Abstract

This study examined the relationships among illness uncertainty, perceived stress and disease symptomatology in outpatients with multiple sclerosis (MS). Forty three subjects with MS and 38 healthy control subjects completed a series of standardized psychological instruments. MS subjects also completed a measure of disease symptomatology. MS subjects scored significantly higher on measures of perceived stress and negative mood, with a significant reduction in positive affect when compared with control subjects. Also, these measures of perceived stress, negative mood, and illness uncertainty correlated significantly with disease symptomatology. Additional analysis demonstrated that perceived stress had direct effects on MS symptomatology, with indirect effects for illness uncertainty. Perceived stress and illness uncertainty may contribute to the occurrence of disease symptoms in individuals with MS.

Key Words: perceived stress, multiple sclerosis, illness uncertainty, symptomatology.

Background of the Problem

Multiple sclerosis (MS) is a chronic, degenerative neurologic disorder evolving from progressive destruction of the myelin sheath, with a resulting loss of nerve propagation. The destruction of myelin is believed to occur as result of an immune response in which immune components attack myelin in the central nervous system (Boccaccio & Steinman, 1996). While the pathogenic process of MS is not fully understood, MS is believed to be an immunopathologic disorder which may emerge from the interaction of genetic susceptibility with precipitating environmental factors (Dean, 1994; Kurtzke, 1993; Weinshenker, 1996). While controversial, one such precipitating factor may be a state of psychological stress that could contribute to the exacerbation of MS through immune modulation (van Noort, 1996).

Illness Uncertainty

The existence of a state of illness uncertainty may contribute to the development of increased levels of psychological stress. Illness uncertainty has been defined as the inability to successfully ascribe meaning to illness-related events (Mishel & Braden, 1988). The lack of meaning is conceptualized to adversely affect cognitive appraisal of illness-related events, contributing to an interpretation of illness-related events with unclear meaning as a potential threat. The existence of a threat appraisal can then lead to the emergence of a state of perceived stress (Lazarus & Folkman, 1984; Mishel, 1981). In hospitalized medical patients, illness uncertainty has been demonstrated to predict the level of perceived stress (Mishel, 1984).

The individual with MS may experience substantial uncertainty regarding disease progression due to the unpredictable course of the disease (Kroencke & Denney, 1999; Zedlow & Pavlou, 1984). The level of such uncertainty that surrounds a chronic disease can then pose a threat to the individual and serve to induce stress (Mishel, 1981, 1984). The illness-related uncertainty of MS and the corresponding deterioration in functional ability could increase an individual’s level of perceived stress and induce negative mood states. In one study, the presence of illness uncertainty was found to account for a significant degree of mood state variance (Wineman, Schwetz, Goodkin, & Rudick, 1996). The emotional well-being of individuals with MS could then be influenced by “a set of stress/uncertainty variables” (Wineman et al., 1996). Those with MS that perceived the illness as having a highly uncertain course, and appraised living with disability as a potential threat, have been shown to experience greater disruption of emotional well-being (Wineman, Durand, & Steiner, 1994).

Illness-related uncertainty could then be a potential contributing factor to a heightened level of psychological stress. Such a state of psychological stress may contribute to disease exacerbation if not actual disease onset. Prior to the onset of symptoms, the individual with MS may report a higher incidence of psychological stress (Grant et al., 1989; Warren, Greenhill, & Warren, 1982; Warren, Warren, & Cockerill, 1991). The presence of psychological stress has also been shown to contribute to disease exacerbation (Warren et al., 1991). Questions remain, however, as to whether stress functions as a causative agent in exacerbation, or whether the occurrence of disease exacerbation itself, produces a higher degree of perceived stress (LaRocca, 1984; Warren, 1990; Warren et al., 1982; Warren et al., 1991). It could be speculated that illness uncertainty may have a direct relationship with disease symptoms, one independent of its relationship with psychological stress. While illness uncertainty has been demonstrated associated with levels of psychological distress in individuals with MS (Mullins et al., 2001; Wineman, O’Brien, Nealon, & Kaskel, 1993; Wineman et al., 1996), the link between illness uncertainty and reported disease symptomatology is as yet unclear.

Purpose of the Study

The purpose of the present study was to examine the relationships among illness uncertainty, perceived stress, and disease symptomatology in MS and control subjects, in order to determine if perceived stress and illness uncertainty related to level of disease symptomatology in individuals with MS. MS subjects were recruited from outpatient settings, in order to examine the relationship between stress and disease in the daily life of MS subjects, rather than examining individuals hospitalized for disease exacerbation. It was hypothesized that MS subjects would exhibit higher levels of perceived stress than control subjects. In addition, it was hypothesized that illness uncertainty would significantly correlate with perceived stress and, secondly, that increased levels of psychological stress and illness uncertainty would significantly correlate with disease symptomatology.

Method

Participants

A convenience sample of male and female patients previously diagnosed with clinically definite MS using the Poser criteria was recruited from the outpatient neurology clinic of a large Mid-Western Level I Medical Center located in Illinois and from surrounding regional community support groups. Control subjects were recruited from the community at large. Prior to implementation of the study, approval was obtained from the Institutional Review Board (IRB).

Subjects were asked to complete a series of standardized psychological instruments that assessed self-reported levels of: perceived stress, illness-related uncertainty, and mood state. Control subjects completed three self-report measures and one demographic data form. MS study participants completed four self-report measures and one demographic data form. The self-report measures completed by MS subjects were: the Perceived Stress Scale (PSS), the Mishel Uncertainty in Illness Scale–Community Version (MUIS), the Profile of Mood States (POMS) and the MS-Related Symptom Checklist (MSSC). Control subjects did not complete the MUIS or the MSSC.

Measures

The Perceived Stress Scale (PSS) is a 10-item, subjective self-report measure designed to measure the cognitive appraisal of a global state of stress (Cohen, 1994). Homogeneity reliability has been demonstrated through a Cronbach’s alpha coefficient of .75 in a norm-referenced sample (Cohen & Williamson, 1988). In this study homogeneity reliability as determined by Cronbach’s alpha was .91.

The Mishel Uncertainty in Illness Scale (MUIS) is a 28-item measure using a five-point Likert type scale, designed to measure illness uncertainty (Mishel, 1981). The version of the MUIS used in this study is derived from the full, 28-item measure designed for use with individuals currently not hospitalized. Reliability for this 23-item version of the MUIS has been shown to range from .74 to .92 (Mishel, 1997). In this study, the Cronbach’s alpha score was .86.

