The purposes of this study are to test four measurement models and a hypothesized structural model which related to maternal-fetal attachment (MFA). The conceptual model of this study is primarily derived from stress and coping theory (Lazarus & Folkman, 1984) and crisis theory (Burgess & Baldwin, 1981) which includes three major conceptual domains: stress (prenatal stress), moderators of stress (social support and spiritual well-being), and manifestation of stress (MFA). A sample of 349 pregnant women in their third trimester was recruited from obstetrical outpatient and inpatient centers, including high-risk and low-risk pregnant units, and childbirth education classes. The questionnaires consisted of the Visual Analog Scale (VAS) and the Taylor Manifest Anxiety Scale (TMAS) designed to measure prenatal stress, the Personal Resource Questionnaire (PRQ), the Spiritual Well-Being Scale (SWBS), the Prenatal Attachment Inventory (PAI), and selected demographic, obstetrical, and health related questions. Confirmatory factor analysis of the four research instruments yielded results that supported the initial structural definition of PAI, TMAS, and prenatal stress. The constructs of the SWBS, and the PRQ were not supported by the data. The violation of multivariate normality assumption and multicollinearity were the factors that seemed to impact model fit. After using item parceling and deleting items with similar wording, both models fit well. The results of testing the hypothesized structural model yielded results that the interaction terms were deleted from the model because of non-normality and multicollinearity problems. Attachment showed positive correlation with prenatal stress (beta = .36, t = 4.15, p < .05) and social support (gamma = .27, t = 3.36, p < .05). Prenatal stress was negatively related to spiritual well-being (SWB) (gamma = -.45, t = -3.40, p < .05). In addition, pregnancy health status had an interaction effect on the structural model indicating the model fit differently for those with high-risk pregnancy as compared to those with low-risk pregnancy. The research indicated the importance of social support in MFA. The PAI is a valid instrument for measuring prenatal attachment. Although the spiritual components did not show direct effect to prenatal attachment, it has an indirect effect to prenatal attachment through prenatal stress as well as social support. The interaction effect of pregnant health status on the structural model suggested that high-risk pregnant women may have different demands in social support, SWB, prenatal stress, and/or MFA as compared to low-risk pregnant women.

Statement of the problem. The purpose of this study was to develop an instrument to measure the content and quality of prenatal care services in a population of low income women. Dimensions of performance as proposed by the Joint Commission on Accreditation of Healthcare Organizations were used to define the quality of prenatal care. The United States Public Health Service Expert Panel Guidelines on the Content of Prenatal Care were used as the standard for the content of care. Methods. The Content and Quality of Prenatal Care Measure (CQPM), a prenatal care record review measure, was developed in this study. An assessment of content validity and intra- and inter-rater reliability was completed. Data collected for the validity sample of 163 records at two county health department sites was scored by content area. The Adequacy of Prenatal Care Utilization Index (APNCU) developed by Kotelchuck was used to categorize each record in the validity sample. Criterion-related validity was assessed with ANOVA using the CQPM scores as the dependent variable and the APNCU groups as the independent variable and by discriminant function analysis using the CQPM content scores as predictors for group membership in APNCU groups. Results. The mean percent agreement for each of the content areas for intra- and inter-rater reliability ranged from 72% to 95% with medical risk assessment having the highest reliability and health promotion having the lowest. Intra and inter-rater percent agreement for items ranking the quality of care was 70% and 51.6%. A significant difference between the groups was found in ANOVA, F(3,157):16.23, p < .00001, confirming criterion-related validity. The discriminant function analysis found an overall Lambda =.451941 (chi2 = 110.79, df 15, p < .00001). The prediction equation accounted for 62% of grouped cases being correctly classified also confirming criterion-related validity. Discussion. These results show that the Content and Quality of Prenatal Care Measure is reliable and valid and may be used to monitor care provided to low income populations and to conduct research on the content of prenatal care. Further research on weighting each item score in the CQPM and the reliability of items for special populations may be indicated.

