infants will incur minor developmental problems, such as learning disabilities.
Davis wants to know how to identify the premature infants who are at risk for developing long{erm problems. lndividual cases
are hard to predict because better than half of the children needing intensive care turn out to be healthy. In the past, developmental patterns of preterm infants were based on what was normal for full-term infants, Davis says. But premature and full-term infants fundamentally are different, due, in part, to stressors incurred by premature infants before they are born. "Most full-term infants have a relatively benign course in utero and a lot of
_-
Every l0 seconds during four-hour observation sessions, UNC researcher Diane H. Davis enters various behaviors of prenature infants into an event recorder.
preterms don'tl' Davis notes. Premature infants have been exposed more often in utero t0 maternal smoking and alcohol drink-
ing, maternal illness, multiple birth, and placental insufficiencies. Davis says researchers know little about the premature periodthe time from birth until infants reach 40 weeks gestational age. "lnstead of ways to compare them to full-term infants, we need ways to compare them to other preterm in-
lantsl' Davis explains that a developmental model for premature babies would highlight those who deviate from norms for all preterm infants. And that could lead to earlier identification of at-risk premature infants, which means possible quicker healthful intervention measures.
In an attempt t0 construct a
developmental
model for the preterm period, Davis observes
sleeping and waking states of premature infants. "Because infants cannot change waking states as readily as adults, the sleeping and waking states of the infants also have a maior
impact on the infant's responsiveness to stimulation and to parental interactionsl' she explains. "Thus, understanding how these sleep-wake patterns are affected by age, nursing activities, and medical procedures wilt help
nurses in identifying infants at risk for later problemsl' To construct a model t0 identify at-risk oremature infants, Davis designed two cohort studies, or studies of groups of babies born about the same time. [n each study, about 35 infants are being observed once a week for
four hours from the time their medical conditions are no longer critical until they reach term age. When the babies reach age 3, tests
will be done to
check each infant's development. Those results will be compared to observations made shortly after birth to see if long-term development can be predicted. The first cohort study included premature babies born at North Carolina Memorial Hospital from December 1985 through August 1988. The second group was to include premature infants born in the twoyear period starting August 1988. Children in intensive care who are selected for study have to meet
one of two criteria to be in either study: They must weigh under 1,500 grams (about 3.3 pounds) or need mechanical ventilation to breathe. "The majority of my babies met both
criterial' Davis
says.
Parents who permit Davis
to observe their
children receive an extra benefit from the hospital-once a week, their child has an extra person monitoring his or her condition. Davis sits quietly and does not touch the babies, but often can help nurses by giving insights into each infant's health. In her lap is an event recorder, a device that looks like a computer keyboard. Every ten seconds, she scores up to 40 behaviors, from a caregiver's interactions to the infant's sleep-wake state, behavior, and respiration. Events recorded when a caregiver is near include feeding, talking by caregiver, and recovering from pain. Davis also notes times of painful care, in which the infant experiences a painful or uncomfortable procedure with caregiver such as tape removal from a wound or a needle stick
for a blood sample. Sleep-wake states
Theta Tau, IBM, UNC School of Nursing, and the National Institutes of Health's Biomedical Research Support Program, so far include no tests of 3-year-olds; these were due to begin in December 1988. Still, preliminary findings support her idea that a developmental model exists for premature infants. The most significant finding is in the type and amount of sleep premature infants get. Davis found that premature babies born ten
vations, parents receive thank-you notes. And for three years, in April and October, Davis sends parents a brief questionnaire asking about the baby's caretaking, health, develop-
weeks before
sleep,
will
con-
active sleep, and quiet sleep. Davis usually does not have to press 40 different buttons
says.
active
in which their eyes are closed, but
in which there is little motor activity and slow respiration, and the time in sleep-wake transition periods increase by gestational age. "These babies go from sleeping a lot 0f the time to sleeping less, but they still have about the same amount of waking timel' Davis says. "They spend more time nodding
duct a complete developmental assessment, including an IQ test and a test to see how parents teach their child. 'At age 3, you can predict IQ and diagnose some of the minor problems, as well as the major onesl' Davis says. Following the developmental assessment, parents are told results, which are interpreted
for any problems. They will receive referrals for help, if needed. "We expect some of these
three-
respiration is uneven and rapid-eye-movements occur. About the time the preterm infants reach the age full-term infants are born, the amount of active sleep drops to about half the observation time. Amounts of quiet sleep,
at UNC-CH where Davis' co-investigators, Cathee Huber and Debbie Brandon,
full term spend about in
fourths of their observation time
ment, and other changes. From birth to age 3, babies also get birthday cards, while families get Christmas cards in the same period. When babies reach age 3, Davis plans to visit the children in their homes, which are scattered throughout North Carolina and parts of Virginia. She will observe child-caregiver interactions and do an assessment of the home environment. Following that, she will ask parents to record sleep patterns for a week. Parents then will take the children to the Clinical Center for Development and Learning
observes include alertness, crying, drowsiness,
she
Davis' results in the first cohort study, funded by various groups including Sigma
six times a minute, but enters any changes that occur in each lO-second period. "lt is tiring, but it's exhilarating because as you do this, you get involved with the babyl' In her first cohort study, Davis averaged 3.5 weekly four-hour visits for each baby. Following the hospital studies of premature infants, Davis keeps in contact with her test group. lmmediately after the series of obser-
off or being drowsyl' which indicates a developmental pattern. "My hypothesis is these developmental changes occur because of development going on in parts of the brainl' Davis guesses that if a premature infant does not follow the normal sleep-wake pattern for premature infants, the way they sleep could indicate developmental problems. Support for
the thesis that a developmental pattern is at work in sleep-wake states comes from Davis' discovery that of her 40 measures, 25 are statistically significant. "The variables l've
kids v,,ill have significant problemsl' Davis
selected are variables that do show strong
tendencies to change over agel' Davis explains. "When you get 25 out of 40, you know you're dealing with a lot of meaningful developmental changesi' If Davis finds a way to identify at-risk premature infants, she says those infants can get help earlier, especially through a federal
a =
program that provides services, such as familybased early intervention, to premature infants. "lt would be more cost effective to target those premature babies more likely to have problems. At this point, there's no way of targeting theml' Davis hopes that analyzing patterns from premature infants' sleep-wake
in relation to development three years later will accomplish this goal.
states
Davis places a rcspiration sensor pad under one of the pretem babies in her study group. Babies lie on the pad so respiration and novenent can be recorded wilhout interfering with treatment given to then.
