The purpose of this study was to describe the bio-psycho-social behaviors that are characteristic of the startle response (SR) in older women with dementia. The secondary aim of the study was to determine the preliminary psychometric properties of the Behavioral Correlates of Fear Checklist (BCFC) designed specifically to assess key attributes of the SR.

A convenience sample of eight women between the ages of 72-92 (mean 82) and living in an assisted living facility was recruited. Informed consent was obtained from the resident's responsible party. Mini-Mental State Examination (MMSE) scores indicated that the majority of the sample were moderately demented (mean 11.6, n = 6) while two of the participants were severely impaired. A battery of neuropsychological tests were administered to assess depression and sub-categorize participants along an aggressive-passivity continuum.

Participants, accompanied by a familiar nursing assistant, were brought to a quiet, comfortable room in an assisted living facility for the SR data collection session. The Polar Vantage® monitor was applied to obtain continuous heart rate monitoring as biological validation of the SR. Videotape monitoring of the session was then initiated. Participants were instructed to relax and view a nature video provided on a large screen television. The SR was elicited through a tap on the shoulder from the nursing assistant while the subject was absorbed in viewing the video. Heart rate was monitored during quiet viewing for 5 minutes before the startle stimulus and continued through a post-resolution period.

Neuropsychological testing revealed the following findings. Scores on the Geriatric Depression Scale (GDS) found that six participants (75%) exhibited probable depression. Ryden Aggression Scale (RAS) scores indicated that the majority of the participants (75%) exhibited few or no aggressive behaviors, while one participant was highly aggressive and another moderately aggressive. The Scale for the Assessment of Negative Symptoms in Alzheimer's Disease (SANS-AD) showed that two participants (25%) exhibited mild levels and two (25%) exhibited moderate levels of affective blunting, apathy and withdrawal. The Irritability/Apathy Scale (IAS) revealed that five of the participants (65%) were moderately irritable while six (80%) demonstrated moderate to high levels of apathy. Apathy sub-scale scores from the SANS-AD and the IAS were moderately correlated (r=0.532, NS).

Analysis of the videotape data using the Behavioral Correlates of Fear Checklist (BCFC) showed that following the shoulder tap, the majority of participants demonstrated an approach versus avoidance response as indicated by turning their heads toward the stimulus tap and inquiring as to the source of the stimulus. No profound behavioral SRs were demonstrated. However, heart rate data indicate that participants responded to the stimulus physiologically. All participants experienced a downward trend in heart rate within five seconds of the SR. The average change in heart rate was 46 bpm with a range of 8-100 bpm.

In conclusion, the rate of probable depression in this small sample would warrant further assessment and follow-up. While the shoulder tap stimulus was not adequate to elicit a full SR, all participants experienced a physiological response as indicated by decreased heart rate. It is possible that while demented elders do not necessarily display behavioral attributes of the SR, even small stimuli produced a physiological heart rate response.

Further research regarding the SR is necessary to elaborate both behavioral and physiological responses in larger populations of elders with dementia. Additional psychometric evaluation of the BCFC is necessary to refine behavioral categories and explore alternative scoring strategies. Recognition that demented elders may be more passive and demonstrate physiological rather than behavioral responses to the SR may necessitate adjustment of caregiver interventions when the possibility of eliciting the SR is present.

The availability of a valid, reliable and clinically useful pain tool would eliminate a major barrier to effective pain management for children with CI. Several studies have described pain behaviors that are common to individuals with CI, suggesting that behavioral observational tools may be useful in this population. The Face, Legs, Activity, Cry, and Consolability (FLACC) tool was developed as a simple behavioral observational scale to rate pain intensity in children unable to use self-report tools. The purpose of this study was to determine the validity and reliability of the FLACC tool as an objective measure of postoperative pain in children with CI.
With approval from the IRB and written informed consent from a parent or legal guardian, children 4-18 years of age with CI presenting for major orthopedic or general surgery were studied. Demographic data were recorded preoperatively. Details of the child's developmental level were obtained, and each child was evaluated for their ability to self-report pain using methods previously described.[Fanurik, 1998 #2] Testing included tasks using blocks and numerals to determine understanding of magnitude ("Which is bigger?") and ordinal position ("Put these in order from smallest to biggest.").

