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Problem: There is a lack of knowledge about women who are screened for breast cancer, have an abnormal finding on mammogram, and then do not return in a timely manner for diagnostics and treatment. Lack of follow- up likely constitutes delayed treatment and poorer outcomes. Delays may result in later entry into the health system with advanced disease, more extensive and expensive care, burdening resources. Late stage breast cancer likely results in poorer health outcomes or early death.Purpose and Aims: The purpose of this research is to describe contextual characteristics at the health delivery level as well as individual characteristics of women with abnormal mammography, and their association with use of follow- up health services. Particularly, this research examines the differences between women who are early and late responders after an abnormal mammogram.Population: The participants were a convenience sample of 380 women who participated in mobile breast cancer screening. A subset of women with inconclusive or abnormal mammogram findings was the focus of analysis.Methods: This research utilized a descriptive design with quantitative data collection through participant survey at mobile mammogram screening events in multiple urban and rural Arizona sites. Participants requiring further health care were followed by chart review. Analysis of correlations with the outcome variable: time to first follow- up appointment for recommended health care in women with abnormal mammograms was conducted.Findings: Data indicated the time to the first follow- up appointment ranged from 1- 110 days with follow- up for 77.4% of participants within 60 days, 6.5% within 60-90 days, and 16.1% without follow- up after 90 days. Significant relationships between contextual and individual characteristics and follow- up were found. Categories included organizational health system characteristics of geographic location, clinical breast exam and shared case management; individual characte

The nursing profession has utilized a variety of terms to describe the work that nurses do, such as observing, monitoring, and critical thinking. Nursing surveillance is a term emerging in the research and clinical environment to describe the care, both seen and unseen, by professional registered nurses. It has been described as a complex, multi-dimensional concept that influences patient outcomes, yet little research has been done to examine the concept, how it is measured, and its role in outcomes.The surveillance process includes ongoing data collection, interpretation, and synthesis for decision making. This research proposes that nursing surveillance is comprised of five dimensions: actions, expertise, early recognition, intuition, and decision making. The purpose of this study is to examine the dimensions of nursing surveillance in the acute care setting.This study used a descriptive design to survey nurses on the dimensions of nursing surveillance. The survey consisted of four existing instruments measuring expertise, early recognition, intuition, and decision making, and one new instrument measuring activities associated with nursing surveillance. A content review panel was used to develop the new Nursing Surveillance Activities Scale. A sample of 158 medical-surgical nurses participated in completing the full Nursing Surveillance Survey.The goal of the analysis was to determine how well the dimensions represented the surveillance variable; however, based on sample size, revisions to the methods were made. Factor analysis was used to analyze each instrument's items and total representation of the variable. The instruments performed adequately in psychometric testing, and modifications were made so composite development could be achieved. The dimensions were factored as a composite variable and four of the five dimensions loaded onto a single variable, while the activities dimensions loaded separately. These results can be explained through a theoretical diff

Work environments for health care providers in acute care hospitals have become increasingly demanding due to the impact of economic constraints, the rapid advancement of treatment modalities, and value systems changes among clients, as well as among heath care providers. In Japan, health care industries also face severe economic constraints. Because Japan has socialized medicine, the government controls reimbursements. Due to the dramatic growth in health care expenditures, the Japanese government has imposed regulations that reward shorter lengths of hospital stays with higher reimbursement. As a result, only patients whose conditions are critical and require complicated nursing care are now hospitalized. Consequently, the acuity levels of patients have increased every year. Under such conditions, administrators are charged with keeping the organization financially solvent so that they can remain in business, while continuing to improve the quality of their services. Although systems research in health care settings has received considerable attention in North American countries, there has been little research in this area in Japan, where systematic leadership training for nurse managers is also still in a developmental stage. Research on organizational effectiveness has shown positive correlations between managers' leadership styles and employees' psychological well-being or self-efficacy.The purposes of this study were: 1) to test Laschinger's Work Empowerment Theory with incorporation of leadership behaviors in acute care hospitals in Japan, and 2) to investigate how leadership behaviors might mitigate burnout and empower staff nurses working in acute care hospitals in Japan. It was expected that employees who perceived a high level of Structural Empowerment would demonstrate high Psychological Empowerment and low burnout level. If employees perceived high leadership behaviors in their immediate supervisors, their Psychological Empowerment was expected to be hi

The purpose of this research project was to examine whether frontline nurse managers who had attended a leadership program, perceived their leadership style as containing behaviors representative of transformational leadership. A secondary purpose was to determine the participant's opinions about the value of a leadership program for their practice. Current literature was utilized to support this research project examining a nursing systems issue.The primary instrument used to collect data about leader practice was the Leadership Practices Inventory (LPI) (University of Georgia, 2002). An evaluation tool was also designed and utilized to gather information about the participant's perception of their leadership behaviors after completion of a training program. Survey participants were selected from nurses who completed the Arizona Healthcare Leadership Academy (AzHCLA) (2007) course in the last four years.A course survey and results from the LPI revealed that study participants perceived an increase in their behaviors related to leading others as well as having learned new skills by having completed the AzHCLA course. Nurse's educational levels were compared to the five leadership practice subgroups from the LPI to examine whether a nurse's educational level could better account for an increase in leadership competencies. Research data revealed that no relationship between educational levels existed but that certain leadership skills were gained by having completed a leadership educational program. By using descriptive statistics, mean scores were used to identify differences in how nurses perceived their individual competencies and behaviors after having completed leadership education. Reported perceptions of competencies and behaviors indicated that educational programs can be beneficial to frontline nurse leaders.While results from an ANOVA showed there was no statistical significance related to education and LPI subgroups, there was a trend in the mean difference

The purpose of this research was to explore nurses' perceptions of the effectiveness of nursing documentation of patient status during a clinical event when using electronic documentation with or without embedded standardized languages. The theoretical framework for this study was based on principles of information theory. This study was significant in two very important ways; first, in contrast to prior studies, the perceptions of nurses were focused on the documentation of a clinical event. Second, this study explored the nurses' opinions about the strengths and limitations of using structured languages (specifically, the North American Nursing Diagnosis Association (NANDA), the Nursing Intervention Classification (NIC), and the Nursing Outcomes Classification (NOC)) for telling the patient's story during a clinical event, as well as collecting nurses' suggestions for improving electronic documentation. Semi-structured interviews of 37 nurses were conducted in two acute care hospitals. Both hospitals used electronic documentation, but only one used embedded standardized nursing languages. Half the interviewees were asked questions from the perspective of the nurse documenting a clinical event; half were asked questions from the perspective of a nurse reviewing another nurse's documentation of a clinical event. Recorded interviews were transcribed, and the transcripts analyzed using qualitative content analysis. A panel of judges was used to establish reliability of the coding scheme. The results showed that nurses perceived aspects of three categories (usability, legibility, and communication) as strengths of the documentation system. Nurses perceived aspects of three categories (usability, communication, and workarounds) as limitations of the documentation system. Potential solutions to improve the documentation system were defined related to three categories (usability, communication, and collaboration). Usability was perceived by the nurses as a strength of the