-Andy
Brack
Preliminary Results Focus on Nursing Care Even though it will be a few years before the completion of Diane Holditch Davis' research, her observations of preterm babies
may help nurses give better care. Eventually, she expects t0 develop a model to identify premature infants who are at risk
for later dwelopmental complications, such as cerebral palsy. For now her obserrations on premature infant pain, apnea,
and respiration may yield better nursing strategies.
"Until recently, physicians didn't think babies felt painl' Davis notes. "We've moved up a step in that we now think babies feel pain, but we don't have the technology to know how to comfort them,
and for a number of painful things, it's not practical to use an anesthetic because the painful event is so brief. But you need a method to calm theml' In observations of about 35 premature infants in a three year period ending August 1988, Davis found no evidence that nurses talked to or touched premature infants to calm them
Ar{ur4
after painful stimuli, such as the slow
re.l;),u,,',"',
removal of tape dressings around a wound
3 $
it6*{r -,e? ..,,-t
:,
:
a
*,.
or insertion of an intravenous tube. "Why they're not doing these things, we don't
knowl' she says. "Part of it is there has not been a really good study of ways to calm babies after painful stimulij' although she adds that one of her graduate students, Gina Young, is working on just that
Chrbty
Seay,
soothes one
at the time a physial therapy student at North Carolina Menorial Hospital, o[ the infants in Davis' study group.
problem.
development and to sleep statel' Davis
Davis also observed frequent apneasperiods of stopped breathing-in preterm
says drugs can be used
infants.
'All
babies have periods when
they stop breathing when they sleep. It's
normal up to l0 secondsl' But almost all premature infants less than 32 week old have prolonged apnea. "They will have periods when they stop breathing for more than 20 seconds, which is when we get concernedl' Davis says better understanding of apneic periods, a maturational disease infants grow out of at about 36 weels, could lead to increased survival rates of preterm infants. "We know it's more frequent
in the preterm period than the period. And, we know
its
post-term
related to brain
to treat apneas,
"but we really don't know how these factors interrelate or even how the drugs workl' By getting detailed descriptions of behaviors of preterm infants with apnea and how they change as the infants age, Davis sap she hopes to contribute to the understanding of the problem.
Another observation revolves around respiration rates of premature infants. Davis says that traditionally', caregivers believed that infant respiration rates of
more than 60 breaths per minute were abnormal. "My data strongly suggest that
in
infants who have been
care, 60
is normall' she
in
cuddles and
that half the preterm babies she observed had average respiration rates greater than
60 breaths per minute, while most of the others had lsolated rates above 60. Davis claims that any care does not have to wait until premature infants' breathing reaches standards for full-term infants. For examplg caregivers often refrain from bottlefeeding or giving medication to infants when their respiration is high and wait until it is less than 60 breaths per minute. ?hat is a practice she questions. "lt seems that in these infants, a respiration rate of 60 is not a problem by itselfll
intensive
says. Davis adds
-Andy Brack
I'
E.il
Pain: How Patients Cope Affects How Clinicians Manage 'All too often,
the physician does not hear the pleading as he uercises his option to leave the scene. The patient and the nurse cannot leaveas much as they both would like to do so."
-Laurel Archer
Copp
"Pain is a very private and highly individual experiencel'says Dr. Laurel Archer Copp, Dean 0f the UNC School of Nursing. "Only the sufferer can tell us what he is feeling; only he knows how to copei' With these words Dean Copp captures the essence of her more than fifteen years of research into the once ignored, and still frequently misunderstood, world of pain. In the 1960s and early 1970s, pain and death were taboo subjects in American society and medicine. "There was a kind of 'We don't have pain here' mentalityl' Copp says of the prevalent attitude at the time. "There was a lot of pressure for patients to behave a
Dean Laurel Archer Copp exanines slides for presentation on pain management.
a
behavior as follows:
certain way, to downplay paini' But in the 1970s, attention was gradually focused on the process of dying-and with the "discovery" of
say, 'Pain
death came the "acknowledgment" of pain,
notes.
she explains.
Now, hundreds more interviews later, Copp has refined her findings and is actively educating health care personnel about the pain experience and pain management techniques. She defines two distinct groups of coping techniques: pain coping via external foci and
In the early
1970s,
while at Penn
State
University, Copp began her inquiry into pain by interviewing 148 critical care patients in five Pennsylvania hospitals. The interview process was difficult because lhe patients' pain often made it hard for them to answer questions, Copp points out. Yet later, when they did not hurt, they were unable to answer because they were in the process of denying, absorbing, or forgetting the pain. Focusing her research on the patients' responses to pain, rather than the pain itself, Copp defined more than thirty pain coping strategies utilized by sufferers. She also characterized pain according to the sufferers-not the clinicians'-perceptions (see coping model chart). "lt was very rewarding to be able to
disengagement from the painful body part or the entire body; heightened dreaming about the pain experience; or tropistic yearning, the desire to feel natural forces and objects such as sunlight, running water, earth, animals, and/or growing things. "These pain behaviors have a significant bearing on what clinicians should do for the patientl' Copp explains. "[f a person is externally oriented and needs to use his muscles, walk around a bit-you let him. But if a person needs quiet to cope, frequent interruptions or moving him from r00m t0 r00m is the worst thing to dol' Copp has also developed a coping model that delineates five behavioral postures assumed by pain sufferers. A posture is meant to indicate a perception of pain and a stance taken by the sufferer. The model evolved from the use of sufferers' pain language and their interpretation of what meaning the pain experience had for them. These pain postures are operationally defined and motivate pain
is what patients say it is, not necessarily what clinicians infer it isl " she
pain coping via internal mental foci. Sufferers who utilize external foci will often apply counter pain, by rubbing or pounding a body area near the pain point; use their
.
o Pain Behavior Posture #2: Pain=invading, Coper:combatant. The patient perceives pain as all powerful but himself as an
.
people to distract
or emotionally
a reality and is responsive to and intraceptive about pain. o Pain Behavior Posture #4: Pain:cunning, Coper=reactive. The patient perceives pain
to be unpredictable and irrational, therefore he is on surveillance to watch and study it
support
Sufferers who utilize internal foci practice mental vigilant focusing, which is intense
concentration on sights, sounds, or mental processes; mind-body separation, the mental
active fighter. Pain Behavior Posture #3: Pain:reality, Coper=responsive. The patient acknowledges pain as
muscles in other ways, such as rocking or pacing; or rely on the presence of other them.
