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Photography projects are an alternative teaching method that can be easily integrated into community programs with adolescents and children. This article provides a brief review of the use of photography in documenting social and health issues. Two examples of community photography projects with easily ignored populations are described. These projects gave a voice to participants and allowed them to demonstrate their creativity with cameras. An implementation guide is presented to provide concrete suggestions for implementing community photography projects.

Article-at-a-Glance Background Many benefits have been associated with the use of clinical pathways, yet developing them can be costly, and implementing them is not always successful. A 300-bed Midwestern community hospital began a clinical pathways program in 1995, and by fall 1998, 15 pathways were in various stages of implementation, with 3 under development. Many challenges had been encountered, but hospital leaders were eager to find ways to increase pathway use. Methods A qualitative case study design was used to investigate four clinical pathways, two perceived as being "used" and two that were perceived as "not used." Each pathway was analyzed as a separate case, followed by cross-case analysis. Qualitative data were collected in 65 semistructured interviews with administrators, physicians, physicians' office staff, nurses, and allied health professionals at the hospital. Data were also collected through observation and document analysis. Results The two used pathways had been introduced as part of a larger change in care, whereas the two pathways not used had been introduced as standalone innovations. Confusing and inadequately developed aspects of the hospital's clinical pathways program included its purposes, the definition of pathway use, pathway procedures, accountability, education, and incentives. A new case management department, ongoing administrative support, and a sophisticated medical information system were viewed as supports for continued growth in the program. Conclusions Implementation of clinical pathways was delayed and complicated by the varied perceptions of the program among stakeholders. Lack of clarity and consistency in how information about the program was communicated made it difficult for clinicians to develop a shared understanding of clinical pathways.

Many doctoral programs in nursing now offer at least one course in qualitative research. Yet it remains a challenge to adequately prepare new qualitative researchers due to lack of faculty expertise and mentorship, student unfamiliarity with qualitative research when entering the doctoral program, and uncertainty as to appropriate teaching methods. The authors describe how they addressed these issues historically and in their current two-course qualitative research sequence. Accompanying reports of four studies conducted by students who completed the two-course sequence during academic year 1996 to 1997 provide evidence of the viability of the authors' approach and serve as the basis for recommendations to others who use a similar strategy for teaching qualitative research

BACKGROUND: The focus of research on families of the severely and persistently mentally ill is on unidirectional caregivingfromfamily members to the ill individual (consumer). It seldom addresses whether the consumer also gives something to the family. Thus the concept of reciprocity was investigated in this context. OBJECTIVE: The objectives of this study were to identify differences in families who report ed reciprocity from consumers with those who did not and to describe the kinds of rec iprocity perceived by these families. DESIGN: The objectives were met with the use of responses from a mailed questionnaire to family members. RESULTS: Reciprocity was reported more by women than men, by respondents who lived with the consumer, and by families who reported giving more assistance to the con sumer and who perceived the consumer as higher functioning. Neither age of family member or consumer nor type of family relationship was related to reciprocity. The kinds of reciprocity families perceived were categorized into instrumental tasks, caring, family solidarity, self-caring, peace of mind, family sensitization, and financial. CONCLUSION: The findings support the importance of planning nursing interventions that recognize that the severely and persistently mentally ill may give to their families as well as receivefrom them. (J Am Psychiatric Nurses Assoc [1998]. 4, 182-189)

Research has indicated that using coping strategies is significantly related to resisting smoking during highly tempting situations. However, little is known about the nature of coping during smoking cessation. The purpose of this study was to identify coping strategies used within the first 10 days of smoking cessation by having participants describe these strategies into a handheld tape recorder at the actual time of occurrence. The aim of a qualitative analysis of the narrative accounts was to create a descriptive taxonomy of smoking cessation strategies grounded in the participants'own terms. Over3 consecutive days, 36participants recruitedfrom smoking cessation programs provided 477 narrative accounts of coping episodes. Seven major taxons-context, anticipatory efforts, awareness, urges, strategies, effects, and metaphors-reflected the entire process participants described when dealing with the urge to smoke. This taxonomy, inductively derivedfrom real time rather than retrospective data, provides a holistic picture of strategies used in the early stages of the quit experience.

This qualitative study describes the experience of individuals who were attempting to quit smoking. Ten respondents participated in the semistructured interactive interviews. Five themes emerged from the data analysis: the intensity of the struggle, the personification of the cigarette, planning to quit, replacement of an old habit with a new habit, and perception of this quit experience as different from previous attempts. Particularly poignant were the participants' descriptions of the very real anguish they felt during their struggle to quit. Feelings of both elation and defeat were expressed over just getting through the day without a cigarette, or the failure to do so. Understanding the depth of the struggle, as well as the other components of the quit experience, should help health care professionals to be more empathetic and supportive to persons struggling to quit. It should also provide guidance in developing realistic strategies helpful to the quitting process.