The Profile of Mood States (POMS) is a 65-item, self-report measure designed to assess affect and mood (McNair, Lorr, & Droppleman, 1992). A total mood disturbance score can be derived (POMS-TD). Additionally, six subscales assess further components of mood: tension-anxiety (POMS-T), depression-dejection (POMS-D), anger-hostility (POMS-A), vigor-activity (POMS-V), fatigue-inertia (POMS-F), and confusion-bewilderment (POMS-C) (McNair et al.). All subscales assess for the presence of negative emotionality and mood except for the vigor-activity subscale. The vigor-activity subscale has been identified as a measure of positive affect (McNair et al.). Homogeneity reliability was demonstrated through Kuder-Richardson 20 scores of between .84 and .95 for the six factors (McNair et al.). For this study, Cronbach’s alpha subscale scores ranged from .69 to .96.

The MS-Related Symptom Checklist (MSSC) is a 26-item, self-report measure designed to assess for the presence of 26 disease symptoms common in patients with MS (Gulick, 1989). The tool consists of five subscales assessing; motor function, sensory disturbance, mental and emotional concerns, bowel function, bladder function, and brain stem symptomatology. Homogeneity reliability was identified through the use of Cronbach’s alpha with subscale scores ranging from .78 to .87 (Gulick, 1989). Scores are determined through the use of a six-point scale with responses ranging from never to always. Higher scores indicate the presence of increased symptomatology (Gulick, 1998). Here, only the total symptom score was utilized (Total MS Symptoms). Total scale homogeneity reliability as determined through Cronbach’s alpha in this study was .90.

The mean scores and standard deviations for all measures are provided in Table 1. Results are presented for both MS and control subject groups, as is the statistical analysis.

Results

The examination of data began with conducting Levine’s test for equality of variance. All mean comparison data between MS and control subjects demonstrated at least a .05 level of significance on the Levine’s, indicating the existence of non-normative patterns of distribution. All data was then examined using a non-parametric statistic, the Mann-Whitney U. In Table 1, the scores from the Mann-Whitney are given and indicated as such. The alpha level determined prior to analysis was p = .05. Further examination of the data was performed using partial correlations and structural model testing. All data analysis was conducted using Statistical Package for the Social Sciences (SPSS) Version 10.05, with the exception of structural model testing, which was conducted using Analysis of Moment Structures (AMOS) 4.0.

Sample Characteristics

Control subjects (N = 34) were between 29 and 54 years of age (M = 43.00, SD = 1.34). All control subjects were identified as Caucasian. Three control subjects were male while the remainder female (n = 31). MS subjects (N = 41) were between 28 and 75 years of age (M = 49.05, SD = 9.11) with 12 male subjects (28.6%) and 31 female subjects (71.4%). In those with MS, individuals identified as Caucasian (n = 38) comprised the majority of the sample (90.5%), with three subjects identified as African-American (7.1%) and one as American Indian. To ensure equality of groups in terms of age, and other demographic variables, independent t-tests and the Mann-Whitney U were performed to examine for the presence of significant variance in demographic variables. The Mann-Whitney U was performed on all nominal data (age, gender, race, and martial status). No significant differences were found between control and MS groups in terms of age, gender, race or martial status. A significant difference was found in terms of education, using a two-tailed t-test for independent samples (t = 4.349, 44, CI of 1.88 to 2.30, p < .01). Control subjects reported significantly more years of education (M = 18.70, SD = 1.34) than did MS subjects (M = 15.19, SD = 2.44).

Form of MS

Each MS subject was asked to self-report whether a sub-type, or form, of MS had been diagnosed. As the use of diagnostic categories has changed over time, individuals with a longer course of disease were often unable to specify a particular form of MS. These individuals were categorized as type unknown. Twenty-four (58.5%) individuals were identified as Relapsing-Remitting, seven (17.0%) as Chronic-Progressive, one as Benign, one as Progressive-Recurring and the remaining eight (19.5%) as Unknown.

In order to determine whether the reported form of MS accounted for variance in scores for psychological measures, serial two-tailed t-tests for independent samples were performed. To provide a sufficient number of subjects for valid comparison, all individuals with a progressive element to the disease process were placed into one group (progressive-recurring, chronic-progressive); labeled progressive disease. This group consisted of eight subjects who scores were compared with individuals who had the relapsing-remitting form of MS (n = 33). No significant mean differences were found to exist for any of the variables between forms of MS (Data not shown).

Perceived Stress and Mood

MS subjects reported significantly higher levels of perceived stress than control subjects. See Table 1. In conjunction with significantly higher levels of perceived stress, MS subjects also reported significantly higher scores on all measures of negative mood derived from the POMS; tension-anxiety, depression-dejection, anger-hostility, fatigue-inertia and confusion-bewilderment. Scores from the negative mood subscales can be summed on the POMS, and the score from a positive mood subscale (vigor-activity) subtracted, to provide a measure of the total amount of negative mood experienced by the respondent (McNair et al., 1992). This score is referred to as the total mood disturbance score (POMS-TD). The total disturbance score for the MS sample was significantly higher than that of the control sample (See Table 1).
In association with significantly higher levels of perceived stress and negative mood, MS subjects also displayed a concomitant decrease in positive affect as measured by the vigor-activity subscale (POMS-V) of the POMS. MS subjects were found to score significantly lower than did control subjects.

PSS scores correlated significantly with POMS-TD scores in individuals with MS, as with control subjects. However, as shown in Table 2, in MS subjects the magnitude of correlation was greater. MS subjects demonstrated significant positive Pearson correlations between level of perceived stress and all negative mood states assessed by the POMS. Scores from the measure of positive mood and the vigor-activity subscale were significantly correlated with perceived stress in a negative manner.
The correlations between perceived stress (PSS) and the POMS subscale scores in the MS sample tended to be twice as strong as the same correlation in normative control subjects. For example, with total mood disturbance (POMS-TD) for normative controls, the correlation between PSS and the measure of total mood disturbance was .447. For the MS subjects, the Pearson correlation between PSS and POMS-TD was .797. Not only did perceived stress significantly correlate with measures of negative mood state in MS subjects (POMS Subscales), the magnitude of these correlations was far greater in those with MS than in normative control subjects.

Psychological Stress, Illness Uncertainty, and MS Symptomatology

The patterns of correlation among measures of negative mood (POMS subscales), perceived stress, total mood disturbance, and total MS symptoms are shown in Table 2. Each measure of negative mood was significantly correlated with reported MS symptomatology (MSSC). Perceived stress and total mood disturbance (POMS-TD) showed significant positive correlation with total MS symptomatology. The measure of positive affect, vigor-activity, was significantly correlated in a negative manner with total MS symptomatology.

Perceived stress and total mood disturbance were positively correlated with the measure of illness uncertainty (MUIS). Illness uncertainty (MUIS) scores of MS subjects were also positively correlated with the total number of MS symptoms. Illness uncertainty correlated selectively with other measures of negative mood, such as tension-anxiety and fatigue-inertia.

We sought to further examine the relationship among these variables by classifying MS subjects into high- and low-stress groups (See Table 3). The criteria determining high- versus low-stress classification was the median score for the PSS. Subjects were classified as high-stress if the PSS scores were at, or above, the median (≥ 20), while those subjects classified as low-stress were those with PSS scores below the median (< 20). A mean comparison was conducted using two-tailed t test for independent samples.