Pain Behavior Posture #1: psin=powerful, Coper=passive. The patient perceives pain as all-powerful and himself as a victim.
carefully.
.
Pain Behavior Posture #5: Pain:demanding,
Coper:interactive. The patient acknowledges the power of pain and believes that unless great care is taken it can get out of
EilDEA
control, inflicting damage in addition to that of the presenting condition or disease. Each coping posture
in the typology
Coping Model
carries
unique implications for staff attempting to manage the patient in pain. Copp stresses that staff-especially nurses-should be aware of the patient's particular needs. "Pain management is the essence of nursing carei' she says. "l know that nurses have lots of other things to dq but I feel that pain management is most importantl' Patients who assume Posture #l (Pain= powerful, Coper:passive), for example, do not hear reassurance, and so staff must consider the nature and magnitude of the dependence of this sufferer. They must demonstrate their
PATIENTS' RESPONSES WHEN ASKED WHAT NURSES AND DOCTORS COULD DO ABOUT PAIN "Slow down, don't hurry so, you can't hurry pain" "What is more important than talking to patients about pain?" "Be prompt. Try to understand. Make more of an etfort." "Stop telling people they don't have pain when they actually do. Don't try to feel for people when you can't know if they hurt or not." "Don't make judgments when you don't
Pain/Self-lmage
Language
Self-Situation
Coping
Type One Pain: Powerful Coper: Passive victim
Merciless Cosmic
Fragile Helpless Dread-filled
Skepticism
lrrevocable lrreparable lrrational
Type Two Pain: lnvading Coper: Combatant
Type Three Pain: Reality
Coper:Responsive
Type Four Pain: Cunning
Coper: Reactive
Type Five Pain: Demanding Coper: lnteractive
know and haven't hurt." "Don't ignore patients in pain and give them the brushoff-we aren't a bunch of neurotics."
"Have confidence you can help the
pain-if
Overwhelming Continuous
Episodic Strong Sharp Dominating Testing
Abandoned Alone Suffering Fighter
Coper Survivor Soldier Confronter
Fate
Ritual Magic
Counterpain Muscle language Delegates Assigns tasks
Armamentarium
Testing Demanding Mysterious Hidden Cosmic
Confronter Endurer Suffering Analyzing
Hidden Faceless Sneaky
Watcher Waiter Monitor
Anticipating
slv
Vigilant
lnvading Degrading
Ready
Early warning Not risking
lntense Persistent Sharp Probing Treacherous lll-tempered Strong
Cooperator
Contractual
Collaborator Communicator
Arrangement
Contractor Dependent
Compliant
Meditating Focusing
Searching for meaning
Strategizing Rehearsal Review
Avoidance
Reporter Consumer
Permission Bonding Rule keeper Sets limits
SOURCE: Copp, L.A. (1985). Pain Coping, in L. Copp (ed.), Ferspectives of pâ‚Ź,in (Recent advances in nursing series). Edinburgh, Scotland: Churchill-Livingstone Company.
you had more confidence we
would, too." "Be realistic about pain. Don't be too casual or flip." "Don't assume the shot or pill helps." "lf you had hurt just once, you wouldn't hand out this 'lt won't hurt a bit' routine."
"l d like one doctor and one nurse each shift. There isn't enough energy to
describe the pain over and over again."
"See patients as individuals and not textbook pictures." "Don't be callous. You treat patients like a garage repairman but we aren't automobiles." "Prescribe fewer pain pills and shots and get down to the cause."
ability to manage the patient's pain experience in view of his passive posture. Assessment, monitoring, checking for feedback, and further reporting all must be efficiently and effectively orchestrated before trust is established. The patient who assumes Posture #4 =cunning, Coper=reactive), however, requires reassurance and pain rehearsal, and extracts promises of help from the staff in advance. He is appreciative of the timing 0f medications and is responsive to family and staff who assist him in this way. He is dependent on staff and knows it, so he avoids alienating them. All of these behaviors are further described in a book Copp edited in 1985 entitled Perspectives on Pain. Over the past several years, Copp has actively disseminated her ideas about pain (Pain
coping styles and their implications for clinical management of patients in pain. "The data I have is precious-people suffered for it, and I really want to get it out to doctors and nursesl' she explains. Since 1985 she has given eleven lectures in five different countries, chaired the 1986 National Institutes of Health Consensus Development Conference on The Integrated Approach to the Management of Pain, and published a chapter in the book Handbook ot Chronic Pain Managemenf on the nurse's role in managing patient pain. In addition, she participates in the World Health Organization Cancer Pain Control Initiative. Currently, Copp is writing her own book, based on her research and titled The Pain Continued on inside back cover
Nursing Researchers Characterizing Pregnant Prisoners
For the last ten years, Catherine lngram-Fogel has been in prison-not as an inmate, but as a teacher and researcher. In March 1988, she received a Ph.D. in sociology for analyzing health problems of women at the North Carolina Correctional Center for Women in Rateigh. Since then, she has focused her research 0n pregnant inmates at the facility which housed just over 600 women in June 1988. Ingram-Fogel, an associate professor in the UNC School of Nursing who teaches a prenatal health education class at the prison, says up t0 25 of those prisoners are pregnant. Ingram-Fogel studies pregnant prisoners to
identify risk factors affecting them. Women prisoners have an increased vulnerability to illness because of several societal factors, including lack of power, lack of control of the environment, and stress, Ingram-Fogel says. "These pregnant women are an extremely high risk group for complicationsl' she explains, adding that their risk generally increases due to pre-prison lifestyles and sociodemographic
.G
z
characteristics, such as low education level,
poor nutrition, and low socioeconomic status. lngram-Fogel, who started the project with seed money from the Nurses' Association of the American College of 0bstetricians and Gynecologists, plans to interview 75 women prisoners before and after they give birth to
E I z
=
determine relevant risk factors. She says she hopes to develop intervention methods to
>
reduce risk once factors are identified. For example, it may develop that pregnant smokers have lower birth weight babies. tf that is the case, Ingram-Fogel explains that a technique may be developed to reduce smoking among pregnant inmates.