Following recovery from anesthesia and prior to postoperative analgesics, the child's nurse observed and scored pain using the FLACC tool. Simultaneously, parents scored the child¹s pain using a 0-10cm visual analogue scale (VAS), and pain scores were obtained from children who were able to self-report pain. Observations were repeated 30 minutes after analgesic administration. Children were videotaped during each observation. Videotaped segments were edited to randomly mix their order and were viewed by 2 experienced nurses blinded to analgesic administration and to the bedside nurses', parents', and patients' assessments.
One hundred forty observations were recorded in 79 children (aged 10.11 ± 4.3 yrs; 51% male). Only 13 (16%) children, all of whom had mild delay, were able to complete the tests necessary for self-report of pain. FLACC scores of both the bedside nurse and the blinded nurses correlated significantly with parent scores (r(113)=0.651; blinded nurses r(94)=0.609 and 0.519, respectively; p<0.001) suggesting good criterion validity. Parent scores, however, tended to be higher than FLACC scores assigned by nurses (bias +.59; precision ± 2.3). There was a decrease in FLACC scores following administration of analgesics (5.3 ± 2.8 vs 2.0 ± 2.4 for the bedside nurses' scores; p<0.001; 5.1 ± 2.9 vs 2.2 ± 3.0 for the blinded nurses¹ scores; p=0.001), supporting the construct validity of the tool. The bedside nurses¹ FLACC scores correlated significantly with those of the blinded nurses (r(116)=0.778; P <0.001), demonstrating good interrater reliability. There were moderate and significant correlations between observers for each of the FLACC categories (see table). There was excellent agreement for scores of "0" between all comparisons, and variable agreement for scores of "1" and "2". Kappa values reached acceptable levels for most comparisons in each category, with lowest levels of agreement in the Legs and Activity categories. Measures of exact agreement were most consistent between the two blinded observers for all categories (Kappa values for Face = .346; Legs = .477; Activity = .405; Cry =.652; Consolability = .555). Pain scores were coded as mild (0-3), moderate (4-6) and severe (7-10) for further comparisons, since interventions may differ based on pain intensity. There were excellent correlations (0.547-.749; p<0.001) between all observers for each level of pain. There was good agreement for mild and severe pain categories (50-92%), but lesser agreement for moderate pain (24-67%). Furthermore, pain interventions varied according to the level of pain scored by the bedside nurse. Children with mild pain most often received no analgesic (64%) or non-opioids (18%), whereas those with moderate to severe pain most often received opioids (60%).

Bedside Nurse vs Parent VAS

Mild Moderate Severe Correlation p < 0.001 for all Kappa Value 70% 67% 47% .606 .436 (53-72) (26-41) (15-19)

Data from this study suggest that the FLACC behavioral observational tool has excellent validity and reasonable reliability in measuring pain intensity postoperatively in children with CI. Modifications to the Legs and Activity components of the tool may improve its precision, and reliability.

Sonia A. Duffy, Ph.D., R.N., Jeff Terrell, M.D., Marcia Valenstein, M.D., David Ronis, Ph.D., Laurel A. Copeland, Ph.D., and Mary Connors, M.S., R.N. (1999 Rho Chapter Research Grant)

Objectives
Head and neck cancer patients are at increased risk for smoking, alcohol intake, depression, and poor quality of life, and these problems are often interrelated. Research has shown that regardless of medical history, head and neck cancer patients who screen negative for smoking, alcohol intake, and depression have greater rates of survival. The purpose of this pilot study was to examine the relationship between smoking, alcohol intake, depression, and the quality of life of head and neck cancer patients.

Methods
A self-administered questionnaire on smoking, alcohol, depression, and quality of life was distributed to head and neck cancer patients (N=81) while they were in the clinic waiting to be seen for their scheduled appointment at a midwestern VA or the affiliated University hospital. Smoking, alcohol intake, depression, and quality of life were measured by the Fagerstrom Test for Nicotine Dependence, Alcohol Use Disorder Identification Test, the Geriatric Depression Scale, the SF-36V, and the Head and Neck Quality of Life instrument. Descriptive statistics are presented for smoking, alcohol intake, depression, and interest in receiving related services. Linear regressions examined the association between smoking, drinking alcohol, and depression and quality of life scores.

Results
Almost one-quarter (23.4%) of head and neck cancer patients were currently smoking and over one-third (35.1%) had smoked within the last 6 months. In addition, 46.0% had drank alcohol within the last 6 months, and 18.2% of these patients were at risk for alcohol-related disorders. Almost half (44.2%) screened positive for depressive symptoms. About one-third of smokers were interested in smoking cessation services and 37.9% of depressed patients were interested in depression treatment. However, less than one-tenth of those who drank alcohol expressed interest in alcohol treatment. Smoking was negatively associated with scores on five scales of the SF-36V including physical functioning, general health, vitality, social functioning, and role-emotional health. Depression was negatively associated with all eight scales on the SF-36V and all four scales of the Head and Neck Quality of Life instrument. In contrast, alcohol was found to be positively associated with the pain scale of the SF-36V.