High-stress MS subjects displayed significantly higher scores on all measures of negative mood (tension-anxiety, depression-dejection, anger-hostility, fatigue-inertia) and total mood disturbance than did low-stress MS subjects. The high-stress MS subjects were also found to display significantly lower scores on the measure of positive affect, vigor-activity, than did low-stress MS subjects. Those MS subjects identified as high stress, reported significantly higher levels of illness uncertainty than did low-stress MS subjects (see Table 3). High-stress MS subjects (n = 24) also reported a significantly higher level of disease symptoms than did low-stress MS subjects (n = 17). Additionally, high-stress MS subjects tended to have had a shorter period of disease (M 7.65 years, SD 6.65) as compared with low-stress MS subjects (M 14.16 years, SD 14.16). This finding may demonstrate that, as the individual grows more accustomed to living within the context of MS, illness uncertainty fades.

As part of the examination of the relationship between illness uncertainty, perceived stress, and MS symptoms, a series of partial correlations were performed in which illness uncertainty (MUIS) scores were held constant (see Table 4). There was little change in the significance of association of variables when MUIS scores were held constant, with correlations decreasing an average of .10.

The role of perceived stress is supported by the presence of a stronger positive correlation between PSS scores and total MS symptom report (r = .745, p = < .01); than that found between MUIS and total MS symptom report (r = .537). In addition, all of the POMS subscales correlated more strongly with total MS symptomatology than did illness uncertainty (Table 2), with the exception of fatigue-inertia.

In order to examine the relative contribution illness uncertainty made to variance in MS symptomatology, an exploratory structural model was constructed based upon previous conceptualizations of illness uncertainty (Mishel, 1981, 1984). A structural recursive model was created that included: illness uncertainty, perceived stress, total MS symptoms and total mood disturbance. Analysis was not conducted using separate mood states as derived from the POMS, for the total mood disturbance score is compiled through summation of negative mood states subscale scores with subtraction of the positive mood state subscale score. The inclusion of such constituent variables was then seen as raising the risk of inadvertent multicollinearity. Analysis was conducted using Amos 4.0, with illness uncertainty as an exogenous variable. Endogenous variables were perceived stress, total mood disturbance and MS symptomatology. The tested model exhibited acceptable fit, x2 (1, N = 80) = .842, p = .359. The tested model is presented in Figure 1, with standardized total effects.

Figure 1. Exploratory path analysis of the relationship among uncertainty, perceived stress, total mood disturbance, and total reported symptoms of multiple sclerosis.

Note: All numbers indicate Standardized Total Effects
Legend: Standardized total effects are presented for each variable, which is a combination of the direct (alone) and indirect (through influence on other variables) effect on MS symptoms for each study variable. Stress, mood disturbance, and illness uncertainty have small, but significant, direct effects on the experience of MS symptoms, with stronger indirect effects, implying that these variables exert a direct influence on the experience of symptoms in MS patients.

Illness uncertainty exhibited a small standardized direct effect (.18) on MS symptoms, while perceived stress demonstrated a slightly larger standardized direct effect (.28). Total mood disturbance exhibited a moderate standardized direct effect (.47). The standardized total effect for illness uncertainty on MS symptoms was weaker (.59) than that of perceived stress (.68). Such data, when taken in conjunction with the partial correlations indicate that the effects of illness uncertainty are predominantly indirect effects, perhaps occurring through the mediation of stress appraisal as originally conceptualized by Mishel. This is supported by a stronger standardized indirect effect for illness uncertainty (.41) than for perceived stress (.39). Other factors yet come to play, for illness uncertainty only explained 21% of the variance in perceived stress. Together, the three psychological variables (perceived stress, total mood disturbance, and illness uncertainty) explained 45% of the variance in MS symptoms.

Discussion

Previous investigators have demonstrated a relationship between heightened levels of perceived stress and clinical exacerbation in individuals with MS (Warren et al., 1991). Yet, many of these studies have not successfully linked levels of perceived stress to reported symptoms. Instead, stress has been linked to periods of disease exacerbation without evaluating the effect of stress on disease symptoms outside these periods. This study examined the contribution that perceived stress and illness uncertainty make to those symptoms reported by individuals with MS during a period of disease remission. In general, the findings of this study are consistent with previous research, which has demonstrated that MS subjects often display higher levels of psychological distress than normative controls (Ackerman, Martino, Heyman, Moyna, & Rabin, 1998; Jean, Beatty, Paul, & Mullins, 1997). MS subjects were found to have significantly higher levels of perceived stress and total mood disturbance than control subjects. MS subjects were also found to have indices of psychological distress (perceived stress, total mood disturbance, negative mood state) that correlated significantly with the incidence of disease symptomatology. Individuals with MS consistently displayed significantly higher scores on all psychological measures than normative controls with the exception of scores on the POMS subscale, vigor-activity. MS subjects consistently scored significantly lower than control subjects on vigor-activity. The effect of perceived stress may then involve more than the manifestation of negative mood, it may well involve a concomitant decrease in the experience of positive mood. Based on this data, we conclude that MS subjects experience a higher level of perceived stress and mood disturbance than control subjects. Indeed, MS subjects that were classified as low-stress displayed a higher mean PSS score (M 13.88, SD 4.39) than control subjects as a whole (M 11.37, SD 4.88). These findings indicate that MS subjects live and function within a heightened state of psychological stress, a state of psychological stress that has significant positive correlation with disease symptomatology.

The subjects classified as high-stress had significantly higher mean scores for measures of disease symptomatology, illness uncertainty, and total mood disturbance than low-stress MS subjects. The division of MS subjects based on level of perceived stress revealed significant differences not only in the scores for psychological variables, but also the importance of examining the influence of perceived stress on other psychological measures. The mean scores for those MS subjects classified as low-stress were lower than the means for illness uncertainty and total mood disturbance reported by other, larger, investigations (Wineman et al., 1996). Yet, the scores for MS subjects classified as high-stress were comparable with the scores found in that previous work. The mean illness uncertainty score in MS individuals classified as high-stress was roughly equitable to that found in previous investigations (M 69.08, SD 11.91). Wineman et al. (1994), found a mean MUIS score of 77.02 with a sample that was ten-fold the size of the present sample (N = 433). The scores on POMS-TD were much larger in the present study, with the high-stress population reporting a mean of 69.58. Whereas, Wineman et al., (1994), reported a mean POMS-TD score of 32.50. Such divergence in terms of mood disturbance and illness uncertainty may indicate the need to examine how differing samples of MS patients may vary in psychological stress scores. Those individuals with MS who experience high levels of stress may be more likely to experience disease exacerbation than those with lower levels of stress. There needs to be closer examination of those subjects with MS who do not report heightened levels of perceived stress, in terms of how these individuals may cope differently from those who report high levels of stress.