Objective: To describe the experiences of families with a relative in the intensive care unit (ICU). Design: Retrospective, descriptive, and qualitative. Setting: The surgical-trauma ICU in a midwestern university-affiliated tertiary medical center. Participants: Eighteen women and 2 men with relatives in a surgical trauma ICU. Outcome Measures: Focus group and individual unstructured interviews. Results: A group interpretive process was used to code, categorize, and identify themes found in the transcribed interviews. Four categories of experiences were identified: hovering, information seeking, tracking, and the garnering of resources. Hovering is an initial sense of confusion, stress, and uncertainty. Information seeking is a tactic used both to move out of the hovering state and to identify the patient's progress. Tracking is the process of observing, analyzing, and evaluating patient care and status and the family's own satisfaction with the environment and with care givers. The garnering of resources is the act of acquiring what family members perceive as needed for themselves or their relative. Conclusions: Families experience a sense of uncertainty that is eventually resolved by seeking information and resources. Health care professionals can minimize the stress associated with hospitalization of relatives in the ICU by anticipating and addressing the family's needs for information and resources.

The following article was written shortly after thefieldwork was completed in 1979. The research was conductedjust after Portugal 's 1974 revolution, prior to which a repressive political regime allowed virtually no social science research. Since that time, some significant works have been published, but no other ethnographies focus on the role of the lay midwife. The kind of information obtained in this study required then, and would now require, heavy reliance on ethnographicfieldwork This publication may serve as a baseline for comparative research. An epilogue provides some updating of statistical information about infant mortality rates; however, little can be determined about rural-urban differences. The limited information available suggests that very little may have changed in the last 15 years for lay midwives in the rural villages studied.

(1981). Part VI: Incorporation and change: The case of the midwife in the United States. Medical Anthropology: Vol. 5, No. 1, pp. 73-88.

This article describes a focused ethnography of a group of chronically mentally ill clients who were involved in a client-run drop-in center. Spradley's (1979) Developmental Research Sequence guided the research. Data were obtained from interviews, participant-observation and documents review. The qualitative analysis identified the major theme of empowerment, which had four process domains: participating, choosing, supporting and negotiating. These domains represented four levels of empowerment for this group. From the client's perspective, empowerment meant they participated more in the community, their choices were increased, they provided support for each other and they negotiated on a more equal basis with staff. A fifth domain, personal significance, described the effects of empowerment for each individual.

Implications for practice and education include recognition of the value of clinical outcome studies to clinicians and administrators in clinical agencies, as well as to nursing education. This project provides an example of the opportunity for mutually beneficial education and practice partnerships. Faculty, staff, and students demonstrated their ability to use the basic model for outcome studies developed by the United Way of America (1996). Teams of staff, faculty, and students were able to design small scale outcome studies that provided valuable information for clinicians and administrators about evaluating and improving the quality of clinical services, as well as for seeking continued funding. It is anticipated that further benefits may be discovered when faculty work with agencies to target program outcomes that will yield the most powerful effect for these agencies.

Clinical pathways represent a strategy for responding to the current healthcare environment with a focus on managing care, reducing costs, increasing patient satisfaction, and improving quality. However, many healthcare organizations have found that implementing clinical pathways is not entirely successful even when they are based on sound evidence. The purpose of this case study was to describe and explain factors related to the success or failure of implementing a clinical pathway for congestive heart failure (CHF) patients in a 300-bed community hospital. The key factors involved in the nonadoption of the CHF pathway were inconsistencies in procedures and the work group culture.

The growing challenges of promoting health and managing illness in an ever-changing health care system require an arsenal of research approaches. Qualitative methods have a long tradition in disciplines such as sociology and anthropology and are being used with greater frequency as interdisciplinary health-related disciplines attempt to understand and explain complex problems. The purpose of this article is to define and describe the main features of qualitative research and to examine ways in which this methodology is relevant and useful in gerontological studies. A concise comparison of quantitative and qualitative methods is made, and suggestions are provided for when qualitative approaches are useful. A review of the three most common approaches is provided. Most important, references are provided for those gerontologists interested in learning more about qualitative research methods.