Conclusion
Head and neck cancer patients are at risk for smoking, alcohol intake, and depression. Those who are currently affected by these conditions have significantly lower quality of life scores than those who are not affected. While smoking, alcohol intake, and depression may be episodically treated, standardized protocols and aggressive intervention strategies for systematically addressing these highly prevalent disorders are needed in this population.

Introduction: Women who suffer a myocardial infarction (MI) are less likely than men to be diagnosed based on their presenting symptoms, to receive aggressive treatment, and to survive an acute cardiac event. Yet, controversy continues as to the underlying reasons for these disparities. The purpose of this study was to examine if emergency department (ED) nurses triage decisions were different when the nurse was presented with similar cues for MI, but different patient gender.

Theoretical Framework: Hammond's (1964) lens model for clinical inference and Evan's (1984) two-stage reasoning model provided the theoretical underpinnings for this investigation.

Method: A non-experimental, descriptive investigation was conducted using methodological triangulation. A random sample of 500 ED nurses received a clinical vignette questionnaire (CVQ) that described simulated patient presentations that differed only by patient sex. Additionally, 12 ED nurses participated in four focus group sessions that discussed triage decision-making.

Results: Of the 500 CVQs distributed, 260 returned (52%). Emergency department nurses perceived the 43 year-old male vignette patient to be in need of more urgent triage, an admission to an ICU bed, and more likely to have cardiac diagnosis considered than the age-matched female vignette patient with identical presentation. However, no differences were noted in the triage decisions for the 66 year-old male or female vignette patients. The qualitative findings supported the quantitative data. Content analysis of the focus group sessions revealed several important issues that influence triage decisions: patient presentation, nursing knowledge and experience, practice environment, intuition, the fear of liability, and gender specific behaviors. Nurses held different perceptions regarding the significance and likelihood of coronary artery disease (CAD) for male and female patients seeking evaluation and treatment. Nurses admitted that CAD is not the first diagnosis considered for middle-aged females who come to the ED.

Implications for Nursing Practice: Emergency department nurses must critically examine their own triage practices for the influence of gender bias. Through critical reflection, ED nurses can begin to eliminate its influence on the selection of patient cues, the determination of suspected cause, and the need for emergent triage, thereby revealing the power gender bias exerts on the decision-making process.

Conclusions: The findings of this study suggest that gender bias and ageism may account for the disparities in triage decisions for middle-aged women with complaints suggestive of CAD. Triage decisions of ED nurses based on a biased perception of a woman's risk for CAD negatively impacts the level of health care women receive. The initial consideration of other than cardiac diagnoses jeopardizes the chance a woman experiencing an acute MI will receive appropriate and aggressive treatment. Although middle-aged women may not suffer the same number of MIs as middle-aged men, their increased morbidity and mortality warrants its consideration.

Significance and Purpose: Traditionally low-risk pregnant women attending prenatal care in the United States have followed the ACOG recommended visit schedule of approximately 14-16 visits during their pregnancies (ACOG, 1997). In 1986, an Expert Panel convened by the USDHHS questioned the current visit schedule and the lack of sound scientific evidence upon which it is based (USDHHS, 1989). The Expert Panel proposed that women who are healthy and of low-obstetric risk may be seen less often during pregnancy without adverse effects on their health or their baby's well-being. Thus, a reduced frequency prenatal visit schedule for low-risk pregnant women based on the timing of specific tests or events that occur in pregnancy was proposed by the Panel. Research supports the use of this visit schedule with women of low-obstetric risk. To date, no research has been done to explore nurse-midwives'/midwives' attitudes toward use of the reduced frequency visit schedule. Since nurse-midwives/midwives primarily care for women of low-obstetric risk, knowledge about their attitudes is key in implementing this schedule on a broader scale. The purpose of this study was to explore nurse-midwives'/midwives/ attitudes toward and use of reduced frequency prenatal care visit schedules.

Methods: A descriptive correlational study was performed. A Likert-type scale was developed by the research team. The instrument was evaluated by expert midwives and pilot tested before implementation. Permission to conduct the study was obtained from the IRB at the University of Michigan and the ACNM Division of Research. Data were gathered at the 1999 ACNM Annual Meeting in Orlando, FL. A convenience sample of 243 respondents was obtained; resulting in 237 completed questionnaires.