While these women are characterized as having a high risk for complications, she notes that many of their babies are born relatively healthy, which may be due to the prison environment. "l have a hunch that they're getting g00d nutrition and are clean of drugs and alcoholl' Ingram-Fogel says. "There's no substance abuse there, other than cigarettes,
and they're also getting good prenatal carei' Her study may show that pregnant prisoners, while coming from a risk-laden environment, have healthier babies because they are in prison. Such a finding would cause her to analyze the positive things being done for
_ts:
pregnant women prisoners, she says. For another study supported by the School of Nursing, Ingram-Fogel has interviewed 24 prisoners to explore what it is like to be a mother while in prison and how prison affects the ability to mother. After transcribing the interviews, each of which lasts about an hour and a half, lngram-Fogel plans to do a content analysis to look for themes and commonalities. "Ultimately, I want to come up with some intervention program that can improve their mothering skills and decrease their dis-
tressl' she says. "But
I
can't do that until
I
get an idea of what it's like to be a mother in prisonl'
-Andy
Brack
AIDS Disinfection Procedures for CPR Manikins Dr. Inge Corless, assistant professor and chairperson of secondary care in the UNC School
Focus on Needs of Nursing, has research
devoted much of her current to studying issues associated with
Acquired Immune Deficiency Syndrome (AIDS). One of the projects she is working on involves investigating the disinfection procedures used by clinicians practicing Cardiopulmonary Resuscitation (CPR) on manikins. "l saw a whole group of CPR manikins in the Skills Lab and began to think about the way we were conceptualizing AIDS infectivityl' Corless says. The emphasis was on wearing masks to
do resuscitation with persons with AIDS. Her concern, however, is with the earlier phases of infection with the Human Immunodeficiency Virus. "Students, nurses, residents, and First Response people all use those manikins for CPR training. What would happen if one of these people-one of us-were in the early phases of the disease and were not aware of his or her seropositivity? How effective is our decontamination procedure?" In light of the AIDS epidemic, a national committee in 1983 revised the recommended guidelines for manikin disinfection, Corless
with regard to Hepatitis B is far greater and it is for this reason that the recommendation to keep the manikin surface wet for thirty seconds requires strict adherence if transmission of infection is to However, the danger
be preventedi' Corless and her colleagues next plan to run a similar experiment with cell-associated AIDS virus-that is, AIDS virus as it would be present in the body. They also plan to investigate the impact of saliva, because saliva itself may attenuate the effect of either the virus or the alcohol. 'Although the virus has been found in saliva, there have been n0 cases of transmission through casual contact;' she notes.
strategies.
-Tlacey J. Mwwell
recommendation had been tested for HIVI,
scenario. The team contaminated a manikin with a very high level of cell-free AIDS virus, much higher than would be found in saliva,
sampled the area, and then applied the disinfectant for ten- or fiye-second periods. They allowed the surface to dry for thirty seconds
and resampled the area. In order to determine whether mechanical manipulation contributed to decontamination, they then rubbed the area for five seconds with a dry sponge and sampled the area for a third time. Their results indicated the ten- and fivesecond durations of continuous disinfectant application are enough to eliminate highJevel AIDS contamination. Corless cautions, however, that "it would be a grave mistake to interpret our research as saying it's permissible to adhere to anything less than strict guidelines. Our research examined the worst fears with regards to AIDS of professionals and laymen
alike and found them without substance.
TLcker, Charlene Garrett, and Joanie Warner, nurses at North Carolina Memorial Hospitalare interviewing the parents of these longterm stay, medically fragile children who are treated in the ICUs and eventually on the general units at Memorial. They are asking about variables such as visiting patterns,
of those engaged in CPR trainingl'
kept wet with a disinfectant (70% isopropyl alcohol) for thirty seconds. Unable to find any published accounts indicating that this
Wellcome Company, Corless tested a worst-case
months and even years. She and a research team-including Annette Frauman and Diane Davis from the School of Nursing and Betty
types of activities undertaken with the sick child, the degree of maintenance of the parenfchild relationship, and parental coping
notes. The revised recommendations sug-
With Drs. Arturo Lisker and Janet Baradell of UNC, Drs. A.J. Langlois and Kent Weinhold of Duke, and Dr. Lyn Smiley of Burroughs
she explains. ln the summer of 1988, Miles launched a new research project aimed at defining the parental experience when a seriously ill infant or young child remains hospitalized for
But, Corless explains, these studies address "both the hysteria and legitimate concerns about safety. The results of our research to date are supportive of the committee's recommendations and should relieve the concerns
gested that the affected surface should be
Corless and several colleagues tested the guidelines themselves.
members cope with the illness, it is important for clinicians to be aware of the stresses parents face and act to reduce these stresses,
Understanding the Needs of Parents with Critically Ill Children While advances in life-saving medical techniques and technology have brought hope to many parents with critically ill children, these adyances also bring unfamiliar, often stressful clinical situations that can affect the parent-
child relationship.
Three distinct groups of parents are included in the study: parents whose child spent at least six months in the hospital but is now recovering at home or has died; parents whose child has been in the hospital for more than six months and is still there; and a group of parents whose children are anticipated to be hospitalized for a lengthy stay, these to be followed over time. The team is also interviewing clinicians, especially nurses, who often become surrogate parents to the sick children. Most of the children suffer from bronchopulmonary dysplasia, inefficient lungs due to premature birth, and birth defects such as severe gastrointestinal problems or congenital heart disease. They range in age hom infants to toddlers. The study is funded by a Frank Porter Graham Innovative Research Award, the UNC School of Nursing Small Grants Program, and by NIH's Division of Research
Dr. Margaret Miles, professor in the UNC
Resources through the UNC Biomedical Research
School of Nursing, has been researching for a decade the ways parents react when their child is hospitalized in intensive care units, or ICUs. "While these specialized units have substantially reduced morbidity and mortality rates, the ICU environment itself, with its pervading atmosphere of criticality and abun-
Support Grant Program. Miles hopes to use research results to better equip nurses to reduce parental stress and enhance parenting throughout the course of a child's hospitalization. "Parents need assis-
dance of technological machinery along with the stresses associated with having a very
But they also need help in dealing with the many alterations in the parent-child relationship and should be provided with assistance in defining their role with the sick childl'
sick child, all create a very difficult period for the parents of these childrenl' Miles notes. Because parents play a critical role in helping their sick child and other family
tance
in coping with the ICU and
hospital
environment and with their child's illness.