Living with a chronic disease that is associated with an uncertain course of progression in conjunction with existent levels of disability, could contribute to the development of a state of chronic psychological stress. Such a state of chronic psychological stress may tax or challenge the adaptive resources of the individual. Here we found that individuals with MS experience higher levels of perceived stress, perhaps due to higher levels of illness uncertainty. Illness uncertainty did correlate significantly with levels of perceived stress and select measures of negative affect (tension-anxiety, fatigue-inertia, total mood disturbance). The effects, however, of illness uncertainty on disease symptoms appeared more indirect and to occur through increased levels of perceived stress, rather than through a large main effect on the part of illness uncertainty itself. A stronger direct effect was found for perceived stress and total mood disturbance on MS symptoms than was found for illness uncertainty. In the conceptual model of Mishel, a higher degree of illness uncertainty could be a contributing factor to the stressful appraisal of an event or situation, dependent on whether the degree of uncertainty was perceived as a threat (Mishel, 1981). This conceptualization appears consistent with the data of this study; that the effects found for illness uncertainty appeared to occur through mediation of perceived stress.

Psychological stress in those with MS could occur as the result of a combination of negative life events and disease related variables (Aikens, Fischer, Namey, & Rudick, 1997). Dalos, Rabins, Brooks, and O’Donnell (1983) found that emotional disturbance was associated with increased disease activity in those with MS. The degree of physical disability present in those with MS has previously been shown to influence psychological functioning. The greater the level of symptomatology and correspondent disability: the greater the effects on the ability of the individual to function socially (Zedlow & Pavlou, 1984). For example, disease symptoms may; (1) increase in relation to states of negative affect and psychological distress or, (2) themselves cause increased levels of negative affect and psychological distress. Psychological stress could function in a circular manner, enhancing the impact of other life events and serving to precipitate disease, which then reinforces a continued state of psychological stress (LaRocca, 1984; Warren, 1990).

Conclusion
We have found that illness uncertainty and perceived stress are directly associated with increased MS symptom report, outside of periods of disease exacerbation. Based on these findings, it could be speculated that psychological factors may influence the daily experience of symptoms in individuals with MS. Perhaps the gradual worsening of symptoms in response to increased levels of perceived stress results in the development of a circular pattern of stress and disease. A pattern in which perceived stress contributes to increased symptomatology, which in turn affects the functional ability of the individual and increases levels of illness uncertainty, resulting in even greater levels of perceived stress, eventually leading to clinical exacerbation in the failure of effective coping mechanisms.

Implications for Spinal Cord Injury Nurses
The patient with MS encountered in the spinal cord setting is more apt to have significant disability, particularly in terms of ambulative ability and ability to perform activities of daily living. In turn, it is possible this patient may be experiencing higher levels of stress and illness related uncertainty. As perceived stress and illness uncertainty may influence the presence of MS symptoms, it is important to investigate with the patient and family feelings regarding stress and the use of coping strategies. The identification and teaching of appropriate and feasible coping strategies can aid the patient in coping with illness-related uncertainty and stress. Helping the patient cope more effectively can, at a minimum, contribute to an improved quality of life and just might have an effect on symptom presentation.

Acknowledgements
We thank Gastone Celesia and Amy Perrin-Ross for their invaluable assistance in the recruitment of subjects. We also wish to thank those individuals with, and without, MS who participated in this study. This project was partly supported by grants from the National Institutes of Health (NIH 1F31 NR07442), American Association of Spinal Cord Injury Nurses (Project Number 177), and Sigma Theta Tau–Alpha Beta Chapter.

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Mathew R. Sorenson, PhD, RN, is assistant professor of nursing at DePaul University, Chicago, Illinois. msorenson@depaul.edu
Linda Janusek, PhD, RN, is a professor of nursing At Loyala University, Chicago.
Herbert L. Mathews, PhD, is a professor of microbiology and immunology at Loyola Unversity, Chicago.

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Introduction
When children or adolescents with spinal cord injury (SCI) receive rehabilitation and follow-up care through a facility that specializes in pediatric rehabilitation, the goal is to provide care that is developmentally-based and geared to the changing needs of children as they grow. A primary challenge for pediatric facilities, however, is to gradually prepare patients and families to transition from the pediatric focus to permanent discharge. It is essential that patients are ready to attain adult health care and move smoothly into adult lives that will be productive and satisfying. A key way to determine how well these individuals are doing as adults is to undertake long-term outcome studies to identify how many of these adults with pediatric-onset SCI, for example, are living independently, are participating in the community, are satisfied with their employment opportunities, are free of medical complication, and have a high quality of life (Vogel & Anderson, 2000; Anderson & Vogel, 2000; Vogel, Krajci, & Anderson, 2002; Anderson, Krajci, & Vogel, 2003; Anderson, Vogel, Betz, & Willis, 2004). These studies provide statistical information that is critical in identifying areas of strength and weakness that can be used to improve rehabilitation programs.

Another approach to understanding the critical aspects of adult transition is to ask former patients, who are now adults, about their own transition experiences. Using open-ended topics as guidelines is an opportunity for the consumers to raise the issues most important to their lives. They can become educators and teach the SCI team about transition to adulthood from the perspective of those who have been through it, or are well on their way.

Our facility recently hosted a day-long SCI round table discussion about transition to adulthood. The 12 adult participants included in the discussion were former SCI patients. They ranged from 23- to 42-years-old (mean age, 29; median age, 27). There were seven females, five males; six with tetraplegia, six with paraplegia. The SCI adults were divided into two discussion groups, facilitated by either the SCI medical director or the clinical psychologist. Topics were assigned for each 45-minute segment and discussion flourished. Some of the highlights are summarized below.

Transition to Adult SCI Health Care
Although one individual had periodic inpatient evaluations by a multidisciplinary SCI team, all others were seen by a primary care physician and specialists who were not necessarily very knowledgeable about SCI and without a team approach as previously experienced in the pediatric facility. Many individuals felt they were the teachers explaining SCI to their physicians. Some of the negative experiences included examination tables that were not accessible to wheelchair users, no wheelchair accessible scales for measuring body weight, and physicians who were not willing to treat common non-SCI-related medical conditions. The participants suggested that it would have been helpful for the opportunity to have the first appointment with adult health care providers while they were still patients at the pediatric facility. They felt this overlap would have provided a smoother health care transition. Patients also suggested that pediatric SCI physicians should provide guidelines related to treatment recommendations and their frequency, such as a listing of recommended routine urological procedures for patients with SCI. Since many of these young adults with SCI have made frequent moves about the country, they also wanted resources for obtaining names of primary care physicians and specialists throughout the country who had expertise and/or willingness to work with individuals with SCI. Discussion also identified the fact that there are official lists of physicians who are members of national SCI organizations (such as American Paraplegia Society or American Spinal Injury Association) or who have passed specialized SCI-Board exams. Some individuals felt that it would be helpful for the ability to communicate among them when they found physicians who were particularly helpful to those with SCI.