Background. Interpersonal violence results in severe injuries requiring treatment in emergency departments and trauma units. Previous studies indicate that women who seek care for intentional injuries are more likely than women who seek care for nonintentional injuries to be discharged without further treatment. Women's opportunities to obtain resources to ensure follow-up services in the community may be limited. Women who survive intentional injuries are discharged with histories of victimization, physical and psychological symptoms, and few resources to assist them to address the sequelae of violence. Few studies have examined how these factors influence functional status. Objective. To identify and explore factors that influence functional status in women who survived an intentional injury by an intimate or ex-intimate partner or another person. Design. A retrospective cohort design. Measures. The Women's Health Questionnaire was developed with previously validated instruments on severity of violence, physical and psychological symptoms, substance abuse, trauma recurrence, social support, and functional status. Setting. R Adams Cowley Shock Trauma Center, University of Maryland Medical System. Participants. Most of the 76 participants were young (18-45 years), African-American (70%), and living in poverty; 74% reported annual incomes of less than {dollar}15,000. Results. The effects of violence (physical, psychological, psychosocial) explained 23.8% of the variance in functional status. Almost 60% of the women screened positive for posttraumatic stress disorder (PTSD), 36.8% reported a lifetime history of drug use, and 64.5% reported a lifetime history of intimate partner violence. Women reported that health care providers gave little attention to the mental health effects of violence and their capacity to fully participate in life; 62% of women assaulted by an intimate or ex-intimate partner were not referred to a domestic violence program or shelter. Conclusions. The effects of violence were the strongest predictor of functional status in intentionally injured women. Women reported serious PTSD symptoms, substantial substance abuse, and multiple traumatic events. They also reported that they had not been provided adequate resources to address the effects of violence. This study should challenge nurses and other health care professional to assess survivors of violence, intervene, and refer the survivors to community-based services that will enable them to maintain optimal functioning.

The environment of managed care has created ethical concerns for practitioners with respect to professional autonomy and ethical practice associated with clinical decision-making. Yet, knowledge and research in this area is limited. The primary purpose of this research was to investigate the influence of individual, organizational, and societal/market contextual factors on practitioners' perceptions of ethical aspects of the managed care environment. In addition, a secondary purpose was to investigate the effect of different data collection methods on response rates. The conceptual model developed for the study derived primarily from Cooper's framework for ethical conduct and principal/agent theory. This study was a cross-sectional, descriptive survey design using a mailed self-administered questionnaire. Data were obtained from a random sample of 700 nurse practitioners (NPs) in the state of Maryland with a response rate of 42.4%. Thirty percent of the sample (n = 210) was provided a disk-by-mail (DBM) option for responding. A slightly higher response rate was indicated for the DBM sample in comparison to respondents who only received the paper-and-pencil measure (45.8% vs. 42.4%). A majority of respondents indicated ethical concerns regarding individual autonomy (78.4%) and personal values/ethics being compromised (67.1%). Moreover, 80% of the sample perceived it necessary to bend managed care guidelines. Significant differences were noted for ethical concern ( p < .001), ethical environment (p < .001), ethical conflict in practice (p < .001), and autonomy (p < .05) in relationship to practice setting. NPs in a staff/group model HMO were less ethically concerned, perceived the ethical environment more positively, and had lower ethical conflict scores. Based on the multiple regression results, a path model was proposed and tested using structural modeling. The perception of the ethical environment, ethical concerns, and the importance of governmental regulation explained 44% of the variance in ethical conflict in practice scores. An idealistic moral philosophy, ethical concerns, ethics content in a continuing education program, and the percentage of the client population enrolled in managed care explained 12% of the variance in autonomy scores. The analysis provided initial support for the model, indicating the importance of ethical considerations in a framework of healthcare.

Problem. Missing items are a common problem in Likert-type measures consisting of multiple questions. Despite frequent use of imputation methods for missing values, data about the performance of different methods on outcome measures are lacking. Purpose. To assess the performance of four imputation methods on item and scale level statistics and psychometric properties under different data conditions and the mechanism of missing completely at random (MCAR). Methods. This is a secondary data analysis using a dataset consisting of responses to the SF-36. The imputation methods under study include item mean substitution (IMS), person mean substitution (PMS), expectation-maximization algorithm (EM), and stochastic regression imputation (SRI). Missing data conditions include percentage of subjects with missing values (10%, 25% and 40%), percentage of missing items (10%, 20-33%, and 33-50%), sample size (200 and 500), and length of scales (2-, 4- and 10-items). After creation of each missing data condition under MCAR, imputation methods were applied and statistics from the imputed datasets were computed. Accuracy and bias of estimates for item level statistics (mean, SD and correlation), scale level statistics (mean, SD and correlation), and psychometric properties (coefficient alpha, goodness-of-fit statistics of confirmatory factor analysis, factor loadings and factor correlations) were compared and contrasted. One-way ANOVA and GLM were used to analyze data. The significant level was set at alpha ≤ .05. Results. There were differences in performance of imputation methods regardless of data conditions. IMS was consistently the worst in terms of accuracy and bias for all but two parameters. PMS was the second worst in parameter estimates. In contrast, EM and SRI produced more accurate estimates for most parameters considered. EM ranked the best for estimation of item mean and intercorrelations among items and scales while SRI ranked the best for item SD, alpha and goodness-of-fit statistics. The two methods were equivalent for other parameters. Further, their performance was less influenced by missing data conditions. In terms of reducing bias, SRI was better for most of the parameters than EM. Conclusion. Model-based approaches, SRI and EM, are preferred over IMS and PMS for imputing missing items in Likert type measures.