-Tlacey J. Maxwell
t0
Exploring the Human Side of Infertility
I 6 z
E E O z 6
a
I
Issues involved in human reproduction have always attracted attention, and one that has
come into the limelight recently is infertility. However, according to Dr. Margarete Sandelowski,
In 1984 a UNC Foundation Fund award enabled Sandelowski, associate professor in the School of Nursing, to begin archival research into nineteenth- and twentieth-
of the personal, human experience of infertility-including some couples' joyous
century responses to infertility, a project which continues to make use of her background in both nursing and American Studies. By looking not only at the medical but also at the popular literature of the last two centuries, Sandelowski is getting a sense of how couples have confronted the problem of childlessness and how the times in which these people lived have made a difference. Early
triumph over it.
twentieth-century case records, personal letters
infertile couples themselves tend to be overlooked by the media and the general public, especially as controversial technological advances in fertilig research often hold more sensational appeal. Sandelowski is therefore engaged in two related research projects in an effort to close the gap in our understanding
written in the 1940s and 1950s, and interviews of women now over 65 who have suffered infertility have contributed to Sandelowski's discovery of a wide range of responses to this dysfunction, from resignation and acceptance of "God's will" to determination to try anything offering the slightest hope, no matter what the cost. In recent decades, medical technology has developed numerous ways to
help couples to conceive. Although most couples today say they are glad to be living in an era offering so much hope, Sandelowski explains that the blessing of technology can also be a curse, as some couples get on a
E.il.D.E
A
Y.O.R
everyone presumes fertility at the outset and
infertility itself is a very ambiguous diagnosis, "people aren't always surel' says Sandelowski, "when they've entered or exited the phases infertility, pregnancy, 0r expectant parenthoodl' The decision to see a fertility specialist may be perceived as the beginning of pregnancy for some couples; others don't quite believe they are pregnant until the first trimester is over. Conception itself may not occur at the usual, single moment in time but rather over the period of time mandated by procedures such as in vitro fertilization. Furthermore, the transition to parenthood can be equally ambiguous. Because the infants of previously infertile couples are often born prematurelyand may therefore remain hospitalized for some time until their conditions are stablethese couples may feel more like visitors or even babysitters rather than parents. Similarly, couples approved for adoption may wait an unspecified number of months or years for their child, wondering meanwhile whether they should yet consider themselves parents. "lmpeded passage" refers to the obstacles people face in their attempts t0 overcome childlessness. These range from denial that
they are infertile at all to age limits imposed by some fertility programs and adoption agencies. The high cost of medical treatment can be especially daunting; not everyone Dr. Margarete Sandelowski,
associate professor
in the School of Nursing,
seeks
to understand the transition
uperienced by couples who overcone infeftility.
"treadmill" of sorts, never able to give up trying.
With the help of Drs. Diane Davis and Betty Harris, assistant professors in the School of Nursing, Sandelowski is also studying the transition to pregnancy and parenthood currently being made by previously infertile couples. "Once your dreams come truel' she explains, "things aren't necessarily what you expectedi' To find out where expectations and actual experience diverge, Sandelowski and
adopting babiesl' Expectant couples who have undergone sterilization reversals and those with normal fertility histories are also part of
the study. Each couple
is interviewed
(always together)
three times during the waiting period and twice after the child arrives. Sandelowski has both men and women complete monthly "symptom" questionnaires in order to learn specifically what the prospective mother and father go through physically as well as psy-
agrees
just who should have access t0 expen-
sive biotechnical help, since American society and the insurance companies may not perceive infertility as a disease meriting treatment. Finally, feminist issues can also become involved: the tendency to blame women for their own infertility goes back a long way. One modern version of this tendency, according to Sandelowski, is the feeling some people express that women have placed themselves at risk by entering potentially hazardous, "male" workplaces or by delaying childbirth by means of contraception. Despite the obstacles, more and more couples are managing t0 overcome infertility.
chologically while awaiting the child's arrival. These questionnaires also help her to explore whether couples approved for adoption experience during the waiting period symptoms similar to those described by pregnant couples.
"They see their experience as a point of intersection among nature, technology, and
technologic advances
1993,
Finally, each couple is twice observed interacting with the new child. Each set of parents is followed for one to two years.
says Sandelowski, "have become pregnant
analyses are underway. Sandelowski describes
her colleagues are following volunteer couples from the time they learn they will be parents until they have had their child for three months. Begun in 1987 with the help of a University Research Council award and now funded by the National Center for Nursing Research (National Institutes
of Health) until this study will eventually include a total of one hundred couples. These people, spontaneously or through biotechnical
means-
in vitro fertilization, artificial insemination, or fertility drugs-or they are such as
Some cases have been completed and initial
two of the common experiences that have become apparent as "ambiguous passage" and "impeded passagel' Because virtually
miraclesl' says Professor Sandelowski. She and her colleagues "hope to learn about human responses to infertility and to modern
in
reproduction which
are rapidly changing the meaning and experience of pregnancy, parenting, and family, and the ways in which nurses can assist these couples and their babies in making a healthful life transitionl'
-Allison
Bulsterbaum
E.il.D.E.A
12
Coping with Cancer Study Investigates Family Members' Concerns
When a cancer diagnosis is made, the patient is not the only one who suffers emotional stress. Family members, toq are directly affected by the frightening implications of the disease. In order to better understand the impact ol cancer 0n family members, Dr. Barbara Germino and Dr. Sandra Funk, associate professors at the UNC School of Nursing, have designed and implemented an extensive study.
Dr. Germino's interest in the subject began during graduate school when, as a research assistant, she interviewed cancer patients about the emotional effects of their diagnosis. "lt was obvious that the family members were also in needl' she explains. "They'd
follow you out to the car or call you up 0n the phone to talk. No one was asking them what they were going throughi' She reviewed the research literature and discovered that very little was known about the impact of cancer on families. For her Ph.D. dissertation she developed an index, called the Family Concerns Inventory (FCI), to facilitate description and comparison of family members' concerns after diagnosis of lifethreatening illness.
With today's emphasis on cost containment
in
health care delivery, people with cancer are spending less time in the hospital. As result, family members are assuming caregiver roles, providing a primary source of
Dr. Barbara Gernino (left) and Dr. Sandra Funk review project guidelines.
National Institutes of Health's National Center for Nursing Research. The interviews were carried out by Germino and graduate student research assistants, who visited the families
a
emotional and concrete support. The ultimate goal of Germino and Funk's current study is
to develop both a research instrument and a
in their homes. Germino and Funk designed this part of the research program to validate the specific types of concerns family members have and how these concerns affect family communication. From the outpatient clinic rosters at North
clinical assessment index that will help evaluate the concerns of cancer patients and their family members. "ln an applied discipline like ours, research has to relate to clinical practicel' Germino explains.