Transition to Education and Employment
Experiences with vocational rehabilitation services varied. Vocation rehabilitation services are federally-funded and administered at the state level. The goal of these programs is to help individuals with disabilities become employed, and often that means helping with college expenses and other training. All participants felt it was worth the effort to look into these services. Most individuals had enjoyed their college experiences and had few SCI-related problems, although they stressed the importance of visiting campuses to evaluate accessibility and advocate for their needs. They felt that education beyond high school was an important transition step. Those who lived at school felt that it provided a good transition to independent living. Most of the participants were employed and agreed that well-paying jobs with health benefits are key, especially because individuals with SCI are more likely to need health services than others of the same age. None of the patients were denied health insurance because of a previously existing condition and none felt that they were not paid as well as others doing the same job. Some reported limitations to accepting jobs because of environmental accessibility issues. For example, one woman reported that she would not take a position if there were not private bathroom facilities available and others said they would require indoor parking and handicap accessible parking spaces. Some individuals changed their way of managing SCI-related issues to help them succeed in the work place. This included abandoning intermittent catheterization for condom catheters or suprapubic catheters which were easier to manage in the workplace. None felt that SCI limited their opportunities for promotion. Some had employment positions that had nothing to do with disabilities while others had taken positions in which their experience with SCI was an advantage, such as case management. The participants felt that more job experiences and internships prior to adulthood would have helped them better prepare for employment.

On an interesting note, one recent college graduate had the experience of traveling abroad to Japan on an exchange program in which people from various countries share experiences of living with disabilities. He and another participant who had traveled in Europe on a similar program-both have tetraplegia-found traveling abroad thoroughly enjoyable. Like many young people without disabilities they were eager to continue traveling even if it meant postponing career plans.

Independent Living
Most participants lived independently, either alone, or with spouses, friends, or assistants. A big issue was the added expense of finding living accommodations that were wheelchair accessible. These included factors such as needing modern buildings with wider hallways; larger, accessible bathrooms; elevator buildings; and buildings with indoor garages. The time needed to search for accommodations was typically longer because of the SCI-related issues. All agreed there was limited reliability as to what a realtor or owner reported as accessible. The issue of home modification and its relation to increasing/decreasing property value was a concern for those who owned homes, particularly since young adults tend to move.

Recreation and Leisure Activities
Some participants like many others their age felt that, as their work and family responsibilities increased, they had less time for recreation and exercise. Others felt discouraged by the comparatively high cost of sports chairs, finding accessible workout facilities, or traveling to participate in wheelchair sports. They felt this made many recreational activities prohibitively expensive for them compared to their non-disabled peers. They also recommended that pediatric rehabilitation should focus on a wide range of recreation and leisure activities, particularly those that do not require specialized equipment and are available to anyone locally. Many felt that typical leisure areas, such as movie theatres, bars, and shopping malls were becoming more barrier-free.

Socialization, Dating, and Sexuality
These were topics that the participants especially wanted to have more time to discuss. Although they were all many years, and even decades, past injury they still noted the repetitious comments made to them in public: “I wish I had one of those (wheelchairs)” or “Slow down, I’ll give you a ticket.” Some noted that others used their chair as though it were common property, hanging things on the chair, asking them to carry packages on their lap, or using the rear wheels as foot rests. Most noted that they had few problems with friends, but dating was a big issue. Both males and females felt that dating in a chair was easier for females than males since traditionally males would be opening doors and assisting females. That role might be reversed if the male was using a wheelchair. One male felt that dating was the hardest issue after SCI. Knowing how and when to talk with a date about SCI and sexuality were also issues. Some who need assistance with care felt that they would not want their significant other or spouse to provide personal care and would like to separate sexuality from personal care issues. Most would have liked to have more sexuality teaching and mentors during their adolescent years.

Summary
The participants felt the most important and difficult areas of transition were dating, sexuality, employment, adult fitness, and recreation. The honesty of the participants in discussing transition issues was much appreciated, and their comments will be included in strategic planning. The authors recommend this process of receiving feedback from patients and note an additional benefit; the participants appreciated meeting others with SCI and learned from each other. They were all valuable teachers to us.

References

Anderson, C. J., Krajci, K. A., & Vogel, L. C. (2003). Community integration among adults with spinal cord injuries sustained as children or adolescents. Developmental Medicine and Child Neurology, 45, 129-134.

Anderson, C. J., Vogel, L. C., Betz, R. R., & Willis, K. M. (2004). Overview of adult outcomes in pediatric-onset spinal cord injuries: Implications for transition to adulthood. The Journal of Spinal Cord Medicine, 27(Supplement 1), S98-S106.

Anderson C. J. & Vogel, L. C. (2000). Employment outcomes of adults who sustained spinal cord injuries as children or adolescents. Archives of Physical Medicine and Rehabilitation, 83, 791-801.

Vogel, L. C. & Anderson, C. J. (2000). Adult outcomes and life satisfaction of pediatric-onset spinal cord injuries: Implications. Topics of Spinal Cord Injury Rehabilitation, 6, 182-187.

Vogel, L. C., Krajci, K. A., & Anderson, C. J. (2002). Adults with pediatric-onset spinal cord injuries. Part 3: Impact of medical complications. The Journal of Spinal Cord Medicine, 25, 297-303.

Caroline Anderson, PhD, is a clinical psychologist at Shriners Hospitals for Children, Chicago, Illinois.
Lawrence C. Vogel, MD is medical director of the SCI Program, and chief of pediatrics at Shriners Hospitals for Children, Chicago, IL.

Lisa Merenda, MSN, RN, CRRN, clinical research nurse at Shriners Hospitals for Children in Philadelphia, Pennsylvania and editor of Pediatric Perspectives, welcomes your input. Please send comments, questions, and suggestions to lmerenda@shrinenet.org

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In the last several years, we have seen an increase in studies, particularly those with a clinical focus that employ research methods from differing traditions, a mixing or blend of research methodologies. The use of mixed methodology in answering research questions is a form of what has been referred to as “triangulation.” In mixed-method studies, a qualitative research strategy is often used in combination with a quantitative strategy.

Qualitative studies have been viewed as providing a sense of the meaning of a phenomenon, whereas quantitative studies provide a means of comparing scores across populations and settings. An integration of both approaches may provide a new sense of the concept under investigation. This blending of approaches can provide a new understanding of concepts of relevance to spinal cord injury (SCI).

Triangulation
Definitions of triangulation in the nursing literature tend to utilize four categories developed by Denzin (1989). These categories are: (1) data, (2) investigator, (3) theoretical, and (4) method. In data triangulation, the investigator collects data from more than one source, for example from nursing staff and family members. Investigator triangulation involves having more than one researcher involved in data collection. Theoretical triangulation employs more than one theoretical perspective to analyze the data or may involve the collection of data using different research tools developed from differing theoretical perspectives. Method triangulation concerns the use of multiple means of collecting data, whether two separate qualitative/quantitative strategies, or the use of a qualitative and a quantitative technique within the some investigation (Denzin).