Little is known about the communication principles necessary for the design and implementation of health information technology (HIT) that supports the needs of healthcare providers from multiple professions. The purpose of this descriptive, exploratory research was to examine the patterns and methods of communication used by nurses, physicians, social workers, respiratory therapists, and pharmacists to share patient information during a patient handoff between units. The principles of complexity science were used as a theoretical framework and an original model of the healthcare organization consisting of embedded complex adaptive systems is presented.Five patient handoffs from the emergency department to participating inpatient units were included in the study. Providers responsible for the care of patients during the designated handoffs were identified through observation and snowball sampling and asked to complete a survey asking whom they communicated with and how. Social Network Analysis was used to map, analyze, and compare the communication patterns used by healthcare providers. Inferential statistics and thematic content analysis were used to examine provider characteristics and satisfaction with the quality of information available.The multi-professional collaborative patterns that emerged revealed the simultaneous use of both synchronous and asynchronous communication methods. HIT was shown to play a major role in the coordination process. Centrality and centralization measures identified that there is no one particular professional group dominating communication and hierarchy metrics indicate a unidirectional communication flow with tiers of dominant providers filtering information to providers on the lower tiers. These patterns suggest that the coordination of patient care during a handoff is a complex process that is the domain of more than one professional group.Satisfaction with the quality of available information was higher for providers working in

The purpose of this study was to test a hypothesized collaboration model composed of four components: team member, context, collaboration process, and degree of collaboration. A descriptive design using a causal modeling approach was used to test the collaboration model. The research settings were the healthcare centers and welfare centers in five provinces of Korea. The sample consisted of 40 nurse teams and 40 social worker teams. Data were collected from each team member and leaders involved in the Korean Home Visiting Services. Psychometric properties of all measures were assessed at both individual and team levels. Psychometric properties of all but one subscale (Agreement of Disciplinary Logic) exhibited reliability and evidence of validity as team measures. First hypothesis, team member and context variables have a direct effect on the collaboration process, was rejected. However, some team member variables directly impacted the collaboration process. Second hypothesis, team member, context, and collaboration process variables have a direct effect on the degree of collaboration, was rejected. However, some team member, context, and collaboration process variables directly impacted the degree of collaboration. Based on the research findings, the hypothesized collaboration model was revised.This study presented some implications for further research and collaboration practice. Future research needs to determine the reciprocal influence of each construct variable, explore the roles of each leadership style, and identify intervening or extraneous variables affecting collaboration. For the collaboration practice, this research can help healthcare providers develop realistic and effective strategies to enhance their collaboration, which would lead them to not only assess the elderly holistically, but to also effectively plan and provide comprehensive care services to solve complex health problems of the elderly. Thus, the elderly can maintain and improve their heal

Telehomecare utilizes electronic communication technologies to support care when distance separates home health nurses from their patients. Telehomecare nurses, or Care Coordinators, use text-based technology to monitor chronically ill patients. Successful home health care outcomes depend on social and technical interactions within diverse patient, caregiver and nurse triad groups. No theory or analysis method for evaluating telehomecare service delivery as a multi-level system exists. Therefore, it is not known which characteristics of interpersonal relationships influence outcomes. This research examined trust, interdependence, communication and technology integration influence on outcomes of satisfaction and self-care. The Sociotechnical Systems Theory and Social Relations Model served as guides to explore individual, relational and group effects on patient quality outcomes. The purpose of this research is to examine the relationships among patients', caregivers' and nurses' social and technical characteristics and quality outcomes in telehomecare.Three VHA sites in the western U.S. participated in this descriptive, multi-level, correlational study. Forty-three groups comprised of patient, nurse and caregiver provided survey data on social and technical characteristics. Additionally, patients provided data on outcomes. All scales performed well, except trust. Results show statistically significant bivariate correlations demonstrate associations between characteristics and outcomes at multi-levels: interdependence with satisfaction at individual and dyad levels; communication with satisfaction at all levels of analysis and simple self care at individual levels; technology integration with satisfaction at group levels as wells as simple and complex self care at individual levels. The principle of joint optimization states that service delivery systems function optimally only if the social and technical characteristics of the subsystem groups fit the demands of each

The purpose of this research was to evaluate the impact of glycemic measures, and changes in identified risk factors (BMI, waist circumference, lipids, blood pressure) on follow-up glycemia, in Pima children at high risk for type two diabetes (type 2 DM).I computed incidence and cumulative incidence of type 2 DM in Pima children 5-19 years of age between 1983 and 2004. Cox proportional hazards rates for development of type 2 DM were calculated by glycemic measure (HbA1C, 20PG, FPG) controlling for confounding factors (age, sex, BMI, blood pressure, and cholesterol). Diabetes was defined by the presence of at least one of four criteria: 1) 20PG of >200 mg/dl, 2) FPG of >126 mg/dl, 3) HbA1C > 8.0%, or 4) hypoglycemic treatment. Linear regression models were computed to identify the impact of changes in risk factors on changes in HbA1C. Only exams performed in non-diabetic children during childhood were included in the regression models.Among 2658 non-diabetic children, 258 cases of diabetes occurred during mean 9.1 years of follow-up (1.5 - 21.7). The age-sex adjusted incident rate of diabetes was 19.0 cases per 1000 person-years, and cumulative incidence was 54% by age 40. Incidence rates increased with increasing baseline values of 20PG, and FPG, but not for HbA1C. For HbA1C the relationship was u-shaped with the lowest and highest quartiles having the highest DM rates. After adjustment for confounding risk factors using Cox proportional hazards analysis, the risk for diabetes increased 2-fold for every 10 mg/dl increase in FPG. Changes in waist circumference best predicted changes in HbA1C (R2 = 0.48, Ï <0.001). However, the ability of waist circumference to predict change is limited due to the powerful effect of regression to the mean, suggesting that these risk factors contribute very little to changes in HbA1C, at least in childhood.Childhood levels of glycemia predict development of type 2 DM later in life. While changes in waist circumference are associated wi