Results: Of the 237 participants, 170 responded that they were familiar with the reduced frequency visit schedule. Midwives familiar with the schedule had a more positive response to the reduced frequency visit schedule. Significant differences were found between the familiar versus the unfamiliar groups (CHI SQ=3.59 (SD .729) VS. CHI SQ=2.92 (SD .679)) with regard to midwives' satisfaction with quality of care (p <.0001). Although our analysis demonstrated positive attitudes toward reduced frequency scheduling, the survey found few respondents actually used it in practice. Only 40 midwives (17%) reported any use of the reduced frequency schedule for multiparous clients, yet 59% indicated that they felt the minimum number of visits needed was 8 or fewer. Neither years of practice nor education of the midwives had implications toward the use of the reduced frequency visit schedule. Further analysis of the survey responses also revealed that midwives with a higher percentage of African-American patients (r=-.41, p=.013) and privately insured patients (r=-.123, p=.071) were slightly less satisfied with quality of care using the reduced frequency visit schedule, but viewed the reduced frequency visit schedule better for Medicaid patients (r=.169, p=.013).

Discussion/Implications For Practice And Research: The majority of nurse-midwives/midwives who reported use of the reduced frequency schedule were satisfied with it but did not actually use the schedule set up by the expert panel (1989). Most respondents viewed the reduced frequency visit schedule as adequate for care for low-obstetric risk patients. Future research is needed to determine what barriers are preventing nurse-midwives/midwives from using a reduced frequency visit schedule when they deem it appropriate with clients. Practicing nurse-midwives/midwives should revisit the exact content of the reduced frequency visit schedule and explore its use with their clients. Future research could also query nurse-midwives/midwives that care for a more diverse patient population, with regards to age, race, and socioeconomic status.

A nursing center is an ambulatory care clinic in which nurses provide health care to clients and manage the operational and financial functions of the center. During the 1980's, academic based nursing centers proliferated largely due to the need for clinical teaching sites for undergraduate and graduate nursing students and the availability of funding for demonstration projects for underserved populations. However, financial instabiity has led to the closure of many nursing centers and placed others at risk for closure. Employing gross costing, activities based costing techniques, and time studies, this study analyzed the operating costs of a financially thriving nursing center. Both nursing centers had similar visit times and direct labor costs but indirect labor costs were much higher at the financially troubled center. The ratio of direct costs to indirect costs was higher at the financially troubled center than at the financially stable center. Excess capacity was examined for both nursing centers and was greater at the financially troubled center.

Scenario analyses were done to determine the number of patient visits needed to reach a break-even point for varying labor conditions. The financially troubled center must increase the number of patient visits and substantially decrease overhead in order to reach a break-even point. Understanding and managing operational costs are crucial for nursing centers to attain financial stability. The combined methodologies of gross-costing and activities-based costing to analyze operational costs enhanced understanding of the two nursing centers' cost structures. Results of this study suggest that indirect labor costs play an important in determining nursing center profitability. Nursing centers with lower ratios of indirect labor costs to direct labor are more likely to be profitable than are nursing centers with high ratios of indirect to direct labor costs. The findings of this study have practical implications for those schools of nursing contemplating starting a nursing center as well as those with existing nursing centers.

Introduction: Emergence delirium (ED) is an acute state of agitation occurring in up to 13% of children, following general anesthesia (GA), and typically includes behaviors such as non-purposeful restlessness or agitation, inconsolability and incoherence. Studies have associated ED with anesthetic angents, medications, or pain. However the etiology remains unclear. This study evaluated factors related to ED in children, and investigated the relationship of underlying temperament and emergence behaviors.

Methods: With IRB approval and parental consent, healthy children (3-7 years old) undergoing general anesthesia were studied. Data regarding the child's health status and history, anesthetic agents/medications received duration of procedure, time of awakening and discharge, awakening behaviors, and adverse events were recorded. Parents completed the Behavioral Style Questionnaire for 3-7 year olds, which yields numerical scores [1 (low/positive) to 6 (high/negative)] for 9 dimensions of temperament. All care givers were blinded to responses on this survey. Parametric data, including temperament scores are presented as M+SD, and were compared using unpaired t tests. Chi square with Fisher's exact tests were used to compare non-parametric data. P values of –5 were considered significant.

Results: 241 children comprised the sample, and 23% exhibited ED behaviors on awakening. Children who experienced ED were more likely to need opiates in the postanesthesia care unit (PACU) (50% vs. 13%; p<0.0001) and required a longer PACU stay than children who awakened without ED behaviors. Lastly, two children injured their operative site during emergence, and one injured the nurse who was providing care.

Conclusions: Our data demonstrate that the use of short-acting volatile anesthetics, namely sevoflurane and isoflurane, and a short time awakening largely contributed to the presence of ED behaviors in children. Girls were more likely to exhibit ED behaviors than boys, and underlying temperament, with the exception of adaptability, did not appear to contribute to ED.