Method triangulation can involve either “within-method” or “between-method” approaches. Within-method triangulation involves use of more than one approach in collection of data (e.g., two different qualitative approaches to data collection). Here, research methods are not chosen from both the qualitative or quantitative tradition, the investigator employs multiple methods with one tradition. The between-method approach reflects the mixing of methods, utilizing both quantitative and qualitative approaches in gathering data. This technique provides the opportunity to expand beyond the limitations of one particular approach and gain a broader picture of the concept under study.

Should an investigator mix approaches throughout several aspects of the research process in terms of theoretical approaches or multiple investigators, in order to maintain some clarity across definitions it has been suggested that this be referred to as mixed model research (Teddlie & Tashakkori, 2003), with the term mixed methods referring more to the process of data collection.

Mixed-Method Research
As with other research traditions, there are several research designs possible with mixed-method research depending on whether the researcher is interested in exploring or confirming a research question. The collection of data using these approaches may occur in a sequential or simultaneous fashion. Examples of design approaches in the conduct of mixed-method studies include:

(1) The use of a qualitative strategy along with a quantitative strategy. An aspect of this design is commonly seen in clinical studies in which the participant is asked to complete a standardized question followed by a series of open-ended questions. A commonly employed approach in mixed-methods studies appears to be the adding of open-ended questions to a quantitative research instrument, typically a self-report questionnaire. This approach provides the investigator with the opportunity to move past the quantitative score generated by the questionnaire and investigate respondent feelings and concerns regarding the particular concept under investigation. This approach, however, could lead the investigator into playing little attention to the conduct of the qualitative aspects, leading to questions of qualitative rigor. More formal designs fully incorporate both methodologies.

(2) The findings from one study could be used to develop instruments used in another. A qualitative study could be done to investigate the perceptions surrounding quality of life in individuals with spinal cord injury. Afterward, the extracted themes could be used in the development of a standardized questionnaire. A similar approach was used in developing a quality of life measure for use with adolescent populations. In that work, qualitative studies served as the basis for model creation, with a series of quantitative studies conducted afterward to establish the instruments’ psychometric properties (Haase, Heiney, Ruccione, & Stutzer, 1999).

(3) Another variant can find one investigator administering a standardized questionnaire to a population, while another investigator conducts a qualitative interview with a comparison of the results afterward. This methodology was seen in a study of individuals with chronic fatigue syndrome, where a quantitative questionnaire was used to assess quality of life, with a subsample qualitatively interviewed (Anderson & Ferrans, 1997).

Relevance for Spinal Cord Nursing
Spinal cord research can involve non-random, purposive samples or samples that are readily accessible. This approach to sampling is less likely to generate the large numbers of subjects necessary to achieve the standard distribution pattern desired for the use of parametric statistics. A researcher could use non-parametric statistics to test for significance with smaller samples and purposive sampling approaches. Yet, this does not bring the same wealth of information that the concomitant use of a quantitative and a qualitative research method could bring. Mixing methods can bring a further dimension to spinal cord research, providing the richness of qualitative description along with standardized quantitative scores that can be compared with other studies. This approach can work well with smaller studies, and those descriptive investigations that are attempting to describe a concept with a SCI study population.

Conclusion
There seems to be an ongoing debate within the nursing literature regarding the philosophical basis of quantitative and qualitative research, such that a mixed-method approach may appear incommensurate. It has been proposed that applied research disciplines should avail themselves of a more pragmatic approach to research. With a pragmatic approach, the research question is considered the primary issue of concern, with less concern for a particular philosophical framework. The pragmatic approach argues that researchers should feel free to ask the questions that interest them and employ the methods that are appropriate to answering the question. This approach states a belief that qualitative and quantitative approaches are not incompatible with one another and argues for a middle ground between constructivist and positivist paradigms (Maxcy, 2003; Teddlie & Tashakkori, 2003). While there are still many questions to be answered regarding the use of mixed-method studies, these approaches may be of value to those conducting research with SCI and deserve a further look.

References

Anderson, J. S. & Ferrans, C. E. (1997). The quality of life of persons with chronic fatigue syndrome. Journal of Nervous and Mental Disease, 185(6), 359-367.

Denzin, N. K. (1989). The research act: A theoretical introduction to sociological methods (3rd ed.). Englewood Cliffs, NJ: Prentice-Hall.

Haase, J. E., Heiney, S. P, Ruccione, K. S., & Stutzer, C. (1999). Research triangulation to derive meaning-based quality-of-life theory: Adolescent resilience model and instrument development. International Journal of Cancer, 12, S125-S131.

Maxcy, S. J. (2003). Pragmatic threads in mixed methods research in the social sciences: The search for multiple modes of inquiry and the end of the philosophy of formalism. In A. Tashakkori & C. Teddlie (Eds.), Handbook of mixed methods in social and behavioral research (pp. 51-89). Thousand Oaks, CA: Sage.

Teddlie, C., & Tashakkori, A. (2003). Major issues and controversies in the social and behavioral sciences. In A. Tashakkori & C. Teddlie (Eds.), Handbook of mixed methods in social and behavioral research (pp. 3-50). Thousand Oaks, CA: Sage.

Matthew R. Sorenson, PhD, RN, is an assistant professor of nursing at DePaul University in Chicago, Illinois. Questions, comments, or suggestions regarding Research Corner may be addressed to msorenso@depaul.edu.

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You begin your shift bombarded with a ton of information, not only regarding the patients to whom you are assigned, but also about the activities of the unit. You are “in charge.” You implement your system to organize your day, absorb as much information as you can, and start prioritizing and checking in on your patients. Shortly into your shift, one of your patient’s medical conditions starts to deteriorate.

As a prudent nurse you intervene accordingly and now you are required to inform and communicate with the patient’s attending physician. One of the new initiatives at Vancouver Coastal Health Authority in Vancouver, British Columbia, is the application of a communication technique called SBAR. SBAR is an acronym and stands for Situation, Background, Assessment, and Recommendation. This technique was developed by Dr. M. Leonard, along with colleagues from Kaiser Permanente of Colorado (Kaiser Permanente of Colorado, 2006).

SBAR is a framework for communication regarding a patient or a situation among health care professionals. The tool consists of standardized “prompt” questions within each of the four sections, to ensure that clear, concise, and focused information is conveyed.
The use of SBAR sets an expectation that specific and relevant information will be shared every time a patient or situation is discussed, thereby promoting consistency and clarity. The SBAR process incorporates critical thinking and organization of information. The communication resulting from the utilization of the framework is assertive, direct, respectful, and results oriented.

