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A Neomodernist Perspective for Researching Chronicity
RESEARCH BRIEFS COLUMN
A Neomodernist Perspective for Researching Chronicity Patricia Liehr and Mary Jane Smith
P
ERSISTENT MENTAL ILLNESS is most commonly referred to as illness that is chronic. The Greek origin of the adjective chronic is rooted in khronikos meaning “of time” (Oxford English Dictionary, 1989). Chronic illness extends over time as a persistently lingering process, presenting as peaks and valleys in the life of the person. Its study necessitates data-gathering techniques that offer evidence of process and assessment of complexity. Persistent mental illness seldom exists as a single health problem. For instance, people with serious mental illness have higher morbidity and mortality rates for cardiovascular disease, diabetes, respiratory disease, and some forms of cancer (Robson & Gray, 2006). Furthermore, lifestyle behaviors of chronically mentally ill people, such as smoking and inactivity, are intertwined with mental illness and mental illness treatment (Robson & Gray, 2006), creating interactions between developing and progressing health problems. These interactions epitomize chronicity, which implicitly incorporates both complexity and time. We are ill prepared to measure chronicity with approaches that emphasize single paper-and-pencil assessments. The purpose of this column is to explore different approaches to more effectively address the measurement of chronicity. To begin, we propose a neomodernist perspective. Through the lens of neomodernism (Reed, 1995), chronicity can be seen as a process of “human developmental potential, transformational and self-transcendent capacity for health and healing” (p. 78). In describing this view, Reed (1995) notes the significance of recognizing developmental histories and their contexts, and more recently, in a description of the tenets of neomodernism (Reed, 2006), she suggests an empiricism that “encourages the use of new tools, methods, (and) technologies” (p. 37). Empirical evidence to document chronic mental illness as a self-transcendent capacity for
health and healing could include measurement of patterns of change over time with new tools, methods, and technologies, and it could include collection of evolving life stories with associated life experiences, bodily sensations, and critical choices. Each of these sorts of evidence will be briefly discussed. MEASURING PATTERNS OF CHANGE OVER TIME
There are many approaches to measuring patterns of change over time, and the sophistication of the methods moves along a continuum from rudimentary tools, such as self-reports, to sophisticated technology, such as electronic monitors. Although we recognize self-report as a valuable and sometimes necessary way to collect data, typical selfreports do not capture change over time. One approach for measuring change over time is diary recording. A diary assessment requires recording of a range of relevant parameters (e.g., time, place, other persons, activities, and feelings) usually with a checklist format as research participants go about everyday living. Researchers using this method must provide a cue, which prompts the participant to record a “page” in the diary. The cues may be interval contingent (regularly prescribed times such as might occur when blood pressure is automatically monitored with an ambulatory monitor), event contingent (when a certain event occurs, such as eating, waking, etc.), or signal contingent (when an external From the Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL; and West Virginia University, School of Nursing, Morgantown, WV. Address reprint requests to Patricia Liehr, PhD, RN, Associate Dean of Nursing Research & Scholarship Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Rd., Boca Raton, FL 33431-2048. E-mail address: [email protected] n 2007 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi: 10.1016/j.apnu.2007.08.002
Archives of Psychiatric Nursing, Vol. 21, No. 6 (December), 2007: pp 345–346
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random signal comes from a beeper or electronic watch; Shiffman, 2000). A researcher could include assessment of feelings, such as sadness or stress, and ask participants to use a Likert-type scale to rate the moment when they are cued. An example of a more technologically sophisticated approach to real-time monitoring is the electronically activated recorder (EAR) developed by Pennebaker et al. Real-time word use can be recorded with the EAR through digital recording technology (Mehl, Pennebaker, Crow, Dabbs, & Price, 2001). Generally, the recorder is set to automatically turn on every 12.5 minutes and record for 30 seconds each time it turns on. The audiotaped words of participants can be transcribed and analyzed with Linguistic Inquiry and Word Count software, a word-based computerized text analysis software, which discerns word categories such as positive and negative emotion as well as cognitive and sensory process words. These categories could provide potentially useful information about the life experiences of people with chronic mental illness. Pennebaker and Stone (2003) assert that word use is a window into a person's world and a measure of psychological state. The EAR technology accesses real-time psychological state in an unobtrusive way with less likelihood of social desirability influences than occurs with standard self-report measures. ASSESSING LIFE STORIES
Collecting stories over time enables documentation of an individuals' reality as it is unfolding. Stories are in-the-moment descriptions of experience as lived, enabling a view of transforming from the person's perspective. An account of an ongoing story offers a way of documenting the selftranscendent capacity for health and healing by centering on what matters most to the person. For the purpose of research, it is suggested that stories be gathered about what matters most to the participant regarding a topic of research interest. For instance, if the topic is loneliness, then the researcher would begin the story gathering by asking people what matters most about being lonely and then moving to how the most important people in their lives are related to what matters most, which then leads to what helps to make things go better when they are lonely. The researcher needs to take good notes
while gathering the story and, immediately after the session, write a reconstructed story (Smith & Liehr, 2005). A reconstructed story is a composite synthesis of what was shared as it is remembered by the researcher. A set of reconstructed stories on the topic of loneliness could then be analyzed to identify how people live with and resolve loneliness. If we can understand how chronically mentally ill people manage their loneliness, we would have important guidance for nursing practice. Threaded throughout this discussion, although not explicitly stated, is the importance of longitudinal study designs to pursue understanding of chronic mental illness through a neomodernist lens. Likewise, a shift to innovative methods within these designs offers promise for comprehending the transformational nature of chronic mental illness, bringing us to the cutting edge of meaningful practice-changing contextual evidence. Only when our evidence is contextual and emergent will we be moving in the direction of addressing the health complexities experienced by people with chronic mental illness.