Even though most clinical information systems (CIS) today are technically sound, the number of successful implementations of these systems is low. For that reason, understanding the characteristics and challenges for organizations implementing CIS is now considered key to successful information technology deployment (Lorenzi & Riley, 1997). Although theory driven information systems models and CIS studies exist, an integrated model to predict a successful CIS has not been evaluated. The purpose of this research was to evaluate the ability of a theoretically-based integrated model of CIS success (CISSM) to predict a successful CIS from the clinicians' perspective. Data were collected and analyzed from 234 registered nurses in 4 hospitals who had used the Cerner PowerChart Admission Health Profile (AHP) longer than 3 months. Construct validity and internal consistency reliability of the 23-item online instrument were established. The results of stepwise multiple regression analyses provided tentative support for the CISSM model.

Evidence-based practice (EBP) is recognized as a means for providing safe, cost-effective, and quality healthcare. Registered Nurses (RNs), like other disciplines, are accountable for providing patient care based on the best evidence. The greatest majority of RNs are employed within the acute care setting. Unknown is what type of organizational infrastructure is necessary to support RNs in EBP. The business community reports positive performance outcomes through development of learning organizations (LO). LOs are reputed to be high functioning, supportive, adaptive, and continuously learning systems, compatible with the needs reflected in today's complex, turbulent healthcare. This descriptive study used a survey methodology to identify relationships between the dimensions of a LO as perceived by RNs within the context of the acute care hospital and their beliefs about and implementation of EBP. Six hospitals, two magnet designated, two non-magnet, and two Veterans Administration Medical Centers in one southwestern state were invited to participate. Three established instruments were used. Distribution of questionnaires to 1750 RNs resulted in a return of 592, for a 34% response rate. Instruments demonstrated adequate reliability and validity for this sample. Psychometrics on the EBP Beliefs Scale resulted in the identification of four subscales that were subsequently included in the analyses. Descriptive statistics indicated differences in characteristics of nurses from the different types organizations. The VA nurse's average age was 48 years, worked 19 years as an RN and 64% reported their highest educational degree as bachelor or above. Nurses responding from the other two types of organizations, on the average, were 42 years old, had 14 years experience, and 52% reported an educational degree of bachelor or above. Relationships were identified between RNs' perceived beliefs about EBP and their reported frequency of EBP implementation. Regressing beliefs on the

There is a paucity of literature evaluating mass casualty systems and no clear 'gold standard' for measuring the efficacy of information decision support systems or triage systems that can be used in mass casualty events. The purpose of this research was the preliminary validation of a comprehensive conceptual model for a mass casualty continuum of care. This research examined key relationships among entities/factors needed to provide real-time visibility of data that track patients, personnel, resources and potential hazards that influence outcomes of care during mass casualty events.A modified Delphi technique was used to validate the proposed model using a panel of experts. The four research questions measured the extent to which experts agreed that the: 1) ten constructs represent appropriate predictors of outcomes of care during mass casualty events; 2) proposed relationships among the constructs provide valid representations of mass casualty triage; 3) proposed indicators for each construct represent appropriate measurements for the constructs; and 4) the proposed model is seen as useful to the further study of information and technology requirements during mass casualty events. The usefulness of the online Delphi process was also evaluated.A purposeful sample of 18 experts who work in the field of emergency preparedness/response was selected from across the United States. Computer, Internet and email applications were used to facilitate a modified Delphi technique through which experts provided initial validation for the proposed conceptual model. Two rounds of the Delphi process were needed to satisfy the criteria for consensus and/or stability related to the constructs, relationships and indicators in the model. Experts viewed the proposed model as relatively useful (Mean = 5.3 on a 7-point scale). Experts rated the online Delphi process favorably.Constructs, relationships and indicators presented in this model are viewed as preliminary. Future research is

The purpose of this research was to test a causal model of interdisciplinary hospice processes and effectiveness. This research examined the impact of organization and team level structure constructs (organizational culture, team complexity, and team leadership) on hospice interdisciplinary team processes and subsequent influence on perceived team effectiveness. The relationships among perceived team effectiveness, team task satisfaction, and family satisfaction with hospice care were also examined.The sample consisted of 41 hospice interdisciplinary teams drawn from two hospice organizations in a southwestern city of the United States. Participants included 410 interdisciplinary team members and 32 hospice team leaders. Measures used in this research were adapted from instruments previously used in non-hospice settings. Data were collected through self-report surveys. Psychometric properties of all instruments were performed at the individual and group level. Psychometric properties of all but three scales (Hospice Organizational Culture: Group Culture, Hierarchical Culture, and Developmental Culture) exhibited reliability and evidence of validity as group measures.Four hypothesized relationships were supported, and six nonhypothesized relationships were significant in the model. All team processes except conflict management had positive direct effects on perceived team effectiveness. Perceived team effectiveness had a positive direct effect on team task satisfaction, and team task satisfaction was positively correlated with family satisfaction with hospice care in a limited sample. The proposed structural factors (hospice organizational culture, team complexity, and team leadership) did not impact hospice interdisciplinary team processes or team effectiveness. Approximately sixty-five percent of the variance in team effectiveness was explained by team hospice experience and team processes (leadership, communication, and coordination). Nearly fifty percent of varia

The purpose of this cross-sectional correlational study was to examine the effects of patient and nursing unit characteristics on nursing-sensitive patient outcomes. The conceptual framework for this study is generated from the Quality Health Outcomes Model. The patient characteristics were patient age, gender, education, duration of illness, severity of illness, and illness representation. The nursing unit characteristics were nurse experience, nurse staffing, nursing unit competency, and group cohesion. Nursing-sensitive patient outcomes were patient’s confidence in self-care and patient’s perception of being well-cared for. Stratified sampling was employed to recruit a sample of 130 hospitalized chronically ill patients in 8 medical care units of 4 hospitals in Thailand. A face-to-face questionnaire interview was used to collect data from patients. A self-administered questionnaire was used to collect data from 90. Nurse staffing data were obtained from nursing administrative data for each unit. Multiple regression analyses were used to examine the relationships, test a mediator, and analyze the contextual effect of the study variables. Severity of illness (β = -.315, p <.01) and illness representation (β = -.234, p < .05) were significant predictors of patient’s confidence in self-care, when controlling for nursing unit characteristics. Illness representation partially mediated the relationship between severity of illness and patient’s confidence in self-care. Nursing unit characteristics were not significant predictors of patient’s confidence in self-care, when controlling for patient characteristics. There was a significant individual effect on patient’s confidence in self-care. Severity of illness (r = -.199, p < .05) and group cohesion (r = -.195, p < .05) were correlated with patient’s perception of being well-cared for. The findings of this study reinforce the need for acute care nurses to be aware of how chronically ill patients perceive health threats si