When applying SBAR to a clinical situation regarding the patient whose condition is worsening, you would describe the specific situation about which you are calling including the patient’s name, physician (if other than the physician you called), patient location, code status, and vital signs. An example of a script would be:

“This is Romilda, a registered nurse on 2East. The reason I’m calling you is that Mrs. Smith in room 225 has become suddenly short of breath, her oxygen saturation has dropped to 88% on room air, her respiration rate is 24 per minute, her heart rate is 110 and her blood pressure is 85/50. We have placed her on 6 Litres of oxygen and her saturation is 93%, her work of breathing is increased, she is anxious, her breath sounds are clear throughout and her respiratory rate remains greater than 20. She has a full code status.”

You then proceed to inform the physician of the patient’s background: admitting diagnosis, date of admission, prior procedures performed current medications, allergies, pertinent laboratory results, and other relevant diagnostic results. This step of the process expects you to have collected information from the patient’s chart, flow sheets, and progress notes.

Mrs. Smith is a 69-year-old woman who was admitted 10 days ago, following a MVC, with a T 5 burst fracture and a T 6 ASIA B SCI. She had T 3-T 7 instrumentation and fusion 9 days ago, her only complication was a right hemothorax for which a chest tube was place. The tube was removed 5 days ago and her CXR has shown significant improvement. She has been mobilizing with physio and has been progressing well. Her hemoglobin is 100 gm/L; otherwise her blood work is within normal limits. She has been on Enoxaparin for DVT prophylaxis and Oxycodone for pain management.

Critical thinking is of significance when informing the physician of your assessment of the situation. This means that you have thought about what might be the underlying reason for your patient’s condition. Not only have you reviewed your findings from your assessment, you have also consolidated these with other objective indicators such as laboratory results. If you do not have an assessment, however, you may say:

“I think she may have had a pulmonary embolus” or “I’m not sure what the problem is, but I am worried.”

Finally, what is your recommendation? That is, what would you like to happen by the end of the conversation with the physician? Any order that is given on the phone needs to be repeated to ensure accuracy (verbal read-back).

“Would you like me get a stat CXR? and ABGs? Start an IV?
“Should I begin organizing a spiral CT?”
When are you going to be able to get here?

One of the programs at the Vancouver Coastal Health adapted SBAR for its specific use. The staff are incorporating this problem-solving language and process into their daily practice and into their daily conversations. A seasoned nurse, thinking that she already communicates assertively, used the framework and technique to “test” it. Little did she know how powerful the tool is when her conversation with a physician turned out to be more compelling and results-oriented than she expected. Junior and senior nurses who surrounded her (hearing only one side of the conversation) were amazed at how she modeled the process and the action plan which resulted from it. From one physician’s perspective, he states: “After seeing how SBAR can effectively reduce communication errors, I have encouraged all the other hospitalists to use SBAR when discussing patient concerns with nursing staff” (”Experiencing SBAR in Action,” 2006).

Conclusion
The climate of our current health care system is such that we experience and encounter information overload and multiple demands on our time. Therefore, the ability to articulate information thoughtfully and succinctly is greatly needed to effectively achieve positive clinical outcomes for our patients.

References

Experiencing SBAR in action. (2006, March).
Current at Vancouver Costal Health, 4(3), 8. Retrieved March 23, 2006 from http://www.vch.ca/publications/docs/current/current_march_2006.pdf.

Kaiser Permanente of Colorado (2006, March). SBAR technique for communication: A situational briefing model. IHI.org. Institute for Healthcare Improvement. Retrieved March 19, 2006 from http://www.ihi.org. Search for “SBAR.”

Romilda Ang, RN, MSc(A)N, CRRN is director of Professional Practice, Nursing and Allied Health at Vancouver Coastal Health in Vancouver, British Columbia. Questions, comments, and suggestions for Innovation Station are welcome and should be directed to romilda.ang@vch.ca

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Berthenya Dunbar, ARNP, MSN, BC; Diane Mayes, MSN, RN, CCRN; Bonnie Park, RN, BSN, CPAN; Rosemary Ashby, MS, ARNP-C; Mary Berger-Wesley, RN, MSN; Terri Cameron, RN, BSN ; Barbara T. Lorenz, ARNP-BC; and Magaret Veneman,BSN, RN, CRRN, CBIS.

Shared governance nursing models were introduced as a vehicle to improve nurses’ satisfaction, retention, and perception of their work environment (Anthony, 2004). Porter-O’Grady (2001), a pioneer in the field, reports nursing shared governance models have been in practice for over 20 years. Between 1986 and 1998, however, Aiken, Clark, & Sloane (2000) found nurses’ perceptions of their freedom to participate in important decisions about patient care and their work had decreased from 98% to 80%. Of equal concern, nurses believed their control over their nursing practice decreased from 92% to 56%. A new nursing shortage (Hess, 2004), the approaching retirement of “baby boomer” nurses ( Batson, 2004), and emerging data indicating that nurses desire some control over their practice (Kramer & Schmalenberg, 2003), has generated a renewed interest in shared governance.

Batson (2004) reports shared governance is a collaborative effort. When decision making is shared, accountability and responsibility is shared. Shared governance empowers nurses to challenge the status quo and to become proactive in their practice of nursing (Doherty & Hope, 2000).

This article will outline the steps taken to design a shared governance model in the first Magnet designated Veterans’ Hospital and its outlying clinics.

The Design Team
The nurse executive at the James A. Haley VA Medical Center (JAHVAMC) located in Tampa, Florida chartered a team and called for volunteers to research, design and recommend a shared governance model for nursing service. Members selected for this design team represented every nursing level and every area of nursing practice in the hospital. Representatives from both collective bargaining units were also invited to join the team. Members of the design team knew the concepts of shared governance were desirable. It was quickly decided, however, that the group needed additional education. There were many questions to answer: What, exactly, did the concept of shared governance entail? What was in the shared governance literature? How would shared governance be integrated within the unique structure of a VA Medical Center? What designs were already available and what were the advantages and disadvantages of each? How would current committees be incorporated into a shared governance model? What shared governance structures existed in the immediate hospital community?

The larger group was divided into subgroups to review the literature and model designs, the existing committee structure, and shared governance structures in the community. Additionally, a timeline and work plan was created that included all the work to be accomplished by the design team including implementation and evaluation. Subgroups reported back to the larger group.

Model Development
Hess (2004) suggests structure is critical to shared governance. He describes three models that appear most often in shared governance literature. With the Councilor Model, decisions are made in councils of managers and staff nurses. In the Administrative Model, the organization is divided into either a clinical or management focus. The Congressional Model includes all staff as members and the work is done by members who belong to cabinets. Unit-based shared governance is another model that is widely used. The Unit-based model permits each unit to develop its own system of shared governance. When used alone, however, the Unit-based system does not afford an opportunity for sharing with other units throughout the hospital (Scott & Caress, 2005). When exploring models within the community, one unit in a facility had a strong shared governance base. In 5 years, however, shared governance had not spread to other units within that facility!

