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The Relationships Among Emotion Regulation, Role Stress, And THE RELATIONSHIPS AMONG EMOTION REGULATION, ROLE STRESS, AND PSYCHOLOGICAL DISTRESS IN SURROGATE DECISION MAKERS OF THE CHRONICALLY CRITICALLY ILL PATIENTS by MARY NJALIAN VARIATH Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Frances Payne Bolton School of Nursing CASE WESTERN RESERVE UNIVERSITY May, 2019 CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES We hereby approve the thesis/dissertation of Mary Njalian Variath candidate for the degree of Doctor in Philosophy*. Committee Chair Ronald L. Hickman, Jr. PhD, RN, ACNP-BC, FNAP, FAAN Committee Member Jaclene A. Zauszniewski, PhD, RN-BC, FAAN Committee Member Mathew Plow, PhD Committee Member Arin Connell, PhD Date of Defense March 21, 2019 *We also certify that written approval has been obtained for any proprietary material contained therein. ii Dedication This dissertation is dedicated to my family. Behind this accomplishment stand the two strong pillars of my life, Variath Njalian (late) and Thressiamma Njalian, my parents. They taught me many important life lessons, instilled the values of hard work and sacrifice, showered unconditional love, and shared their passionate desire for education; all of which inspired me to accomplish this milestone. To Anice Sebastian, Lissy Jose, and Varghese Njalian, my siblings, whose encouragement, love, and support boosted my wavering confidence during this prolonged endeavor. And to my husband, whose love, constant support, and encouragement helped me to get through the obstacles of this journey. My deepest gratitude and love iii Table of Contents Page Title Page ............................................................................................................................. i Committee Members .......................................................................................................... ii Dedication .......................................................................................................................... iii Table of Contents .............................................................................................................. iv List of Tables ................................................................................................................... vii List of Figures ................................................................................................................. viii Acknowledgements ............................................................................................................ ix Abstract ........................................................................................................................................... x Chapter I: Statement of the Problem .......................................................................................... 1 Background and Significance ............................................................................................ 3 Conceptual Framework ..................................................................................................... 12 Constructs and Operational Definitions of Study Model ................................................. 17 Research Questions .......................................................................................................... 20 Study Implications ............................................................................................................ 21 Chapter II: Literature Review ................................................................................................... 26 Definition of Chronic Critical Illness .............................................................................. 27 Impact of Chronic Critical Illness ..................................................................................... 29 Influence of Chronic Critical Illness on SDM .................................................................. 31 Definition of Emotion Regulation ................................................................................... 36 iv Influence of Emotion Regulation on SDM ....................................................................... 39 Role Stress ....................................................................................................................... 41 Role Stress in SDM of CCI Patients ................................................................................. 46 Psychological Distress ..................................................................................................... 49 Selection of Demographic Variables ............................................................................... 58 Chapter III: Methods and Procedures ....................................................................................... 67 Description of the Parent Study ....................................................................................... 67 Methodology for the Proposed Secondary Data Analysis ................................................ 68 Operational Definitions and Instruments .......................................................................... 76 Data Collection Procedures for the Parent Study ............................................................. 82 Data Management and Analysis ....................................................................................... 83 Human Subject Protection ............................................................................................... 88 Chapter IV: Results ..................................................................................................................... 92 Sample Characteristics ..................................................................................................... 92 Summary of Demographic Variables ................................................................................ 92 Descriptive Summary of Scores ....................................................................................... 95 Findings Related to Research Questions .......................................................................... 98 Chapter V: Discussion ............................................................................................................... 110 Discussion of Research Questions ................................................................................. 111 Study Limitations ........................................................................................................... 124 Study Implications ......................................................................................................... 125 v Recommendations for Future Research ......................................................................... 127 Conclusion ..................................................................................................................... 128 Appendix A ................................................................................................................................. 129 References ................................................................................................................................... 133 vi List of Tables Page Table 1: .............................................................................................................................81 Table 2: .............................................................................................................................82 Table 3: .............................................................................................................................94 Table 4: .............................................................................................................................97 Table 5: ...........................................................................................................................101 Table 6: ...........................................................................................................................103 Table 7: ...........................................................................................................................108 vii List of Figures Page Figure 1: ............................................................................................................................13 Figure 2: ............................................................................................................................20 Figure 3: ............................................................................................................................88 viii Acknowledgment First of all, I thank God for this opportunity and the ability to accomplish this milestone. I gratefully acknowledge the generosity, assistance, and guidance of Dr. Hickman, my advisor and Dissertation Committee Chairperson. I express my deepest gratitude to you for sharing your data so that my study could be completed in a timely manner. I am thankful for your unwavering support throughout this entire journey. I thank you Dr. Zauszniewski, my former advisor and committee member, for guiding me to the correct sources and for your continued support. I thank the rest of my committee members: Dr. Plow, for your time and support with statistics, and Dr. Connell for sharing your expertise. I express my deepest gratitude to you Dr. Nosek for spending much of your time and energy to assist me in refining my writing and shaping it according to APA writing style. Even amidst your health and technological issues, you made yourself available with your best resources
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