Control over nursing practice (CONP) is a participatory process through which nurses have input and engage in decision making about the context of practice and unit operations related to nursing practice. CONP has been associated with a number of positive outcomes related to nurse satisfaction, nurse status, effectiveness of patient care, and quality of patient outcomes. However, no comprehensive model has been created nor comprehensive analysis been conducted related to approaches for increasing CONP. This study tested a hypothesized model of antecedents to CONP developed from a review of the literature in nursing, psychology, and organizational management using a complexity theory perspective.The study used a nonexperimental, comparative design. The sample for data analysis consisted of 28 nurse managers and 583 staff nurses from 32 units in 10 hospitals. Existing instruments were used in a paper and pencil format to collect demographic and perceptual data on CONP and the hypothesized antecedent variables. Data were aggregated to provide an analysis of organizational and unit level contextual and variable effects related to CONP.Contextual regression indicated a greater influence of unit-level variables than organizational-level variables on nurses' perceptions of CONP. Regression analyses and revised model testing demonstrated that nurse manager supportiveness, implementation of a formal structure for CONP, and information flow consisting of open and accurate communication were positively related to CONP. Hierarchy of authority was negatively related to CONP. The relationship between CONP and job codification and autonomy varied based upon the measurement of the dependent variable. Manager's perception that participative decision making enhances organizational effectiveness; manager's perception that participative decision making does not reduce their power; nurses' experience, expertise, and educational preparation; and nurses' desire for control did not signifi

The purpose of this descriptive study was to determine what Home Health nurses perceived to be the Essentials of Magnetism (EOM), the degree to which the EOM exists within each Home Health agency (HHA), and whether there was a relationship between quality HHAs and their scores on the EOM. HHAs were determined to be high or low quality agencies based on their published Home Health Compare results as obtained on the Medicare.gov website. The system research organizing model (SROM) was used as an organizing framework for this study.Research in this study was conducted with two different sets of RNs in two different phases. The first phase of RNs (N = 106) determined what Home Health nurses perceived to be the EOM from the 37-item Dimensions of Magnetism (DOM) instrument. The results showed that 7 of the top 8 EOM items chosen by the Home Health nurses were the same EOM items chosen by acute care nurses in previous studies. A test retest of the top 10 items revealed a high level of reliability (Spearman-Brown correlation of .77).Phase Two RNs (N = 125) determined the degree to which the EOM existed in each HHA and whether there was a significant difference between high and low quality agencies. RNs were given the new 10-item EOM instrument and were asked to rank each of the items based on the degree of its presence in their current work environment. The results showed that low quality agencies had a lower and better mean score (M = 1.40, SD = .34) than did higher quality agencies (M = 1.67, SD = .48). An independent sample t-test was significant t (110.91) = -3.63, p = .00, which is counter to the literature.While the results were not as expected, the high reliability of the instrument suggests that it is a reliable measure of attributes perceived by RNs that allow them to provide quality patient care. Several issues identified with the outcome variables such as time sensitivity and validity may provide some explanation of the results.

The Industrial Revolution created sweeping cultural and technological changes in 19th century American society. During this era, nursing evolved from an unskilled to a skilled form of work. Changes in manufacturing, communication, and transportation occurred differentially in America, which favored the growth of different regional economies. Sectionalism erupted into the first modern war in American history. The Civil War created the conditions in which nursing, medicine, and the hospital formed organizational structures, roles, and boundaries that would later form the template for the modern healthcare system. The purpose of this research was to study how the context and culture of mid-nineteenth century American life affected the evolution of nursing during the Civil War, and the later affect it would have on skilled nursing knowledge, roles, education, and practice. The overall goal of the work is to contribute to the body of research on parallel historic processes that had an influence over the formation of early skilled nursing practice and the evolution of the nursing role. The effect of parallel processes associated with the Industrial Revolution and the advent of modern warfare on the development of skilled nursing were the particular focus of this research. A social history methodology was utilized to examine texts and discourse from the Civil War period. It was found that advances in transportation, communication, and manufacturing were both integral to the advent of modern war and modern nursing, and that the advent of these was highly integrated. It was also found that the industrialization of the hospital in response to wartime was highly influential on the development of skilled nursing programs later in the century. The role that nurses would take in the postbellum hospital, however, reflected the mass media image of nursing generated during the war rather than actual wartime practice.

The purpose of this study was to begin testing of a downward cross-level model for studying the ability of older adults to transition from a nursing home after a Medicare Part A reimbursed stay. Transitions are known to be a weak point in the provision of healthcare to older adults and thus far, research has not identified those factors that influence older adult's transitions i.e., from the nursing home after a post acute stay. The theoretical background for this study was supported by Resource Dependency Theory which is a theory that contends that organizations are externally controlled by activities outside the organization such as the "free-market" economic model that predominates the nursing home industry. It was thought that nursing homes may prioritize their need for resident census above the resident's need for discharge. The hypothesis was that both individual resident characteristics and organizational characteristics might influence the ability of older adults to transfer from the nursing home after a Medicare Part A stay. The method of analysis in this study was contextual regression. Individual and facility characteristics were the independent variables and length of stay was the dependent variable. For this project, emphasis was placed on the development of a methodology for using the MDS in this and future research studies. Selection of variables and methods for variable computation were highlighted. Individual and facility characteristics and discharge disposition (level of care) were reported descriptively. Although facility characteristics did not contribute significantly to the model, individual characteristics explained 28% of the variance in the length of stay. Fifteen percent of individuals in the sample died during their Medicare Part A stay and 18% were readmitted to the hospital. The most prevalent diagnoses of the sample were hypertension (35%), falls (34%) and arthritis (32%). Findings suggest that individual characteristics account for on