The Councilor and Unit-based models were chosen to meet the needs of the JAHVAMC. The two-tiered structure permits staff on all levels to be involved in shared governance-either at the unit or council level. Existing committees were categorized and assigned to groups. The process provided the appropriate names and work for the proposed councils. The four resulting councils are Practice, Professional Development, Advocacy, and Quality. A Coordinating Council was added to the design to provide linkage and oversight for the four hospital councils and for unit-based councils. The hospital was divided into seven practice areas by grouping units of similar practices together. For example, Practice Area 1 is made up of all medical surgical units. Practice Area 2 is made up of intensive care and operative services.

The two-tiered model also permits the formation of forums. Forums are groups that meet primarily for education, support, and communication. This model provides for three forums- research, advanced practice nursing, and nurse managers. Forums are created or dissolved through the Coordinating Council.

The Councils: Purpose and Membership Structure
The Coordinating Council is chaired by the nurse executive. To maintain the integrity of staff nurse involvement, only staff nurses serve as chairs of the other four councils. Each council has a professional advisor who is an expert in the area of practice the council represents. For an example, the Quality Council’s professional adviser is the Associate Chief of Nursing for Quality Improvement and the professional advisor for the Advocacy Council is the Director of Nursing for Staff Relations. Council membership is through election from the practice areas; professional advisors are position driven. There is also union representation on the councils. Each of the seven practice areas has a representative at each meeting. Meetings are held at least monthly, and more frequently as needed. Councils receive their work from the overall nursing service strategic plan and from Council Action Requests. A Council Action Request is a form that permits a unit, a group, or an individual to request a particular council to consider a specific proposal.

Each council has a specific purpose. The Coordinating Council provides direction, communication and linkage to the other four councils. The Practice Council defines, implements, and maintains standards of clinical practice while setting the criteria for evidence-based practice. The Professional Development Council oversees the development and implementation of programs that support competency, academic endeavors, and professional development of nursing staff. The Quality Council monitors and evaluates performance and outcome measurements based on evidence-based practice and research. The Advocacy Council provides a forum for nursing staff to proactively address issues that make an impact on nursing satisfaction, recruitment, retention, and recognition.

The Unit-Based Model
To help units engage in Unit-based shared governance, the design team created the role of the Unit-based facilitator. The Unit-based facilitator is a member of a unit whose responsibilities include helping units coordinate their meetings and unit-based activities. Each unit decides how the role will be filled. The facilitator’s responsibilities include filing a quarterly report to the Professional Development Council. The quarterly report helps the Professional Development Council identify the successes and challenges of a particular unit. The Professional Development Council reports unit findings and actions to the Coordinating Council in its quarterly report. The quarterly reporting is a communication link that eliminates the problem of isolation identified by Scott and Caress (2005).

Bylaws
Though shared governance promotes nursing empowerment and pro-activity, the design team determined the mission statement of this institution’s shared governance structure would reflect the goal of developing and maintaining a structure that is patient-centered. The mission statement reflects the goals of this institution’s nursing service-high quality care, that is cost-effective, safe, timely, efficient, equitable, comprehensive, compassionate, ethical, and patient-centered (James A. Haley Nursing Service Shared Governance Bylaws, 2005). The bylaws define the structure and membership guidelines of the councils, details council duties, and explains the elections process.

Readiness Plan
Scott and Caress (2005) stress the fact that implementation is not an overnight venture. Kennerly (2000) reports education and communication are vital to the process of transitioning. The design team took these issues into consideration. The hospital was divided into small educational work groups to give all staff an opportunity to aid in the final design structure. The small groups were interdisciplinary, including key human resource personnel and members of the hospital’s executive board. A self study booklet was created early in the process and an Intranet Web site was set up to aid in the communication process. The first councils were staffed with volunteers. Subsequent council members were elected. The readiness plan included three phases: council set-up and education, hospital awareness and unit-based set-up, and the initial implementation program title: Soaring to New Heights.

JAHVAMC and its outlying clinics is a large and highly structured organizational system. Such a system presented a true design challenge. The design group used all available resources and 2 years to develop a shared governance structure based on current literature, the best of what the community had to offer, interdisciplinary staff input, and organizational need

References

Aiken, L., Clark, S., & Sloane, D. (2000). Hospital restructuring: Does it adversely affect care and outcomes? Journal of Nursing Administration 30(10): 457-465

Anthony, M. K. (2004) Shared governance models:
The theory, practice, and evidence.
Online Journal of Issues in Nursing 59(1), retrieved February 9, 2004 from www.nursingworld.org/ojin/topic23/tpc23_4.htm.

Batson, V., (2004) Shared governance in an integrated health care network. AORN Journal (Association of Operating Room Nurses), 80(3). 494-509

Doherty, C. & Hope, W. (2000) Shared governance–Nurses making a difference. Journal of Nursing Management 8, 77-81.

Hess, R. G. (2004) From bedside to boardroom:
Nursing shared governance.
Online Journal of Issues in Nursing, 9(1). Retrieved November 22, 2004 from www.nursingworld.org/ojin/topic23/tpc23_1.htm.

James A Haley Veterans Hospital Nursing Service Shared Governance Bylaws (2005) Mission Statement, July 6, 3.

Kennerly, S. (2000) Perceived worker autonomy: The foundation for shared governance. Journal of Nursing Administration 30(12) 611-617.

Kramer, M. & Schmalenberg, C. E. (2003) Magnet hospital nurses describe control over nursing practice. Western Journal of Nursing Research, 25(4), 424-452.

Porter O’Grady, T. (2001). Is shared governance still relevant? Journal of Nursing Administration, 31(10), 468-473.

Scott, L. & Caress, A. (2005) Shared governance and shared leadership: Meeting the challenges of implementation. Journal of Nursing Management, 13, 4-12.

All authors are with the James A. Haley VAMC in Tampa, Florida. Berthenya Dunbar, ARNP, MSN, BC, is a mental health nurse liaison; Diane Mayes, MSN, RN, CCRN, is a clinical educator; Bonnie Park, RN, BSN, CPAN, is a staff nurse; Rosemary Ashby, MS, ARNP-C, is a gastroenterology specialist; Mary Berger-Wesley, RN, MSN, is a geriatric clinic coordinator; Terri Cameron, RN, BSN, is an assistant nurse manager; Barbara T. Lorenz, ARNP-BC, is a cardiothoracic nurse practitioner; and Magaret Veneman,BSN, RN, CRRN, CBIS, is a nurse manager, rehabilitation.

Laureen Doloresco, MN, RN, CNAA-BC, associate chief of nursing, Haley VA Medical Center, Tampa, Florida and editor of the Leadership Circle column, welcomes your comments, questions and suggestions; contact her at laureen.doloresco@med.va.gov.

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