REFERENCES Mehl, M., Pennebaker, J. W., Crow, M. D., Dabbs, J., & Price, J. H. (2001). The electronically activated recorder (EAR): A device for sampling naturalistic daily activities and conversations. Behavioral Research Methods, Instruments, Computers, 33, 517–533. Oxford English dictionary. Oxford: Clarendon Press. Pennebaker, J. W., & Stone, L. D. (2003). Words of wisdom: Language use over the life span. Journal of Personality and Social Psychology, 85(2), 291–301. Reed, P. (1995). A treatise on nursing knowledge development for the 21st century: Beyond postmodernism. Advances in Nursing Science, 17, 70–84. Reed, P. (2006). Commentary on neomodernism and evidencebased nursing: Implication for production of nursing knowledge. Nursing Outlook, 54(1), 36–38. Robson, D., & Gray, R. (2006). Serious mental illness and physical health problems. International Journal of Nursing Studies, 44, 457–466. Shiffman, S. (2000). Real-time self-report of momentary states in natural environment: Computerized ecological momentary assessment. In A. A. Stone, J. S. Turkkan, C. A. Bachrach, et al. (Eds.), The science of self report: Implications for research and practice. Mahwah, NJ: Lawrence Erlbaum, 277–296. Smith, M. J., & Liehr, P. L. (2005). Story theory: Advancing nursing practice scholarship. Holistic Nursing Practice, 19(6), 272–277.
A Neomodernist Perspective for Researching Chronicity Patricia Liehr and Mary Jane Smith
P
ERSISTENT MENTAL ILLNESS is most commonly referred to as illness that is chronic. The Greek origin of the adjective chronic is rooted in khronikos meaning “of time” (Oxford English Dictionary, 1989). Chronic illness extends over time as a persistently lingering process, presenting as peaks and valleys in the life of the person. Its study necessitates data-gathering techniques that offer evidence of process and assessment of complexity. Persistent mental illness seldom exists as a single health problem. For instance, people with serious mental illness have higher morbidity and mortality rates for cardiovascular disease, diabetes, respiratory disease, and some forms of cancer (Robson & Gray, 2006). Furthermore, lifestyle behaviors of chronically mentally ill people, such as smoking and inactivity, are intertwined with mental illness and mental illness treatment (Robson & Gray, 2006), creating interactions between developing and progressing health problems. These interactions epitomize chronicity, which implicitly incorporates both complexity and time. We are ill prepared to measure chronicity with approaches that emphasize single paper-and-pencil assessments. The purpose of this column is to explore different approaches to more effectively address the measurement of chronicity. To begin, we propose a neomodernist perspective. Through the lens of neomodernism (Reed, 1995), chronicity can be seen as a process of “human developmental potential, transformational and self-transcendent capacity for health and healing” (p. 78). In describing this view, Reed (1995) notes the significance of recognizing developmental histories and their contexts, and more recently, in a description of the tenets of neomodernism (Reed, 2006), she suggests an empiricism that “encourages the use of new tools, methods, (and) technologies” (p. 37). Empirical evidence to document chronic mental illness as a self-transcendent capacity for
health and healing could include measurement of patterns of change over time with new tools, methods, and technologies, and it could include collection of evolving life stories with associated life experiences, bodily sensations, and critical choices. Each of these sorts of evidence will be briefly discussed. MEASURING PATTERNS OF CHANGE OVER TIME
There are many approaches to measuring patterns of change over time, and the sophistication of the methods moves along a continuum from rudimentary tools, such as self-reports, to sophisticated technology, such as electronic monitors. Although we recognize self-report as a valuable and sometimes necessary way to collect data, typical selfreports do not capture change over time. One approach for measuring change over time is diary recording. A diary assessment requires recording of a range of relevant parameters (e.g., time, place, other persons, activities, and feelings) usually with a checklist format as research participants go about everyday living. Researchers using this method must provide a cue, which prompts the participant to record a “page” in the diary. The cues may be interval contingent (regularly prescribed times such as might occur when blood pressure is automatically monitored with an ambulatory monitor), event contingent (when a certain event occurs, such as eating, waking, etc.), or signal contingent (when an external From the Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL; and West Virginia University, School of Nursing, Morgantown, WV. Address reprint requests to Patricia Liehr, PhD, RN, Associate Dean of Nursing Research & Scholarship Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Rd., Boca Raton, FL 33431-2048. E-mail address: [email protected] n 2007 Elsevier Inc. All rights reserved. 0883-9417/1801-0005$30.00/0 doi: 10.1016/j.apnu.2007.08.002
