Blood and marrow transplantation (BMT) has become an increasingly acceptable treatment for children with life threatening malignant diseases. Survival rates for transplant recipients vary from 23% to 63%. Children with complications from BMT, typically die in the hospital after a prolonged stay. The parental decision to allow a child to die a natural death is typically made in an aura of emotional duress and bewilderment at the complexity and volume of new information that must be assimilated.The purpose of this study was to describe the process of parental decision making for Do Not Resuscitate (DNR) or to withdraw life support in pediatric BMT.The framework for this study was developed from the author's epistemology that blends neo-modernism (recognition of individual uniqueness yet acknowledgment that certain underlying universal principals exist) with the idea that the nature of all things may be viewed as an ongoing, self-constructing process.Grounded theory methodology was used. The sample (determined through theoretical sampling) consisted of seven parents of children who died following BMT and for whom the parent made an end-of-life decision. Data was analyzed using constant comparative analysis, a method that combines both substantive and theoretical coding of data with a qualitative style of theory development.The realization of parental knowing was the process that parents used to navigate the human problem of having to make the end-of-life decision for their children who were dying following blood and marrow transplantation. This process consisted of four categories: Developing Trust, Committed to Seeing It Through, Facing My Worst Fear, and Acceptance of Self.The knowledge gained from this study will inform nurses who care for children who are dying following pediatric BMT. Strategies may be developed that will assist nurses to support the development of parental trust, to help sustain the commitment of parents as they move through the BMT treatment journey, and to assist parents as they face their worst fear. As a result, parents should be better able to achieve an acceptance for themselves that will facilitate a more satisfying experience of the ever changing process occurring in their own lives.

Major depression affects up to 40% of U.S. adolescents in mild to severe forms, compromising emotional, academic, and relational functioning, including that of interacting with parents. The purpose of this study was to explore the parent-adolescent relationship during an episode of depression in order to elucidate the adolescent experience of being parented and the parental experience as it contributes to the context of the adolescent. Research questions included: 1) What are the depressed adolescent's meanings and experiences of being parented? 2) How do the meanings and experiences of parenting contribute to the context of the lifeworld of the depressed adolescent? An adapted Colaizzian (1978) method was used to phenomenologically analyze interview data from 6 adolescents and 5 parents. Findings for adolescents supported an essential pattern of Dysphoric Tension Between Moving Away and Moving Toward, including themes of Feeling Devalued within the Relationship and Renegotiating the Relationship. Parent findings supported the essential pattern of Tension Between Pulling Closer and Letting Go, with 4 themes including Losing the Familiar, At the Nexus of Action, Composing Life with the Stranger, and Crisis Management Within. The adolescent and parent findings were compared for differences and commonalities to assist in understanding the context provided by the parents. Findings were used to refine the investigator's previous model of adolescent depression.

Background: Palliative care means improving quality of life along a spectrum of illnesses including cancer. Cancer is one of the leading causes of death. Having the discussion of goals of care including palliative care is important to have with individuals who have advanced cancer. There were limited studies that identify the providers’ attitudes, subjective norms, and perceived behavioral control on discussion of goals of care including palliative care. Purpose/Aim: This Doctoral Project consisted of identifying factors (i.e., attitudes, behaviors and subjective norms) in discussion of goals of care with their terminal cancer patients in the outpatient oncology clinic. Multiple studies have demonstrated the lack of knowledge providers have about palliative care. Through this study, the attitudes, subjective norms, and behaviors of providers were evaluated regarding goals of care for palliative care. Methods: An investigator developed questionnaire with six-point Likert-type scaling was used to measure each dimension (attitudes, subjective norms, and perceived behavioral control) regarding discussion of goals regarding care. These questionnaires were sent electronically to the oncology providers at Arizona Center for Cancer Care in Phoenix, Arizona. The data were collected through Qualtrics. Outcomes: Six providers participated in the survey. Results on the Attitude subscale indicated that the providers regarded discussing goals of care including palliative as very important and beneficial to patients. In comparison to this subscale score, the results on the Subjective Norms and Perceived Behavioral Control subscales were somewhat lower, though still above the mean, indicating that providers regarded the norm and level of resources available for discussing goals of care as somewhat lacking in their work setting. Further research is needed in this area of inquiry, including a quality improvement project to promote quality care in discussing goals of care including palliative care with patients who are diagnosed with advanced cancer.