The purpose of this study is to test a theory-based intervention program to reverse excess disability of nursing homes elders in Taiwan. The program called the Self-Care Self-Efficacy Enhancement Program (SCSEEP) was derived from Social Cognitive Theory and Theory of Conformity with Nature. The program was tested by an experimental, two-group, pre-post design with forty-two qualified subjects, recruited from the two nursing homes located in the southern Taiwan. The subjects were randomly assigned to one of the two groups: the experimental group (n = 21) and the comparison group (n = 21). Subjects in the experimental group, who were aged from 73.8 to 94.7, received the SCSEEP. Subjects in the comparison group, who were aged from 71.2 to 95.6, received six-week social visits. Statistical data analysis showed that the following pair-variables were positively correlated: 1) life satisfaction and self-esteem, 2) life satisfaction and motivation, 3) self-esteem and motivation in health behavior, 4) self-esteem and levels of BADL performance, and 5) motivation in health behavior and levels of BADL performance. It also was found that elders receiving the SCSEEP significantly improved in most self-care abilities, after controlling for baseline BADL performance. However, the SCSEEP did not significantly affect elders' life satisfaction, self-esteem, and motivation in health behavior. This study provides a theory-based caring model for Chinese nursing home elders in improving their BADL performance if SCSEEP is provided.

The quality of care in nursing homes has generally improved since the implementation of the OBRA-1987; however reports of serious problems such as inadequate pain management, pressure sores, malnutrition, and urinary incontinence persist. While the primary concern remains lack of staffing, investigators have found that even the highest staffed nursing homes are deficient in some care processes. It has been suggested that a lack of effective management structure may be a contributing factor. There is theoretical and empirical evidence to suggest that effective management structure is best guided by the complexity of work performed by the organization. The purpose of this study was to develop a reliable and valid instrument to measure nursing care complexity in nursing homes. Items were developed based on a comprehensive review of the literature and the adaptation of items from existing instruments to make them relevant to the nursing home setting. Content validity was evaluated by nurse experts with extensive knowledge of the theory and/or nursing home care. One hundred sixty-eight direct care providers from seven nursing homes located in central and southern Arizona participated in the study.Reliability was estimated using Cronbach's alpha. Reliabilities using individual level data were generally acceptable for a new scale, however, the alpha for the client technology subscale was low (total scale = .78, client technology = .65, operations technology = .78, and knowledge technology = .79). Exploratory factor analysis demonstrated three domains of nursing care complexity as conceptualized. Explained variance for the 3 factors was 36.19%. There was a very modest correlation of the instrument with an established instrument of work unit technology and a modified magnitude estimate of nursing care complexity. One subscale (knowledge technology) discriminated between nursing subunits in the nursing home.The instrument demonstrated modest psychometric properties in measuri

Telephone nursing (TpN) care is delivered in a wide range of settings and provides a variety of services to individuals and populations across the age span. Although a viable specialty practice, there is little evidence regarding how the process of care delivery contributes to successful outcomes. To study the effects of TpN care, and to develop appropriate clinical and education interventions, a solid understanding of the process is needed. This study utilized grounded theory method to identify and describe the core concepts of the TpN process, the relationships among these concepts, and the factors influencing the process. Study findings were validated through peer and participant review. Based on interviews with ten telephone nurses from four sites, the following components were identified and organized into a conceptual model of the TpN process. The process generally proceeds through three phases, gathering information to cognitive processing to output. Throughout these phases, the nurse engages in a goal oriented parallel process focusing on both explicit (e.g., verbal, physical) and implicit (non-verbal, contextual) dimensions. Inherent to this parallel process is a two-way interpreting process in which information from the caller is translated into health care language for processing and then health care information is translated back into the language of the caller to identify and meet their needs. Factors influencing the process include prioritization and the level of complexity of the call, resources of the nurse and the organization, and the nurse's desire for validation of the service and the appropriateness of the output. The model highlights the need for research further delineating how implicit information is gathered and processed and how it influences output. Research is also needed on the value of implicit output and on the effects of feedback regarding output on nurse performance and satisfaction. The model suggests that more nursing education sho

Medication errors are the second most frequent cause of injury among all types of medical errors (Leape, et al., 1991). Of concern to nursing practice, medication administration errors (MAE) are second only to ordering errors (Bates, Cullen, et al., 1995). The introduction of information technology designed to promote safe medication practice, such as the Bar Code Medication Administration (BCMA) system, offers new opportunities for reducing MAE. BCMA was developed to improve patient safety, improve documentation of medication administration, decrease medication errors, and capture medication accountability data. The overall goal of this study was to evaluate the impact of BCMA on medication administration errors: wrong patient, medication, dose, time, and route. Rogers' (1995) theory, organizational diffusion of innovations, provided the study's framework.A descriptive comparative design examined incidence of MAEs before (Time 1) and after implementation (Time 2) of BCMA on eight units in one medical center. MAE incidence was calculated using MAE and patient-days data. Nurse adherence to BCMA usage procedure was assessed with a questionnaire created for the study.Findings indicated that total MAEs increased from Time 1 to Time 2, however, wrong patient and wrong dose errors decreased. There was a statistically significant (p < 0.05) increase in wrong route errors at Time 2. Comparing these findings with previous research demonstrated a diversity of methods, limiting conclusions. Nurse adherence findings indicated high overall adherence. However, completion of certain steps was hindered by software, equipment, or the work environment.Study findings were significant to nursing, informatics and patient safety research. Findings demonstrated the early state of BCMA research, added to knowledge about MAE detection methods, and brought a nursing perspective to information technology research on a process primarily within nursing purview. Implications for future research

The issue of occupational stress in nurses is significant because it has been associated with absenteeism, burnout and turnover among nurses. This study was an attempt to illuminate the occupational stress experience of workers in general with a focus upon nurses as subjects. Consequently, this research evaluated multiple contributory components to this stress process. Further, consideration of the fit between this stress-coping-depression model and General Systems Theory was another major focus of this study. The independent variables of daily hassles, occupational stress, primary stress appraisal, coping strategies, social support, repression and extraversion were measured in an attempt to determine their combined and singular influence upon the dependent variable of professional depression. These variables were measured by means of a paper-and-pencil self-report inventory of questionnaires mailed to a random sample of six hundred registered nurses in the state of Arizona. Analyses of returned questionnaires consisted of regression analyses of a causal model of the above noted variables. The findings indicate that emotion-focused coping strategies, especially escape avoidance and distancing strategies, demonstrated the most consistently significant effect upon depression for the total sample as well as for all of the demographic subgroups. The next most significant variable measured in this study was that of social support. This variable demonstrated an inverse relationship to depression and thereby appears to provide protection from depression when an individual is exposed to external stressors. External stressors, especially the daily hassles subscales of work, and time pressures, were also significantly related to increased depression in most of the analyses. Occupational stress, on the other hand, as measured revealed a statistically significant relationship to depression for only two subsamples of the study population, charge nurse/clinical specialists and nu