Cancer treatment-related fatigue is a distressing effect of cancer therapy. Early efforts on describing the fatigue experience have progressed to testing potential interventions. This study built on the fatigue, functional capacity, and exercise activity of previous studies (MacVicar et al 1989, Mock et al 1994, 1997, 2001, and Schwartz 2000). Strength training and the nature of the relationship of physical self-efficacy and performance to functional wellness contribute new understanding to this area of fatigue and symptom management.

The purpose of this pilot study was to test the effectiveness of a structured exercise program in decreasing fatigue, increasing strength and endurance, increasing physical self-efficacy, and enhancing perceptions of functional wellness in women undergoing adjuvant chemotherapy (Adriamycin and Cytoxan) for early stage breast cancer. Specific aims of this study in women undergoing adjuvant therapy for newly diagnosed breast cancer were: 1) to determine the effects of a structured exercise program on fatigue, performance (endurance and strength), and physical self-efficacy; 2) to determine the effects of a structured exercise program on functional wellness; and 3) to determine the feasibility of conducting an exercise study with this population.

A conceptual model was proposed, identifying relationships among the focal concepts of cancer treatment-related fatigue, performance, physical self-efficacy, and functional wellness. The structured exercise program was the predictor variable. A randomized two-group repeated measures experimental design was used. A sample of 26 women (36-58 years) with newly diagnosed Stage I or II breast cancer, were randomized to comparison (n=11) and intervention (n=15) groups. Both groups were tested at weeks 1 and 13 for endurance (VO2max) and strength (1-Repetition Maximum). Measurement of fatigue (Revised Piper Fatigue Scale, Attention Functional Index), physical self-efficacy (Physical Self-Efficacy Subscale), and functional wellness (MOS SF-36, Functional Wellness Questionnaire) occurred at weeks 1, 7, and 13.

The study intervention consisted of a 13-week, home-based, structured endurance and strength-training exercise program. The endurance intervention consisted of a walking prescription for frequency, duration, and intensity targets per week. The strength intervention consisted of performance of weekly targets for frequency and repetitions with progressive resistance training using exercise tubing. The comparison group continued their current exercise program over the 13-week period. Exercise diaries were maintained by all study participants over the study period.

Data analysis found significant differences between the groups in VO2max, exercise activity, and perceptions of fatigue and functional wellness over the 13 week period.

The intervention group reported significantly higher minutes and days per week of exercise activity than the comparison group. The comparison group had a 4.38 mean decline (16.94%) in VO2max as compared to a 0.459 mean improvement (1.96%) in VO2max in the intervention group. A significant difference in the total fatigue score was found between the two groups at week 13, with the intervention group reporting lower levels of fatigue than the comparison group. Perceptions of functional wellness were significant at week 7 between the two groups, with the intervention group having a more positive perception of their state of wellness at the midpoint of their treatment regimen. Significant correlations were found between fatigue, vitality, attentional fatigue, and physical self-efficacy. The SF-36 physical functioning subscale significantly correlated to physical self-efficacy.

Preliminary testing of the conceptual model proposed in this study was performed via stepwise multiple regression. Support was found for several of the proposed relationships with this sample population. Exercise dose was calculated for all study participants to differentiate the impact of exercise alone from the effect of an exercise program. Dose regressed on VO2max explained 21.5% of the variability of the change in VO2max over time. As the dose of activity increased, the negative change in VO2max decreased. When participation in a structured exercise program was regressed on VO2max change over time, almost 37% of the variance could be explained by group assignment (comparison versus intervention group). It was postulated that as fatigue increased over time, perceptions of physical self-efficacy would decrease. Cancer treatment-related fatigue explained 51% of the change from time 2 to time 3 in physical self-efficacy.

The results of this pilot study suggest that:

1. being a participant in a structured exercise program does make a difference in perceptions of fatigue, physical self-efficacy, physical performance, and functional wellness;
2. the midpoint of treatment (week 7), may be the time where the strongest negative effects of treatment are perceived by patients;
3. a structured exercise program may provide a means to enhance perceptions of empowerment, confidence, and focus across the treatment period;
4. exercise appears to have a role in lessening the overall perception of fatigue, specifically that fatigue that interferes with the ability to work and socialize; and
5. middle-aged women undergoing a specific type of adjuvant chemotherapy for early stage breast cancer, may engage in structured exercise across a treatment period.

Results from this preliminary work, will be further tested and explored with additional sample populations of women undergoing treatment for early stage breast cancer.