The study is aimed at: (a) testing a structural model on the relations among maternal alcohol use, family cohesion, quality of parenting, and children's well-being, and (b) examining the mediational effects of family cohesion and quality of parenting on children's well-being. The data from both the National Longitudinal Survey of Youth 1979 (NLSY79) and the Children of NLSY79 datasets in 1994 were used to obtain a study sample of 1381 mother-child dyads. All the children in this study were between 10 and 14 years old in 1994. The mothers answered questions related to their alcohol use, such as the duration, frequency, quantity of drinking, and the impact of drinking. Information regarding family cohesion, quality of parenting, and child's well-being including psychological well-being, school performance, and child's own substance use/abuse were obtained from both the mothers and the children. A tentative model that highlights the relationships among these four constructs was developed based on literature review. Structural equation modeling was used to test the model in a random-split sample, which contained 691 of the subjects. The final revised theoretical model was cross-validated using the rest of the total sample. Although the chi-square test value for the overall model fit of the final revised theoretical model is 882.7, with df = 454, p < 0.01, the ratio of the chi2/df is less than 2, indicating an acceptable fit. The fitness of the model to the sample is also supported by other fit indices, such as the GFI, CFI, and the NNFI. In this model, mother's alcohol use is associated with decreased family cohesion, and decreased family cohesion contributes to child's increased level of substance use/abuse. In addition, higher level of parental control/discipline is also associated with lower level of child's substance use/abuse, higher level of psychological well-being, and better school performance. The cross-validation also partially supports the external validity of the model. Early intervention aimed at promoting children's development may need to focus on how to promote closeness within the family and the quality of parenting rather than mother's own alcohol use behaviors.

Purpose. The coagulopathy noted in hypothermic trauma patients has been variously theorized to be caused by either enzyme inhibition, platelet alteration, or fibrinolytic processes, but no study has examined the possibility that all three processes may work in conjunction. The purpose of this study was to determine the interrelationship of these three mechanisms as the causes of coagulopathy in adult trauma patients at varying levels of clinically common hypothermia (33.0 degrees C-36.9 degrees C). Methods. Of 232 consecutive adult trauma patients presenting to a Level I Trauma Center, n = 112 met the inclusion criteria of an Injury Severity Score of 9 or greater and time since injury of less than 2 hours. Patients with frank DIC at presentation were excluded. Of the included patients, 40 were normothermic and 72 were hypothermic (>=37 degrees C, n = 40, 36 superscript 9-36 degrees C, n = 29; 35 superscript 9-35 degrees C, n = 20; 34 superscript 9-34 degrees C, n = 16; 33 superscript 9-33 degrees C, n = 7). Included patients were prospectively studied with thrombelastography adjusted to core body temperature. Thrombelastography measures the shear elasticity of blood and is sensitive to interacting cellular and plasmatic components. Six parameters of blood clotting were analyzed (two each for enzyme speed, platelet activity, and fibrinolysis), and an overall index of coagulation was calculated. Additionally, PT, aPTT, platelets, CO2, hemoglobin, hematocrit, and ISS were measured. Results. Analysis by MANOVA of the relationship between coagulation and temperature demonstrated that in hypothermic trauma patients, 34 degrees C was the critical point where enzyme activity slowed significantly (p<.0001), and significant alteration in platelet activity was seen (p<.001). Fibrinolysis was not signifcantly different at an of the measured temperatures (p>.25). The coagulation index was also significantly lower for the patients with temperatures below 34 degrees C (p<.001). Conclusions. Enzyme activity slowing and decreased platelet function individually contribute to hypothermic coagulopathy in trauma patients, particularly below 34.0 degrees C. All three coagulation measure affected are part of the polymerization process of platelets and fibrin, and this may be the mechanism by which the alteration in coagulation occurs.