The purpose of this study was to test one theoretical explanation for elders' perceived current adequacy of everyday remembering, and the antecedent perceptions, values and beliefs, and consequent feelings related to this perception. Fourteen hypotheses, deduced from the theory of subjective forgetfulness in elders (Cromwell, 1991), tested one theoretical explanation for the relationships among: Personal Importance of Remembering, Perceived Seriousness of Forgetting, Perceived Frequency of Forgetting, Belief in a Relationship between Aging and Memory Decline, Belief in a Personal Health Risk for Memory Decline, Perceived Current Adequacy of Everyday Remembering, Distress about Current Forgetting, Concern about Future Forgetting and Self Esteem in elders. Multiple regression analysis of the data obtained from 202 community based elders, age 65 to 97, supported the assertions that perceiving self to forget frequently negatively influenced elders' judgments of their current memory adequacy and increased their distress about current forgetting. Believing that one had risk factors for memory decline influenced the current distress experienced about forgetting, and the level of concern about future memory. Present concerns about forgetting, in response to perceived frequency of forgetting and perceived risks, influenced in part the degree to which the present situation was viewed as a warning sign of potential progressive future decline. Concerns about memory and forgetting influenced elders' level of self esteem. Intriguing differences in the relationships among antecedent perceptions, values and beliefs, and consequent feelings about self were discovered between older and younger elders, and between elders who highly valued remembering and those for whom remembering was of lesser importance. Future research to expand our understanding of the subjective experience of forgetfulness in elders and potential future intervention research to increase perceived memory adequacy

The purpose of this descriptive correlational study was to examine relationships among the sensations and cognition components of perceived hunger and four contextual correlates: physiological, emotional, environmental, and established patterns. The study examined (1) relationships among the contextual factors and components of perceived hunger, (2) differences between normal weight and overweight individuals in their perception of hunger, and (3) multivariate relationships among contextual factors and perceived hunger. The convenience sample was comprised of 359 healthy adults living in western Canada. The theoretical framework for this study emerged from the global context of the eating experience, specifically the relationship between the constructs of contextual factors and hunger. Physiological context was estimated by body mass index. Instruments used to estimate the concepts, emotional context, environmental context, established patterns, sensations, and cognition were immature instruments. Reliability and validity had been assessed in a pilot study. Statistical analysis of data included descriptive statistics, Pearson Product Moment Correlation, one-way analysis of variance, and stepwise multiple regression techniques. Approximately 58 percent of the variance in the cognitive struggle component of perceived hunger, was accounted for by the intensity of the individual's negative emotions and their degree of adiposity. Other patterns were indicative of trends. The linear composite of negative emotions, environmental factors, and the immediacy component of the established patterns accounted for 22 percent of the variance in the enhancers aspect of cognition. Nineteen percent of the variance in the sensations component was accounted for by the linear composite of the immediacy component of established patterns, environmental context, degree of adiposity, and negative emotions. Both overweight and obese individual's perception of sensations denoting hunger was si

The purpose of this study was to generate a grounded theory explaining the social and psychological processes used by spouses during the waiting period prior to heart transplantation. Theory discovery was accomplished using the grounded theory methodology. Life on Hold was identified as the basic social psychological process generated from the data that explains the responses of spouses during the waiting period prior to heart transplantation. Life on Hold is the process of "tabling" life's activities for an indefinite period of time in order to devote one's life to another person(s) or event. Spouses of heart transplant candidates set aside life's activities and focus all thoughts, actions, and energy on maintaining the life of the candidate until a donor heart is obtained. The process consists of two stages: Freeing Self and Making Life the Transplant. The theory provides a basis for the development of relevant interventions to assist family members to cope with the uncertainty and stress of the transplant experience.

The purpose of this research was to investigate the impact of social support on adherence to a therapeutic regimen among obese Type II diabetic clinic patients. The aims of the study were to compare the effect of small reference group management with an educational advice program on the therapeutic outcomes of adherence and to test a theoretical model proposed to explain adherence to a diabetic regimen. The concepts of the model were derived from symbolic interactionist and role theory. Forty-one patients attending an outpatient diabetic clinic were randomly assigned to the two treatment programs and 32 patients completed the 6 month study. Subjects met for a total of 10 one-hour sessions which were held weekly the first month, biweekly the second month, and monthly the final 4 months. Demographic information, knowledge of diabetes, and measures of the model variables (social support, health locus of control, health perceptions, diabetic belief, regimen adherence), were collected at the start (t₁) and the termination of the study (t₁₀). Analysis of audiotapes recorded at t₂ and t₉ indicated that patient-initiated interactions were significantly longer in duration for the small reference group. The experimental group also demonstrated significantly lower blood glucose values at t₁₀, however, there was not a corresponding difference between groups in glycohemoglobin, urine glucose, or percent overweight. The total sample experienced a significant mean reduction in glycohemoglobin (-11.1%; p < .05) and an increase in social support and knowledge. Serial blood glucose and glycohemoglobin values indicated improvement in diabetic control was more marked when subjects met weekly or biweekly and stabilized or worsened when meetings were reduced. The staged recursive theoretical model was analyzed using multiple regression statistics. The empirical test of the model of t₁ indicated minimal support in terms of significant explained variance in 6 of the 8 dependent variables.