Spirituality has become a construct of interest in American health care: however, there remains a limited understanding of how patients themselves describe spirituality and view its impact on their health and well-being. The purpose of this study was to identify and describe elements of patient-reported, health-related spirituality. A qualitative study utilized focus group interviews of 17 women with type 2 diabetes mellitus and 18 women with no self-identified illness. Purposeful sampling of participants who had prior experiences in healthcare settings, with or without a chronic illness, guided the sampling strategy. Editing analysis of the interview transcripts were coded into conceptual categories. Participant narratives were grouped into eight general categories: (1) change in functional status, (2) core beliefs, (3) medical/disease state information gathering and processing, (4) interpretation and understanding, (5) life scheme, (6) positive intentionality, (7) agency, and (8) subjective well-being. A change in functional status was the catalyst for two process-oriented categories; medical/disease state information gathering and processing, and the higher-order interpretation and understanding, or meaning making of life events. Core beliefs were sources that grounded and maintained an interpretative structure through which participants viewed their life events and positively framed their experiences. Life scheme described a heuristic framework through which all life events were viewed. Positive intentionality was participant belief in the capacity to execute a specific action that was required for a desired outcome. Participants tied the attitudes and practices of positive intentionality with agency, or the use or exertion of power through belief, practice, or community. Participants outlined both a positive affective and cognitive component of subjective well-being. Patients describe several interrelated elements and a process of events in their depiction of spirituality in healthcare settings. Patient-reported spirituality is predominantly a cognitive construct incorporating the domains of life scheme and positive intentionality.

Nurses can take a leadership role in the process of helping rural Americans to recognize and implement their vision of a healthy community. This necessitates an understanding of rural communities' perceptions of health and health care and allows nurses to more appropriately provide primary health care. As defined by the World Health Organization, primary health care is comprised of concepts of essentiality, community participation, intersectorial collaboration, access, and empowerment (Barnes et al., 1995). A focused ethnography involving 150 residents was conducted in a midwestern rural community and included 56 personal and 8 focus group interviews. A qualitative analysis of responses to the question, "What is your vision of a healthy community?" was conducted using Leininger's (1985) categories of economics, social-kinship, cultural, political-legal, religion, technology, and education. An eighth category of environmental concern emerged from the data. Responses were further assimilated into descriptive statements reflecting the community's vision of a healthy community, including issues of accessible and technologically adequate healthcare, job availability, strong community support by schools and churches, a caring community membership, and an attractive, pollution-free environment. This analysis demonstrates the need for application of primary health care at the level of community in designing services to achieve healthy rural communities.

• Interviews with 41 patients with amyotrophic lateral sclerosis regarding their perspectives of the roles of doctor, nurse, and allied health personnel showed that emotional support, information, and access to assistive devices were the primary expectations that they held for each of these professional roles. In addition, physicians were expected to evaluate the progress of the disease, help with immediate problems, and continue research to find a cure. Patients wanted to see a physician at each clinic visit. In being given the diagnosis of amyotrophic lateral sclerosis, patients expected the physician to be straightforward, honest but not premature, sensitive to patients' readiness for information, and to convey some degree of hope. Patients were accurate in their knowledge of the disease, but came to the clinic expecting help in managing the illness.

The representative case study method was used in a 1-year longitudinal study of two individuals with a chronic, degenerative, terminal neurological disease, ALS (amyotrophic lateral sclerosis, also known as Lou Gehrig's Disease). Participants were interviewed in their homes every 2 months to examine the effects of the illness on relationships with family, friends and the health care system. Changing ideas regarding causation, the use and evaluation of various therapies, use of illness role models, spiritual changes and symptom experience were also explored. Kleinman's concept of explanatory models guides the analysis of the data, although we argue for a greater emphasis on evaluation of therapies within this model.

James Dow. The Shaman's Touch: Otomi Indian Symbolic Healing. Salt Lake City, UT: University of Utah Press, 1986. xiii plus 180 pp. $13.95 (cloth). Alan R. Sandstrom and Pamela Effrein Sandstrom. Traditional Papermaking and Paper Cult Figures of Mexico. Norman, OK: University of Oklahoma Press, 1986. xxv plus 327 pp. $24.95 (cloth). Barbara A. Babcock. Guy Monthan. and Doris Monthan. The Pueblo Storyteller. Tucson, AZ: The University of Arizona Press, 1986. xix plus 201 pp. $40.00 (cloth).

Summary In summary, nurse managed clinics can be another step toward narrowing the gap between education and service and providing a non-traditional setting for the developing of leaders in futuristic nursing.

With the proliferation of interest in qualitative research in nursing comes the attendant problem of how to evaluate it appropriately. Qualitative research has its own unique history, philosophical foundations, and methodologies that separate it from the quantitative approach. Although the literature is crowded with guidelines for evaluating the latter, little is offered for the qualitative reviewer. The Research Proposal Evaluation Form: Qualitative Methodology is a partial solution to this dilemma. It provides a framework for critiquing the proposal phase of a qualitative study and can be an important guide both for the educator and for the novice researcher.