The purpose of this study was to examine the cost and frequency of health services utilization by substance dependent women before and after the initiation of substance dependence treatment in a Medicaid population. The specific goal of the study was to determine whether cost and frequency of health services utilization are different before and after the subject has begun substance dependence treatment. The design was a secondary analysis of the Maryland Medicaid Claims Database created by the Maryland Center for Health Program Development and Management. The sample consisted of 114 females, the total number of female Maryland Medicaid recipients age 18 or older, who were residents of Baltimore City and were new to substance dependence treatment during the first half of fiscal year 1997 for whom complete data were available. Data were selected from the database and analyzed using paired t-tests and multiple regression to test four hypotheses related to cost and frequency of health services utilization. Both frequency and cost of health services were higher in the six month period following the initiation of substance dependence treatment than for the six month period before. These findings suggest that the severity of the consequences of substance dependence for women, as reported in the literature, was demonstrated in the Maryland Medicaid population. The findings also suggest that the initiation of substance dependence treatment may have brought about a behavioral change of renewed caring for self. Further research is needed regarding the specific services utilized and documented outcomes in order to design appropriate health care delivery systems for this population.

A high percent of Medicare dollars are attributed to a small number of beneficiaries who have a recurring need for acute care intervention, often through multiple hospitalizations. The association between the use of home care services and hospital readmissions continues to have conflicting reports in the literature. The purpose of this study was to determine whether a referral to home care has an association with hospital readmission. The Behavioral Model for Health Services Use provided the conceptual framework for the study. Data for Medicare patients who had an index hospitalization in 1995 for congestive heart failure were obtained from the Connecticut Health Information and Exchange (CHIME). A total sample of 4094 subjects was randomly split into two subsamples to create a calibration sample and a validation sample. A multiple logistic regression analysis was conducted on the calibration sample of 2038 subjects to determine those factors predictive of a hospital readmission. An additional logistic regression analysis examined the 902 subjects who were readmitted to determine the factors associated with a prior referral to home care. When the predisposing variables age, gender and race were entered into the logistic regression with referral to home care, the referral was a statistically significant predictor of readmission (chi2(1) = 8.69, p =.003). In further analysis with additional factors, the number of prior admissions was the only statistically significant variable in predicting the likelihood of readmission (chi2(1) = 68.77, p = <.001). For those who were readmitted, older women with prior admissions were more likely to have received a referral to home care. Those who had lower ancillary hospital charges for the readmission also were more likely to have received a referral to home health care (chi2(1) = 12.17, p<.001). The regression equations were cross-validated on the validation sample of 2056 subjects. The logistic models were able to correctly classify approximately 61% of the subjects for both the calibration and the validation samples. The reduction in ancillary charges for readmitted patients who had received a referral to home health care is an interesting finding worthy of further investigation. A better understanding of the relationship between home care and hospitalization has important implications for public policy and nursing practice.

The purpose of this descriptive study was to examine the use of the moral perspectives of care and justice, the level of nurse activism, and relationships between these variables and selected factors in practicing registered nurses (RNs). The study also evaluated the construct validity of a measure of care- and justice-based moral reasoning, the Care-Justice Inventory (CJI). Data were obtained via a questionnaire from 214 registered nurses at three southern hospitals (35% response rate). The sample consisted of 68 male RNs and 146 female RNs; 62 subjects were in advanced nursing practice roles and 152 were staff nurses. The CJI demonstrated evidence of construct validity in two tests: a qualitative-quantitative triangulation procedure, and confirmatory factor analysis. Both male and female subjects scored significantly higher on the justice perspective than the care perspective; there were no significant differences between genders. Analysis of specific CJI scenarios, while revealing differences between the four scenarios, also revealed that justice elements received considerably higher rankings overall than care elements. CJI care and justice scores were positively correlated with each other (r =.626, p < .001). However, only the CJI justice score was correlated with nurse activism (r =.201, p =.005). The main predictor of the CJI care score was the CJI justice score. With justice controlled, RNs with lower ethical concern and lower clinical knowledge had higher care scores. Higher justice scores were significantly related to higher care scores, higher ethical concern and higher nurse influence. Moral behavior as measured by nurse activism scores was significantly related to nurse influence, clinical knowledge, ethical concern and continuing education in ethics. Together, these variables accounted for 34.8% of the variance in nurse activism. The CJI justice score for one scenario was a significant predictor of nurse activism, and the overall justice score was a significant predictor for nurses with formal education beyond their basic nursing preparation. The findings of this study challenge the notion that the care perspective is dominant in the moral reasoning of nurses, or that moral reasoning directs the moral behavior of nurses. Implications for practice, theory and further research are presented.