Carolina Memorial Hospital and Duke University Hospital, the researchers selected as potential subjects adult patients who had been diagnosed with breast, lung, or colorectal cancer no longer than five months
Germino and Funk recently finished collecting data for this study, a process involving indepth interviews with 60 cancer patients and their families. Funding was provided by the
before. "North Carolina has a very diverse population of families, and the clinic popu-
lation reflects this diversityl' Germino says. "Our study sub.iects are racially and socio
economically diverse and range from people
with Ph.Dls to those who cannot read or writel' After the patients' physicians determined that they were medically able to take part in the study, the research assistants approached the patients in the clinic. In a private section of the clinic, the assistant explained the study and asked if the patient and family would like to be involved. Most patients talked it over with their families and then agreed to take part a few days later, when a research assistant called them at home. Those who declined usually did so because they were just too stressed to deal with any extra demands, Germino notes. Teams of two to three research assistants then visited the family's home and each privately interviewed a family member. De-
pending on the family structure, possible interview combinations were: the patient, spouse, and an adult child; just the patient and spouse; or just the patient and an adult
SIMILARITIES OF CONCERNS ACROSS FAMILY MEMBERS
child. Interviewers asked each family member the same set of questions, most of which were open-ended. Topics included concerns about treatment and caregivers, symptoms, work and finances, social dependency, existential con-
The patient's care and treatment The spouse's future The child's future The patient's future The patient's physical symptoms The patient's personal feelings
cerns, emotional issues and feelings, and
religion. "The interviews are often very emotional, very powerfull' Germino says. 'A lot of people cry. But n0 one wants t0 stop; they ,just ask for a minute to get themselves togetherl' Al[ interviews were tape recorded. After completion of the interviews, usually in sixty to ninety minutes, the family re-
DIVERGENT CONCERNS OF FAMILY MEMBERS
assembled and the research assistants debriefed
PATIENT dependency dependency feelings
them. "We try not t0 g0 into a home, stir up problems, and then just leavel' Germino explains. While giving the family a chance to ask questions or air concerns, the interviewers never revealed what another family member said during an interview-confidentiality was crucial. The families' responses have been
Own Spouse's Handling own
is cruciall' During role-playing sessions, Germino and Funk acted as patients and family members, gradually increasing the stress level of the interviews until they felt the students were ready for the real thing. After the student's first official interview, Germino listened to the tape and made suggestions for improvement. The research assistants, supported by the study grant, usually conducted two or three interviews per week and traveled as far as 75 miles to a patient's home. "lf they did more, they would quickly burn outl' Germino explains. "lt's a very intense, time-consuming experiencei' The project team-from four to six research assistants, a secretary, and the investigators-met once a week to trouble shoot and offer each other support. Preliminary analysis of the interviews indicates that patients and their families have many similar concerns. Patients had the greatest number of concerns about themselves. The majority of those concerns were related
Own personal feelings
CHILD
Own personal feelings Patient's dependency Non-ill parent's dependency Patient's relationships with others Non-ill parent's physical symptoms
overwhelmingly positive, Germino notes. "Sub,jects say that they're so glad we camei' The research assistants were recruited from UNC's Schools of Nursing, Medicine, and Public Health. Germino and Funk trained them for about a month, familiarizing them with the study and working on interviewing techniques. 'An interviewer has to be a very good listenerl' Germino says. "The rapport between the family member and the interviewer
SPOUSE Patient and spouse's work/finances Own physical symptoms
Tlpical concerns of patient and fanily members as revealed by interviews.
to their future, their physical symptoms, and their care and treatment. Similarly, spouse's and children's concerns focused mostly on the patient's future, physical symptoms, and care and treatment. When family members focused on themselyes or other family members, the predominant concern was the future of the family.
Germino and Funk intend to revise the Family Concerns Inventory using these new data, after which they plan to run a small pilot test of its readability and clarity, as well as the quality of the data generated. To test its reliability, they will then use the FCI with patients who are either stabilized or in remis-
sion. Dr. Funk, who is a psychometrician, has the technical expertise to help plan and carry out the instrument-testing process, Germino explains. 0nce the FCI has been finalized, Germino envisions a health care provider sitting down with family members shortly after a cancer diagnosis and using the inventory t0 gauge
their levels and types of need. To facilitate use, the questionnaire will be relatively short and easy to comprehend. Even if family members cannot read or write well enough to fill out the FCI themselves, the clinician will be able to ask them the questions and record
their answers
accurately.
Ultimately, health care personnel who are more aware of a particular family's needs will be better able to assist and support that family. "We need to understand family members' concerns to help them live with the illness
and help their sick family memberl' Germino says. "The time is rightl'
-Tlacey J. Maxwell
AYORS
l4
Nutrition and Health Is the Time Right for a Policy for All Americans?
A comprehensive government health policy could improve the overall health of Americans. Such a policy has worked in Norway, says
declining, but when the political climate was favorable and the country's food supply was vulnerable to changes in the global food
Nancy Milio.
supply.
"ln
Milio's research in Norway, requested and
the United States, health policy means almost exclusively health services policy and does not mean policy that affects the health of the publicl' she says. "We advise people on what they should eat but the focus of attention is on how each individual should change his or her eating patterns. We do
sponsored by the Wortd Health 0rganization, in general found that the parts of the policy most readily implemented were those most important t0 the strongest political and eco nomic interests, specifically those in the agriculture system. So today, Norwegian farmers
little about making health-promoting foods easily available to people, especially disadvantaged people. The easiest foods to get are the less health-promoting foods-highly sweetened, refined, low fiber, high fat, highly-salted foods-which because they're so refined, sugary, and fatty are also very calorie dense; so at least 25 percent of Americans are
enjoy social security, health insurance, and paid vacations. Also, government subsidies encouraged wheat production and limited pro-
duction of whole milk. And Norway has boosted fish breeding, potato and vegetable production, and development of new foods, such as high fiber breads, lower fat dairy products, forms of more healthy fast food, and lowfat sausage. 0ther parts of the policy,
overweighti'
Milio, professor of nursing in the UNC
particularly in health education and community health centers, have been slower to advance, but have accelerated in the 1980s,
School of Nursing and professor of health policy and administration in the UNC School of Public Health, contrasts the health of Americans with that of the people of Norway.