Archives of Psychiatric Nursing, Vol. 21, No. 6 (December), 2007: pp 345–346
345
346
LIEHR AND SMITH
random signal comes from a beeper or electronic watch; Shiffman, 2000). A researcher could include assessment of feelings, such as sadness or stress, and ask participants to use a Likert-type scale to rate the moment when they are cued. An example of a more technologically sophisticated approach to real-time monitoring is the electronically activated recorder (EAR) developed by Pennebaker et al. Real-time word use can be recorded with the EAR through digital recording technology (Mehl, Pennebaker, Crow, Dabbs, & Price, 2001). Generally, the recorder is set to automatically turn on every 12.5 minutes and record for 30 seconds each time it turns on. The audiotaped words of participants can be transcribed and analyzed with Linguistic Inquiry and Word Count software, a word-based computerized text analysis software, which discerns word categories such as positive and negative emotion as well as cognitive and sensory process words. These categories could provide potentially useful information about the life experiences of people with chronic mental illness. Pennebaker and Stone (2003) assert that word use is a window into a person's world and a measure of psychological state. The EAR technology accesses real-time psychological state in an unobtrusive way with less likelihood of social desirability influences than occurs with standard self-report measures. ASSESSING LIFE STORIES
Collecting stories over time enables documentation of an individuals' reality as it is unfolding. Stories are in-the-moment descriptions of experience as lived, enabling a view of transforming from the person's perspective. An account of an ongoing story offers a way of documenting the selftranscendent capacity for health and healing by centering on what matters most to the person. For the purpose of research, it is suggested that stories be gathered about what matters most to the participant regarding a topic of research interest. For instance, if the topic is loneliness, then the researcher would begin the story gathering by asking people what matters most about being lonely and then moving to how the most important people in their lives are related to what matters most, which then leads to what helps to make things go better when they are lonely. The researcher needs to take good notes
while gathering the story and, immediately after the session, write a reconstructed story (Smith & Liehr, 2005). A reconstructed story is a composite synthesis of what was shared as it is remembered by the researcher. A set of reconstructed stories on the topic of loneliness could then be analyzed to identify how people live with and resolve loneliness. If we can understand how chronically mentally ill people manage their loneliness, we would have important guidance for nursing practice. Threaded throughout this discussion, although not explicitly stated, is the importance of longitudinal study designs to pursue understanding of chronic mental illness through a neomodernist lens. Likewise, a shift to innovative methods within these designs offers promise for comprehending the transformational nature of chronic mental illness, bringing us to the cutting edge of meaningful practice-changing contextual evidence. Only when our evidence is contextual and emergent will we be moving in the direction of addressing the health complexities experienced by people with chronic mental illness.
REFERENCES Mehl, M., Pennebaker, J. W., Crow, M. D., Dabbs, J., & Price, J. H. (2001). The electronically activated recorder (EAR): A device for sampling naturalistic daily activities and conversations. Behavioral Research Methods, Instruments, Computers, 33, 517–533. Oxford English dictionary. Oxford: Clarendon Press. Pennebaker, J. W., & Stone, L. D. (2003). Words of wisdom: Language use over the life span. Journal of Personality and Social Psychology, 85(2), 291–301. Reed, P. (1995). A treatise on nursing knowledge development for the 21st century: Beyond postmodernism. Advances in Nursing Science, 17, 70–84. Reed, P. (2006). Commentary on neomodernism and evidencebased nursing: Implication for production of nursing knowledge. Nursing Outlook, 54(1), 36–38. Robson, D., & Gray, R. (2006). Serious mental illness and physical health problems. International Journal of Nursing Studies, 44, 457–466. Shiffman, S. (2000). Real-time self-report of momentary states in natural environment: Computerized ecological momentary assessment. In A. A. Stone, J. S. Turkkan, C. A. Bachrach, et al. (Eds.), The science of self report: Implications for research and practice. Mahwah, NJ: Lawrence Erlbaum, 277–296. Smith, M. J., & Liehr, P. L. (2005). Story theory: Advancing nursing practice scholarship. Holistic Nursing Practice, 19(6), 272–277.