This study examined the reliability and the validity of the Exercise Suitability Scale (ESS). The ESS was a psychometric instrument developed to measure the suitability of four different forms of exercise (aerobics, bicycling, jogging, and swimming) for different individuals. Aspects of Exercise Suitability included in the ESS were ease, satisfaction, enjoyableness, fatigue, interest, convenience, comfort, safety, affordability, and time-involvement. Background information relating to the development of the ESS as well as methods and results of testing the instrument for reliability and validity were included in this study. Data from a student population were used for estimating the reliability and validity of the ESS. Reliability testing included computing inter-item and item-to-total correlation coefficients, Cronbach's alpha, and internal consistency coefficients (theta and omega) derived from factor analytic techniques. Several types of validity were assessed: content validity, criterion-related validity, and construct validity. Criterion-related validity was estimated by comparing scores on the ESS with information about participation in exercise. Multiple regression was also used to assess criterion-related validity. Principal components analysis was used to examine the construct and content validity of the ESS. Construct validity was also estimated by correlating ESS scale scores with a parallel instrumentation approach, a Q-Sort. Satisfactory reliability indices were obtained for all four ESS exercise scales. Criterion-related validity indices were also adequate. Factor analysis provided some evidence of content validity of the ESS, but provided little support for the construct validity of the ESS. Construct validity was supported, however by the convergence approach.

The purpose of the descriptive research was to investigate the relationship between an adherence to the Black community's belief and value system about Black skin tones and Black school-age children's skin tone preferences and perceptions of occupational life opportunities. Six Black skin tones were scaled via Thurstone's method of paired comparisons and the law of comparative judgment. The result was an interval level Skin Tone Scale on which the skin tones were positioned from most to least preferred by the children. The most preferred skin tones ranged from medium to honey brown. The least preferred were the extreme tones of very light yellow and very dark brown. Data collection was accomplished with the Porter Skin Tone Connotation Scale (PSTCS). The instrument was constructed from the forced choice preference paradigm. Data were obtained from a volunteer sample of 98 Black school-age children who resided in a city in Arizona. Data collection and analyses were constructed to test two hypotheses: (1) Black school-age children's skin tone classifications for differential status occupations will be related to gender, age, and perception of own skin tone as indexed by the skin tone values of the Skin Tone Scale, and (2) with increasing age, Black school-age children's skin tone preferences will be more systematically related to the skin tone values of the Skin Tone Scale. Testing of the first hypothesis with multiple regression indicated that the independent variables did not account for enough variance to support the hypothesis. Analysis of the second hypothesis with coefficient gamma suggested a trend toward more systematic agreement with the Skin Tone Scale with increasing age. Results of the first hypothesis were discussed in relation to composition of the sample, gender differences, the achievement value of the Black sociocultural system, and these Black children's lived experience. Results of the second hypothesis reflected those from similar investigations co

The purpose of this research was the development of an instrument to measure the complexity of nursing care requirements in ambulatory care settings. Charles Perrow's sociological theory of organizations was adapted to nursng in order to define the complexity concept. Four research questions were investigated in this study. These questions related first, to the construct validity of the instrument's activity category system; second, to the criterion validity of the complexity weighting system; third, to the equivalent reliability to the instrument and fourth, to the instrument's clinical generalizability. Construct validity was evaluated through the regression of subjective estimations of complexity on the individual categories which make up the 154 ratings that contained measurement error, 641 independent client ratings remained for analysis. This data indicated that the classification instrument accounted for 52 percent of the total nursing care complexity in the ambulatory setting. An 18 variable equation was as statistically effective in explaining complexity as was the original 44 variable equation. Criterion validity was examined by comparing empirical complexity weights established through the regression of subjective complexity estimations on activity categories with theoretical weights determined by nurse experts in a Delphi exercise. Kendall's tau, a measure of rank association, was used for analysis. This examination revealed no statistically significant direct association between empirical and theoretical sets of complexity weights. Equivalent reliability was investigated by looking at the percent agreement among six trained raters using the classification instrument. The data indicated agreement on ratings was above 90 percent which met the criterion pre-established for interrater reliability. Finally, by a graphical analysis of residuals from regression equations, instrument generalizability across clinical services was examined. The Ambulatory Care Cl

The purpose of this study was to identify variables that facilitate lay caregivers in maintaining dependent elders in the home setting. Specifically, this study: (1) tested a deduced theory designed to explain home maintenance of a dependent elder; (2) examined the relationship between the following variables: Seriousness of an Elder's Illness, Caregiver Overload, Quality of Care, Learning State, Caregivers Maintenance Ability, Acceptance of the Maintenance Role and the Caregiver's Perception of Power; and (3) evaluated the reliability and validity of the instruments that measured the proposed variables. A descriptive correlational design with causal modeling methodology was used to assess a five stage theory. The convenience sample was comprised of 70 English speaking caregivers providing a minimum of five hours of direct care to a dependent elder in the home setting. Reliability and validity of the instruments used to evaluate the theoretical concepts were assessed by Cronbach's alpha, factor analysis and predictive model testing. Multiple regression statistics were used to evaluate the theory and residual analysis was used to assess violations of statistical and causal modeling assumptions. The findings supported two of the predicted relationships: Seriousness of Illness had a direct and positive relationship with Caregiver Overload (B =.60, R² =.35) and Learning State had a direct and positive influence on Acceptance of the Maintenance Role (B =.36, R² =.18). As the disabilities of the dependent elder became more acute, the caregivers' feelings of being overloaded with the burden of the caregiving responsibilities increased. However, when the caregivers had a positive perception of their abilities to implement prescribed health care instruction as well as felt positively about their caregiving role (Learning State), they spent a greater amount of time giving direct care to the dependent elder (Acceptance of Maintenance Role). Identification of learning needs as

The purpose of the study was to identify and compare characteristics of preterm infants' pulse rate, respiratory rate, stress related behavior and self comforting behavior in two situations: (1) the infant receiving routine nursing care in the environment of a neonatal intensive care nursery, and (2) the infant in the same environment after experiencing a gentle back massage. Specifically, the research question for this study was: what patterns of pulse rate, respiratory rate and behavior, are associated with massage? Preterm infants between 33 and 36 weeks gestational age were observed for a baseline period of 50 minutes, given a 10 minute back massage, and observed for an additional 50 minutes. Exploratory data analysis revealed changes in the pulse rate, and in the frequencies of stress related and self comforting behaviors after massage that were associated with gestational age. Younger infants displayed a decline in pulse rate and an increase in respiratory rate after massage when compared to baseline observations, whereas older infants showed an increase in pulse rate immediately following massage. Stress related behavior declined during the first 10 minutes after massage in all age groups. Most preterm infants in this sample did not manifest any stress related behavior for several minutes after the massage. The frequency of self comforting behaviors increased after infants experienced a massage. Behavioral patterns were coupled with physiological variables; the frequency of self comforting behaviors was reflected in the pattern of respiratory rate whereas the frequency of stress related behaviors was more closely coupled with pulse rate. As infants became more aroused, they used a greater variety of behaviors. The behavioral reportoire also increased with gestational age. Content analysis demonstrated that infants spent more time in quiet sleep after having a massage than before massage. There were more frequent changes between active and quiet sleep before m