"The Norwegians are one of the healthiest populations in the worldl' she says. For a year after spending July 1987 in Norway, Milio assessed the progress of a comprehensive health-related policy adopted in the mid-1970s by the Norwegian Parliament. "My purpose was not t0 concentrate on whether
they have reached their goals, but the extent to which the policy is being implementedl' she explains. This farm-food-nutrition policy, which set national health goals for 1990, tries to bring the food supply into line with a national dietary pattern. It encourages a health-promoting diet of grains, fresh fruits and vegetables, fish, and less fatty meats and dairy products; promotes domestic food production, especially wheat; advances en-
vironmentally sound rural agricultural development, particularly in disadvantaged
Dr. Nancy Milio, professor of nursing in the UNC School of Nursing and professor of health policy and adninistration in the UNC School of Public Health, spent a month interviewing nore than 50 Norwegian officials as a basis for an analysis of the success of a conprehensive governnent farnfood-nutrition policy.
to promole world food security by helping farm and food production in poor countries. 0ther parts of the policy areas; and seeks
call for supportive consumer information regulations, farm subsidies, and health, nutri-
tion, and agriculture education and research. Milio explains that Norwegians implemented the policy at a time when they not only realized their cardiovascular health was
Milio discovered. In fact in the 1980s, public pressure has encouraged farm organizations t0 promote and invest in more healthful foods, she says. "You don't expect farm organizations that produce pork and beef to advertise and promote lowfat foods and fish.
I
think this is a 'sign of the times' that these producers realize that in order for them to sustain public and political support, they have
to be seen to be doing things that are more supportive to what is understood to be health promoting in the way of diet and foodl' 0verall, she says the Norwegian farm-foodnutrition policy is working, as shown by a shift in dietary patterns and perhaps by the dropping rate of cardiovascular disease and dental caries. Her biggest conclusion, however, is that those seeking to implement health policies should translate their health goals into political and economic terms. "To say something is healthy
wiil
always get
RS
l5
health measure passed unless people can see how your health issue helps the political and economic concerns you already havei' Such a finding has implications in the United States, which has dietary guidelines much like those in Norway. "0n the downside, there have been few if any, policy efforts to implement them herel' Milio explains. "0n the upside, there is a report now being prepared on how to implement the national dietary guidelines. My own sense is the implementation recommendations will not be as broad as some of us think they ought to be, but the fact that some attention is finally
I c
s
being given is encouraging. Hopefully, the new administration might be able to start afresh and move aheadl' Milio, whose book Nutrition Policy for Food-Rich Countries: A Strategic Analysis and Case Study in Public Heailrl should be published in 1989, claims
an integrated farm-food-nutrition policy could work in the United States. "l think the interests of agriculture and health and nutrition and the environment can be benefited at the same time ,=
rhetorical support, but you won't get policy
and economic benefits, such as self-
changes unless you do your political
sufficiency in wheat or a lowering of food imports, for a nutrition and health poltcy to be initiated. 'You don't get an important
organizational homeworkl' Milio says. In other words, a legislator must recognize political
if a
mechanism is created for
them to work together at a political leveli' After all, as Milio says, the concept of a "marriage between agriculture, nutrition, and health was first proposed in the United States
fifty years agoi'
-Andy
Brack
Ilivorced Parents: Cooperation or Gompetition? The news is not all bad for children of divorced parents. Dr. Anne Hopkins Fishel, an associate professor in the School of Nursing, has been studying the negotiating strategies used by such parents to make decisions about their children. She has found many parents are able to put aside their personal differences and make decisions that are in their children's best interests.
Fishel began her research with the assumption that the negotiation methods divorced parents use to make parental decisions
will directly influence the family
her subjects to indicate which behaviors accurately described the interactions between the parents. Some behaviors, such as listening or taking the other person's point of view were classified as cooperative. Other behaviors, such as name-
calling or belittting the other's parental abilities, were said to be competitive. Fishel also asked the parents to describe a disagreement and explain how they handled
it.
home each week, instead of sending the parents'homes.
as being either cooperative, competitive, or s
stability and the child's welfare. With the help of a School of Nursing grant, she interviewed 101 fathers and mothers who had recently divorced or separated, using a structured questionnaire that included 50 decision-making behaviors. She asked
some parents with joint custody preferred to move themselves in and out of the
children back and forth between the
She coded these responses
a combination of both. In her sample,
lutions. Fishel said many divorced parents ignored traditional arrangements for their children in favor of arrangements more closely tailored to their needs. For example,
she
found 45 percent ol the parents used a competitive style, 27 percent used a cooperative style, and 28 percent used elements of both styles. Couples who were able to negotiate cooperatively, at least part of the time, were more likely to develop creative so-
Because her sample was skewed toward highly educated people, Fishel plans to refine her measurement questionnaire and administer it to a group that is more representative of the general population. She believes the questionnaire could help divorced couples pinpoint negotiation behaviors that are not productive, as well
as suggest new behaviors couples can
-kthleen A.
use.
McMorrow
E.III
16
D
E
A
Substance Abuse in Medicine Researcher Uncovers Consumers' Perceptions
If workers abuse drugs on the job, they can jeopardize their own performance. If health
providers. Interestingly, the race, age, sex, education level, and income level of the respondent made no significant difference. Seventy-six percent of those surveyed agreed
care providers abuse drugs on the iob, they can jeopardize someone else's life. "You see and hear a lot about drug abuse in the media; about doctors and nurses being
that drug testing should occur, while about 18 percent were against mandatory drug
testing. Again, respondent demographics did
disciplined, some clinicians even dying from abusel' says Lorna Harris, assistant professor
not significantly affect their opinions. Slightly more than half said that health care providers who are found to be abusing substances should be fired, even if there is no evidence that substance abuse is affecting their job performance. Thirty-nine percent stated that firing was inappropriate. For this question, the respondents' education level
in the UNC School of Nursing. But the health industry has no way of knowing how,
or if, this media attention affects health
con-
sumers. "Patients have to feel comfortable, confident with their caregiverl' she explains. "lf patients lose that necessary trust I think we're going to have problemsl' A lack of trust could lead to a breakdown in patient-clinician
made a difference
'{,
effectiveness.
ln order to help avoid that situation, Harris has set out t0 gauge consumers' thoughts about possible sanctions for substance abuse. "l wanted to find out what the consumers preferred because the health care system should consider consumer preferences when developing employee drug abuse policyl' she explains.