This study (1) developed and tested the Socially Supportive Activity Inventory (SSAI) to assess the quantity and quality of socially supportive activities that institutionalized elders receive, and (2) tested the predicted relationships among the variables proposed in the hypothesized causal model, socially supportive activities, self-transcendence, and depression in institutionalized elders. For pilot testing psychometric properties of the SSAI, the content validity was 0.96. Test-retest reliability from a sample of 10 participants yielded stability coefficients of 0.76-1.00, indicating the SSAI is a highly relevant and reliable culturally-based instrument. In the main study, a total of 196 participants were recruited from eight elder care institutions. The results showed an elder's expectation of filial responsibility did not have a moderating effect on the willingness to be/remain institutionalized and on perceived stress. An elder's acceptance of institutionalization was significantly related to perceived stress and indirectly affected depression. The mediator effect of self-transcendence on the relationship between perceived stress and depression was supported. The participation of elderly residents in socially supportive activities demonstrated a moderating effect on the strength of a negative relationship between perceived stress and self-transcendence. In the modified model, an elder's willingness to remain institutionalized, perceived stress, and self-transcendence were significant predictors of depression, accounting for 54.7% of variance. Self-transcendence was the best predictor of depression. These findings contribute to an awareness of importance of culture factors as potential stressors. These findings also help to explain how the psychosocial mechanism of participation in socially supportive activities and the perception of self-transcendence act on depressed elders.

The prolonged civil-war and famine in the African nation of Sudan has displaced millions over the last two decades, many of these are women and children. Refugee women who are resettled to the US with their children must make profound adjustments to learn how to live in the American society and culture. Very little is understood about the factors and conditions that affect the health of immigrant and refugee populations who resettle to a host country.This ethnographic study investigates the influences to health and well-being in 10 refugee women from the Dinka tribe of southern Sudan who were resettled with their children to a Midwestern city in the United States (US). The in-depth interviews and participant observation that occurred over the one-year period of the study resulted in an interpretive theory of Well-Being in Refugee Women Experiencing Cultural Transition. Well-being in Dinka mothers is understood through the relationships between three major themes: Liminality: Living Between Two Cultures, Standing for Myself, and Hope for the Future. Liminality: Living Between Two Cultures describes how the women struggled to maintain a delicate balance between their traditional Dinka culture and the new American culture. The theme of Standing for Myself addresses how learning new skills and taking on new roles in the US, led to transformation of the refugee women. The third theme of Hope for the Future emphasizes the Dinka cultural values of communality and religious convictions that gave the women hope for a better future for their families and countrymen.The middle-range theory of transitions was used as a theoretical framework to guide the investigation of well-being of the refugee women and their families during resettlement. The study extends of the theory of transitions to refugee women from southern Sudan by developing a theoretical explanation for how refugee Dinka women attain well-being during transition. The results of this study strongly indicate that `cultural transition' be added as a distinct type of transition significant to understand the health needs of refugee women. The knowledge from this study will lead to the development of culturally competent interventions for resettled refugee families.

In this Practice Inquiry, Mexican American parents' perceptions of cultural influences on grieving the death of their child were described. Findings were used to inform a continuing education module for nurses involved in the care of Mexican American parents who have experienced the death of their child. This line of inquiry is important as the needs of grieving Mexican American parents are not always recognized by those providing care. Ethnographic methodology was used to explore the narratives of three Mexican American fathers and three Mexican American mothers who had experienced the death of their child. A purposive sample was recruited from a faith based community health center in Tucson, AZ. In depth interviews were conducted primarily in the participants' homes by the researcher. All interviews were conducted in Spanish language. Data sources included participant interviews, participant observation, field notes and measures for demographic data and acculturation (ARSMA-II).The overarching cultural theme that represents the participants' perspectives is El Dolor de los Padres: Pain in the Parent. The three major themes that support the overarching cultural theme include: (a) Enduring Great Pain, (b) Voices of Mexican American Parents, and (c) Cultural Death Traditions. The fourth major theme, Going Forward: For the Provider specifically addresses data gathered to educate nurses for supporting Mexican American parents grieving the death of a child. The findings of the study are interpreted within the context of the Mexican cultural concepts of familismo, machismo, marianismo, fatalismo, spiritualidad, respeto, confianza and personalismo and the concept of vulnerability.The study's significance for the practice of nursing is upheld in the findings that are specific to understanding and preventing disparities in the care of Mexican American parents who have experienced the death of a child. Increasing nursing knowledge of the cultural context of grieving, especially spiritualidad and continuing memories, offering culturally competent nursing interventions at this time of deep emotional pain are elucidated in this Practice Inquiry.