The purpose of this research was to test the predicted relationships among a component of nurse-midwifery care, psychosocial health outcomes and other maternal psychosocial variables. The theoretical framework for the research was the Intrapartum Care Level of the Nurse-Midwifery Practice Model, a middle range theory. Previous nurse-midwifery research had been based on theories and models not specific to nurse-midwifery practice. A nonexperimental, correlational design was used, with measures in the last trimester of pregnancy and the first month following birth. The psychosocial variables measured were prenatal care satisfaction, personable environment, positive presence, labor support, transcendence, labor satisfaction and enhanced self-concept. Purposive sampling was used at a birth center in a Southwestern city where women received nurse-midwifery care for pregnancy, labor and birth. The sample of 89 women consisted of 35 primiparas and 54 multiparas, with a mean age of 29 years; 46.1% gave birth at the birth center and 53.9% gave birth at a local hospital. The primary instruments for the research included the Prenatal Satisfaction Questionnaire, the Attitude Toward Issues in Choice of Childbirth Scale, the Positive Presence Index, the Labor and Birth Support Inventory, the Coping in Labor and Delivery Scale, the Labor and Delivery Satisfaction Questionnaire, and the Self-Confidence Scale of the Adjective Check List. The secondary instruments, used for the evaluation of construct validity, included the Positive Presence Index - Alternate Format, the Labor and Birth Coping Index, the Labor and Birth Satisfaction Index, and the Self-Concept Index - Alternate Format. Acceptable levels of reliability and validity were obtained for the instruments. The predicted relationships from the Model were tested with causal analysis using multiple regression and residual analysis. The empirical rather than the theoretical model was supported by the data. Prenatal care satisfac

The purpose of this study was to generate a grounded theory explaining the social and psychological processes employed by gay men in living with the threat of Acquired Immunodeficiency Syndrome (AIDS). As members of the high risk group for AIDS, gay men are living with a prolonged threat of unprecedented complexity which has unknown demands on health. An exhaustive preliminary literature review revealed a dearth of theoretical or empirical data addressing this problem. Theory discovery was accomplished using the grounded theory methodology. Two major data collection procedures were utilized: The conduct of increasingly structured interviews of healthy gay men, and an ongoing, progressive literature and media search. Data were sampled theoretically, as guided by the emergent theory. The constant comparative method of analytic induction was used for the analysis of data, in order to identify the elements and structure of the theory. Multiple procedures were incorporated into the analysis to ensure its trackability and credibility. A basic social process, Surviving Survival, was identified as the core category of the theory. Surviving Survival is the continuous process used by gay men to ensure mortal survival as well as outlive the extremity of the AIDS threat. The process is comprised of three subcategories: Vigilance, Safeguarding, and Balancing. The subcategory of Vigilance explains the work of monitoring the threat of AIDS and has both personal and social components. Safeguarding explains the behavior of protecting self and others from the AIDS threat, including AIDS' eventuality. The subcategory of Safeguarding contains Safer Sex, Reassuring Others, and Forecasting. The subcategory of Balancing explains efforts to conserve energy required to sustain affirmation of life and living in spite of the AIDS threat. In continuous interaction, the subcategories of Surviving Survival are interwoven into multiple aspects of gay living. This theory explains the profound impa

The purpose of this study was to test a theoretical model which predicted subjective well-being in patients who had been diagnosed with malignant melanoma. The theoretical model was developed from empirical findings based on a review of the literature in which health locus of control, social support and self-esteem were identified as significant predictors of well-being. The specific aim of this study was to examine the strength of the predicted relationships between selected psychosocial variables and subjective well-being. The study utilized a nonexperimental correlational design with a causal modeling approach. The convenience sample was composed of 75 individuals (x age = 52.5) who had been diagnosed with malignant melanoma. Subjects completed four instruments which measured the theoretical concepts under study. Two additional instruments were administered which indexed the variables of search for meaning and concern of recurrence. Descriptive statistics were used in examining the demographic and situational characteristics of the sample. Multiple regression techniques were utilized to empirically test the predicted theoretical relationships and to estimate predictive validity for the theoretical concepts. Graphic residual analysis was performed to assess for violations in the statistical and causal model assumptions. Study findings revealed that social support had a direct positive impact on self-esteem (B =.27, R² =.06) and that self-esteem had a direct positive impact on well-being (B =.49, R² =.37). The two demographic variables of employment and income were found to have a direct positive impact on well-being (B =.22 and B =.26, respectively), and resulted in a 10% increase in the total explained variance in well-being. The theoretical model, which was generated to predict subjective well-being in malignant melanoma patients, explained 47% of the total variance in well-being. Research into the variables which influence patient well-being during the cancer e

The purpose of this study was to test research instruments to measure social and therapeutic rules, role incompetence and violence in hospitalized psychiatric patients. Instruments were tested to measure the specific concepts of: the Discrepant Interpretation of the Therapeutic Rules (GTRS and PTRSI), the Inconsistent Enforcement of the Social Rules (SRSI), the patients' Inability to Adhere to the Therapeutic Rules (PTRSII), the patients' Inability to Adhere to the Social Rules (SRSII) and Violence (VS). The study used a descriptive correlational design. The nursing staff sample consisted of 57 nursing staff working in nine clinical psychiatric units of four local hospitals. The nursing staff sample completed research ratings on 162 patient subjects hospitalized on the units. The data were analyzed for estimations of the psychometric properties of the research instruments. The theory was estimated using correlational and multiple regression techniques. The results indicated that with the exception of the General Therapeutic Rule Scale, the instruments had strong evidence of reliability and validity. The General Therapeutic Rule Scale had limited evidence of reliability and validity. The theoretical model testing indicated that three of the predicted theoretical relationships were supported. The expanded empirical model testing indicated three additional relationships. The amount of variance in violence explained by the expanded empirical model was R² = 18%. The major findings of this study were: (a) the social rules were more important than the therapeutic rules in predicting violence, (b) contrary to the literature, personal patient variables such as, age, sex, and diagnosis did not contribute to violence in the hospital setting, (c) a patient history of violence outside the hospital contributed to the patients' inability to adhere to the rules, (d) a direct relationship existed between the therapeutic and social rules, (e) the subdimensions of violence against sel