Harris designed a questionnaire that was included in a 198i public opinion survey of North Carolina citizens called the Spring Carolina Poll, which was conducted by the UNC School of Journalism. Nearly 500 North Carolina residents, age 18 and older, were interviewed by telephone. Random digit dialing was used to give every residential telephone in the state an approximately equal chance of being dialed. The survey asked the respondents' opinions about substance abuse by doctors, nurses, dentistS, pharmacists, and physical therapists. Substance abuse was defined as the use of
illegal drugs and the abuse of legal drugs and alcohol. The respondents were asked three questions on the issue:
r
Would you say you are very concerned,
in their response.
Those
who completed n0 more education than
relations and ultimately reduce therapeutic
a
junior college program tended to agree that health care providers who are substance
]-w-
tl::l
"
**'..**'rr-1,
Lorna Harris presented her research in a poster session at the American Medical Association's 8th National Conference on the lmpaired Health Professional, Chicago, 1987.
somewhat concerned, 0r not at all concerned
about substance abuse among health care professionals?
o Do you
agree
or
disagree that some form
of drug testing should be required for all
r
abusers should be fired. Those
with
a
bachelor's or graduate degree held the view
that firing was inappropriate. Since education level seems to affect the of tolerance consumers have toward health professionals who are substance abusers suggests to Harris that administrators need to degree
consider carefully that demographic feature of their clientele when developing substance abuse policies. A health care agency's sur-
vival is directly related to the consumer's willingness to use the services provided, she points out. The key to an effective policy is both to assure the public's safety and give the public a sense of well-being.
"lf
you're a manager of a hospital or clinic
health care providers?
in a small, rural town where clients are
Do you agree 0r disagree that health care professionals who are substance abusers should be fired, even if substance abuse has not been shown to affect their ability to perform their jobs?
educated, you need to consider that there may
Analysis revealed that 94 percent of the respondents were very
or somewhat concerned
about substance abuse among health care
less
be strong opposition if you allow known substance abusing employees who are in rehabilitation to continue t0 engage in even a very limited practicel' she says. "But if you're in a metropolitan area with more educated clients,
you could probably let employees continue limited practice while in rehabilitationl'
a
1. LEVEL OF CONCERN ABOUT SUBSTANCE ABUSE
(N = 4eA Somewhat Concerned
Health care providers, for example, should determine how widespread the problem of substance abuse really is in their profession. "lf a low incidence of substance abuse by health care professionals is documented, and this information is shared with the pubtic, the public may have less desire t0 see mandatory drug testingi' she explains. -Tlacey J. Maxwell
Concerned 4o/o
Cloning and Analysis of Cellulose-Richard
Lightfoot,Biology
...
Yeast Signals-Mark Underwood, Genetics
Endeavors Research and Gnduate Education
at the University
of North Carolina at Chapel Hill
Very Concerned
continued
fran page
Winter
7
54.7o/o
1989
Vl, Number
Volume
Experience*The Nurse's Response. She is also surveying 1,100 doctors and nurses nationwide about their own pain experiences and how those experiences relate to their
2. OPINION ABOUT MANDATORY DRUG TESTING
(N = 4e4
management
of patient pain.
Copp balances these activities with her administrative duties at the School, where
2
Endeavors is a magazine published three times a year
by the 0ffice of Research Services, a division of the Graduate School of the University of North Carolina at Chapel Hill. Each issue ol Endeavors describes only a few of the many research projects undertaken by laculty and students ol the University.
she also teaches a course 0n managing pain.
"[n this country we really don't teach pain
Requests
management adequately in medical and nursing schoolsl'she says, "and I think it shows up
comments, and requests for exha copies should be
in our hospitalsl'The
result, she feels, is a Iack of self-regulation by clinicians concerning
their quality of pain management. Clinicians cannot assess their performance in this regard if they do not understand pain and its relationship to pain management, she explains. Copp, who is an active member of the lnternational Association for the Study of
3. COURSE OF ACTION FOR EMPLOYERS
(N = 4eA Firing lnappropriate 390/o
for permission to reprint material,
sent to Editor, Endeavors,0ffice of Research Services, CB# 4100, 300 Bynum Hatl, The University of
North Carolina at Chapel Hill, Chapel Hill, NC 27599.4100 (919/966.5625).
Chancellor: Paul Hardin Vice Chancellor for Research and Graduate Studies and Dean of the Graduate School: J. Dennis 0'Connor Director, 0ffice of Research Services: Tom K. Scott Editor-in-Chief: Tom K, Scott
Pain, serving on its Committee for Education,
Managing Editor: Suzanne Appelbaum
is eager to continue her research and inter-
Assistant Editors: Andy Brack
national lecturing on pain coping and management. "l get a lot of feedback from nursing,
Allison Bulsterbaum
medical, and dental clinicians around the worldl' she says. "They are absolutely hungry
Tlacey J. Maxwell
Kathleen
Photographer:
for itl'
readers'
Will
A. McMorrow
Owens
Designer: Lynn Kenney
-TracE J. Maxwell
O
Faring Appropriate 52o/o
Results
of Harris'
1987
substance abuse by
public opinion suuey
hulth
on
care providers.
This issue of Endawrs could not hare been produced without the help and coopration of Dr. Joan Uhl, Associate Dean of the UNC{H School of Nursing. Endawn is gnteful for Dr. Uhl's efforts and dedication to this project.
conferences.
No part of this publication may be reproduced without the consent of the University of Norih Carolina at Chapel Hill.
Cover: Clockwise, from upper left: Dr. Inge Corless, with colleagues Dr. Robert Buckheit and Dr.
Special lssue on Gnduate Student Research,
Arturo Lisker, examine slides for indications of the effectiveness of AIDS decontamination procedure; Body Recall class at Chapel Hill Community Center, conducted by Salli Benedict, a health
induding..
educator
Coming in Spring 1989 Endeavorc.,. Harris' findings give policy makers some insight into consumer preference, which, she says, they need to consider-along with organizational and professional preferenceswhen developing substance abuse policy. But the potential remains for doing a lot more, says Harris, who has published her findings and also presented them at three national
ol No(h Carolina at Hill in the United States. All rights reserved.
1989 by the University
Chapel
The Culture ot
fovertl-.fcfael
Foster, Economia
in the Department of Family Medicine; Elizabeth Bailey, occupational health nurse at Burroughs Wellcome, gauges fitness of company
employee Patrice McAbee; student nurses at North Carolina Memorial Hospital check premature
Dietary Fat Consumption Among Women-Kathleen
inlant's vital signs.
Reidy, Nutrition
Photographs: Upper by
E. Barnes
Will 0wens; lower by Billy